Perineal Massage in Pregnancy - Why Bother?

WARNING FOR COLORFUL LANGUAGE

Ok you’ve made it this far. Keep reading. You’ve probably heard about perineal massage and you might have even thought – “nah – I’ll come back to that” and skipped forward to a more appealing topic.   So here’s your chance to come back to it with a little bit of encouragement from me to consider why it’s worth considering for your future physical, mental and relationship health. Yep your perineum and pelvic floor are THAT important.

What Is it?

Let’s start with the basics.  Your perineum is the area between the bottom of the vaginal opening and your anus. Research suggests that massaging the perineum during the last few weeks of pregnancy can help increase muscle and tissue elasticity and make it less likely that you’ll tear during your baby’s birth. Tearing sounds scary but there is so much going on down there and competing tissue stimulus signals coming from different parts of your pelvis, vagina, uterus most women don’t feel the tear when it’s happening even without an epidural. Most perineal injury heals well without any long term complications. But it seems fairly logical that if you can stack the odds in your favor of reducing your risk (we can’t fully eliminate the risk) well that might be something to think about no matter how weird it all seems.

Personally I think it’s more about getting used to that stretching sensation as it can be really intense for a minute or so that you don’t A – panic and go hell for leather pushing to get it over with and push through tissues not quite ready   Or B you freak out and tense up against the sensations.  When you practice perineal massage it gets you used to the sensation so it’s not a shock and you can let it happen slowly and gradually and reducing your chances of tearing.  Most moms who do this feel more prepared for labor and would also do it again.

Most recommendations suggest doing a few minutes a week from about 35 weeks – 3-4 days a week.  But there’s no harm in trying it out once or twice before your bump gets too big so you can figure out comfortable positions.   You’ll insert 1-2 lubricated fingers about 2 inches into the vaginal opening (short nails and clean hands of course) and apply slight pressure against the back of the vaginal wall and down and then from side to side for about 5-10 minutes In labor as your baby’s head begins to stretch the perineum that sensation is your cue to stop any conscious pushing you’re doing and let the uterus nudge your baby out (and trust me it’s irresistible – you WANT to push). 

Some midwives also suggest mom gives little nudges between the surges so you have more control.

 Involving Your Partner – Practice saying WTF - loudly!

I usually suggest moms have a bath so the tissues are already nice and stretchy and have your partner help you with it while practicing slow focused breathing or debating baby names.  Distraction is a wonderful analgesia.

One aspect of your partner helping you is to get more comfortable saying ‘WTF dude” or  “for fcks sake take it easy” loudly if he/she is too vigorous with the massage.  Whatever words help you to convey your disapproval.

The words “STOP that right now” are also effective.  Why do this?   If your careprovider starts perineal massage as your baby is being born feeling comfortable saying “WTF – seriously?” can also help you avoid perineal injury as this is NOT supposed to be done IN LABOR but a lot of careproviers do it anyway especially with an epidural, which means you cannot feel it while it’s being done. You know how the dentist tells you not to eat while your mouth is numb? Well, perineal massage when you’re numb can create unnecessary perineal trauma.  So be sure your partner keeps a look out for this if you have an epidural and read this blog about epidural birth preferences.  If you’re doing your perineal massage alone you can still practice saying these words so they come a little easier and those careproviders will learn quite quickly that some carefully selected words conveyed with a disapproving tone can help change bad habits (sorta like puppy training). If you’re an OB/Midwife that practices in line with the evidence this comment won’t be offensive to you…if it is then it may be time to reflect on your practice.

To Lube or Not to Lube

A lot of expectant moms opt to avoid products such as KY or other lubes as they can mess with your vaginal microbiome (that also includes the lube used for vaginal exams in hospital). We all have specific strains of bacteria in our vagina that benefit us throughout our reproductive life and your baby is supposed to be exposed to these bacteria to start ‘training’ their immune system baby right from birth. Coconut oil is known to have antimicrobial properties and feels great but there’s limited research on this at the moment.  Some microbiome experts suggest organic extra virgin olive oil instead.  I did come across this new product that claims to not disrupt the vaginal microbiome.   https://www.fairhavenhealth.com/babyit-perineal-massage-postpartum-tear-gel  (I’m not affiliated with this company). A water based lube are recommended over oils.

Will it help me avoid an episiotomy?

Some of the research suggests perineal massage results in a reduction in episiotomies but here’s the deal. The best way to avoid an episiotomy is to choose a careprovider with a low rate. Episiotomies should be rare and only in the case of an emergency or a forceps (they are rarely done with a vacuum assisted birth anymore). Have the discussion sooner rather than later and be sure to add it to your birth preferences especially when discussing vaginal exams before or during labor.  The research is quite clear on this an episiotomy is more likely to extend into a more severe injury.  

No amount of perineal massage will prevent an episiotomy if your careprovider does them routinely.

So if you ask tell your careprovider you prefer not to have one and he/she answers with “only if necessary” that sounds good - but what if necessary is 50%? The question you want to ask is what percentage of your patients have episiotomies (ideally it’s around 10% or less…) anything more and this is a reasonable response…

This is my second labor – should I bother?

This is where it get’s interesting.  Perineal massage doesn’t seem to reduce the risk of perineal trauma that needs stitches but moms who did perineal massage had less pain at 3 months postpartum.  That’s a big deal.  There’s an abundance of research on the potential psychological effects of perineal trauma on mental health. If you’re getting advice not to bother – I would consider if being in pain 3 months later with a 3 month old might bother you…personally I would bother.  I had an 8lb 15oz baby with episiotomy on my first (thankfully only a second degree injury).  On my 10lb 7oz juicy baby boy I had no episiotomy and a 1st degree tear that healed quickly.

What about that new 2020 AJOG research? 

It was a tiny study - 114 did perineal massage prenatally.  The authors claim no difference between the women who did the massage and those who didn’t.  This was a very small study and had similar episiotomy rates – allow me to insert a WTF here..that’s excessively high +30%. Who is doing all of these episiotomies?

Is it possible to do too much perineal massage? 

One study suggested that too much of a good thing can in fact reduce the benefits however here’s what one of the authors said about this finding.

“The original papers (and this analysis) are underpowered to reach conclusions that more frequent massage is ineffective… Generally, higher frequency of massage had similar point estimates (to lower frequency), but the confidence intervals crossed 1 (RR 0.94; 95% CI 0.86 to 1.02)”. (Personal Communication MM Beckmann 2017) Unfortunately, the lack of power in this analysis has been reported in some medical literature as a finding against more frequent massage.  Ellington et al (2017)

Even the women themselves felt they had increased elasticity of the tissues when they did the massage more.

Yes it’s one of the less glamorous aspects of birth preparation but the majority of women say they found perineal massage useful especially to increasing their tolerance and confidence for those intense sensations during stretching. 

So have a go - you’ve nothing to lose and lots to gain.

For more information on ways to protect your perineum during labor check out this blog ( a warm compress can be your best friend!) and have a listen to ‘Learning How to Push’ in the GentleBirth App.

 Resources:

Takeuchi S, Horiuchi S (2016) Randomised controlled trial using smartphone website vs leaflet to support antenatal perineal massage practice for pregnant women. Women Birth 29:430-435.

Haef A (2015) Effects of prenatal perineal massage and kegel exercise on the episotomy rate. Journal of Nursing Health Science 4:61-70.

Takeuchi S, Horiuchi S (2014) Why don't pregnant women practice antenatal perineal massage?: An empirical investigation. J Japan Acad Midwifery 28:173-182. - English version

Beckmann MM, Stock OM (2013) Antenatal perineal massage for reducing perineal trauma. Cochrane Database Syst Rev:Cd005123.

Labrecque M, Eason E, Marcoux S (2001) Women's views on the practice of prenatal perineal massage. BJOG 108:499-504.

(Labrecque, Eason et al. 1999).

.  There’s only 5 families of bacteria supposed to be found in the vagina.  Women having intravaginal ultrasound research….a single exposure to that lube significantly damages the microbiome – and it may never recover……What are the implications? Most yeast infections, chronic BV, dysbiosis of vaginal microbiome…then you get an antibiotic which messes with your gut microbiome and vaginal microbiome.  Microbiome can  impact the health of woman’s ovaries…and infertility…. (Kiran Krishan).  Then this dysfunctional microbiome is then passed to your baby.  What should women use instead as personal lubricant? 

• No coconut oil – use organic extra virgin olive oil.  No lubes available that are good for vaginal microbiome.  University of Maryland – 2020 – Rebecca Brotman

• Ellington et al (2017) Antenatal Perineal Massage Improves Women’s Experience of Childbirth and Postpartum Recovery: A Review to Facilitate Provider and Patient Education on the Technique. J Womens Health, Issues Care 6:2. doi: 10.4172/2325-9795.1000266

• Labrecque M, Eason E, Marcoux S (2001) Women's views on the practice of prenatal perineal massage. BJOG 108:499-504.