Thursday, December 24, 2009

Perineal Massage Helpful? Tain't Necessarily So.

[Title edited as per comments.]

I recently received this question from reader Cathy in a comment:
I recently discovered your blog and love it. Can you do a short post on perineum massage if you have the time or direct me to a resource you particularly like? I tried it, but I feel too tight, it hurts, it burns, and I'm afraid I'm going to bust my cervix, haha. I've read over and over "how-to", but I'm a visual learner, and I can't find a video or even illustrations of the technique. I used my thumbs up to the first knuckle, so I don't think I'm doing it completely wrong. I used avocado oil (okay) and Easiotomy Cream (not nice - seemed to burn more.) I guess "For External Use Only" doesn't just mean "Don't put this stuff on toast." Thanks in advance.

FIRST AND FOREMOST: "Easiotomy" cream has to be either the greatest or most horrible product name I have ever heard. HA! When I shared this on Twitter (I mean, how could I resist?), @Crunchynurse had the best response: "Maybe they should call it 'Easy Outta Me' cream." Rimshot!

But seriously, folks. This is a topic well worth addressing, as you're liable to hear different things from different people on the matter. Your timing is excellent, as I recently came across a very interesting post from Peaceful Parenting about it. I did some more poking around on the matter (on the internet, people - get your minds out of the gutter) and found some other resources as well. But before we get to it, I do have a few questions: Is this your first baby? If not, did you have an episiotomy with a previous birth? Was perineal massage recommended by your care provider? If so, what was their reasoning for it? Also, what are your overall plans for birth?

I ask because my initial reaction is summed up well by Gloria LeMay in her "Guide to an Intact Perineum", in which the only thing she has to say about perineal massage is: "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." And I quite agree, from everything I have read so far. A woman who is well-supported in healthy birth practices, i.e. who is able to move freely during her labor, is not numbed and immobilized, and who is able to push in a physiologically sensible position, has already reduced her risk of tearing. Being in a lithotomy position not only closes off the pelvis, making it more difficult for the baby to rotate normally, it also puts all of the pressure right ON the perineum.

Equally important if not more so is whether the woman is able to follow her OWN urges to push (or to not actively push, as the case may be - the uterus can do the work all on its own for many) and can take her time. In many hospital settings, as soon as the mother is complete (dilated to 10 centimeters), the staff often seems to go into pit crew at NASCAR mode, 'breaking' the bed to put the mom's legs up, insisting that the mother start bearing down immediately, shouting at her to pushpushPUUUUSH (this would have been intolerable for me, just on a personal note), even counting to ten, telling her to hold her breath - all adding up to directed, valsalva or 'purple' pushing, which has been shown to lead to pelvic floor problems for the mother on top of being problematic for the baby to boot.

In case it isn't clear, I feel pretty strongly that the most important factors in avoiding tearing and episiotomy are, first, an environment that supports healthy birth practices, as summarized briefly above, and, second, a care provider whose standards of practice don't include routine or frequent episiotomy. This is really the bottom line. Jill of Unnecesarean fame responded to my aforementioned tweet about the Easiotomy cream, first quoting the product's ad copy: "'A well-prepared mother can greatly reduce the need for an episiotomy'... Cream won't save u from one if your doc does 90% epis."

Ay, there's the rub.

. . . I do apologize. That was totally uncalled for. So without further ado, here's that post by Peaceful Parenting on perineal massage, noting that it is prefaced by many of the same caveats I've shared as well, including LeMay's statement. Some highlights:

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.

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.

This last part is echoed in a post by Barefoot Birth on perineal support, saying that "Gentle perineal massage during the last weeks of pregnancy could help a first time mom get acquainted with different sensations in the perineum." Peaceful Parenting then goes on to give what seems like a good protocol for gentle perineal massage, focusing more on exploring rather than stretching. In step 11, I note that they mention hot compresses being applied during labor, along with providing perineal counterpressure/support - to me, this also seems much more important than trying to stretch the tissue artificially in advance.

Readers, especially birth professionals, I'm very interested in your thoughts and experiences on this. On (another) personal note, when I asked my own midwives about this, they felt that massage prior to labor was not only not necessary, but could actually weaken or damage the tissue, especially if done too roughly. I'm interested in studies and experiences that speak to that concern as well. Please share!

I hope this gives you some food for thought, Cathy! I encourage you to read the entire post from Peaceful Parenting - it's wonderfully thorough, even including an excerpt from William and Martha Sears on the same subject. I'm also curious to hear your answers to the questions I posited early on, so I can get a better idea of where you're coming from. I'm hoping you'll keep me posted on your pregnancy in general. And if you have any leftover Easiotomy cream once the babe arrives, I'll gladly take it off your hands, for placement in my future museum of fascinating birth- and baby-related products!


By the way, I like the concept of "doing requests". Though I have enough drafts and outlines on other birth and birth-related topics to last me a good long time, I'm happy to get ideas from readers, too. Would you like to get some info, with my thoughts, on a particular topic? Feel free to send it my way!


  1. I had never heard of a perineal massage until my OB brought it up. I was asking him if it was safe for me to get a regular massage and then he said something to the effect of "Oh, and you don't need one of those perineal massages. I had a patient ask me if it was ok if her masseuse stuck his fingers up there to massage it and I just don't recommend it." I was so shocked at the idea of some random person giving me a perineal massage that I didn't think to ask him for more information on why he didn't recommend it. He was a very thoughtful doctor, slow to do c-sections and episiotomies, so I assume that they just don't help...?

  2. Since massage therapist is another one of the hats I wear, that is absolutely HILARIOUS to me. And all the more mind-boggling. O_o

  3. I think another reason women tear, but not animals, (in addition to managed birth)is they are naked all the time. Our bodies our not expsed to the elements, so maybe we are a little more sensitive to pressure. I had an unmanaged homebirth (midwife didn't even make it in time) in a hands and knees psoition and I still managed a second degree tear. For me it was likely because she was posterior and it was very speedy 2-3 pushes...Ithink finding a good provider is very important, but I really believe animals being exposed has a lot to do with the difference.

  4. Thank you so much for your thoughtful, interesting, and HILARIOUS post. I agree about the name of the cream. I LOL'd when I saw it. In their defense, it's really recommended post-episiotomy(ugh, just typing the word...) for healing.
    I am a big believer in natural healing and prevention - I am one of those people who literally cannot remember the last time I was sick. I don't just "believe" in herbs, I am aware of the scientific evidence of their powers, so I'm sure St. John's Wort, etc. really do heal damaged tissue post episiotomy.
    Hopefully I won't need it!

    This is my first pregnancy - I do have a daughter who is 3 who came to us through adoption.
    I have not been sick one time, I am not irritable, and most people do not know I am 22 weeks pregnant until I tell them. I have to admit, I have never felt better in my life.

    I am under the care of the Midwives at Swedish Covenant Hospital in Chicago. When I called her to "interview" her, one of the first things the Chief Midwife asked was my age. I said, "I'm 37" kind of sheepishly, and without hesitating, she said, "Some people call that 'Advanced Maternal Age.' We call it normal. You're healthy and pregnancy is natural and normal. You are not sick. Some women your age are menstruating. Some are ovulating. Some are pregnant. All of these conditions are normal at 37."
    (As an aside, I highly recommend providers who put "Advanced Maternal Age" in air quotes every time they say it. I love these women. I would have their babies if I wasn't already knocked up.)

    The midwives have a C section rate of less than 15%. As a bonus, the OBs at Swedish also have a lower-than-average rate of Section.
    Their (back to the midwives, now) episiotomy rate is 1%. Their epidural rate is around 30%. Their VBAC success rate is over 60%.
    Their "assisted vaginal delivery rate" is 0.5%.

    Here is a fantastic article about Swedish's Chief Midwife Sherri:

    It makes so much sense and makes me feel so much better to know that I don't have to spend hours upon hours having private time (honestly, with a 3 year old... five minutes is a challenge) to avoid a cut.
    AND OMG a massage therapist is NOT the same thing as yourself! WHY would a masseuse OFFER to put his/her hands up there?! OMG. OMG. Ew. That OB should have told her to find a new masseuse, stat!
    I DO find it funny when docs say "Nothing up in the vag, you might introduce germs!"
    One word.


    Again, thank you so much for the post. I am definitely eager to read the Sears article and the Peaceful Parenting article.
    And thanks to your kind readers for their advice/stories, too.
    I feel like this makes so much more sense than trying to stretch things out.

    With my care providers, I feel like I've given myself the best chance at normalcy.
    You've helped reinforce that feeling in me!

  5. Oh, and I have two awesome doulas, too. They work as a team. One of them has been a nurse for nine years. She just got a new job recently. GUESS WHERE? As an L&D nurse at Swedish Hospital, that's where!
    We are both SO excited that she can take care of me medically, also.

  6. Cathy, glad you enjoyed. You know, I realized just after I went offline this morning to spend the day in various airports - this really should have been titled "Perineal Massage Helpful? Tain't Necessarily So." Is it unforgivably poor form to change a post title once it's published? Hmm.

    Glad to have your extra info - and that IS great news about your doula turned nurse! I'll bet anything she's one of the great ones.

  7. One of my main reasons for doing a waterbirth, besides pain relief, was because I wanted it to help elasticize and soften my perineum. I think it worked - his head blasted out of me FAST, no slow crowning here! and I only had a very small tear.

    One of my midwives was applying some kind of compress to my perineum as I was pushing...I hated the feeling so much that I told her to stop. it was totally distracting to me.

  8. Anne,
    You MUST rename it hahaha!

    Were you at ORD? That's where I work...

    Good to know about waterbirth!

  9. Jenn (I meant to comment on this before - blame the travel madness), WHOA, a posterior baby born that fast? How crazy! I would think that unusual combination had something to do with it, yeah. And that is a very interesting theory on the nudity. There are definitely a multitude of factors at play - my post is nowhere near comprehensive. It is also true that sometimes some tearing will happen even under the best conditions - even in the greatest, gentlest, most supported birth situations possible, there's not a 100% guarantee (as with any outcome). But we do know so much now about what can improve your chances dramatically. Yay for evidence-based practices!

    Jill, my thoughts were exactly the same. Lily was born in the water and I had only a tiny, TINY tear - nothing even worth stitching.

    Cathy, I was nowhere near ORD, for once! But often enough . . . Another Chicagoan, eh? I'm really starting to think Chicago would be a good location for Birthapalooza (but that's another topic for another day).

    Merry merry, everyone!

  10. Anne,

    I'm a transplant - from FL originally.
    But YEAHHHH Birthapalooza woooooooooooo!


  11. I'm a Chicagoan originally and if someone organizes a Birthapalooza, I will totally be there, AMA be damned.

    I'm so glad you posted this~Perineal Massage is at best a chore. Totally unnecessary.

  12. Hi Anne, just found your blog and was skimming through and came on this post. I wanted to tell you what my midwife said about massage after I spoke to her about it after our first birthing class. She said, there's not necessarily proof either way about it helping or hurting, but if I wanted to do it gently to get myself acquainted with the area - that was ok, But she said she didn't recommend it at all before 36 weeks. Just wanted to pass that along, though it was interesting! She talked about hot compresses and massage at my birth because I know my practice is very strong about avoiding episiotimies as much as possible so that was comforting!

  13. Right on, Rachel! Your midwife sounds on the ball.