Perineal Massage for Prevention of Episiotomy and Obstetric Anal Sphincter Injuries: An Umbrella Review

Perineal trauma affects approximately 85% of women delivering vaginally. Episiotomy and obstetric anal sphincter injuries (OASIS) carry substantial short- and long-term morbidity. Published systematic reviews on perineal massage reach inconsistent conclusions. The objective of this umbrella review was to synthesize the direction, magnitude, and certainty of the evidence from published systematic reviews evaluating antenatal and intrapartum perineal massage on episiotomy rates and OASIS incidence.

PubMed/MEDLINE and the Cochrane Library were searched from inception to 15 March 2026 for systematic reviews with meta-analysis (SRMAs) of randomized controlled trials evaluating perineal massage versus standard care. Primary outcomes were episiotomy rate and OASIS incidence. Methodological quality was assessed with AMSTAR-2 and certainty of evidence with GRADE.

Eight SRMAs encompassing 1057 to 13,695 women per review were included. Intrapartum (second-stage) massage was consistently associated with reductions in episiotomy rates (relative risk [RR] 0.53-0.71). For OASIS, the two SRMAs reporting relative risks both showed significant reductions (RR 0.49 and 0.52, each with I² = 0%). Antenatal massage showed more modest episiotomy reductions (RR 0.79-0.84) and inconsistent effects on severe tears. Evidence certainty ranged from very low to moderate.

Published SRMAs show a consistent direction of effect suggesting that perineal massage may reduce episiotomy rates and severe perineal trauma, although GRADE certainty was low or very low for most outcomes. The synthesis does not support strong recommendations for routine use; clinical application should remain optional and calibrated to the local baseline episiotomy rate and shared decision-making.