antenatal perineal massage

Perineal Massage Made Easy

pregnant woman getting ready for perineal massage

Part 1: What is Antenatal Perineal Massage (APM) and Why Should I Do It Before I Give Birth?

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 recently 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.

Antenatal Perineal Massage has Level 1 evidence showing its medical value for preserving the health of the mother's genital tissues during childbirth.

Just how successful is APM in helping new mothers during childbirth?

Let's look at a few common medical interventions to see how they compare in making people healthier. APM is 5 times more effective in providing benefit to women at childbirth than steroid inhalers are for helping asthma patients avoid a major episode. APM is 12 times more effective in helping pregnant women than daily aspirin is for preventing strokes and 60 times of more benefit for these women than cholesterol lowering statins are for preventing a heart attack in people without previous heart disease.

APM is a safe procedure that could benefit millions of women, and yet many people don't know about it, and even many doctors are unsure how to guide women about how to use this technique to optimize healthy birth outcomes.

The lack of knowledge about APM, is due in part, to the fact that the anatomy inside the human pelvis can't be seen, so it is hard to understand the structures involved. Also, the incorrect language we often use to discuss female reproductive and pelvic anatomy further confuses teaching about APM.BabyIt Perineal Massage and Postpartum Comfort GelLearn more about BabyIt Perineal Massage Gel, isotonic, paraben-free and recommended by Nurse Midwives and OBGYNs!

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, visit The Pelvic Floor Part 1 and Part 2.

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 (that is, after childbirth). As a result, doing all we can to optimize the chances of a woman keeping her perineum intact is important! That said, about half of women will suffer some perineal trauma during childbirth, and of course this rate is highest in first time moms.

Perineal Trauma Causes Short and Long-Term Complications

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 images of 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 stature of this "man-made" perineal trauma has fallen for normal births.

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.

Concern about perineal trauma during birthing is also increasing the requests for C-sections by some mothers. Overall, C-section rates in the US are double the World Health Organization recommended rates. There are many reasons for this increase, but I read with concern a female physician's post at her clinic website touting how she chose an elective C-section to avoid perineal trauma. Her upbeat blog failed to discuss the many other risks moms and babies may encounter following C-Section such as decreases in nursing success and increases in postpartum depression, as well as possible increases in lifelong disease for these babies (e.g. asthma, diabetes, and obesity). Of course C-sections can be lifesavers, but the US C-section rate has increased by 500% since 1970 (see 2014 Consumer Reports "C-Sections increase risks for mothers and infants"). Fear of perineal trauma shouldn't be a deciding factor for choosing a C-Section in most women.

Preventing Perineal Trauma with Perineal Massage

So what else can women do to increase their chances of maintaining an intact perineum during childbirth? The answer, of course is the ancient woman's practice of Antenatal Perineal Massage! 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.

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). The benefit of APM for women is best expressed by looking at the Number Needed to Treat (NNT). NNT is a new way of looking at how effective medical treatments are in helping to stop a medical problem. Specifically, it is the average number of patients who need to be treated before one additional bad outcome is stopped. Simply stated, the lower the number needed to treat (NNT), the more effective the treatment.

Example NNT outcomes from common medical conditions include the following:

  • 73 asthma suffers would need to be treated with steroid inhalers to stop one severe asthma attack;

  • 104 people without heart disease would have to take statins to prevent one heart attack; and

  • 200 people would have to take daily aspirin to stop one non-fatal stroke.

In contrast, positive effects from APM were seen with a very low number needed to treat.

  • Only 15 first time moms need to do this massage to prevent one woman from suffering perineal trauma that required stitches during childbirth.

  • Only 11 experienced moms needed to do the massage to prevent one of them from suffering chronic perineal pain 3 months after childbirth.

In short, medical evidence shows that APM is very effective in giving women their best chance for an intact perineum while having a baby.

Vaginal delivery commonly results in genital or "perineal" trauma. Women with perineal trauma have more pain after childbirth than women whose perineums remain intact. Antenatal Perineal Massage in the final month of pregnancy decreases the rates of perineal trauma, episiotomies and postpartum pain.

OK great! Let the APM begin! But wait, HOW does a pregnant woman massage this very unseen and unknown region of her body in order to protect her perineum? Stay tuned for Part 2 to learn how to do Antenatal Perineal Massage, as well as how to avoid the pitfalls that cause over half of women who start APM to not use the technique to their best advantage.

Learn about BabyIt, the only paraben-free biogel designed specifically for perineal massage.

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.

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