you ask any woman what they are worried about when it comes to giving birth the first thing she will say is that she is worried that she is going to tear!
How likely are you to tear?
It is difficult to estimate rates of tearing because different countries have different practices when it comes to whether they routinely give episiotomies.
Around 50-75% of women who have a vaginal birth will have tear sufficiently extensive to require stitches (meaning 2nd degree or higher)
If you consider any type of tear, this number increases to around 90% of women experiencing some form of trauma which is a very scary statistic!
Reducing the risk of tearing during childbirth
Antenatal digital perineal massage reduces the likelihood of either tearing or having an episiotomy by around 9%.
Women who practised perineal massage were 16% less likely to have an episiotomy.
Perineal massage also reduces the reporting of ongoing perineal pain, and is generally well accepted by women, although it is mainly women who have previously given birth vaginally. Perineal massage may also be helpful for overactive pelvic floor muscles, pain with sex, and mobilizing scar tissue after perineal tearing or episiotomy.
Whats the evidence?
All the statistics quoted above were taken from this Cochrane review from 2013:
It included four trials (2497 women) comparing digital perineal massage with control. All the trials were of good quality. Antenatal digital perineal massage was associated with an overall reduction in the incidence of trauma requiring suturing (four trials, 2480 women, risk ratio (RR) 0.91 (95% confidence interval (CI) 0.86 to 0.96), number needed to treat to benefit (NNTB) 15 (10 to 36)).
Women practicing perineal massage were less likely to have an episiotomy (four trials, 2480 women, RR 0.84 (95% CI 0.74 to 0.95), NNTB 21 (12 to 75)). These findings were significant for women without previous vaginal birth only.
Only women who have previously birthed vaginally reported a statistically significant reduction in the incidence of pain at three months postpartum (one trial, 376 women, RR 0.45 (95% CI 0.24 to 0.87) NNTB 13 (7 to 60)).
Whats the technique?
Here are the top tips for doing perineal massage by a pelvic therapist, Jeanice Mitchell. You can find her on Instagram @mypelvicfloormuscles
During pregnancy do not practice perineal massage if you have vaginal bleeding, an active infection or a ruptured membrane.
In general, do not practice perineal massage if you have abnormal vaginal bleeding, open wounds or an active infection. Wait for your doctor’s approval before massaging over new scars to ensure they are fully healed. If the skin around the vagina is red or painful to touch, check with your doctor first to make sure there are no other issues.
Be careful to avoid inserting your fingers too far into the vagina as you should not stimulate the cervix which may lead to pre-term labour
You may feel some discomfort when you first start perineal massage, but it should feel easier by your second of third week or practice.
During pregnancy begin at 35 weeks gestation. Practice 3-10 minutes 1-2 times per week.
For non-pregnancy perineal massage start at 5-10 minutes daily, or as directed by a health care provider.
Choose a space where you feel comfortable and have privacy.
Some people like to take a shower or sit in a bath first to soften the skin.
Clean your hands and trim your fingernails.
Have lubricant within reach. You can use a vaginal lubricant of your choosing, or some women use sweet almond oil. You can use household oils such as coconut or olive oil, or pregnancy specific lubricant such as this one. If you use a household oil make sure that it is not used for cooking or contaminated from the kitchen!
Find a position where you can comfortably reach the vaginal opening. You can try lying down with knees bent and your head and trunk propped up on pillows, sitting on the toilet, or standing with one foot up on a stool. You can also let your partner help.
1. Place lubricant around the lower half of the vaginal opening and on one finger or thumb.
2. Gently insert your finger or thumb about one inch into the vagina.
3. Light pressure: Press down towards the anus until you feel a stretch. Hold there a few seconds.
4. Press in, side to side, clockwise circles and counter clockwise circles. Then advance by inserting your finger or thumb inside your vaginal canal.
5. Deep Pressure: once inside the vaginal canal, press downwards toward your rectum, and then also make a sweeping motion side to side. Visualize your vaginal canal like a clock with 12:00 being at your pubic bone and 6:00 at your rectum. You are stretching from 3:00-9:00 like a U. Avoid pressing towards your pubic bone as this may be uncomfortable and is not the target tissue to stretch. Gradually increase the pressure to your tolerance. The stretch will be intense but should not be painful.
6. If it is comfortable insert a second finger or thumb to work both sides at once.
7. Throughout the massage focus on taking smooth slow breaths.
8. Try to keep your body relaxed. If the first position you tried is not comfortable, pause and reposition. This may take many tries before you find the best position for you.
9. Point Pressure: another option for internal stretching is to hold a clock position for 30-60 seconds- especially if you feel increased tension. For example, during your sweep of 3:00-9:00, if you feel increased tension at 4:30, stop and hold that for 30-60 seconds or until you feel the tissue soften.
Personal: ideally this stretching is performed on YOUR perineum by YOU. If however you have a friend or birth partner that would like to be involved, or you’re unable to reach your perineum to stretch, it’s ok to have help. Just make sure you focus on the task at hand 🙂
Post stretching: it’s normal to feel mild soreness (like what you may feel after a massage) but if you have pain, difficulty using the restroom, or difficulty sitting, you may have done too much. If you’re not sure, check with your birth provider or pelvic therapist.
There is also a really useful animation which can be found here (it is in Spanish but the pictures are helpful!)
Jeanice from @mypelvicfloormuscles made this really useful animation:
This guest blog was written by "The OBGYN Mum" Dr. Brooke Vandermolen. You can find her website here.
More about Dr. Vandermolen:
"My name is Brooke Vandermolen, and I am an NHS doctor currently working and training as a Registrar in Obstetrics and Gynaecology (or OBGYN as it is known in America!) in London. I have experience clinically, dealing with all aspects of women’s health and pregnancy, including assessing patients with a range of gynaecological concerns, and performing and assisting in surgical procedures.
My research in the fields of maternal medicine and high-risk pregnancy has been presented at major international conferences and published in prominent medical journals.
Much more exciting than this, however, is that I recently became a mother myself. Experiencing pregnancy and labour as a patient was one of the most transformative experiences of my career. This new perspective drove me to seek out and share answers to the questions I had myself when I was pregnant."