Pelvic Floor Training Combined With Perineal Massage Reduces Episiotomy to 5.7%

Episiotomy, a surgical incision of the perineum performed during the second stage of labor, was once widely advocated for the prevention of severe perineal lacerations. However, a growing body of evidence has demonstrated that routine episiotomy is not without consequence: it is associated with increased rates of posterior perineal trauma, dyspareunia, perineal pain, and postpartum hemorrhage. In alignment with this evidence, the World Health Organization now recommends against routine or liberal episiotomy use and endorses a restrictive approach, targeting episiotomy rates below 10%. Despite these recommendations, episiotomy rates remain high in many settings, particularly among nulliparous womenDespite the individual promise of these modalities, few studies have evaluated their combined effects on episiotomy and other perineal outcomes. The different mechanisms through which PFMT, perineal massage, and Swiss ball exercises operate suggest that their concurrent use may yield additive or synergistic benefits. Nevertheless, comparative data examining PFMT alone versus PFMT combined with Swiss ball or perineal massage remain scarce.

Inclusion Criteria: * Age ≥ 18 years * No prior exposure to any of the study interventions * Gestational age between 20 and 36 weeks at the time of enrollment * No history of previous episiotomy * Estimated fetal weight between 3,000 and 4,000 grams * No labor induction * Absence of any systemic disease complicating the current pregnancy * No regular use of medications or supplements other than multivitamins * Pre-pregnancy body mass index within the range of 18-25 kg/m² Exclusion Criteria: * Failure to meet any of the above inclusion criteria * Declining to provide written informed consen