Warm Compresses and Massage in Labor Fail to Ease Postpartum Perineal Pain, Trial Finds

For generations, midwives have pressed warm cloths against the perineum and massaged the stretching tissue during the final, burning moments of childbirth, hoping to spare mothers the searing pain that so often follows delivery. The practice feels intuitive, is endorsed in clinical guidelines, and has been adopted in birthing rooms around the world. Yet a rigorous new randomized controlled trial, published in Reproductive Sciences, suggests that this beloved technique may not deliver the pain relief that clinicians and expectant mothers have long promised themselves. In a secondary analysis of 800 women, those who received perineal massage combined with warm compresses during the second stage of labor reported slightly less perineal pain at 24 hours, three months, and six months after birth than women who received the conventional hands-on technique, but the differences never reached statistical significance. The finding is a sobering reminder that in obstetrics, as elsewhere in medicine, plausibility is not proof.

The study, led by Silvia Rodrigues of the Escola Superior de Enfermagem at the Universidade do Minho in Portugal, together with colleagues from the Hospital of Braga and the Catalan Health Service in Barcelona, drew its participants from a larger randomized controlled trial designed to prevent perineal trauma during vaginal birth. Between March 2019 and December 2020, the researchers recruited women aged 18 or older who were between 37 and 41 weeks pregnant and planning a vaginal delivery of a fetus in the cephalic presentation, meaning head-first, the standard orientation for uncomplicated birth. Of the 848 women enrolled in the parent trial, 800 met the inclusion criteria for this secondary analysis and were allocated evenly: 400 women to the perineal massage and warm compresses group, and 400 to the control group, in which attendants used the hands-on technique of manually supporting the perineum as the baby’s head crowns.

The intervention itself was straightforward but carefully standardized. In the massage and compresses group, birth attendants applied warm compresses to the perineum and performed massage of the perineal tissue during the second stage of labor, the period of active pushing that precedes delivery. The control group received the hands-on technique, in which the midwife or physician places fingers against the perineum to provide counter-pressure and support as the tissue stretches. Both approaches are widely practiced, and the trial was designed to determine whether the gentler, warmth-based alternative could reduce not only tearing during birth, the focus of the parent study, but also the persistent and often debilitating pain that lingers in the weeks and months afterward.

To measure pain, the researchers used the Numerical Rating Scale, a validated instrument in which patients rate their pain intensity on a simple numeric scale, administered at three time points: 24 hours after birth, and again at three and six months postpartum. All 800 women were included in the 24-hour analysis, while 498 women were followed at the three- and six-month assessments. This longitudinal design is one of the study’s strengths, because most research on perineal techniques has focused narrowly on outcomes during delivery, such as the rate of tears or episiotomies, while paying far less attention to how women actually feel once they have gone home with their newborns.

The results told a nuanced story. Women in the massage and warm compresses group did report lower perineal pain at every measured time point compared with the hands-on group, a consistent directional trend across 24 hours, three months, and six months. But the differences were small enough that they could have arisen by chance, and the authors concluded that the technique was not statistically significantly better than the standard approach. Crucially, the intervention was also not associated with more postpartum perineal pain, which means that warm compresses and massage remain a safe option. For a technique with no demonstrated harms, a neutral result still carries practical weight: midwives who prefer the warmth-based approach can continue using it without fear that they are worsening their patients’ recovery.

Perhaps the most clinically consequential finding of the study concerns what actually drives postpartum perineal pain. The researchers found that the occurrence of obstetric anal sphincter injury, a severe tear involving the muscles that control the bowel, and the performance of episiotomy, the surgical incision made to enlarge the birth opening, were the main determinants of perineal pain at 24 hours, three months, and six months after birth. In other words, the severity of the trauma inflicted during delivery, rather than the technique used to support the perineum during crowning, dictated how much women suffered afterward. This aligns with a substantial body of prior research showing that genital trauma severity, suture techniques, and the angle of mediolateral episiotomies all correlate strongly with pain, dyspareunia, and long-term pelvic floor dysfunction.

The implications reach beyond a single hospital ward. Perineal pain after childbirth is not a trivial complaint. It can interfere with breastfeeding, mobility, infant care, sexual function, and the mother’s ability to assume her maternal role, a point the authors emphasize in their rationale for the study. Previous cohort research has documented persistent pelvic and genito-pelvic pain lasting a full year after delivery, and population-based surveys have linked perineal trauma to adverse postpartum psychological outcomes. If the interventions applied during the second stage of labor have only modest effects on downstream pain, then the field’s attention may need to shift toward preventing the severe injuries themselves, through judicious and selective use of episiotomy, improved recognition and repair of sphincter tears, and better postpartum follow-up in dedicated perineal clinics.

The new trial also adds texture to a contested and sometimes confusing evidence base. Systematic reviews and meta-analyses of warm perineal compresses have reported reductions in perineal trauma and pain intensity during labor, and randomized trials of perineal massage, both during pregnancy and during the second stage, have shown mixed effects on episiotomy rates and tearing. A Cochrane review of perineal techniques during the second stage of labor concluded that the evidence for reducing perineal trauma remains limited and heterogeneous. Trials comparing hands-on with hands-off or poised techniques have likewise produced inconsistent results, with some meta-analyses suggesting modest benefits for one approach or the other but no decisive winner. Against this backdrop, the Portuguese trial’s rigorous design, adequate sample size, and long follow-up make its null finding on pain a meaningful data point rather than an outlier to be dismissed.

There are, of course, limits to how far the results can be generalized. The study was conducted at a single center, the Hospital of Braga in Portugal, with ethical approval from the hospital’s ethics committee, and its participants were women planning uncomplicated vaginal births at term. Birth practices, staffing models, and episiotomy policies vary considerably across countries and institutions, and pain is inherently subjective, shaped by cultural expectations, analgesia use, and individual pain thresholds. The loss to follow-up between the 24-hour assessment and the later time points, with 498 of 800 women retained, also introduces the possibility of attrition bias, although the consistency of the pattern across all three time points lends some confidence to the direction of the effect. The trial is registered with ClinicalTrials.gov under identifier NCT05854888, and the authors report no relevant financial or non-financial conflicts of interest.

For clinicians and birthing women alike, the takeaway is one of reassurance rather than revolution. Warm compresses and perineal massage during the second stage of labor neither relieve postpartum pain dramatically nor cause harm, leaving the choice of technique largely to the preferences of the mother and her birth attendant. What matters far more, this study suggests, is whether the delivery ends with an intact perineum or with a sphincter injury or episiotomy, because those are the events that echo through the following six months and beyond. As maternity services worldwide work toward the World Health Organization’s vision of a positive childbirth experience, the message from Braga is clear: the gentlest hands in the delivery room may matter less than the skill to keep tissue intact, and the systems in place to recognize and properly repair the injuries that do occur.

Subject of Research: Effect of perineal massage and warm compresses during the second stage of labor on postpartum perineal pain

Article Title: Effect of Perineal Massage and Warm Compresses Technique in Postpartum Perineal Pain. A Secondary Analysis from a Randomised Controlled Trial

Article References: Rodrigues, S., Silva, P., Esperança, M., Silva, J. N., & Escuriet, R. (2026). Effect of Perineal Massage and Warm Compresses Technique in Postpartum Perineal Pain. A Secondary Analysis from a Randomised Controlled Trial. Reproductive Sciences. https://doi.org/10.1007/s43032-026-02204-6

Image Credits: AI Generated

DOI: 10.1007/s43032-026-02204-6

Keywords: perineal massage, warm compresses, postpartum pain, second stage of labor, randomized controlled trial, obstetric anal sphincter injury, episiotomy, perineal trauma, midwifery, childbirth, women's health, Reproductive Sciences