Perineal massage during pregnancy is often recommended in the last few weeks before birth. You may have heard that it can help prevent tearing, but there may be another benefit that gets less attention. Perineal massage can also help you practise relaxing your pelvic floor while experiencing pressure and stretch, helping prepare your brain and nervous system for some of the sensations you may experience during vaginal birth.
Research suggests that perineal massage may slightly lower the chance of having a tear that needs stitches, mainly by reducing the chance of needing an episiotomy. An episiotomy is a cut made by a care provider to make the vaginal opening larger during birth. The research shows the most benefit for people preparing for their first vaginal birth.
While this research is helpful, we don't think perineal massage is only about physically stretching the tissue. It can also be used as a way to slowly introduce your brain, nervous system and pelvic floor to pressure and stretch while learning how to stay relaxed.
What Is Perineal Massage?
The perineum is the area around the vaginal opening and between the vagina and anus. During a vaginal birth, the pelvic floor and perineum need to stretch as the baby moves through the vaginal opening.
Perineal massage involves gently applying pressure and stretch to this area in the last few weeks of pregnancy. It is usually done using one or two fingers and plenty of lubricant.
It is often described as a way to make the perineum more flexible before birth. While preparing the tissue may be part of the benefit, we also use perineal massage to practise how the pelvic floor responds to pressure and stretch.
What Are the Benefits of Perineal Massage During Pregnancy?
Research suggests that doing perineal massage in the last few weeks of pregnancy may slightly lower the chance of having a tear that needs stitches. Much of this benefit seems to come from reducing the chance of needing an episiotomy.
The research shows the most benefit for people preparing for their first vaginal birth. The benefit is less clear for people who have given birth vaginally before.
Perineal massage cannot guarantee that you will not tear. Many things affect what happens during birth, including the baby's position, how quickly the baby is born, previous births and differences between people's bodies. Someone can practise perineal massage regularly and still have a tear, while someone who never does it may not tear at all.
For this reason, preventing tearing does not need to be the only goal of perineal massage. It can also be an opportunity to prepare your pelvic floor and nervous system for birth.
How Can Perineal Massage Prepare Your Nervous System for Birth?
As the baby's head moves through the vaginal opening, the pelvic floor and perineum experience increasing pressure and stretch. These feelings can be very unfamiliar, particularly during a first vaginal birth.
When your brain experiences something new or uncomfortable, your nervous system may respond by trying to protect you. You might tighten your muscles, hold your breath or pull away from the pressure. This is a normal protective response, but during birth we want the pelvic floor to be able to relax and lengthen as pressure increases.
Perineal massage gives you a chance to experience a smaller and more controlled version of these feelings before labour. You can practise breathing and relaxing your pelvic floor while you remain completely in control of the amount of pressure.
This may also be a way to build more positive neurotags around pressure and stretch. A neurotag is a group of connections your brain makes around an experience. Your brain connects physical feelings with thoughts, emotions, memories and past experiences.
If pressure around the vaginal opening feels painful or scary, your brain may connect that feeling with tightening or wanting to pull away. With gentle and comfortable practice, you can start creating a different experience. You can feel pressure while also breathing normally, relaxing your pelvic floor and knowing that you are safe and in control.
This does not mean convincing yourself that the pressure feels good or ignoring pain. The goal is to make the feeling more familiar so your brain and nervous system do not need to react as strongly to it.
When Should You Start Perineal Massage?
Most research has looked at starting perineal massage around 34 to 35 weeks of pregnancy and continuing until labour.
There is no perfect schedule that everyone needs to follow. A few short sessions each week may be easier to fit into your routine than trying to practise every day.
If you have questions about whether perineal massage is appropriate for your pregnancy, speak with your midwife, physician or pelvic health physiotherapist before starting.
How to Do Perineal Massage
Start with clean hands and plenty of lubricant. Lubricant is important because it reduces friction and irritation and allows you to focus on the feeling of pressure and stretch.
Imagine the vaginal opening as the face of a clock and focus on the bottom half of the clock. Apply gentle pressure downward and slightly to one side until you feel a noticeable but manageable stretch.
When you are first learning, you don't need to start by massaging back and forth. Instead, hold the stretch and use this time to practise your breathing, visualization and pelvic floor relaxation.
Keep your breathing slow and comfortable while noticing whether you are tightening your jaw, stomach, buttocks or pelvic floor. You can also use visualization to help the pelvic floor relax. Some people imagine the vaginal opening gently widening, the pelvic floor dropping down or the sit bones moving apart. Choose an image that makes sense to you and helps you feel your muscles letting go.
Pay attention to what happens to the discomfort while you hold the stretch. Ideally, the same amount of pressure should gradually start to feel easier as you breathe and relax.
Once you are comfortable holding pressure in different areas along the bottom half of the vaginal opening, you can progress to gentle side-to-side massage. You can slowly increase the pressure as your body becomes more comfortable, while continuing to focus on relaxation rather than how much stretch you can tolerate.
Should Perineal Massage Hurt?
Some pressure, stretching or mild discomfort is expected, but perineal massage should not be very painful. We generally recommend keeping discomfort at 5/10 or less.
More discomfort does not make the massage more effective. If the pressure is too strong, your body may respond by tightening and protecting the area, which is the opposite of what you are trying to practise.
Ideally, the discomfort should decrease as you hold the stretch. For example, you may begin with pressure that feels like a 4/10 and notice that it settles to a 2 or 3/10 as you breathe and allow the pelvic floor to relax. This is a sign that your brain and body are becoming more comfortable with the feeling.
Perineal massage should also not cause significant anxiety or distress. If you notice yourself holding your breath, tightening your pelvic floor, becoming increasingly uncomfortable or wanting to pull away, decrease the pressure or stop.
Can Your Partner Do Perineal Massage?
If you are comfortable with it, perineal massage can be a great birth preparation exercise to practise with your partner.
Your partner can apply the pressure while you focus on your breathing, visualization and pelvic floor relaxation. This gives you both a chance to figure out what kind of support you find helpful before labour.
Your partner can also practise the cues or affirmations you may want to hear during birth. You may find it helpful to be reminded to slow your breathing, relax your jaw or soften your pelvic floor. You may prefer an affirmation that reminds you that you are safe and can relax around the pressure.
Practising these things ahead of time can help your partner understand what actually helps you relax rather than trying to figure it out for the first time during labour.
Partner involvement is completely optional. If involving someone else makes it harder for you to relax or makes the experience uncomfortable, there is no need to include them.
If you are struggling to reach on your own and including a partner isn't an option a pelvic wand can be a helpful tool to provide extra leverage.
Does Perineal Massage Prevent Tearing?
Perineal massage may slightly lower the chance of some types of perineal injury, but it cannot prevent all tearing during birth.
Research suggests that antenatal perineal massage may reduce the chance of trauma that needs stitches, with much of the benefit coming from fewer episiotomies. The benefit appears to be greatest for people preparing for their first vaginal birth.
There is also research showing that warm compresses and perineal massage used by care providers during the pushing stage of labour may help reduce the chance of more serious tears.
If these are techniques you are interested in using during birth, you can discuss them with your midwife or physician before labour and include them in your birth preferences.
When Should You Avoid Perineal Massage?
Perineal massage is optional. You do not need to do it to be well prepared for birth.
For some people, touch or pressure around the vaginal opening may cause significant pain, anxiety or distress. This may be more common for people who have pelvic pain, pain with penetration, difficulty relaxing their pelvic floor, previous birth trauma or a history of sexual trauma.
Pushing through significant pain or distress is not the goal. If you are using perineal massage to help your nervous system become more comfortable with pressure and stretch, the experience itself needs to feel safe and within your control.
A pelvic health physiotherapist can help you find other ways to practise the same skills. This may include breathing, pelvic floor relaxation, visualization, birth positions or a slower approach to becoming comfortable with pressure and touch.
How Can a Pelvic Health Physiotherapist Help You Prepare for Birth?
Preparing your pelvic floor for birth is not only about making it stronger. During vaginal birth, the pelvic floor also needs to relax and lengthen as the baby moves through the vaginal opening.
A pelvic health physiotherapist can help you learn how to relax and lengthen these muscles, find breathing and visualization techniques that work for you, practise different birth positions and learn how to perform perineal massage safely if you choose to include it in your birth preparation.
Perineal massage can therefore be thought of as more than a way to stretch the tissue before birth. It is a chance to slowly get your brain, nervous system and pelvic floor used to pressure and stretch while practising how to stay relaxed as those feelings increase.
The goal is not to become better at tolerating pain. Instead, we want the pressure and stretch to become less uncomfortable as your brain and body become more familiar with the sensations.
If you would like more support preparing your pelvic floor for birth, Core Connection Mobile Physiotherapy provides in-home pelvic health physiotherapy and birth preparation in Greater Victoria, the Cowichan Valley, North Vancouver and West Vancouver. A pelvic health physiotherapist can provide individualized guidance based on your pregnancy, pelvic floor and birth goals.