Antenatal Pelvic Floor Muscle Training Combined With Perineal Massage Significantly Reduces Episiotomy Rates: A Randomized Controlled Trial

Background: Episiotomy rates remain high worldwide despite recommendations supporting restrictive use. Although antenatal pelvic floor muscle training (PFMT) and perineal massage have each demonstrated efficacy individually, their comparative effectiveness and their combined efficacy relative to other nonpharmacological interventions remain unclear. Methods: This randomized, assessor-blinded, controlled trial enrolled 431 low-risk pregnant women between 20–36 weeks of gestation. Participants were allocated to one of four study groups: PFMT alone (n = 132), PFMT + Swiss ball exercises (n = 58), PFMT + perineal massage (n = 88), and standard care (n = 153). The primary outcome was the episiotomy rate. Logistic regression analysis was performed to identify independent predictors of episiotomy. Results: The rates were 5.7% in the PFMT + perineal massage group, 58.6% in the PFMT + Swiss ball group, 68.6% in the control group, and 85.6% in the PFMT-alone group. PFMT + perineal massage significantly reduced the risk of episiotomy compared with both the control group and the PFMT-alone group (p < 0.001 for both). However, there was no significant difference in episiotomy rates between the PFMT + perineal massage group and the PFMT + Swiss ball group (p > 0.05). In contrast, PFMT alone was associated with a higher episiotomy rate than standard care (p = 0.001). Younger maternal age (adjusted odds ratio [aOR] = 0.89, 95% confidence interval [CI]: 0.85–0.93) and nulliparity (aOR = 25.4, 95% CI: 10.5–60.1) were strongly associated with episiotomy (p = 0.001). Conclusion: Combining antenatal PFMT with perineal massage dramatically lowered episiotomy rates. In contrast, isolated PFMT without perineal preparation may paradoxically increase episiotomy risk, potentially due to pelvic floor hypertonia. Antenatal education should therefore emphasize both pelvic floor strengthening and perineal distensibility. Clinical Trial Registration: This trial was retrospectively registered with ClinicalTrials.gov (registration link: https://clinicaltrials.gov/study/NCT07626333, registration number: NCT07626333).