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!