The Ins and Outs of Perineal Massage
The ancient practice of antenatal perineal massage (APM), which aims to widen and relax a woman's birth canal during her last month of pregnancy with manual massage of the region, has been shown to decrease chances of genital damage and chronic pain due to childbirth.
An Ancient Practice Validated by Modern Science
A recent meta-analysis on the effectiveness of APM offered the strongest evidence yet that this simple, home intervention allows the mother's birth canal to stretch more easily during childbirth resulting in less trauma and need for stitches, and less pain up to three months later. For reference, a meta-analysis is a study of all of the studies in an area of medicine, looking at the quality of the data. Medical interventions that show a benefit over numerous studies with well-designed experiments are said to have "Level 1" evidence. This is the highest scientific support for effectiveness of a medical procedure.
Anatomy of the Perineum
So let's take the time to review the anatomy involved, as well as to discuss what can go wrong with these structures during childbirth and how APM can prevent this. The perineum in women is basically what most of us consider our "crotch". For women, if you squat down and pat between your legs, the area you are patting is your "perineal" area. It includes the area at the back of your vagina and vulva and goes to your anus and rectum. Specifically, the perineum includes the back portion of a woman's birth canal.
While most of a woman's birth canal tissues are stretchy, this back perineal area is more rigid and firm. It is made up of several layers of muscles and connective tissue (fascia) that create a strong pelvic floor, so we humans can walk upright. Without an intact or healthy perineum every time humans coughed or sneezed, or as we moved around, we would urinate and defecate without control. For an easy to follow 3-D explanation of the perineum and pelvic floor tissues involved in childbirth, see this video.
The perineum thus has two very different jobs in women. For 99.99% of the woman's life we want a strong, tight perineum so we can run and jump and laugh without peeing or worse. But when it comes time for childbirth we want a flexible, stretchy perineum so the baby can come out without tearing of these tissues.
In our human past, women squatted to eliminate. Squatting and contracting our perineal muscles to defecate or urinate all worked to flex and stretch these muscles on a regular basis, keeping them strong, yet flexible, without women giving them a second thought. In contrast, the perineal muscles of modern women get little exercise. And just like our calves or triceps, if we don't stretch these muscles they become tight and rigid, which is OK until… we want our birth canal to open during childbirth. Then suddenly, this often-ignored part of our anatomy becomes a major player in our lives. A perineum that can't stretch to let the baby's head out of the birth canal will undergo perineal trauma and either tear, or be cut by a doctor in an episiotomy, especially in first time moms. These perineal tears or cuts require suturing to heal, and they often cause scarring and pain after childbirth, which can negatively impact sexual function. Some tears can even result in incontinence of gas, urine or feces.
An intact perineum is one that stretches to let the baby out and doesn't undergo tearing or cutting, and suturing.
Studies have shown that women who keep an intact perineum during childbirth have less pain and incontinence and better sexual satisfaction postpartum. As a result, doing all we can to optimize the chances of a woman keeping her perineum intact is important!
Perineal Trauma Causes Short and Long-Term Complications
About half of women will suffer some perineal trauma during childbirth, and this rate is highest in first time moms. Perineal trauma is classified by health care providers in degrees: first degree trauma involves just the perineal skin and vaginal lining; second degree trauma involves the skin, perineal muscles and connective tissue; third degree trauma involves the perineal muscles through to the anal sphincter; and fourth degree trauma involves opening the entire perineal area into the rectum itself. Click here to view the different types of tears.
Perineal trauma includes both tearing and episiotomy. Episiotomy is a medical procedure where the perineum is cut to allow the baby to be delivered faster. Because an episiotomy often cuts deeper than a perineal tear would have gone, and because it cuts through nerves and muscles that may be spared during natural tearing, many health care providers don't use episiotomies as often as they used to. It is still a valuable medical procedure in some settings, but the use of this "man-made" perineal trauma has decreased in recent years.
Both tears or episiotomies can be sutured or stitched after childbirth to facilitate healing. No matter what the cause, perineal trauma increases healing time and postpartum complications. Perineal pain from trauma after childbirth is high with 40% of women reporting pain during the first two weeks after giving birth (is that really all!), 20% reporting pain at two months, and 9% still feeling pain at three months. Women who have an intact perineum report significantly less pain than women who have experienced perineal trauma.
Painful sex is also common in women after having a baby, with 60% of women reporting it at 3 months, 30% at six months and 15% after three years. Women with perineal trauma from childbirth report higher levels of pain during sex. In contrast, women with an intact perineum after childbirth resume intercourse earlier; report less pain during intercourse; have greater sexual satisfaction; greater likelihood of orgasm and more sexual sensation then women who had perineal damage.
Preventing Perineal Trauma with Perineal Massage
Antenatal perineal massageincreases the chances of maintaining an intact perineum during childbirth. Our ancestors, from cultures all over the world, have used some form of APM for generations. The Western Medicine name of the technique refers to the fact that the massage of the perineum is done before(ante) birthing. This technique was taught by older women to expectant women, long before our science proved its effectiveness. Women have historically used APM because they observed that it increased stretchiness of the birth canal, especially that rigid perineal portion, and that it allowed the mom-to-be to feel the burn of perineal stretching before labor, so she could learn to breath through this unique sensation and relax, rather than tense with the feeling. As you can imagine, using good technique is key, including using an appropriate massage medium like BabyIt Perineal Massage Gel. For detailed instructions and helpful illustrations on how to perform antenatal perineal massage, click here.
Of course APM doesn't stop all childbirth perineal trauma, but our modern studies show it does statistically decrease the number of women who experience perineal trauma requiring stitches, especially in first time moms; as well as decreasing pain women feel after childbirth (even for women who have delivered before).
Disclaimer: Please note that the information in this website is an educational resource. All decisions about any treatment you need must be made in consultation with your doctor or your healthcare provider who has examined you. Nothing in this post is meant to be used to diagnose or treat any person.