Pelvic floor Physiotherapy- Perineal Massage in Pregnancy

Perineal Massage in Pregnancy

I am very frequently asked by my pregnant clients if and when they should start perineal massage.  Perineal massage during the last few weeks of pregnancy is a manual stretching technique that is believed to help improve the elasticity and flexibility of the perineal area, thereby decreasing muscular resistance to stretch during crowning.   This is intended to enable the perineum to stretch during delivery, thereby preventing or minimizing tearing and/or need for an episiotomy.  The medical definition of the term, episiotomy, describes this intervention as “a perineal incision to facilitate vaginal delivery of an infant”[i].

What is the perineum and where is it?

The term perineum, clinically refers to the tissues between the vaginal opening (introitus) and the anus[ii].  Trauma to the perineum is surprisingly common during vaginal births and even more so for first time mothers.  It occurs as a result of episiotomies, spontaneous tears or both.  The reported rates of perineal trauma vary significantly due to the broadness and inconsistency of definitions[iii].

What are the effects of perineal trauma?

Perineal trauma can result in persistent and ongoing perineal pain into the post-partum period.  A study in 1995[iv] reported that up to 20% of women who sustained perineal trauma reported pain at eight weeks post-partum.  Women with an intact perineum, however, were reported to have less pain up to 3 months post-partum[v].  Perineal pain resulting from perineal trauma can impair and impede normal return to pain free and pleasurable sexual activity compared to women with an intact perineum[vi].  Carroli et al.[vii] suggested that restricting the use of episiotomies resulted in less posterior perineal trauma, less suturing, and fewer healing complications.

What are the factors that lead to greater risk of perineal trauma?

Perineal trauma is more likely to occur with first time vaginal deliveries, increasing fetal head diameter and weight, and interventions such as vacuum and forceps.  There is no clear consensus that the position with which one delivers or the use of perineal massage during second stage of labour reduces the incidence of perineal trauma[viii].

What does the research say?

A Cochrane Review from 2013, investigated four studies with a total of 2, 497 participants to determine specific outcomes following perineal massage during the final four weeks of pregnancy.  It was found that women who performed perineal massage and who had not previously delivered vaginally, showed a reduction in perineal trauma requiring suturing and had decreased need for episiotomy intervention.  It was also found significant that women with a previous vaginal delivery who performed perineal massage reported a lower incidence of pain at 3 months post-partum.
The author’s conclusions were that “antenatal digital perineal massage from approximately 35 weeks gestation reduces the incidence of perineal trauma requiring suturing (mainly episiotomies) and women are less likely to report perineal pain at 3 months postpartum (regardless of whether or not an episiotomy was performed)”.   Furthermore, the review concluded the potential benefits of perineal massage should be communicated to pregnant women and information provided on how to perform this technique. [ix]

Is it worth while performing this technique?

In my personal practitioner experience, I have found that perineal massage is quite an effective tool for clients to enhance their mind-body connection to the current state of the muscles of their pelvic floor.  This is especially true for those who hold excess tension in their pelvic floor muscles.  With this technique, they are better able to connect to the sensation of perineal muscle stretching and can thus, attempt to focus and encourage their bodies into relaxing and “letting go” of that tension as the fingers gently maintain the stretch.      Perineal stretching can create a light stinging sensation and this is believed to help the mother become familiar and comfortable with the intense sensations that occurs as the baby’s head is crowning.  This may further help to facilitate the mother to practice relaxing the pelvic floor muscles during the sensation.

How do I do perineal massage during pregnancy?

Perineal massage and the practice of focusing on relaxing the pelvic floor complement each other but it isn’t indicated for everyone in all cases.  I strongly believe this exercise is best directed by a Pelvic Health Physiotherapist a better who is able to guide you directly and can check with your Obstetrician or Midwife whether or not this particular exercise is appropriate for you.  There are situations during the later stage of pregnancy that may even contraindicate doing this exercise such as placenta praevia (a low–lying placenta), any other condition where there is bleeding from the vagina during the second half of pregnancy, or if you are suffering from vaginal herpes, thrush or any other vaginal infection, as massage could spread the infection and worsen the condition.  If you have not been assessed by a Pelvic Health Physiotherapist, always check with your Obstetrician or Midwife regarding this technique before starting it on your own.
A general guideline is included below:[x]
It is recommended to start perineal massage at 35-36 weeks pregnant.  Be sure to wash your hands thoroughly prior to commencing the massage and make sure the nail(s) of the finger(s) you will be using are clipped very short.  It is recommended to use a water based soluble lubricant for increased comfort.
Find a position at home that you are able to comfortably reach your vaginal opening without tensing your whole body.  This is often accomplished sitting in the bathtub with your legs comfortably bent (no water) with towels and pillows/cushions to support you.  The bathtub can help support your thighs.

Other positions are sitting in your bed with pillows supporting your thighs in a modified butterfly pose.
The massage usually starts by placing one index finger (or thumb) to the depth of the first knuckle into the vagina.  As the stretch becomes easier, you can progress by adding two fingers or two thumbs to increase the surface area of the stretch.
If you are facing the opening of your vagina, picture it as the face of a clock.
Press the finger down toward the 6 o’clock position until you feel some muscle tension and possibly a slight burning/stinging sensation.  Ensure the intensity of the stretch is such that you are not guarding/tensing your pelvic floor muscles.
Hold the stretch for 30 seconds-1 minute.
Repeat the same stretch at the 4 o’clock and 8 o’clock position.
While maintaining pressure, slowly massage along the vaginal opening to a depth of the first knuckle starting at 11 o’clock all the way to the 1 o’clock position using a “U” shaped stroke for a period of 1-2 minutes.
Concentrate on breathing and relaxing the muscles of the pelvic floor throughout the massage.

How often should I do it?

The Cochrane review reported that those women who performed massage up to 1.5 times per week on average had a significant decrease in the need for an episiotomy.  It was found that those who performed the massage more frequently did not show the same result.  This suggests that more isn’t necessarily better.  Typically, I recommend this exercise 1x per day from 35-36 weeks onward.
By Leeanna Maher
Registered Physiotherapist
Physiotherapist Leeanna Maher
[i] Bates, B. A Guide to Physical Examination and History Taking.  Fifth Editions.  J.B. Lippincott, 1991
[ii] Bates, B. A Guide to Physical Examination and History Taking.  Fifth Editions.  J.B. Lippincott, 1991

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