Perineal massage and tearing

Your perineum

Your perineum is the tissue between your vagina and your anus.  During birth you can experience perineal trauma/tearing.  This can be classified into four degrees of severity:

1^st degree – these only affect the skin, they usually do not require any repair and heal quickly on their own.

2^nd degree – these affect the skin and the perineal muscle layer, repair is usually needed.

3^rd and 4^th degree – 3.5% of women will experience a more substantial tear which involves the muscle that controls the anus. This degree of tear will need to be repaired in theatre.

Episiotomy

An episiotomy is when a cut is made into your perineum at the point when baby’s head is very close to being born.  The cut is made at a 60 degree angle in order to avoid the involvement of the anal sphincter.  The aim of this is to make more space for your baby to be born.  An episiotomy may be advised for several reasons:

• If there is a concern about your baby’s heart rate
• If it looks as though your perineum may tear towards your anus
• You are having an instrumental birth (ventouse or forceps)

Perineal protection when giving birth

There are a few different options available when birthing your baby:

Warm compresses: this is when a warm large swab or pad is put into warm water, wrung out and then held against your perineum in the later stages of birth – usually when baby’s head is beginning to swell your perineum from moving down. It can be held on during contractions and between, the aim is to warm your perineal muscles and aid in stretching in order to avoid perineal tearing.

The evidence for warm compresses is very clear from several studies.  It has been shown to:

• Increase the chance of not tearing
• Reduce the chance of having a 3^rd or 4^th degree tear
• Reduce the chance of needing an episiotomy
• Increases comfort during the pushing stage
• Decrease the chance of having urinary incontinence after birth

(Magoga et al, 2019; Aasheim et al, 2017; Dahlen et al, 2007)

Hands poised – this is when the midwife doesn’t touch your perineum or baby’s head, but has her hands close by and observes.  If baby’s head is birthing quickly she may offer to apply some counterpressure to try and protect the perineum from tearing.

Perineal massage

Research shows that perineal massage during pregnancy helps to reduce the chance of tearing during birth.  It is something you can do yourself or your partner can do it.  You can start perineal massage from 35 weeks of pregnancy. 

How to do it

It is best to avoid using any perfumed oil.  Almond, olive or vitamin E are good ones to use. Ensure you or your partner have thoroughly washed your hands and make sure your finger nails are short.  Make sure you’re in a comfortable environment, free from disturbances. Some women find that a good time to do perineal massage is after a bath.  Find a position where you can easily reach your perineum, maybe propped up in bed with a pillow, in the bath or standing up with one leg raised.  As you reach the later stages of pregnancy it can be difficult to reach your perineum so this is a good time to ask your partner to assist you. 

1. Place your thumbs a couple of centimetres inside the back wall of your vagina
2. Press down with your thumbs towards your anus
3. You will feel a stretching sensation, try and hold this stretch for a couple of minutes
4. Then gently massage the lower half of your vagina/perineum using a U shaped motion for a few minutes 

For a demonstration on how to do this, please watch this video: 

My Expert Midwife - How To Do Perineal Massage - YouTube 

It’s a good idea to try and do perineal massage daily, try and fit it into a part of your daily routine such as after a shower/bath. 

References

Magoga et al (2019) Warm perineal compresses during the second stage of labor for reducing perineal trauma: A meta-analysis - PubMed (nih.gov) 

Asheim et al (2017) Perineal techniques during the second stage of labour for reducing perineal trauma - PubMed (nih.gov) 

Dahlen et al (2007) Perineal outcomes and maternal comfort related to the application of perineal warm packs in the second stage of labor: a randomized controlled trial - PubMed (nih.gov)