At the time I was writing this I was still a midwife fetus, in the early gestation stages of midwifery school. This was a paper for Reproduction (our reproductive anatomy and physiology course), and was meant to inform the reader about perineal massage application and pelvic floor exercises during pregnancy to potentially reduce perineal trauma during childbirth. I’d like to preface all of the following with this… You can choose to perform perineal massage or not. I do not typically encourage people to do perineal massage, unless asked earlier on, and we have fantastic rates of intact perineums or very minimal lacerations that usually do not require suturing. Though I do believe pelvic floor therapy (PFT) is an excellent modality for first time birthers to utilize, I’ve seen stellar births with parents who’ve had PFT throughout the pregnancy. So please trust yourself enough to decide if perineal massage is a good tool for your childbirth prep! And yes, I will absolutely walk you through how to do perineal massage and Kegel’s.
Most of the literature used studied perineal massage beginning at 34-36 weeks gestation. However, literature studying general massage therapy mentions the longer a massage regimen is followed the more resistant muscles are to damage with faster healing time ensuing trauma. My 14 years experience as a Licensed Massage Therapist supports this as well. So it is my opinion that, if a client is interested in a perineal massage regimen they would benefit greatly to begin at around 26-28 weeks allowing for, at the very least, 12 weeks of perineal massage 3-4 times per week (or every other day). Please understand that genetics play a VERY large role in perineal integrity (overall tissue health in general, ie: likelihood of stretch marks) as it determines how elastic your tissues are, how your tissues heal from trauma, etc. So no matter how many things you do to prep your bottom for birth, a laceration may not be completely preventable. Additional therapies that are shown to increase pelvic floor health, elasticity, collagen production and ability to heal from trauma include: Pelvic Floor Therapy, Spinning Babies, squatting and proper Kegel exercises (the latter being very helpful postpartum!), balanced nutrition, sufficient hydration, supplementation with collagen, vitamin C, vitamin D, vitamin E, omega-3’s and Magnesium, and warm compresses or hydrotherapy in labor, as well as avoiding certain positions during pushing. We will dive into all of these shortly. But, let’s jump back into the antepartum & intrapartum practice of perineal massage first.
Antenatal perineal massage does have the potential to positively impact perineal health during childbirth. Massage therapy in general creates micro-tears within the muscle body, stimulating blood flow and nerve innervations to the muscle fibers and skin that assist in increasing overall muscle strength, elasticity and ductility of the tissues during the healing period following the massage. In addition massage therapy elongates the muscle body and boosts endorphin release. This application to the muscles of the pelvic floor and perineum can assist in the preparation for cervical exams and the intense vaginal sensations experienced during the second stage of childbirth (pushing), reducing the length of second stage as well as the risk of perineal laceration (significantly reducing the risk of 3rd or 4th degree lacerations) and notably decreases the likelihood of postpartum perineal pain.
Perineal massage is performed methodically with moderate pressure and can be quite uncomfortable in the first couple of weeks of therapy. Vitamin E, coconut and grapeseed oils are all hypoallergenic and perfect to use for this massage. After a thorough cleansing of the hands and fingernails, either the thumbs or index fingers are inserted into the introitus of the vagina and swept down toward the rectum and outward while simultaneously massaging the exterior of the perineum. People participating in perineal massage reported “by the second or third week…the pain and burning sensation had decreased or [disappeared] and that massage was easier to perform…even pleasant, easy and relaxing” (Labrecque, Eason, & Marcoux, 2001). Furthermore, they reported “increased elasticity and suppleness of the vaginal entrance and perineum and tolerance for increased stretching before feeling any burning discomfort” during the labor process (Labrecque, Eason, & Marcoux, 2001). Confirming that most people, who engaged in the perineal massage regimen, felt physically and psychologically prepared for the intensities of the second stage of labor.
So when is perineal massage not advantageous? If perineal massage is performed during the second stage of labor but the patient had not participated in antepartum perineal massage, they are statistically much more likely to experience pelvic floor trauma and higher degrees of laceration. The possibility of prolapse or incontinence is not affected by a perineal massage regimen.
Getting back to additional therapies that help increase pelvic floor health, strength and ability to heal. Squats are extremely effective at enhancing blood flow and building tone within the entire pelvic floor. Depending on the width of your squat (aka: tiered squats), you will target different areas of the pelvic floor, providing a well-rounded exercise! Practicing Spinning Babies consistently will not only make space by stretching the muscles of the pelvic floor and hips, it will also encourage baby to settle into an optimal well-flexed position. When your baby is in a great position and your pelvic floor is elongated & supple, you’re likely to avoid a presentation that could add stress on the perineum as well as diminish your overall pushing time, which highly reduces the risk of laceration. Certain positions during second stage also impact the integrity of the perineum. Side-lying or lateral position highly increases the chance of remaining intact or is associated with very minimal tearing at the moment of birth. Whereas a deep squat, extremely effective at bringing baby down in labor or in early pushing, can be too much pressure too quickly and not allow the perineum to stretch properly, risking laceration at the moment of birth. Warm, damp compresses applied before and during crowing or utilizing hydrotherapy in second stage stimulate blood flow and soften the tissues of the perineum and slightly decrease the risk of tearing. If second stage or pushing occurs too soon, with directed or forced pushing before baby has labored down vs. spontaneous & instinctive pushing (Ferguson’s reflex), varying degrees of pelvic floor trauma & lacerations are much more likely.
Some extra things you can do within your means include balanced nutrition (fats, proteins & carbs from what is common within your region, culture, religion, etc!) and sufficient hydration (about half of your body weight in plain ounces of water everyday) are essential for tissue health. You may also increase foods or supplements for additional collagen, vitamin C, vitamin D, vitamin E, omega-3’s and Magnesium as these all allow for adequate circulation and provide the nutrients essential for tissue elasticity, production, repair, etc. while Magnesium keeps stools soft and smooth which will keep your bottom comfortable during bowel movements following a birth (with or without a laceration, you don’t want to worry about constipation while healing!).
Proper Kegel exercises are quite helpful in aiding your awareness of your pelvic floor muscles and learning how to isolate, engage & control them. It’s important to do this exercise properly. You can start by getting yourself comfy on a bed or couch and think of this as an elevator ride. You begin by stepping into the elevator (using the anterior muscles, attempting to stop the flow of urine), then count to 8 or 10 as you ride the elevator up (contract your muscles towards the back, posterior, as if you’re attempting to hold in gas). Hold yourself on this highest level for 3 deep breaths and then slowly ride the elevator back down. The slow, controlled release is just as important as riding the elevator up. Kegel's used during postpartum stimulate blood flow to the pelvic floor and perineum for speedy healing. Additionally, Kegel’s work to repair any prolapses or damage to the urethra and/or rectum that may have occurred during birth, all while being able to complete this exercise during the postpartum resting period!!
So with all of that said, please consider speaking with your provider for their insights and recommendations regarding these techniques, exercises, diet & supplements to fit your needs, budget and lifestyle. They should also be able to refer you to a pelvic floor specialist for antepartum & postpartum therapy as indicated. I hope you’ve enjoyed this long rant about perineal health! Furthermore, I hope you feel more confident about how to apply perineal massage or perform Kegel’s and how they can effect perineal health during childbirth.
If you would like us to cover additional topics or if you’re curious about our stance on things, such as common herbal induction methods, pre-labor release of membranes, newborn medications or *anything* else… Please don’t hesitate to comment here or send your thoughts and suggestions through our website or emailed to: support{at}cloverleafmidwifery{dot}com
Love, Light and Informed Consent!
References
KİREMİTLİ, S., KİREMİTLİ, T., ULUĞ, P., & YILMAZ, N. (2022). Comparison of obstetric outcomes and morbidity in nulliparous pregnant women who received antenatal and intrapartum perineal massage. Pelviperineology, 41(1), 17–22. https://doi.org/10.34057/ppj.2022.41.01.2022-2-1
Chen, Q., Qiu, X., Fu, A., & Han, Y. (2022). Effect of prenatal perineal massage on postpartum perineal injury and postpartum complications: A meta-analysis. Computational and Mathematical Methods in Medicine, 2022, 1–10. https://doi.org/10.1155/2022/3315638
Brubaker, MD, FACOG, L. (n.d.). Patient education: Pelvic floor muscle exercises (Beyond the Basics). UpToDate. Retrieved August 27, 2022, from https://www.uptodate.com/contents/pelvic-floor-muscle-exercises-beyond-the-basics#!
Elenskaia, K., Thakar, R., Sultan, A. H., Scheer, I., & Beggs, A. (2011). The effect of pregnancy and childbirth on pelvic floor muscle function. International Urogynecology Journal. doi:10.1007/s00192-011-1501-5
Eogan, M., Daly, L., & O'Herlihy, C. (2006). The effect of regular antenatal perineal massage on postnatal pain and anal sphincter injury: A prospective observational study. Journal of Maternal-fetal & Neonatal Medicine, 19(4), 225-229. doi:10.1080/14767050600593155
Field, T., Diego, M., & Hernandez-Reif, M. (2010). Moderate Pressure is Essential for Massage Therapy Effects. International Journal of Neuroscience, 120, 381-385. doi:10.3109/00207450903579475
Foroughipour, A., Firuzeh, F., Ghahiri, A., Norbakhsh, V., & Heidari, T. (2011). The effect of perineal control with hands-on and hand-poised methods on perineal trauma and delivery outcome. Journal of Research inMedical Sciences, 16(8), 1040-1046.
Geranmayeh, M., Habibabadi, Z. R., Fallahkish, B., Farahani, M. A., Khakbazan, Z., & Mehran, A. (2012). Reducing perineal trauma through perineal massage with vaseline in second stage of labor. Archives of Gynecology and Obstetrics, 285, 77-81. doi:10.1007/s00404-011-1919-5
Hastings-Tolsma, M., Vincent, D., Emeis, C., & Francisco, T. (2007). Getting Through Birth in One Piece: Protecting the Perineum. Mcn-the American Journal of Maternal-child Nursing, 32(3), 158-164. doi:10.1097/01.NMC.0000269565.20111.92
Johanson, R. (2000). Perineal massage for prevention of perineal trauma in childbirth. Lancet, 355, 250-251. doi:10.1016/S0140-6736(00)00020-9
Labrecque, M., Eason, E., & Marcoux, S. (2001). Women's views on the practice of prenatal perineal massage. Bjog-an International Journal of Obstetrics and Gynaecology, 108, 499-504. doi:10.1111/j.1471-0528.2001.00111.x
Moyer, C. A., Rounds, J., & Hannum, J. W. (2004). A Meta-Analysis of Massage Therapy Research. Psychological Bulletin, 130(1), 3-18. doi:10.1037/0033-2909.130.1.3
Sanders, J., Peters, T. J., & Campbell, R. (2005). Techniques to reduce perineal pain during spontaneous vaginal delivery and perineal suturing: a UK survey of midwifery practice. Midwifery, 21, 154-160. doi:10.1016/j.midw.2004.12.003
Sigurdardottir, T., Steingrimsdottir, T., Arnason, A., & Bø, K. (2011). Pelvic floor muscle function before and after first childbirth. International Urogynecology Journal. doi:10.1007/s00192-011-1518-9
Stamp, G., Kruzins, G., & Crowther, C. (2001). Perineal massage in labour and prevention of perineal trauma: randomised controlled trial. British Medical Journal, 322, 1277-1280. doi:10.1136/bmj.322.7297.1277
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