Perineal Massage with Helen Keeble – Clinical Specialist Pelvic Health Physiotherapist

 

Perineal massage is a stretching and manipulating of the perineum and surrounding skin and muscle. It is a safe, free and easy to do technique that has been proven to help reduce 

  • perineal tears (1)
  • ongoing perineal pain for up to three months after delivery (1)
  • the incidence of episiotomies (2)

What is the perineum?

The perineum is the piece of skin & muscle in between the vaginal opening & anus. It is an important anchor and attachment point for the pelvic floor muscles. Damage to the perineum can lead to temporary and sometimes long term difficulties in pelvic floor muscle function – resulting in pain, incontinence, sexual difficulties and/or prolapse. perineal massage


90% of first time vaginal deliveries will have a cut, tear or graze of some sort during delivery (3) so please do not feel as though you haven’t done a good job if you end up with one! Tears can occur in theory anywhere in and around the vulval area but severe perineal tears can have the most significant long term health consequences which is why perineal massage specifically targets preventing and reducing the severity of these. 


How to do perineal massage?

  • Ensure you are warm & in a comfortable position, somewhere like a bath (doesn’t have to be full of water) is ideal as you’re propped up in a supported way with your knees also supported out to the side (Our inner thigh muscles connect into the pelvic floor so if your legs are dropped out to the side & they are pulling a lot/not supported, it will make the massage harder to do). If you prefer you could set up on your bed or somewhere else with pillows behind you & a few pillows under each knee to achieve the same relaxed position.
  • Choosing which oil or lubricant – its totally up to you depending on budget & taste but it is actually not mandatory to have any. You can just use any plain oil that you already have in your bathroom or kitchen without having to buy anything fancy too. 
  • It’s a good idea to have clipped your nails at this point if they are long! Insert the tips of your clean (oil/lubrication covered, if using) thumb/s (no more than up to the first knuckle) into the vaginal opening. 
  • Apply pressure downwards with the thumb/s in long & sustained strokes towards the rectum. You can fan out a bit with the direction of pressure on the left & right sides (as shown in the picture).
  • 5-10mins at a time is sufficient so long as you are using firm enough pressure. 
  • You should use enough pressure so as to feel discomfort/slight burning sensation but not sharp or severe pain. See if you can increase your pressure as the massage continues.
  • You should be able to feel the stretching/slight burning internally and externally.
  • At the same time as massaging, focus on relaxing the pelvic floor. This can be by taking deep breaths in – when we breathe in, the pelvic floor should relax due to the anatomical connections to our main breathing muscle, the diaphragm. Visualising the vagina opening/pelvic floor letting go can also help. 

When & for how long?

  • Twice a week in the last few weeks of pregnancy has been shown to be enough to gain the benefits (1, 2).
  • It’s ideal to start from 35/40. 
  • It is safe to massage earlier/for longer if you wish but no further benefits have been shown to occur if you do so.

Why does is work?

  • The pelvic floor muscles stretch by up to three times their normal length during vaginal delivery. It’s believed that doing perineal massage enables the pelvic floor muscles and skin around the vaginal opening to become more flexible and therefore be able to stretch easier and with less pain at the point of crowning & delivery.
  • It’s thought to be particularly helpful in first time vaginal deliveries as the skin & muscles are stretching for the first time 

Should you still do pelvic floor squeezes in these last few weeks?

Pelvic floor exercises (aka kegels) to keep the pelvic floor muscles strong are still very important so don’t forget to keep those up. The perineal massage works on flexibility and the squeezes work on strength, so if you are doing them both correctly then they compliment each other well. Ideally we are aiming for the pelvic floor muscles to be as strong & as flexible as possible going into labour. 



Alternatives 

If you don’t like the idea of doing perineal massage to yourself or are finding it hard to reach! Then you have the following options;

  • Ask for help – this could be your partner or a pelvic health physio can do it for you 
  • Use a device – the Epi-no and Ani-ball devices are specifically designed to stretch the perineum for you in preparation for delivery 

What if I still have a tear?

  • Although perineal massage for some women (1 in 15) will mean they do not tear, it is not of course an absolute guarantee for avoiding tears altogether.
  • For the others it will reduce the severity of the tear or need for episiotomy though. 
  • If you do still have a tear remember that all tears will heal & it’s not because of anything you did wrong
  • Straight after delivery, start a few gentle pelvic floor squeezes each day to aid the circulation & healing process. 
  • At 6 week/once the tear has fully healed - start massage of your tear. Just use any plain oil and pinch, move and firmly stoke the scar for 2-3mins, twice per week until any tenderness has gone. 

Other factors to consider to reduce your likelihood of tearing 

  • Not pushing for more than 99 mins if it’s your first delivery (4).
  • Considering the length of your perineum if it’s your first delivery – those with a perineal body (the measurement from the bottom of the entrance to your vagina to the centre of the anal orifice) less than 3.5cm long where more likely to experience a more serious perineal tear (4).
  • Holding a hot compress on the perineum at the point of crowning/delivery whilst controlling the descent of the baby (5).




Helen Keeble (www.Helen-Keeble.com) is committed to providing women with evidenced based yet easily digestible information about every single aspect of pelvic health. Helen is the Clinical Specialist Physiotherapist and team lead in Pelvic Health at Blackrock Clinic, Dublin. She also mentors and manages a team of pelvic health physiotherapists in her London clinic (www.pHphysiotherapy.com) and is one of the founders of Umi Health (www.umi-health.com) - making pelvic health accessible to every woman, every where!

1.Beckmann & Stock (2013). Antenatal perineal massage for reducing perineal trauma. Cochrane Library.

2.BMJ (2006) Perineal massage in the weeks leading up to delivery helps some women avoid episiotomy. Mar (18), 332 (7542)

3.RCOG (2020). Perineal tears during childbirth. www.rcog.org.uk/en/patients/tears/tears-childbirth/

4.Lance Lane et al (2017) Perineal body length and perineal lacerations during delivery in primigravid patients. Proc (Bay; Univ Med Cent.) Apr 30 (2): 151-153.

5.Asheim et al (2017) Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane library.