THE INTIMATE ISSUE OF PERINEAL MASSAGE IN PREGNANCY AND LABOUR

For many years, experienced midwives had massaged the perineum during the second stage of labour [birth of the baby] with great success, to prevent tearing, and allow stretching of the vagina.

Many women fear the possibility of tearing and having an episiotomy [cut to enlarge the vaginal opening during birth] and opt for an unnecessary caesarean section because of the fear of vaginal trauma and possible sexual dysfunction later in life.

Prenatal perineal massage is the gentle massaging and stretching of the skin between the anus and the vagina [called the perineum], during the last weeks of pregnancy. Perineal massage appears to be more effective from 34 weeks of pregnancy.

For many years, experienced midwives had massaged the perineum during the second stage of labour [birth of the baby] with great success, to prevent tearing, and allow stretching of the vagina. In addition to perineal massage, a slow gentle delivery will help to avoid perineal trauma.

Some interesting facts:

The perineum is the area extending from the base of the labia minora [small inner labial lips] to the anal canal.
It is roughly triangular and consists of connective tissue, muscle and fat and provides attachment to the muscles of the pelvic floor.
The pelvic floor is divided into 2 identical halves that unite along the midline

Why perineal massage?

Perineal massage has been shown effective in preventing the need for episiotomy and a decrease in the amount of tearing a woman has during her birth.

Progesterone and Relaxin hormones soften the muscles and ligaments to allow stretching and the pelvic floor and the perineum are no exception.

Perineal massage is particularly effective in women oven the age of 20. Massage should be done gently to avoid trauma to the perineum or upsetting the mom.

Other benefits include:

You become aware of how your vagina and vulva look and feel, allowing you to become better connected to your body.
It helps to stretch the vagina gently to allow greater suppleness and elasticity.
By contracting and relaxing the pelvic floor muscles, the strength of the muscle is maintained.
Kegel exercises and pressure and stretching, creates an awareness of where the perineum is [an area that we normally do not pay any attention to]. This will help you to push more effectively especially if an epidural forms part of your birth plan.
It will also assist you in becoming aware of the pressure sensation that you will feel during delivery and enable you to have confidence that your muscles can distend to facilitate childbirth.
It enables you to relax when the head is crowning [because of the burning sensation it creates].
It helps to prepare you for the feeling of pressure when the baby’s head is born.
All this contributes to your understanding of the birth process and your ability to give birth in a gentle slow manner to allow the perineum to stretch naturally.
By involving your partner, your relationship may be strengthened.

Is an episiotomy still common in South Africa?

Although the perceived benefits of an episiotomy had long been disproven, some midwives and obstetricians still routinely perform one.

It is a good idea to have this intimate conversation with your caregiver during an antenatal consultation. This is little evidence that support a routine episiotomy.

What can we do to prevent an episiotomy or serous tear during birth?

It is essential that you eat a well-balanced diet that includes adequate amounts of protein. This allows skin elasticity and promotes healing.
Do Kegel exercises and aim for 2-3 sets daily.

Squatting exercises can assist, and if your caregiver is willing to do so, squatting during birth may increase the pelvic diameter by 10%, shortens the depth of the birth canal, shortens the second stage of labour and decreases the need for obstetric instruments [vacuum and forceps] and episiotomy.
A slow controlled delivery where you follow your own instinct, coupled with good guidance by the midwife, will furthermore reduce the risk of tearing

When is perineal massage not a good idea?

Perineal massage should be avoided when you have an active sexually transmitted disease, herpes, thrush, or any other vaginal infection, because the risk of spreading the infection and worsening of the condition. It can be done again once the infection was adequately treated.

What do you use for perineal massage?

Use a lubricant like vitamin E oil, almond oil, or olive oil. All the following can be used during perineal massage, to act as a lubricant:

Sweet almond oil. Almond oil is an ideal lubricant, because the oil will not be absorbed into the skin, allowing a longer lubrication period.
Wheat germ oil
Olive oil
Simple (pure) vegetable oil
K-Y jelly®
Specifically, designed oils that may contain herbal preparations

A petroleum-based oil should not be used to avoid damage to the vaginal mucosa.

How often?

Researchers differ in their opinion on the length and timing of the massage, but if done daily, it may help you to set into a routine more easily.

The massage need not be long, 2-4 minutes 3-4 times a week or even daily, as the mood dictates.

Perineal Massage Tips:

Setting the scene

Click on the images to enlarge

A private area, alone or with the partner should provide for uninterrupted time.
Warm bath: Sit in a warm bath or use warm compresses on the perineum for about 10 minutes before you start to help you relax before the massage and loosen the muscles around your perineum.
If you do not feel like bathing, remember to wash your hands thoroughly.
Short nails: Trim thumb nails to prevent scratching the skin or cause any discomfort to the area.
Comfortable position: The best place to perform this massage is in bed, but it can be any warm comfortable area of your choice.
Assume a semi-sitting birthing position. Prop yourself up with pillows to support your back and bend your knees.
Remember to position a mirror at the bottom if you are massaging your perineum yourself.

Position your thumbs

Lubricate your thumbs and the perineum.
Insert your thumbs as deeply as possible inside the vagina and spread them down toward the rectum and toward the sides.
If your partner is doing this massage, he may use his thumbs or index fingers
Hold your thumbs in the position shown for about 1 minute ( see diagram 1).
Press down towards the anus and to the sides of the vagina walls. Hold your thumbs in this position for about 1 minute. You will begin to feel a stretching sensation. Breathe deeply and try to deliberately relax the bottom bits.
Hold the stretch for about two minutes until the tingling subsides and the area feels numb

Gentle Massage

Gently massage the lower half of your vagina using a U-shaped movement for 2-3 minutes. Repeat this 2-3 times. [Diagram 2]
The gently massage should continue to stretch the muscle until a burning or tingling sensation is experienced
Gently massage the lower perineum back and forth
Finally massage the tissues between the thumb and forefinger back and forth over the bottom area of the vaginal tissues, while massaging the lubricant into the tissue.
Pull the thumbs out slightly (thus hook the thumbs onto the sides of the vaginal canal) and gently pull the perineum forward, as the baby’s head will do during birth.
If you have a scar from a previous episiotomy or tear pay attention to the scar tissue. [Massage a bit longer and exert more firm pressure].
The massage should be gentle as to avoid bruising or swelling
Avoid pressure on the urethra as it can introduce irritation or infection.
Light stretching, tingling or light burning should be experienced, not immense pain
Repeat daily or when possible
It may take a couple of weeks of daily massage before you notice more elasticity in your perineal area.

Dr Diana du Plessis

Diana du Plessis is an independent Midwifery consultant and researcher. She specializes in midwifery and neonatology and lectures widely to nursing professionals and academic audiences on a national and international level. She is a passionate childbirth educator and national spokesperson on breastfeeding. She is the author and co-author of various nursing and midwifery publications (books and peer-reviewed articles).