Prenatal Perineal Massage

I’ve been asked a few times lately during normal prenatal visits with clients as they get near term – usually first time parents, “So what do you think about perineal massage? And when do you think we should start it?”

In case you don’t know what prenatal perineal massage is – it is using the fingers to manually stretch the vaginal opening in attempt to prepare it to stretch during birth in hopes to avoid trauma and tears to the perineum (area between the vaginal opening and the rectum) during the birth of their baby.  (it is NOT, as this site says, “a gentle massage that promotes the elasticity of the lower regions of the cervix.”  REALLY?  Please, no matter what your opinion on perineal massage it, please do not massage your lower cervix!)

An instructional image showing where and how to do perineal massage. The perineum is the area in front of the thumb tips in this picture...

THE SUPPORTERS SAY….
Those who recommend doing it say that expectant mothers (and their partners) should begin this exercise by 35 weeks of gestation. You should lubricate two fingers, insert them into the vagina, and stretch and press on the perineal area, relaxing the muscles and stretching the vaginal and perineal tissues. They believe that by doing this you will help train the mother how to surrender those tissues during pushing as well as stretch the perineum so that it won’t tear during the birth. With those kinds of promises, it’s no wonder that so many women are asking about it! Seriously, what woman about to have a baby wouldn’t do ANYTHING to reduce the risk of tearing the most sensitive part of their body!!

If you look at the studies, on the surface they would appear to agree with this idea! Shipman et al published a study in 2005 that concluded that with perineal massage there was a 6% reduction in perineal trauma. The problem with this study is that they included pelvic floor exercises (beneficial) as well as massage – and also that “perineal trauma” included episiotomies! Reduce the number of episiotomies and you reduce the incidents of perineal trauma? Of course!

Labrecque et all published a study in 1999 that showed a 9% decrease in trauma for first time moms who did the massage (although they showed a slight increase in trauma for 2nd+ times mom). Again, they did not control for episiotomies or other factors.

This is just a beautiful picture I added so that when people link to it on facebook it has a nice picture rather than the vagina picture seen above. This is also a GREAT type of massage as an alternative to the perineal massage....

WHAT I SAY….
I am not a fan of prenatal perineal massage for a variety of reasons….

No studies have been done that I believe show the effectiveness. Stamp et all did a study in 2001 that concluded, “The practice of perineal massage in labour does not increase the likelihood of an intact perineum or reduce the risk of pain, dyspareunia, or urinary and faecal problems.” I don’t accept that study as an authority either – I haven’t found ANY studies that I feel adequately show benefit or risk.

So what’s the problem with doing it if there haven’t been any risks found? If you ENJOY doing it, you like the feeling, then there is no problem at all! However, if you don’t enjoy it (and most women do not – even when agreeing to be a part of the above studies quoted, only 30% of those that AGREED to do the massage actually did it adequately) then why are you doing it? Why do any intervention without a known benefit?

However, I do believe there to be negative effects of doing prenatal perineal massage…

1. Aggressive massage can cause a tough perineum by causing microtears in the skin. I’ve read some instructions who encourage the mother’s to do massage “until you feel a light burn”. That burning is damage to the tissue, and your body will heal ANY injury with scar tissue. Scar tissue is tougher than our undamaged skin and can, possibly, create a LESS stretchy perineum.

2. It can undermine a woman’s confidence in her body. Why is she doing it? Because she doesn’t believe that her body is going to birth her baby without trauma unless she takes action – in other words, her body doesn’t work as it is. She believes her body isn’t good enough to complete the job of birthing her baby and so employs the massage either by herself or with the help of her partner. So they begin the massage and she finds it uncomfortable to fit even 2 fingers inside more yet to stretch them – and she gets scared. More often than not she will express concern that if she can’t comfortably fit two fingers inside her vagina then how in the world is she going to push a baby out!! She is now scared rather than empowered…unnecessarily. See reason #3 as to why this fear of her body’s capabilities is unfounded.

3. Childbirth is a dynamic event – our muscles smoothe away, our pelvic bones open up (remember my blog post on Pelvimetry?)….and our tissue changes with the hormonal changes of labor. I get asked to check a woman’s cervix in my office at the end of her pregnancy (I wrote a blog post about that, too!) and I find that fitting two fingers inside is a little snug. I try to be as gentle as possible, but it’s not always possible to do it with absolutely no discomfort. That same woman, while in the throws of labor, blossoms open…her tissues smoothing away and relaxing for their baby – and that same woman I can almost literally fit my entire hand inside her vagina. Her tissues have responded to the hormones of labor by preparing to open for her baby. She didn’t feel that way 2 weeks ago because her body wasn’t opening for her baby 2 weeks ago!! So when we do that massage at the end of pregnancy while knowing the tissues will change in labor, why do we believe that what we do when she is 36 weeks is going to effect what it does when she is 40 weeks?

4. I’m not convinced that there is anything wrong with the smallest of tears to the perineum. Just as our hymen tears away during our first sexual encounter, we don’t stitch that back up….but we are afraid of the small perineal nicks that can accompany birth. I’m not talking about the deep tears that go into the muscle (or worse) – I’m talking about those little “skid marks” that women fear so much. Our bodies stretch, our bodies heal. The discussion of perineal massage has nothing to do with any other part other than the PERINEUM….(although following the studies, if the massage keeps your care provider from cutting an episiotomy, then by all means TELL THEM YOU DID IT!!! Just say NO to routine episiotomies!)

So my conclusion would be this: Spend your final weeks, days, hours of your pregnancy doing what feels right for you – but please know that your body was made to birth your baby. Still feel like you want to do something to prepare your body? Make sweet love to the man in your life (also helps prepare the perineum, also helps prepare the cervix, and if you do it right it can feel darn good!), spoil yourself with fun activities in these final weeks and ENJOY the end of your pregnancy. And learn to trust that your body is awesome just the way it is….

11 Comments

  1. Patti Blomme wrote:

    I concur and have always felt this way. The body was designed to birth, our bigggest job is to keep meddling minds and hands away and let it do the job.

    Monday, July 18, 2011 at 10:11 am | Permalink
  2. Gloria Lemay wrote:

    This is a very nice resource on this subject. Thanks for putting it all down so plainly and with common sense. It’s quite amazing how our female tissues are designed for giving birth.

    Monday, July 18, 2011 at 1:16 pm | Permalink
  3. Stephanie Mushonga wrote:

    Perineal massage doesn’t feel right to me at all. I have had 3 normal natural births. With my third the OB massaged while I pushed and it hurt. I told him to stop! I second your statement that women have to do what’s right for them.

    Monday, July 18, 2011 at 2:46 pm | Permalink
  4. Melissa wrote:

    I always wondered if it could be increasing your chance for infections, too.

    Monday, July 18, 2011 at 3:25 pm | Permalink
  5. LizzyZ wrote:

    I totally agree with your analysis of why perineal massage isn’t helpful. However, I just have to correct your reason #1.

    As a wound care nurse your statement that “ANY injury [is healed] with scar tissue” is like fingernails on a chalkboard to me. It is simply not true and, like many of your rationales against perineal massage, can create paranoia and stress for someone who doesn’t understand just how wondrous our body is. Any injury that extends beyond the epithelial layer and cannot be healed via reepithelialization in a routine amount of time will instead begin to form scar tissue in an attempt to draw the edges of the wound together so the epithelial cells have a chance to do their job. I doubt that stretching to the point of “a light burn” tears the tissue beyond the epithelial layer. Otherwise it would be beyond a burn and instead be a bleed.

    Thank you for your blog. I’ve learned a lot and enjoyed your many birth stories.

    Monday, July 18, 2011 at 10:40 pm | Permalink
  6. Brittney wrote:

    Love this! I’ve never really liked the idea and I’m glad to hear I’m not missing out on anything. Also, I had to laugh at your gratuitous massage picture. Brilliant! I hate when I go to post things on FB and have to use the “no thumbnail” option because the photos aren’t decent.

    Monday, July 18, 2011 at 11:50 pm | Permalink
  7. Kelly wrote:

    I love your blog! I was wondering if you would do a post on breech homebirths. I recently had a wonderful homebirth and I have sister whose babies are always breech the last 3 weeks of her pregnancy and has never gotten to experience at natural birth. What are your thoughts on this topic? What about homebirth breech VBACs?

    Tuesday, August 2, 2011 at 6:11 pm | Permalink
  8. Karen Joy wrote:

    Of course, this is only my personal experience, but out of my five children, the only one who I birthed with not even a “skid mark” was my 4th, and I was faithful to do perineal massage for the 4 weeks leading up to her birthday (starting at 37 weeks… she was born at 41/1).

    I had studied up on it because, unlike most women, I found that my tendency is to PUSH LIKE A CRAZY ROBOT WOMAN during the pushing phase, and man! I can push out a baby fast, but it led to tears. So, when prepping for my 4th birth, I looked into all sorts of ways I could prepare myself better, including my perineum.

    Of course, there’s no telling what other factors were in play, but that was my only tear-free birth. My last one (my 5th) I had a tiny tear that probably could have gone unstitched.

    I found perineal massage oddly satisfying, just because it felt like I was taking an active role in preparing for my baby’s birth.

    However, I think what has best served me is mostly NOT pushing — breathing/humming through most of the pushing stage, letting my uterus do most of the work, and being really judicious about my pushing. I still go really fast through the pushing stage… about 6-10 minutes for all five of my children. :)

    Wednesday, August 3, 2011 at 4:46 pm | Permalink
  9. I also very much dislike perineal massage during birth, for basically the same reasons you listed above for not liking it prenatally. I also strongly believe that perineal massage can lead to deep and painful tears. I’ve had 2 clients have “W” shaped tears, and both of them had care providers who did aggressive perineal massage. I couldn’t help but wonder if the W was caused by two fingers pushing in and tearing the skin under them.

    Tuesday, August 23, 2011 at 4:40 pm | Permalink
  10. Chanel wrote:

    I have a few questions about this. I am looking for professional advice on episiotomy procedure.

    1-Do you feel episiotomies are necessary for some women? (due to baby size, fast descend, woman’s body response etc) Is tearing necessary?

    2-Obviously some women tear in horrible ways, why do you believe this happens since our bodies were made to birth? In other words what causes severe tearing? Prevention?

    3- Obviously wether you tear and require stithces or get an episiotomy there will be a pro-longed healing time than if you didn’t experience either. Is there data comparing/contrasting healing time in women who have tears compariable to episiotomies?

    Also, I tend to hear that women who hated episiomties are comparing it to when they didn’t tear alot, so the experience is not similar, but woman who have torn alot prefer the episiotomy. 4- What are your thoughts?

    I WOULD LOVE A RESPONSE!! chanelista at yahoo.com

    My doctor says he avoids episiotomies and cuts as little as possible, and only as necessary. He is not worried about me needing one, since he doubts my baby will be too large, which he credits to most episiotimies He reccomended I take a Lamaze class, for a natural birth, he seemed ambivalent on peri massage, but did HIGHLY (like authoritavely) reccomend water aerobics to ease all aspects labor naturally by strengthening my body. Also he said aerobics will help me with sciatic pain and hopefully wear me out enough that I sleep better. He’s pretty holistic as far as I can tell, and not the type of doctor people hate. I would have loved to have a mid-wife, but I am considered high-risk.

    I do love my doctor. I am not afraid of his procedures, I am afraid of hospital procedures that even he can’t change. But I don’t have a choice in where I deliver due to my high-risk categorization. So….
    5-Any advice on working with the nursing staff who prefer epidural patients? Keep in mind I don’t want one, and my doc prefers not to do them, and we aren’t going that route unless I need a C-section.
    THANKS!!

    Saturday, October 15, 2011 at 2:03 am | Permalink
  11. elfanie wrote:

    1. I consider an episiotomy to be a life saving surgical proceedure – so the reasons you listed would never be a reason I would consider doing an episiotomy. The only instance in which I would consider performing one would be that baby is in trouble and needs to be born RIGHT NOW to have a happy outcome.

    2. I believe that nutrition plays a huge role in a woman’s risk of tearing….as does being told what position to get in and/or directed pushing.

    3. there HAVE been studies (although I don’t have them handy to pull up, but a google search can help with this) that show faster healing and less pain with a tear than with an episiotomy.

    Saturday, October 15, 2011 at 8:32 am | Permalink

2 Trackbacks/Pingbacks

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