Prenatal Perineal Massage to Decrease Risk of Tearing and Episiotomy

Pregnant woman laboring in the hospital
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When people think of an episiotomy during birth, they rarely think of anything beyond what a doctor or midwife can do to avoid it. While there are ways for you and your provider to help minimize the likelihood of severe tearing or episiotomy during labor, preventative steps can begin during pregnancy with prenatal perineal massage.

What Is an Episiotomy?

To aid with vaginal delivery, an incision may be made to the pregnant person's perineum, the skin between their vagina and rectum. The surgical procedure, known as an episiotomy, has its risks, so there are only very specific circumstances under which it is performed.

Experts including the American College of Obstetricians and Gynecologists (ACOG) recommend against routine episiotomy going as far as laying out steps for providers to take to avoid it and advising that the procedure only be done when absolutely necessary, such as when the baby is in distress and needs to be delivered quickly or to prevent much larger tears. An episiotomy may be recommended if:

  • There is a need for a vacuum or forceps delivery.
  • The baby experiences a lack of oxygen or decreased heart rate while crowning.
  • The baby's shoulders won't emerge (known as shoulder dystocia).

Benefits and Risks of Episiotomy

Between 53% and 79% of vaginal deliveries include some degree of laceration or "tearing." Most of these lacerations heal well and don't result in long-term complications. But severe lacerations, though less common, are associated with an increased risk of pelvic floor injury, fecal and urinary incontinence, pain, and sexual dysfunction. In cases where there is a clear risk of severe tearing, providers may recommend an episiotomy.

But there are risks associated with episiotomy. Episiotomy incisions may cause tears beyond the skin's surface involving the muscles and rectal sphincter as well as the anal wall and increased maternal blood loss. Post-surgery, there is the risk of infection, narrowing of the vaginal canal, skin tags, development of a hole in the vaginal canal, and increased pain. Some people also experience anal sphincter dysfunction, anal incontinence, and dyspareunia (painful intercourse) long after the episiotomy incision heals. There is also an increase in the risk of perineal tearing in a future delivery.

Why Perineal Massage?

Perineal massage involves massaging and stretching the skin of the perineum (the area of skin between the vaginal opening and rectum). The technique can be performed during late pregnancy and during the pushing stage of labor to decrease muscular resistance and reduce the risk of severe perineal tearing during delivery.

Though there is limited research on the effectiveness of prenatal perineal massage for decreasing tearing during delivery, there is stronger evidence supporting its use during labor.

A 2013 review concluded that prenatal perineal massage can reduce the likelihood of perineal trauma during birth. While the use of perineal massage during pregnancy was associated with a reduction in trauma requiring stitches, this was mainly a result of the reduction in the need for episiotomy, not the overall reduction of tearing.

A 2017 review found that perineal massage and support during the second stage of labor, however, was linked with a reduced risk of third- and fourth-degree tears when compared to an unsupported or "hands-off" second stage. That said, the review did not uncover a significant difference in the incidence of first- and second-degree tears.

A 2019 study of 99 cases also found that there was a significant reduction in episiotomies when perineal massage was performed during labor. Perineal massage during labor was also associated with a shorter second stage.

In addition to potentially reducing the likelihood of episiotomy, prenatal perineal massage may also familiarize you with some of the sensations of birth and how to control your pelvic floor muscles. The knowledge of what you are feeling can help you relax more during birth.

How to Do Prenatal Perineal Massage

Before you try prenatal perineal massage, consult with your healthcare provider to ensure the technique is right for you. Once cleared to try, these are the basic steps:

  1. Find a comfortable spot where you can sit and be alone, or with your partner, uninterrupted.
  2. Find your perineum with a mirror to see what it looks like.
  3. You can apply a warm compress or take a warm bath to help relax your muscles.
  4. Wash your hands thoroughly.
  5. Lubricate your thumbs and perineum with a lubricant like KY Jelly, vitamin E oil, or pure vegetable oil.
  6. Place your thumbs about an inch inside the vagina, press downward and pull towards the sides. You should feel a light stretching, tingling, or burning sensation, but you should not feel immense pain. Hold this stretch for about two minutes, or until the area becomes slightly numb.
  7. If you've had a previous episiotomy or tear, be sure to pay special attention to that scar tissue. It will not stretch as readily and may need some extra work.
  8. Massage back and forth over the bottom area of the vaginal tissues, while working in the lubricant.
  9. Pull the thumbs out slightly, imagining how it would pull as your baby's head will be born.
  10. If your partner is doing this massage, they may use their thumbs or index fingers; sometimes it's only possible to get one finger in until the area has been stretched. Ask your partner to be sensitive to your body and open to feedback on the amount of pressure to use.

You can do this massage as often as once a day during late pregnancy to prepare for delivery.

During a perineal massage, avoid the urinary opening (at the top of the vaginal opening) to prevent urinary tract infections. Do not massage the perineum if you have active herpes lesions as it can cause the lesions to spread.

A Word From Verywell

There are many factors to consider when it comes time for your baby's birth, and there is little control to be had over most of them. Still, there are ways that you can prepare for the experience in advance, including reducing the risk of severe tearing and episiotomy during delivery. Perineal massage alone will not protect your perineum, but it can be one part of your birthing plan, especially if you wish for perineal support from your provider during delivery.

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  1. Cichowski S, Rogers R. Committee on Practice Bulletins-Obstetrics. ACOG Practice Bulletin No. 198: Prevention and Management of Obstetric Lacerations at Vaginal Delivery. Obstet Gynecol. 2018 Sep;132(3):e87-e102. doi:10.1097/AOG.0000000000002841

  2. International Childbirth Education Association. Episiotomy. 2017.

  3. Backmann MM, Stock OM. Antenatal perineal massage for reducing perineal trauma. Cochrane Database Syst Rev. 2013 Apr 30;(4):CD005123. doi:10.1002/14651858.CD005123.pub3

  4. Aasheim V, Nilsen ABV, Reinar LM, Lukasse M. Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database Syst Rev. 2017 Jun 13;6(6):CD006672. doi:10.1002/14651858.CD006672.pub3

  5. Akhlaghi F, Baygi Z, Miri M, Najafi M. Effect of perineal massage on the rate of episiotomy. J Family Reprod Health. 2019;13(3):160-166. PMID:32201491

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