Perineal Massage: What is it, Why do it, When & How Should I Get Started?
What is perineal massage?
Perineal massage is a manual technique that you can perform in order to help promote pelvic floor muscle relaxation during birth. This can reduce the risk of perineal tear or the higher grade tears such as 3rd or 4th degree. This manual release technique addresses the skin and deep tissues around the opening of the vagina by helping prepare you to relax into a lengthening sensation. Through utilization of perineal massage, we hope to reduce the risk of perineal tearing and improve the possibility of pelvic pain following birth.
What is perineal tearing?
Perineal tearing is tearing that occurs between the vaginal opening and anus during vaginal delivery. These tears are graded on a scale from 1-4. When discussing the classifications of the grades, it’s helpful to understand what the grades mean:
A grade 1 tear includes is the skin of the vagina.
A grade 2 tear includes the skin of the vagina and the muscles.
A grade 3 tear is partial disruption of the external anal sphincter and internal anal sphincter.
A grade 4 tear is through the lining of the anus including the external and internal anal sphincter.
From a statistical standpoint, 85% of women will experience a first or second degree tear. The 3rd and 4th degree tears are more likely to be associated with fecal urgency and incontinence of flatulence or stool in the postpartum period.
How does perineal massage actually help?
Perineal massage primarily helps by prepping you to relax while lengthening the pelvic floor muscles in order to increase ease with relaxation of the pelvic floor during birth. Our muscles inherently react to pain and discomfort through tensing up. When we experience pain and stress of any kind, our bodies think they are trying to protect us by tensing up, and our pelvic floor muscles are no different. However, we need our pelvic floor muscles to lengthen and move out of the way for baby to come through during vaginal birth.
Since the muscles of the pelvic floor have to stretch 2-3x their resting length during birth, we cannot actually stretch the muscles out to that degree prior but we can still work to prepare them. The main goal with performing perineal massage is that you are able to learn how to tap into breath and relaxation while experiencing that uncomfortable sensation. When your pelvic floor muscles relax, they are not on high alert during vaginal delivery. With perineal massage, you are able to practice this relaxation at home and since practice makes perfect, this will be helpful for the main event - birth.
When should I think about performing perineal massage?
You can begin perineal massage at 35 weeks pregnant. Make sure to get clearance from your OBGYN or Midwife prior to beginning perineal massage. You should perform perineal massage for up to ten minutes at a time, a couple of times throughout the week. This should be consistent weekly until delivery.
The usage of perineal massage can also be helpful during delivery to help reduce the risk of perineal tearing. How, you ask? Your birth team can perform perineal massage between pushes to help encourage pelvic floor muscle relaxation.
How do I perform perineal massage?
To perform perineal massage you want to start in a relaxed position. Typically we advise starting in a reclined position, such as lying on your back (propping your top half up with pillows as needed) with your legs butterfly open. You can perform the massage portion with your own finger, a device, or have your partner help.
Start by inserting either finger or device about an inch into the vaginal opening. The focus of perineal massage is at the lower border of the vaginal opening. If we think about the vaginal opening like the face of a clock, perineal massage is performed between 3 and 9 on the face of the clock.
Apply mild pressure throughout this region while searching for any areas of tenderness, tightness, or discomfort. You can think of this as finding the “knots” in the muscle tissue that you are going to try to massage out.
As you work through the tissue, you can begin to apply sweeping motion while maintaining pressure from the 3 o’clock to 9 o’clock region of the vaginal opening.
Another option is to insert two thumbs and perform an outward sweeping motion on both sides simultaneously.
Since the main goal of perineal massage is to learn relaxation against an uncomfortable sensation but not pain, we advise keeping the discomfort felt during perineal massage to a 3/10 or below. Since a 0-10 subjective scale can be challenging to navigate, think of it as discomfort that you are able to breathe through. If you have to start light, that is okay, you are still working through breathing and that is the goal!
Are there other ways I can reduce perineal tearing postpartum?
In addition to the usage of perineal massage, there are other techniques and tactics that we advise to reduce perineal tearing, reduce the chance of 3rd and 4th degree perineal tears, and decrease pelvic pain postpartum.
The first is to consider alternative birthing positions. Research shows that a side lying or upright position can reduce the likelihood of perineal tearing.
Another trick is to apply a warm compress to the perineal area between pushes in order to encourage relaxation of the muscles.
Lastly, we recommend pushing when you feel the need instead pushing when encouraged to. This is referred to as self-lead pushing and can be helpful in reduction of perineal tearing.
If you found this blog post of benefit but wish you learn perineal massage directly, you can always reach out to us to schedule a birth prep appointment! Schedule your appointment today by calling 512-766-2649 or send us a message here.
This blog post was written by Dr. Elizabeth Knoble, PT, DPT, OCS. Elizabeth was raised in Houston, Texas and moved to Austin to attend The University of Texas for her undergraduate degree. After completing her undergrad degree in Exercise Science with special focus in medical fitness and rehabilitation and a minor in biology, she moved to Dallas to complete her Doctorate in Physical Therapy at Texas Woman’s University. Following her DPT, she continued her education and completed an optional orthopedic residency at Memorial Hermann Rocket’s Sports Medicine Institute in Houston, Texas. Here, Elizabeth received continued education in orthopedics and sports, completed research, taught at the local PT and PTA programs, and was directly mentored by specialized clinicians in the field. Following her residency program, Elizabeth became an Orthopedic Certified Specialist through the American Board of Physical Therapy Specialties.
Elizabeth’s goal has always been to utilize her specialized knowledge to advocate for a more niche population that incorporates pelvic health. With the hopes to blend her passion and her current skills, Elizabeth has completed a pelvic floor certification and continuing education focusing on pelvic health. Elizabeth prides herself on treating the whole person and loves supplying her patients with all the knowledge, empowerment, and support they need to return to all of their most meaningful activities.