Introduction

As a student midwife I was assigned to a very old fashioned midwife for my community secondment. My mentor had 40 years of experience underpinning her practice and introduced me to the art of perineal massage especially in labour to prevent vaginal tears and therefore reduce the mother's discomfort post-natal so that she could bond well with her baby. When I wrote the technique up in my case studies my tutors were horrified and insisted that I take it out as I would be failed if it was known I was employing such an old-fashioned practice. My arguments that the women had not minded it and that the majority had had intact perineums fell on deaf ears – it had to be taken out. That was in 1984 and, whilst there was a wealth o0f anecdotal evidence, there was not much research to back up my stance. However in my own practice I continued to use what I had been taught by my community midwife mentor with excellent results. When pregnant myself I started perineal massage at 34 weeks; despite having an OP labour with epidural analgesia, I delivered a 3.6kg baby at 36 weeks gestation with an intact perineum and one less thing to worry about post-nataly. When starting the massage course I was keen to find out the latest on perineal massage because I had left midwifery 5 years previously and felt out of touch – this project is the result of that interest.

 

Background

Moore and Dalley state that the ‘perineum is the area extending from the base of the labia minora to the anal canal. It is roughly triangular and consists of connective tissue, muscle and fat and provides attachment to the muscles of the pelvic floor'. The pelvic floor is divided into 2 identical halves that unite along the midline. Each half contains the Levator ani muscle – a broad flat muscle that forms the anterior part of the pelvic floor, together these muscles form a sling which supports the pelvic organs. The coccygeous muscle is a smaller triangular sheet of muscle behind the levator ani. The perineum is an especially important structure in women because it is the final support for the pelvic viscera, stretching or tearing of this area during childbirth can remove the support from the posterior wall of the vagina leading to prolapse. A weak pelvic floor area can also result in faecal and urinary incontinence.

 

In the 1970's it was widespread practice in UK maternity units that all nulliparous women had an episiotomy (mediolateral) to prevent stretching and tearing of these muscles; the premise being that this would decrease the prevalence of excessive perineal body attenuation and decrease trauma to the pelvic diaphragm and musculature. In his book Episiotomy: Can its routine use be defended? Dr J M Thorpe says ‘There is little evidence to support the routine use of episiotomy'. Although routine episiotomy is not practiced in UK hospitals anymore the rate for episiotomy is still quite high.

 

Perineal Massage

Preparation for delivery begins during pregnancy with the hormones Progesterone and Relaxin softening muscles and ligaments to encourage stretching, this process occurs throughout the body and the perineum and pelvic floor are no exception. My contention is that light and gentle massage of the perineum can improve its ability to stretch whilst improved blood flow to the area and the use of good quality oil will nourish the tissues.

 

There have been many studies into the practice of perineal massage both in the ante-natal period and soley in 2nd stage of labour.

 

Shipman et al published the results of their research into antenatal perineal massage and subsequent perineal outcomes in the British Journal of Obstetrics and Gynaecology in 1997. This was a randomised, single-blind prospective study carried out at Watford General Hospital; it involved 861 nulliparous women with a singleton pregnancy and was conducted between June 1994 and Oct 1995. The results showed a reduction of 6.1% in 2nd or 3rd degree tears in women assigned to the massage group compared to those receiving no massage. Tear rates were 75.1% in the no-massage group compared to 69.0% in the massage group. There was also a corresponding reduction in instrumental deliveries from 40.9% no-massage group to 34.6% in the massage group. Analysis by maternal age showed that massage provided a much larger benefit in those aged over 30 years old.

 

A systematic review of perineal trauma prevention was carried out by Eason etal in 1999. The objective was to review systematically techniques proposed to prevent perineal trauma during childbirth and meta- analyse the evidence of their efficiency from randomised controlled trials (RCTs). More than 1500 articles were reviewed. Results indicated good evidence that avoiding episiotomy decreased perineal trauma and that in nulliparous women, perineal massage during the weeks before giving birth also protected against perineal trauma. Upright positions in 2nd stage seemed to have little impact on perineal outcome but the authors concluded that more information on techniques to protect the perineum during spontaneous delivery was needed.

 

A study by Richard Johanson MD MRCOG undertaken at North Staffordshire Maternity Hospital also supported the findings that perineal massage in pregnancy can decrease the risk of perineal trauma during a first vaginal delivery but did not affect other perineal outcomes 3 months post delivery. Such findings were supported by Labrecque's work in 2000. Labrecque etal published a study in the American Journal of Obstetrics and Gynaecology in Jan 2000 that looked specifically at evaluating the effect of perineal massage performed during pregnancy on perineal symptoms 3 months after delivery. This was a single-blind, randomised controlled trial using pregnant women from 5 hospitals in Quebec , Canada . Women in the massage groups were asked to perform perineal massage for 10 minutes daily from 34/35 th weeks of pregnancy to delivery. Participants completed a self-administered questionnaire on perineal pain, dyspareunia, sexual satisfaction, flatus and incontinence of urine. The results showed that among women without a previous vaginal birth there was no difference between the 2 groups with respect to dyspaerunia, perineal pain etc. In the group with a previous vaginal birth more women in the massage group were free from perineal pain but the frequencies of incontinence and dyspaerunia were the same. The authors concluded that perineal massage in pregnancy neither impairs nor substantially protects perineal function at 3 months post partum.

 

A review of randomised trials of perineum massage by Vendittelli et al in the Journal of Gynaecology, Obstetrics, Biological Reproduction in Paris also supported the conclusion that antenatal perineal massage seemed valid in reducing perineal trauma but that further studies should be undertaken to evaluate its effectiveness in the avoidance of serious perineal injuries and in assessing women's satisfaction with the technique.

 

The use of perineal massage just in the second stage of labour has also been investigated. Georgina Stamp at The University of South Australia undertook a randomised trial of perineal massage in 2nd stage of labour but prior to this she did a study looking at midwives current views and practices. She questioned independent midwives in South Australia and 194 midwives in 7 public hospitals in 4 states of Australia. Midwives were surveyed using a questionnaire which sought their views on and practices relating to second stage perineal massage, delivery of the head and reasons for an episiotomy. The results showed that a third of the respondents never practised perineal massage in the 2nd stage of labour, 43% were undecided as to its value and 19% disagreed with the practice. More than half (55%) disagreed with the statement that perineal massage can help stretch the perineum and prevent tearing indicting that they would find the practice distasteful.

 

Her follow up study found that perineal massage had no effect on preventing episiotomies and most tears but that the practice is safe and may reduce the most severe form of tears. Stamp's finding were supported by the work of Michel Labrecque MD PhD at Laval University in Quebec , Canada who found that perineal massage during labour did not prevent perineal trauma or reduce postpartum pain. In his research there was no evidence of a pilot study to assess midwives views on the practice before the study was conducted. In both cases no evidence was presented of the training and explanation given to the midwives in how to perform perineal massage in labour and no assessment of competency was available.

 

Labrecque etal also went on to assess women's views on the practice of prenatal perineal massage. 763 women were assigned to the massage group of a clinical trail of perineal massage during pregnancy, they were given a 20 item questionnaire to complete a few days after birth – 90% completed this questionnaire. The results showed perineal massage to be quite acceptable, pain and technical problems during the first week or two of doing the massage soon disappeared. Women's assessment of the effect of massage on preparation for birth and on delivery was positive. Women's views about using the perineal massage on their relationship with their partner were proportional to the partner's participation with the massage and were either positive or negative accordingly. Most women said they would massage again in a subsequent pregnancy and would recommend it to another pregnant woman.

 

Case Study Responses

My experience of response to perineal massage amongst my small group of case studies and new clients has been that the idea of perineal massage as preparation for labour is very acceptable. Having spoken to other pregnancy massage therapists who advocate perineal massage they have also found women to be keen to do something which may reduce the need for an episiotomy.

 

Again my experience has been that if perineal massage and Kegel pelvic floor exercises are practiced in pregnancy it helps the mother become more aware of her perineum and that the baby will be emerging from here. She becomes aware of how her vagina and vulva look and feel allowing her to become better connected to her body. Perineal massage will also help her to become aware of the pressure sensation that she will feel during delivery and enable her to have confidence that her muscles can distend to facilitate childbirth without ‘ripping from stem to stern'. All this contributes to her understanding of the birth process and her ability to give birth in a gentle slow manner to allow the perineum to stretch naturally – a role it is perfectly designed to do. By practising to relax as much as possible during the period of stretching the mother will be able to prepare herself to ‘let go' when the baby's head emerges. By contracting the pelvic floor muscles muscle strength is maintained.

 

Of my case studies only one has actually delivered so far – Esther. I really did not think that Esther would take to the idea of perineal massage and pelvic floor exercises as she seemed so keen to give up all her ‘rights' and be ‘done to' in labour. Esther was very worried about getting everything right which was another reason that I thought she would not ‘fiddle with her undercarriage' as she put it. Although I did not think Esther would use the technique I decided to discuss it with her so that she could make an informed choice based on the benefits and drawbacks of perineal massage. I also gave her instructions on the technique with a written copy of the ‘how to do it' paper so that she could practice at home should she want to. When Esther came back for her post-natal massage I was delighted to find out that she and Julian had been doing the perineal massage regularly and attributed her intact perineum to the technique. During her previous delivery she had had a 1 st degree tear that required a suture, this time baby Ryan was considerably larger than Chloe had been and she was delighted to have an intact perineum and felt that the technique had definitely worked. She was also doing the pelvic floor exercises so felt her control of her bladder was also coming back sooner as she knew about her nether regions. This really made me think about my judgement calls and that I would always talk to women about both pelvic floor exercises and perineal massage enabling them to make an informed choice about whether they use it or not.

 

Having spoken to other members of the July group who have been teaching perineal massage the outcomes have been quite good with a high proportion of intact perineums and small tears/grazes that have not required sutures.

 

Additional Factors

Perineal massage alone is not the only technique that can help women have a labour without an episiotomy or serious tear, other preventative measures include:

 

• good nutrition – a balanced diet as healthy skin stretches more easily.
• Pelvic floor exercises – a muscle that is used is better prepared to stretch than one which is tight and unrelenting.
• Squatting which works with gravity, increases pelvic diameter by 10%, shortens the depth of the birth canal, shortens second stage of labour and decreases the need for instrumental delivery and episiotomy. These benefits are achieved because squatting tilts the uterus and pelvis forward placing the baby in the proper alignment for birth. Squatting encourages and strengthens the intensity of contractions whilst relieving back pressure and helps relax and stretch the pelvic floor muscles.
• Home birth. A study by Murphy and Feinland in New York of 1068 women who had home births 69.6% had intact perineums. In multiparous women lower socioeconomic status and higher parity were associated with intact perineums whereas maternal age greater than 40 years, previous episiotomy, weight gain of more than 40 pounds and prolonged second stage were associated with perineal trauma.
• Slow controlled delivery is another key to an intact perineum and reduced incidence of laceration. Mother and partner must listen closely to the midwife for advice on when to push and when to stop pushing.

 

How

In researching the best ‘how to' method there seemed to be several different ways of doing the same thing. As a massage therapist I want to be able to let the mother have options to choose what feels right for her so I have introduced 2 forms of the massage in the massage guide written instructions. The first is based on the article by Alice Lyon (midwife) for Well Mother January 1993 based on the work of Sheila Kitzinger and the second is based on the work of Peg Plumbo a certified nurse –midwife in America writing on parentsplace.com.

 

Before giving advice it is important to ensure that as the therapist you know when this technique should not be used – that is if the mother had vaginal herpes, thrush or any other vaginal infection as massage could spread the infection and worsen the condition.

 

My review of the research suggests that relationships are strengthened if both partners are involved in performing perineal massage – it may help the partner appreciate the vagina as something other than a sexual organ! Therefore although the mother and I discuss perineal massage at an earlier session I always ask her permission to reiterate the benefits at the joint labour session.

 

Timings on the how to front also seemed to differ widely from 2 minutes to 10 minutes and frequency from once a day to every day. Dr Yehudi Gordon in ‘Birth and Beyond' suggests 2-4 minutes 3-4 times a week whilst Labrecque's work demonstrated that 10 minutes massage every day from the 34 th week of pregnancy was the recipe for success. My preference is for Labrecque's approach as done daily the massage is less likely to become a chore and more likely to become part of labour preparation, his work also showed that the likelihood of an intact perineum increased with compliance with regular perineal massage. The option of 3-4 times a week makes it into an arduous add-on activity that will be done twice some weeks and 4 times on others. I have used this approach to doing the pelvic tilt in pregnancy as a regular check of pelvic alignment and my clients have had real success in maintaining a strong position with back supported and abdominal muscles engaged just be checking pelvic posture several times during their day.

 

What to massage with is a less complicated question – my choice would be sweet almond oil for its nourishing properties but olive oil, wheat germ oil and a simple vegetable oil would also work as lubricants.

 

 

Conclusion

This has been a fascinating project – it was interesting to see that whilst some things have moved on since my experience as a student midwife some things remain very much the same. It was sad to see that many midwives found the idea of perineal massage distasteful and I have to wonder about the validity of Stamp's finding of perineal massage in second stage if it was these same midwives performing it. My experience of perineal massage in second stage across more than 100 births has been very positive but it is always performed gently so as not to traumatise the perineum or the mother experiencing the sensation. Midwives must remain sensitive to the needs of the person on the end of their fingers!

 

I was delighted to see that several studies demonstrated the benefit of ante-natal perineal massage in nulliparous women and I will be quite happy to recommend its use. The benefits to multiparous women are less clearly defined but my experience with my clients has been that perineal massage has connected them with the wonders of their bodies and how the miracle of birth happens. For me anything that will give a woman confidence in her body's abilities to perform its natural role in these days of instant results and high tech living and birth is to be applauded.

 

Prior to undertaking this project I had not been particularly proactive about extolling the benefits of squatting but have been very encouraged by the real benefits of this technique to include it into the exercise program with the Gym Ball at an early massage session to help women have the choice whether or not to use it. The use of supported squatting positions in the labour discussion is also something that I will emphasise more from now on.

 

Encouraging good nutrition is another facet of the pregnancy work that I will pay more attention to. Having run a weight management clinic as a practice nurse I have the basic knowledge to help clients find an optimal eating program for pregnancy and now I can give them yet another reason for helping themselves to better health – the good of their perineums!

 

The other facet of preventing perineal trauma was a slow controlled delivery – this is certainly borne out by my experience when a midwife. The more controlled the delivery the better the outcome; control did not mean amazing force to flex the foetal head to its chest but the ability to get the woman's confidence to push when you asked and to not push when you required it. Whilst I am unable to influence the experience level of the midwives my clients are allocated to in labour, I shall make sure that I teach my Mums the simple but effective techniques for withstanding the urge to push and to keep control when asked to do so. I will ensure that they know to listen to the midwife and be advised by him/her.

 

In conclusion therefore I will teach each person I give a pregnancy massage to the importance of pelvic floor exercises and perineal massage to minimise perineal trauma during delivery. I will, if the client is having a course of massages, reiterate the importance of nutrition in pregnancy, extol the virtues of squatting and introduce them to simple exercises to tone the legs and the supported squat for delivery. Techniques for pushing and for overcoming the desire to push will be incorporated into the labour session. I believe the perineal massage in conjunction with pelvic floor exercise is a great way to help a woman get in tune with her body, learn its abilities and have confidence in those abilities to deliver her baby.

 

 

References

Eason, E., Labrecque, M., Wells, G., Feldman, P. Preventing perineal trauma during childbirth: a systematic review. Obstetrics and Gynaecology. 2000 Mar; 95 (3): 464-71.

 

Gordon, Y. (2004) Birth and beyond… Vermillion

Johanson, R. Perineal massage for prevention of perineal trauma in childbirth. Lancet. 2000 Jan 22; 355(9200): 250-1.

 

Labrebcque, M. Perineal massage during labour did not prevent perineal trauma or reduce postpartum pain. Evidence-based Obstetrics and Gynaecology 2002 Mar; Vol 4(1) 13-14.

 

Labrebcque, M., Eason, E., Marcoux, S. Women's views on the practice of prenatal perineal massage. British Journal of Obstetrics and Gynaecology. 2001 May; Vol 108 (5) 499-504.

 

Labrebcque, M., Eason, E., Marcoux, S., Lemieux, F., Pinault, JJ., Feldman, P., Lapierre, L., Randomised Controlled trial of prevention of perineal trauma by perineal massage during pregnancy. American Journal Obstetrics and Gynaecology. 1999 Mar; 180 (3Pt 1): 593-600

Labrebcque, M., Eason, E., Marcoux, S., Randomised trial of perineal massage during pregnancy: perineal symptoms three months after delivery. American Journal Obstetrics and Gynaecology. 2000 Jan; 182 (1 Pt 1): 76-80.

 

 

Moore , Keith and Dalley, Arthur.(1999) Anatomy Maryland , Lippincott, Williams and Wilkins.

 

Murphy, Patricia and Feinland, Julie. Perineal outcomes in a homebirth setting Birth 1998 Dec; Vol 25 (4) 1523-536.

 

Shipman, M.K., Boniface, D.R., Tefft , M.E. , McCloghry, F. Antenatal perineal massage and subsequent perineal outcomes: a randomised controlled trial. British Journal of Obstetrics and Gynaecology 1997 Jul; 104(7): 787-91.

 

Stamp,G.E. Care of the perineum in the second stage of labour: A study of views and practices of Australian midwives. Midwifery. 1997 Jun Vol 13 (2): 100-104.

 

Vendittelli, F., Tabaste, J.L., Janky, E. Antepartum perineal massage: review of randomised trials. Journal Gynecology, Obstetrics and Biological Reproduction. Paris 2001 Oct; 30(6): 565-71.

 

Additional Material

 

Plumbo, P. Perineal Massage: Your how to guide. Internet at Parentsplace.com

 

Yates, S. Well Mother Course Notes.