Perineal Massage & Support

By Danelle Frisbie ©2009

For ages, midwives have been known in story-book tales to call out for "buckets of hot water" when attending birth. Just what were these buckets (not cups - but buckets) of hot water used for? In his book, Husband Coached Childbirth, obstetrician, Robert Bradley, explains:

The midwife put salts in these steaming buckets of water, then she begins rounding up clean cloths, freshly ironed to sterilize them. She has been known to improvise with her own petticoats in time of need. The cloths are torn into strips and placed in hot salt water to be used as steaming compresses to be applied to the laboring woman's vaginal area. After one cloth cools down, a hot replacement is applied, and so on through the entire course of labor. These hot salt water compresses are alternated with applications of olive oil and manual massaging of the vaginal opening to effect stretching. If you have ever soaked some minor infection of your skin in hot salt water for a time, you will recall how the skin becomes loose and wrinkled, losing its normal elasticity [and stretching easily as a result].

And so, it would seem, this perineal massage and support helped aid women in gentle birthing at home and preserved their intact perineums. But why would humans be the only mammal in need of such massage (either prior to birth or during labor) and perineal 'support'? All of us birthing within the animal kingdom do so in much the same fashion - the same hormones guiding labor and birth all along the way. Could our perineums somehow be defunct? Out of order? Hmmm...

Bradley had what he called a "pet theory" for the reason the human mammal benefits from this perineum massage/support, but no other animal needs such things to birth without tearing (or cutting). He believed it may be because we are the only mammal to both walk erect (and thereby use and put different pressures on our perineum) and to constantly cover the perineum with clothes (and often multiple layers of them). Bradley asserted that when he worked as an obstetrician among nudists, he did not find the same needs for perineum massage and support to exist before or during birth (Bradley 2008). Their skin and perineum, like other mammals, was exposed to the elements (sunlight, air, water) on a regular basis and was stronger and more flexible as a result. Bradley admitted his theory may not explain everything, but he did give us something to think about.

Not every birth practitioner is convinced that women 'need' perineal massage or support. Could it be that just by suggesting to women that we NEED such things we place doubt into pregnant mother's minds regarding the birth process itself?

In Midwifery Today, skilled midwife and gentle-birth advocate, Gloria Lemay writes, "Folklore abounds about doing perineal massage prenatally. No other species of mammal does this. Advising a woman to do perineal massage in pregnancy implies a lack of confidence that her tissues have been designed perfectly to give birth to her infant." Lemay reminds us that an "intact perineum begins long before the day of birth" and encourages birth practitioners to empower women with the knowledge of what the second stage (pushing) of birth will feel like. Lemay describes this in detail in an effort to familiarize women with these sensations in her article, Midwife's Guide to an Intact Perineum.

It may just be that the best advice for keeping your perineum intact is not to spend hours upon hours massaging prenatally and supporting during birth - but rather to let labor and birth unfold naturally, normally, in its own time, with PATIENCE and a mother's bodily instincts (of how to move and position and when to push) as the guide. Maybe the reason no other mammal tears (or needs to be cut) during birth is not because their perineum is so different - but because birth is treated differently. It is purely instinctual. Physiological. Happening in its own, sometimes s-l-o-w and easy, time frame.

However, the "how-to" question of perineal massage is one that I've been presented with frequently. So, for those who feel like this is right for them and something they wish to embark upon, I'd like to highlight some answers here. I don't believe that getting to know our bodies - how they work, how they feel, etc., ever does us any harm. If perineal massage serves no other purpose than to allow you to know what it feels like to have your perineum stretched, gives you an opportunity to feel the tinglings sensations that come with it, so that it is not 'surprising' (and thereby fear-creating) on your birthing day, then it will serve a good purpose. Plus, perineal massage can give pregnant women an excuse to get away into a private room without interruption, take a warm bath, light your favorite scented candles, relax, and focus on yourself, your amazing body, and the flawless baby that is going to be working with you on your birthing day to make his way earthside.

Let's begin.

Good options for Perineum Massage Ingredients:

(1) Olive Oil -- most textbooks and journal articles on perineum massage call for using simple, clean olive oil as a massage agent. It seems to work well without irritating the tissues. I suspect Jojoba Oil would work exceptionally well also, as it is the oil closest to our natural human oils. However, unless you have a bit of $ to spare, you will find that olive oil is much cheaper than jojoba oil.

(2) Having a Baby Naturally calls for the use of vitamin E oil, or a homemade mixture of 1 ounce wheat germ oil, 3 drops lavender oil, and 1 drop geranium oil.

(3) You can also use plain vegetable oil (this is MUCH better than using a perfumed or chemical 'lube' or oil as that can be irritating to the sensitive vagina and healthy microflora - especially during pregnancy. Do NOT use petroleum based lubricants or oils.)

perineum massage
(can be done with 1 or 2 thumbs at a time)

The Massage:

1) Start about 6 weeks prior to your guess date.

2) Choose a time when you are relaxed and will not be bothered. Sometimes taking a warm bath first will help to calm and relax you.

3) Once a day for about 10 minutes, massage the perineum with your own hands, or have a trusted partner do so.

4) Make sure your hands (or your partner's hands) are very clean. I personally suggest using the pumpable HibiClens that you can purchase without a prescription at any pharmacy to clean your hands (or your partner's) any time they are going to be in or around the vagina while pregnant. HibiClens will rid your hands of any unfriendly viruses/bacteria and it is EXCELLENT to use for hand-cleaning after changing poopy diapers once baby is here. Ask your local pharmacy to order you a bottle of the foaming pink HibiClens that comes with the pump. HibiClens can also be used to safely eliminate group B strep in GBS positive women instead of antibiotics. Use HibiClens prior to having a GBS test done if you want to ensure that your results are negative (and forgo hospital pressure to have antibiotics or have your baby taken from you at birth).

5) Make sure your fingernails (or partner's) are short before perineum massage so that no scratching will occur on accident.

6) Place your thumb or thumbs (whichever is comfortable) about 1 - 1 1/2 inches inside, against the floor (wall) of the vagina. Your fingers will land on the outside skin of your butt/thighs. Run your thumbs back and forth in a "U" or semi-circle motion with slow, increasing pressure as you push downward (toward your anus) and out (toward your thighs). Stretch the perineum just enough to have a slight tingling feeling, and hold the stretch gently until the tingling subsides. In addition to this downward and out "U" motion of stretching and holding, you can also massage the perineum tissues between your thumb and fingers, gently rolling and stretching and pushing (down and out) until you feel the same tingling sensation. The first time you do this it may feel odd, but with practice it will get easier each time and you will get more accustomed to the feeling and how it best works for you.

If your partner is massaging your perineum, 2 fingers can be used, about 1 - 1 1/2 inches deep, and apply the same gentle, slow down and out pressure. Tell your partner when to pause and hold the stretch (when you feel the slight tightening and tingling). It may take longer for your partner to learn this technique than you would doing it yourself, simply because they have to listen to your every cue on how things feel. Slow, easy, gentle, and you will get the hang of it soon.

7) It may help to sit in a private, comfortable position with a mirror in front of your legs and a flashlight to explore and 'get to know' your body in this area if you have not done so before. Just knowing how everything works - what feels what way - can help during labor in recognizing sensations and being familiar (and therefor not scared) when pressure sensations occur as your vagina naturally and easily opens and expands and your perineum gently stretches to allow your baby to slide out.

8) Some women prefer particular scents and it is a great idea to include these scents (maybe from a favorite candle or incense or oil, for example) into your relaxation and massage routine. Bring this candle/scent with you on your birthing day (or have it set up at home if you are having a homebirth) so that the smells take you back to your place of quiet, calm, relaxation.

9) Some women include perineum massage into lovemaking with a partner. And there may be times when it is physically easier for a partner to reach and massage your perineum than you are able to do yourself depending on how big your beautiful baby belly is and how able you are to reach around it with your own arms/hands.

10) Have a fresh bottle of olive oil (or other natural oil) ready for your birthing day to reduce the chance of spreading bacteria from an already opened bottle.

11) During labor you can have hot compresses applied during second stage (pushing) to help soften the perineum.

12) Ask your midwife (or doctor) ahead of time (and have a doula remind them) to perform perineal support if they notice your perineum becoming taught and white from stretching. At this point most midwives would also suggest you just relax and resist bearing down while you give your perineum time to stretch on its own. Doctors who are episiotomy-happy will frequently cut at this point. MOST cut today without even asking, even if you have previously stated you did not want an episiotomy. There is much to be said for PATIENCE in the second stage. It is not uncommon for the body to take a break once full dilation has occurred. This allows the perineum time to stretch naturally, and for baby to slide into position. Directed pushing (or 'purple pushing') is not necessary and is typically harmful to the gentle birth process. Directed pushing (someone other than the mother 'counting' and telling mother when to push) increases the chance of tearing, as well as increasing a mother's fatigue while decreasing oxygen supply for both mother and baby. A non-drugged mother will know when to push. Her body works perfectly and can be trusted.

13) Remember that gravity, moving around, and utilizing several birthing positions (whatever feels best to you at the moment) is all perineum-friendly! Being in an upright position - squatting, on hands-and-knees, sitting, kneeling - all reduce the chances of tearing.

Diagram highlighting the pelvic outlet, sacrum, and how pressure is less (on the perineum and other birthing 'parts') when a woman is upright during labor/birth (Balaskas 1992)

Additional Tips to Avoiding Tearing (or being cut via episiotomy):

1) Hire a midwife or doctor to attend your birth who has a less than 20% rate of cutting episiotomies and has a reputation for allowing birth to unfold naturally in non-supine positions. Inquire about the percentage of natural (non-medicated) births that take place and how often episiotomies are performed. Hire a birth attendant who is knowledgeable, skilled, and comfortable with perineal massage during birth (or make sure you have a doula who is capable of doing so).

2) Have a good support team who believes in birth and knows how to assist and support you - this includes a doula who can advocate for you and work with you, especially if you are birthing in a standard U.S. hospital setting -- no one else on staff that day may know how to assist in natural, normal birth.

3) During pregnancy enjoy some yoga and pelvic floor exercises on a regular basis.

4) Stay upright. Gravity is not helping when a woman is on her back or lying down during the second stage (as the diagram above highlights). There is more unnatural pressure on the perineum when in a supine position. Squat, sit, kneel, use all-fours, stand, rotate on a birthing ball, hang from a birthing bar - whatever works for you in your environment and what you feel comfortable with.

5) Move around - change positions as you feel comfortable - during labor and birth. It is not necessary to "get the baby out quickly" once full dilation has occurred. When women can move with their instinctual needs (allowing a baby to rotate and opening the pelvis widely) during birth, very rarely is there a need for episiotomy, and usually birth occurs without tears to the perineum (Harper 2005).

6) Birth in a dark room or another location where you feel safe and in privacy. Birthing in a quiet, darkened location where you feel that you have privacy and safety, decreases labor time, decreases fear, decreases discomfort, and decreases the likelihood of tearing (Odent 2003). Have as few people present as possible (so that you do not feel like you are being 'watched' or 'monitored'). Make your birth team up of people you know and trust and who believe in birth themselves. Your body will 'open up' more easily if you do not feel that you have an audience watching you, or people that you need to perform for (Gaskin 2003). Birth is not about setting goals or meeting expectations - it is about turning inward to yourself, your baby, your body's instinctual voice, and letting go.

7) Birth in water. Warm water works wonders on labor, but also on allowing muscles and tissues to relax naturally and stretch gently (Napierala 1994). Tearing is much less likely to occur in water - especially when it is coupled with a patient birth attendant who knows how to provide perineal support at crowning (Balaskas 2004). If you cannot birth in water (or do not feel like pushing in water when the time comes) just sitting in warm water will help the perineum to stretch gently (Harper 2005).

8) Push only when you feel the urge (not when someone tells you 'push') and push slowly, gently during crowning. No 'purple pushing'!

9) Don't rush. Don't hold your breath or feel you need to breath any particular way. Don't push too forcefully. Go with what feels good and feels right to you. Listen to your own instincts and let your uterus guide your birth. Balaskas reminds us that, "If you don't try to hurry the process, your perineum will have time to stretch" (Balaskas 1992).

10) Allow the crowning of baby's head to naturally stretch the vaginal entrance. It is not unheard of for midwives to allow a baby's head to protract and retract at crowning for an hour or so to allow the gentle stretching of the perineum.

11) Feel your baby's head with your own hand. If you are comfortable and feel like doing so, ease the tissues on your own around your baby's head, with your own hand, or massage them with olive oil or in the water (if having a waterbirth). Dr. Michael Rosenthal of the Family Birthing Center in Upland, California reports that mothers who use their own hands to feel their baby at crowning, and help him/her enter the world, very rarely tear.

12) Ask a midwife/nurse (and discuss this with your doula ahead of time) not to swab you down with disinfectant which washes away natural lubrication and increases the likelihood of a tear.

13) Have a hot compress applied if the perineum seems very tight. Anything can be used for this - a small towel, washcloth, rag, diaper - dipped in hot water and wrung out completely. The temperature can be tested on an attendent's wrist ahead of placing it on the perineum.

perineum support during crowning

14) Feel free to shout, moan, bellow - open your throat, relax your jaw - and your perineum will follow. Sphincters follow each other - relax one 'on purpose' and you will relax the others all the way through your body (Gaskin 2003; Balaskas 1992). Gaskin's technique of encouraging women to use 'horse lips' (i.e. blow air through your relaxed mouth/lips like a horse who is braying) greatly serves to relax the cervix, the vagina AND the perineum. Someday, in the not too distant future, when you are no longer pregnant, "horse lips" may still come in handy as the relaxation and air blowing technique works great for menstrual cramps as well.

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Occasionally, it pays to read things written from another perspective. As such, I will include an excerpt on perineum massage written by Dr. William and Martha Sears in The Birth Book:

The better you prepare your perineal tissues for the stretching of birth, the less they will tear, and the better they will heal. Like training muscles to perform at their best in an athletic event, conditioning the tissues around the vaginal opening with massage prepares the perineum to perform. Midwives report that women who practice perineal massage daily in the last six weeks of pregnancy experience less stinging sensation during crowning. Mothers with a more conditioned perineum are less likely to tear or get an episiotomy. An added value of perineal massage is that it familiarizes a woman with stretching sensations in this area so she will more easily relax these stretching muscles when stinging occurs just before the moment of birth.

Try this technique:

* Scrub your hands and trim your thumb nails. Sit in a warm comfortable area, spreading your legs apart in a semi-sitting birthing position. To become familiar with your perineal area use a mirror for the first few massages (a floor-to-ceiling mirror works best). Use natural oil, such as pure vegetable oil, olive oil, or a water-soluble lubricant, such as K-Y Jelly (not a petroleum-based oil) on your fingers and thumbs and around your perineum.

* Insert your thumbs as deeply as you can inside your vagina and spread your legs. Press the perineal area down toward the rectum and toward the sides. Gently continue to stretch this opening until you feel a slight burn or tingling.

* Hold this stretch until the tingling subsides and gently massage the lower part of the vaginal canal back and forth.

* While massaging, hook your thumbs onto the sides of the vaginal canal and gently pull these tissues forward, as your baby's head will do during delivery.

* Finally, massage the tissues between the thumb and forefinger back and forth for about a minute.

* Being too vigorous could cause bruising or swelling in these sensitive tissues. During the massage avoid pressure on the urethra as this could induce irritation or infection.

* As you become adept with this procedure, add Kegel exercises to your routine to help you get the feel for your pelvic muscles. Do this ritual daily beginning around week 34 of pregnancy.

* Many midwives and obstetricians believe that perineal massage is neither useful nor necessary as long as the mother's perineum is supported during crowning, her pushing is properly timed, and the baby's head and shoulders are eased out. Discuss the value of perineal massage with your birth attendant.

Related Reading:

Avoiding an Episiotomy

Getting Through Birth in One Piece



REFERENCES:

Balaskas, Janet (2004) The Water Birth Book

Balaskas, Janet (1992) Active Birth

Bradley, Robert (2008) Husband-Coached Childbirth

Buckley, Sarah J. (2009) Gentle Birth, Gentle Mothering

Davis, Elizabeth (2004) Heart & Hands: A Midwife's Guide to Pregnancy and Birth

Epstein, Abby & Lake, Ricki (2009) Your Best Birth

Gaskin, Ina May (2003) Ina May's Guide to Childbirth

Goer, Henci (1999) The Thinking Woman's Guide to a Better Birth

Harper, Barbara (2005) Gentle Birth Choices

Lemay, Gloria (2009) www.glorialemay.com

Napierala, Susanna (1994) Water Birth: A Midwife's Perspective

Odent, Michel (2003) Birth & Breastfeeding

O'Mara, Peggy (2003) Having a Baby, Naturally

Sears, William (1994) The Birth Book