Perineal Massage: When to Start, How to Do It and Whether It Works

How and when do you do perineal massage?

Perineal massage is stretching the perineum, the skin and muscle between the vagina and anus, with oiled thumbs or fingers for a few minutes at a time, starting at 34 or 35 weeks of pregnancy. The Royal College of Obstetricians and Gynaecologists (RCOG) says that from 35 weeks, you or your partner can massage daily until the birth, which may reduce your risk of tearing. Cambridge University Hospitals, an NHS trust, recommends starting any time from 34 weeks and massaging at least three to four times a week for three to five minutes each time.

In the US, Cleveland Clinic ob-gyn Salena Zanotti, MD, says that if you choose to do it, you should start four to six weeks before your due date.

Should you start perineal massage at 34 or 35 weeks?

UK guidance gives both weeks: Cambridge University Hospitals says any time from 34 weeks, and the RCOG and Harrogate and District NHS Foundation Trust say from 35 weeks. The 2013 Cochrane review that pooled the trials included only studies in which massage was done for at least the last four weeks of pregnancy.

The RCOG says it may take a couple of weeks of daily massage before you notice more elasticity in your perineal area. If daily sessions are not realistic, Cambridge University Hospitals says massaging as little as once or twice a week from 34 weeks may still be of benefit.

How do you do perineal massage step by step?

The RCOG and Cambridge University Hospitals describe the same basic method: oil your thumbs, press down toward the anus until you feel a stretch, then sweep in a U shape for a few minutes.

1. Wash your hands, empty your bladder and make sure your nails are short (Cambridge University Hospitals, RCOG).
2. Sit in a warm bath first if you can; the RCOG says it may help loosen the muscles around your perineum.
3. Get comfortable. The RCOG suggests bed, propped up with pillows and knees bent; Cambridge University Hospitals also lists semi-sitting, squatting against a wall, or standing with one foot raised on the bath, toilet or a chair.
4. Oil your thumbs. Cambridge University Hospitals advises an unscented oil such as olive, sweet almond or sunflower oil, or a water-soluble jelly if you are sensitive to those, and says not to use baby oil, mineral oil or petroleum jelly.
5. Place your thumbs about 2 inches (5 cm) into the vagina, up to the second knuckle, as Cambridge University Hospitals describes. Cleveland Clinic gives 1 to 1.5 inches, about to the first knuckle.
6. Press down toward the anus and to the sides of the vagina until you feel a stretch, and hold for about 1 minute while you breathe deeply (RCOG).
7. Gently massage the lower half of the vagina with a U-shaped movement for 2 to 3 minutes, and repeat this 2 to 3 times (RCOG).

A partner doing the massage should use their index fingers instead of thumbs, according to Cambridge University Hospitals. The same leaflet says the massage should be firm and can be uncomfortable, but it should not be painful; if it is, stop and take a break. Your perineum may feel tight at first and relax with practice.

Does perineal massage work?

Perineal massage lowers the chance of a tear or cut that needs stitches, mainly in a first vaginal birth, according to a 2013 Cochrane review of four good-quality trials with 2,497 women. In the pooled results, one fewer woman needed stitches for every 15 who massaged, and one fewer had an episiotomy, a cut to widen the vaginal opening, for every 21. The review found these results significant only for women who had not given birth vaginally before.

The same review found no difference in first- or second-degree tears, or in third- or fourth-degree tears, the more serious kind that reach the muscle around the anus. Women who had given birth vaginally before reported less perineal pain three months after the birth. Massage made no difference to forceps or vacuum births, sexual satisfaction, or leaking urine, stool or gas.

Dr. Zanotti at Cleveland Clinic calls the research mixed, and says that if you want to try it, it is not likely to do any harm. The NHS notes that up to 9 in 10 first-time mothers who have a vaginal birth have some sort of tear, graze or episiotomy.

Cambridge University Hospitals says you may particularly benefit if you are having your first baby (or planning a vaginal birth after a cesarean), are 30 or older, or have had an episiotomy before.

Who should not do perineal massage?

Cambridge University Hospitals says not to do perineal massage if you think your waters might have broken, or if you have a vaginal infection such as a yeast infection (thrush) or herpes, and to contact your midwife instead. Outside those situations, the leaflet says there are no known risks.

Cleveland Clinic recommends talking with your healthcare provider before you start, so you know where to press and how hard. Harrogate and District NHS Foundation Trust points out that some people are not comfortable touching their bodies this way, and that this is fine.

What else lowers the chance of a tear during birth?

The RCOG lists several things your midwife or doctor can do at the birth: a warm compress on the perineum as the baby's head stretches it, support for the perineum with their hands as the baby is born, and a slow, controlled birth. The RCOG adds that kneeling, being on all fours or lying on your side may reduce the severity of tearing, and that your care team will work with you so you can give birth in your chosen position. You can write a preferred position into your birth plan.

The NHS describes the midwife asking you to stop pushing and pant or puff a couple of quick, short breaths as the head appears, so it emerges slowly and the perineum has time to stretch.

The RCOG says there is often no clear reason for third- and fourth-degree tears, but they are more likely in a first vaginal birth, with a baby over 9 lb (4 kg), a long pushing stage, a shoulder that gets stuck (shoulder dystocia), or a forceps or vacuum birth. Assisted birth explains how forceps and vacuum births work.

When to call your doctor or midwife

• You think your waters have broken. Stop the massage and call: the NHS lists waters breaking as a reason to call your midwife or maternity unit urgently. When your waters break covers what to look for.
• You have any vaginal bleeding, another reason the NHS gives for an urgent call.
• You think you have a vaginal infection such as thrush or herpes (Cambridge University Hospitals).
• You find the massage painful or hard to do; Cambridge University Hospitals says to contact your midwife to talk through any concerns.