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Overview

Your perineum is the area between your vaginal opening and your rectum. This area stretches during birth and it is possible to have a tear. If you have an episiotomy, this is the area that is cut during the birth of your baby. Perineal massage is an exercise done by you in the weeks leading up to birth to prevent tearing. The theory behind perineal massage is that by stretching this area leading up to your birth will allow it to stretch more easily, and without tearing when your baby is crowning. There have been studies on perineal massage both during pregnancy and during the second stage of labor. This article examines these studies to determine whether there is evidence to support this practice.

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The Perineum

Your perineum is the area between your vaginal opening and your rectum. This area stretches during birth, especially when your baby’s head is emerging and this is referred to as crowning. As your skin stretches you may experience some pain and discomfort. Your baby’s head has the largest circumference and once their head is out there is less stretching and it is a very short time until the rest of their body is born.

Tearing

During the birth of your baby, it is very common to tear your perineum. This is especially true for your first birth. This study shows the rates of tearing with a first baby are 90% and decrease to 69% in subsequent births. According to the American College of Obstetricians and Gynecologists, the rate of tearing for all births is between 53-79%.

Episiotomy

In some cases, an intervention called an episiotomy is performed where your perineum is surgically cut during the birth of your baby.

The Goal of Perineal Massage

Perineal massage is an exercise done by you in the weeks leading up to birth to prevent tearing. The theory behind perineal massage is that by stretching this area leading up to your birth will allow it to stretch more easily, and without tearing when your baby is crowning. There have been studies on perineal massage both during pregnancy and during the second stage of labor. This article examines these studies to determine whether there is evidence to support this practice.

Talking to Your Doctor or Midwife

The first thing you should do if you are considering this is to run it by your care provider. Just in case there is something in your medical history or with your pregnancy that is a contraindication for perineal massage. Some examples of contraindications for perineal massage are if you have placenta previa or any bleeding or if you had any kind of infection.

The Evidence on Perineal Massage

A Cochrane review of four trials with just under 2500 women found that perineal massage was associated with an overall 9% reduction in the incidence of trauma requiring suturing. This only applied to women without a previous vaginal birth. It is interesting that the benefits decreased with the frequency of perineal massage. Women who did this 1.5 times per week had a 16% reduction in needing sutures. Those who massaged 1.5-3.4 had only an 8% reduction. Women who massaged 3.5 times per week or more did not experience a reduction in the instances of trauma requiring suturing. These percentages are the relative risks. To put this into perspective, I looked at the data and did some calculations. The instances requiring sutures were about 31% in the group who practiced perineal massage and close to 35% in the group who didn’t.

First time mothers or women who have not had a previous vaginal birth practicing perineal massage were less likely to have an episiotomy, by 16%. Again, this only applied to women who did a perineal massage an average of 1.5 times per week. Keep in mind this is the relative risk. Overall, the instance of episiotomy was about 12% in the group that did perineal massage and 15% in the group that didn’t. The researchers do note that it is possible the mothers who practice massage are less likely to opt for or consent to an episiotomy. That could explain why the instance of episiotomy was lower in the group that practiced perineal massage.

What do all these statistics mean? These two points are connected. Fewer episiotomies mean fewer mothers need sutures. There was no statistical significance in tearing in any of the groups. No significant differences were observed in the incidence of instrumental deliveries, sexual satisfaction, or incontinence for any women who practiced perineal massage compared with those who did not massage.

Overall the second stage of labor was not shorter for women who did perineal massage. For women who did it 3.5 times per week or more, their second stage was longer by about 10 minutes. When the researchers excluded participants who received an episiotomy the time in the second stage of labor was more even between the two groups. It turns out that perineal massage may not make your second stage longer, and having an episiotomy would make it quicker.

Overall, there isn’t a pile of evidence supporting perineal massage during pregnancy prior to birth. As long as your care provider gives you the okay and you are comfortable doing it, there also isn’t really a downside to this.

How to Massage Your Perineum

Generally, this is a practice you would perform on yourself. You could also involve your partner if you want to get creative. The first step is to wash your hands. You do not want to introduce any bacteria into your vagina and you want to start with clean hands.

You can use a lubricant like a vitamin E oil, olive oil, K-Y Jelly. To begin you place your thumbs inside your vagina, about an inch in. Then you press down towards your butt and to the sides until you feel a slight burning, stretching sensation. You want to hold that position for 1-2 minutes. While you are holding this stretch you can slowly massage the lower half of your vagina and concentrate on relaxing your muscles. This would also be a good time to do some deep breathing.

This activity should not be painful. Think of it in the same way you would if you were stretching a muscle, you want to feel the stretch but it should not hurt.

How Often

There is not a consensus on the ideal frequency or duration of the massage. I have seen anywhere from once or twice per day to once per week for about 10 minutes during the last 5 or 6 weeks of your pregnancy. The data we just went through supported doing it an average of 1.5 times per week and the benefits decreased with frequency.

The Evidence of Perineal Massage During Labor

One other thing I researched for this article was whether there is evidence supporting perineal massage during birth. A randomized controlled trial of 1,340 women looked at the rates of an intact perineum, first and second-degree tears, and episiotomies. They found that for all of these outcomes the results were similar in the massage and the control groups. The only significant difference was in the rates of third-degree tears. This was 3.6% in the group who did not perform any perineal massage during labor and 1.2% in the group who did. Overall, there was no strong evidence supporting perineal massage during labor. If this is something you want to consider please bring it up with your doctor or midwife.

 

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