Part 2: Baby Steps for Successful Perineal Massage
By Dr. Joanna Ellington
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 using manual massage, has recently been shown to decrease chances of genital damage and chronic pain due to childbirth. In Part 1 of Decreasing Damage “Down Under” During Childbirth: Perineal Massage Made Easy we discussed the anatomy of the birth canal and the strong medical evidence that APM can increase a woman’s chances of coming through childbirth without perineal trauma or the need for stitches. Now let’s look at what APM is and how to make it work for busy, pregnant women today.
As to the benefits, childbirth happens on one specific day of a woman’s life. But the perineal trauma that can occur during this day can impact a woman’s sex life, her urinary and fecal continence, and her chances of chronic genital pain for a lifetime. Practicing APM a few minutes a day for a month is well worth the hassle and time for the chance of fewer long-term permanent changes to our bodies during labor and delivery.
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With regards to technique, in general terms, APM is a daily stretching of the back of the birth canal, where the muscles form a tight U-shaped rim at the back side of the vaginal opening, using fingers or thumbs. The goal of APM is to make this firm ridge more stretchy and supple so that it naturally expands during childbirth. This perineal massage increases the flexibility of the perineal muscles and decreases their resistance during labor enabling the perineum to stretch at delivery without tearing or needing cutting. APM can be done by the pregnant woman herself or by her partner, or by a combination of the two.
APM also helps the mom-to-be experience the unique burning sensation of these perineal muscles as they stretch, and helps her learn to breathe through this new feeling. Most of us have done stretches for tight calf or neck muscles, and have trained ourselves to instinctively breathe through the burn as we coax these body parts to lengthen and relax. It is much more productive for a pregnant women to “feel the burn” of her perineal muscles for the first time in a relaxed setting where she can practice breathing as she works to release tension, versus encountering this sensation for the first time in the rush of labor at the hospital. If this perineal burning sensation is completely new to a woman in labor, it can make her suddenly tense these muscles, at the very time she needs to be relaxing them, thereby increasing her chances of perineal trauma.
Most APM instructions offer very specific positions and hand motions for doing the massage. But actually, APM can be done by the pregnant woman herself using any combination of her middle fingers, her index fingers, or her thumbs, as she reaches in front of herself between her legs, or behind herself around her buttocks. Feel free to change up positions, the fingers being used, and the pressure being applied to prevent developing cramping or discomfort.
Positions that work well for very pregnant women include:
|Standing in the shower with one leg raised on a shower bench or bathtub edge;||Lying on a bed propped up on pillows with knees bent; or||Squatting against the wall.|
Partner APM usually works best if the partner sits on the bed facing the pregnant woman, situated between her legs as she lays back and he does the APM for her, using his index fingers.
APM isn’t about a certain proscribed position or finger movement. It is about a regular daily stretching of the perineal area, however that gets done. Making it a conscious part of the daily schedule, such as during a shower or before bedtime, can help ensure the massage happens. Many women find the first few weeks of APM uncomfortable and somewhat awkward, with some tissue burning; and more than a little lack of confidence in the technique. But these insecurities usually disappear by the third week, as the massage becomes routine. In fact, over 75% of women who were taught the correct method for APM said they planned to use it in their next pregnancy and 87% said they would encourage their friends to use the technique. This is one part of pregnancy that gets easier and better over time!
Some Common Concerns and Solutions
Knowing some of the common concerns women have with APM and how to navigate these can further help ensure success. Here are some of the difficulties that women report when practicing APM, and some solutions for you to try.
Long fingernails: Unless you plan on having your partner do all the massage, the nails really do have to go. But it is only for a short while, and personally I like having shorter nails with a newborn anyway. Better chance for less pain after childbirth and a more satisfying sex life versus long nails?? Come on Ladies J
Difficulties with the technique : I used APM with both my pregnancies, but I am very short-waisted. I couldn’t use the technique most materials recommend for the massage. Even now I can’t figure out how to enact the drawing many sites use to illustrate APM. Because of not knowing what else to do, I only did the massage if my husband could help. Of course that meant it usually only got done a few times a week, given our schedules. Now I know there are lots of different positions I could have tried by myself, such as reaching from behind with one foot raised in the shower. Remember, the important thing is stretching, massaging and feeling that burn, however you need to get there.
Partner’s lack of involvement: Involving your partner can be a special bonding time for the two of you. About a quarter of women found it embarrassing to do APM with their partner, whereas about 60% enjoyed doing it with the dad. But keep in mind APM is for your own best health, so even if dad doesn’t help, you can still reap the benefits of the massage. Some men feel insecure and don’t want to hurt their wives. If he doesn’t seem enthused about doing the massage don’t take it personally. Remind dad there isn’t really a wrong or right way (other than something super rough), and that any massage is better than no massage. But, doing APM together takes a lot of communication to stretch the perineum enough to feel the burn without mom wanting to slap dad. And sometimes it is just boring to do. Find the right mix of partnered versus solo APM for your house.
For partnered APM, I suggest you don’t do the massage while watching TV (because less active work gets done if either party is distracted). But try having Mom read to Dad from a book as she lays back and he focuses on the massage. Once he starts feeling the tissues relax and soften over the first few weeks he may even get motivated and “into it”, since it could mean better sex for him after the baby is born! That said, APM is uncomfortable and not usually a turn on for the ladies. On the other hand, your man is massaging his holy grail. So if he gets aroused and APM turns into love making – nothing wrong with that, just make sure he gives you a little extra time to transition from feeling clinical about your vaginal area to sexual.
Fingers sticking to the vaginal lining: The most widely recommended massage product for APM in the past has been almond oil. But almond oil is sticky, it also doesn’t work well in the shower and it can have high levels of contaminating reactive oxygen products that trigger vaginal irritation. In general, oils increase rates of vaginal infection, and although they are often recommended for APM, there is no data supporting their safety during vaginal massage. In fact, one study from Italy with women using almond oil for pregnancy massage showed a negative effect on birthing outcomes.
Feeling ridiculous and ashamed. The first few times you do APM it will seem so simple you will just know you are doing it wrong. It may feel awkward touching yourself this way, and you may want to lock your partner out of the bathroom while you experiment. I suggest getting a mirror to study yourself and have one hand try the massage while you hold the mirror and watch with the other hand. Just remember, perineal trauma isn’t sexy. And although APM isn’t particularly sexy either, motherhood is very sexy and empowering, so put on some soft music, practice deep breathing and focus on the fact that by doing APM you are doing the best you can to have the safest, most healthy outcome possible for you and your baby.
Feeling irritation: A moderate burning sensation during the massage as you press towards the back of the perineum is normal, especially in the first two weeks. Extreme pain is a sign to lessen the pressure, and is something you should discuss with your doctor in case there are anatomical problems they should know about. Burning that lasts after the massage may be triggered by massage products or lubricants that were used. Although many APM sites suggest the use of KY Jelly or Astroglide, these water-soluble lubricants have a high ion (salt) concentration and have been shown to cause severe irritation and even damage of the cells lining the vagina. Of course, using such products every day can cause burning and irritation for some women.
|The National Institutes of Health states that “not having an episiotomy is best for most women in labor”, it further suggests that APM is one of the key things women can do to avoid an episiotomy.|
5 Minutes of APM each day has lasting benefits
Of course, APM won’t stop all perineal trauma. And it is important to distinguish between perineal massage that is done before childbirth (antepartum perineal massage) and the type of massage that is done during labor by healthcare providers. The latter kind, done during labor, has not shown a clear benefit to date.
Practicing APM requires motivation and following a daily intervention without any immediate obvious benefit. Sadly, in spite of medical evidence showing possible life-time benefits of the massage for women, there has been a significant lack of patient education on how to make APM work in real life for most women. In fact, less than 5% of pregnant women even know the correct technique for APM. This is disappointing given that APM done consistently enhances the chance of an easier, less painful and less traumatic delivery with less risk of future pelvic floor dysfunction.
Perineal Massage is a safe and effective way to reduce the chance that you will experience perineal trauma and pain after having a baby. Some days it will be easy. Some days you won’t want to do it. But stay on task knowing it is a proven technique that women have used around the world and through the ages to prepare for motherhood.
Making APM easier with BabyIt
Because of the risks of oils causing vaginal infections (up to an 8 fold increase) and because common lubricants can cause tissue irritation and/or damage, I have spent the last year working with Fairhaven Health to develop a mild, safe perineal massage gel for women to use every day. Our new gel, called BabyIt ™ has the same salt concentration as a woman’s body (it is isotonic) and it is paraben-free, using a nature-identical preservative instead. In clinical testing, BabyIt was found to be 3 times less irritating than KY Jelly! I am very proud of this new silky-smooth product which can also be used as a soothing postpartum comfort gel for mom’s perineal tissues, and even to relieve baby’s dry or chapped skin. Each tube of BabyIt comes with clear and descriptive instructions for performing perineal massage by yourself or with your partner. I am confident that BabyIt will help you effectively and comfortably incorporate perineal massage into your daily routine.
Learn more about how BabyIt can optimize perineal massage to help reduce trauma associated with childbirth.
This original article was written by Joanna Ellington, PhD. Dr. Ellington is an internationally-recognized researcher in the field of andrology and serves as medical advisor to Fairhaven Health. She has had numerous featured blogs on women’s health at BlogHer, as well as other media channels. More information about Dr. Ellington can be found at her website, SexScienceandNature.com
Disclaimer: Please note that the information in this website is an educational resource and represents Dr. Ellington’s personal opinions. 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.
Other pregnancy articles:
- Your Pregnancy by Trimester
- Pregnancy Health & Nutrition
- Pregnancy Challenges and Possible Risks
- Decreasing Damage “Down Under” During Childbirth: Perineal Massage Made Easy
- Decreasing Damage “Down Under” During Childbirth: Perineal Massage Made Easy: Part 2