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...

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....

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….