Perineal Massage: Yes? No? When? How Long?

Does perineal massage during pushing help protect your bottom?

Does perineal massage during pushing help protect your bottom?

To massage or not to massage?  That is the question. If yes, when? And for how long?  As always, in health care, one question leads to others.

Many women giving birth worry about their perineum tearing or being cut. This is probably one of the top two concerns expressed by mothers in the childbirth classes we teach. Perineal trauma is less frequently discussed as a birth outcome, but it can have long-lasting impacts. Women report pain during recovery from weeks to months postpartum.  Some experience pain during subsequent intercourse for as long as 3 years following the injury.

There are so many confounding factors that may influence perineal outcomes during birth: location of birth, attendant, genetics, parity, skin elasticity, nutrition, pushing position, epidural, pushing force, maternal age, maternal weight gain, episiotomy, forceps or vacuum, baby’s head size and position, etc. Without question, women who are having a subsequent vaginal birth are less likely to encounter serious tears. In a hospital setting, it is not uncommon for roughly 85% of women to experience some type of perineal injury, but that proportion is higher for first-time mothers and lower for subsequent births. Studies have shown that when episiotomy is restricted, 51-77% of women experience perineal trauma.  In one study focused on home birth setting (which is a unique population of women), 30% of birthing moms experienced trauma, but less than 1% sustained 3rd and 4th degree injuries (and 1.4% had an episiotomy).  It is obvious from this wide variation that many variables contribute to perineal outcomes in birth.  Some studies have even suggested that maternal fear may also be a factor.

There has been decades-long debate about whether perineal massage is effective at reducing the risk of perineal trauma and vaginal lacerations, and if it is, when it should be done.  Should it be done a specific way? What about alternatives such as hot compresses or special oils or lubricants?  A 2012 Cochrane Review points to the use of warm compresses during the second stage of labor to reduce serious tears (3rd and 4th degree). But the methods of the eight randomized controlled trials included in the review vary widely. The same review also concluded that when care providers adopt a “hands-off” approach, the risk of episiotomy is significantly lowered.  There’s no surprise there; if your doctor or midwife isn’t touching your vaginal opening, he/she is less likely to recommend an episiotomy.

Fortunately, another Cochrane Review published in 2013 is fairly clear that in a first time vaginal birth, antenatal (during pregnancy) massage can be effective at reducing the type of tears that require stitches, and in multiparous mothers, reducing postpartum pain. Techniques vary, but in general, women who apply this treatment  from about 35 weeks gestation, 2-3 minutes at a time, roughly 4 times per week can reduce their likelihood of severe tearing in a first-time vaginal birth.  In Shelia Kitzinger’s book Episiotomy and the 2nd Stage of Labor, one of the contributing authors mentions that the antenatal perineal massage may be beneficial for a reason other than the supposed increased elasticity produced by massage: it acquaints mother with the sensations of a perineum that stretches and helps her to understand how to relax her pelvic floor through those sensations.

But what about actively massaging during the pushing phase of labor?  That is less clear. Different studies produce different results; however, there is one thing they have in common: none of the techniques applied during pushing show a strong advantage over the other.

It is important to highlight one particular study, though.  A 2005 randomized controlled trial performed during the pushing phase did show that there was a statistically significant increase in perineal trauma if the massage during pushing was done longer. The study was set up remarkably well,  with women randomized to treatment and control, and with caregivers being trained in exactly how to administer the treatment. The result was there were no obvious differences in outcomes between massage, hot compress, or hands off.  Additionally, it was noted that “for the compress group, the mean time the technique was used was 17.8 minutes (SD=19.5 min) among women with trauma and 13.4 minutes (SD=16.1 min) among women without trauma (P = .06). For the massage group, the mean time was 11.6 minutes (SD=14.0 min) among women with trauma and 5.8 minutes (SD=6.8 min) among women with no trauma (P < .01).” In other words, women whose attendants manipulated their perineum during pushing for an average of 11 minutes experienced some type of trauma, where as women who were massaged for an avg of 6 minutes did not.  This was a statistically significant difference.

So what does this mean?  As always it comes down to discussion with your care provider, and, in particular, your nurse. Massage during the pushing phase should not be done for very long, which seems intuitive. Extended periods of perineal and vaginal manipulation, particularly aggressive manipulation, can increase swelling, which increases risks of tears and lacerations. If you choose this intervention, ask for gentle manipulation for a very short time. In this case, less is more. A hot compress may or may not be helpful, but it has not been shown to be harmful, and it might feel soothing.

Most importantly, if you are uncomfortable with the thought of your vagina being touched or stretched by another person during your childbirth, or if you aren’t sure how gentle your attendant’s technique is, you can make the choice to limit it or avoid it knowing that you are not increasing risk to your perineum.

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