Perineal Massage - Do or don’t? Interview with pelvic floor therapist, Dr. Ivy Colbert

So you’re scrolling #birthtok and learning about perineal massage but hearing mixed messages - one influencer is saying perineal massage is a MUST if you want to prevent tearing during childbirth, yet another is telling you it’s not worth your time. Who is actually right?! 

We are here today to clear this up once and for all in this interview with pelvic floor therapist, Dr. Ivy Colbert who specializes working with pregnant and postpartum patients in North County San Diego.

Let’s begin!

First of all, what exactly is perineal massage?

Perineal massage is a technique that involves gentle massage and stretching of the perineum, which is a thick band of tissue that runs between your vaginal and anal opening. It is often recommended to pregnant people by some pelvic floor therapists, doulas or midwives to prepare these tissues to stretch for birth. Perineal tearing occurs in about 85% of people that give birth and is graded on a 1- 4 severity scale. The thought behind perineal massage is to reduce the likelihood and severity of perineal tearing. 

What does the evidence say about perineal massage to reduce the likelihood of tearing in childbirth? 

Perineal massage has been practiced for many years, however the evidence supporting it’s effectiveness is still somewhat mixed. Here we will review several studies and what the research demonstrates about perineal massage.

Here are several studies that have shown it’s potential benefits:

• Cochrane Review: A systematic review published in the Cochrane Database of Systematic Reviews in 2017 analyzed 26 randomized controlled trials (RCTs) involving over 12,000 women. The review found that perineal massage performed in the last month of pregnancy reduced the likelihood of perineal trauma requiring stitches (episiotomy or perineal tear) and the risk of ongoing perineal pain postpartum.
• Another study published in Birth: Issues in Perinatal Care in 2005 involved 191 women and examined the effects of perineal massage during labor. The study found that women who had received perineal massage had a significantly lower rate of episiotomy and perineal tears compared to those who did not receive the massage.
• A systematic review published in the Journal of Maternal-Fetal and Neonatal Medicine in 2019 examined 14 studies and concluded that perineal massage reduced the risk of severe perineal trauma (third- and fourth-degree tears) during childbirth.

However, some other studies have not found significant benefits. Here are a few studies highlighting the opposing viewpoints:

• A randomized controlled trial published in the Lancet in 2013 examined the effects of antenatal perineal massage in 1,057 women. The study found no significant difference in rates of perineal trauma or episiotomy between the massage group and the control group.
• A systematic review published in the Journal of Obstetrics and Gynaecology Canada in 2017 analyzed nine studies and concluded that the evidence on perineal massage was inconsistent and insufficient to support its routine use.
• A Cochrane Review published in 2020 analyzed 15 studies involving over 6,000 women and found limited evidence to determine the effectiveness of perineal massage in preventing perineal trauma or improving other outcomes. The review noted that the quality of evidence was generally low, and more research is needed.

The decision on whether or not to perform perineal massage should be based on the individual’s preferences and discussion with a healthcare provider. While the evidence is mixed on whether perineal massage is effective or not, as pelvic floor therapists we still see a benefit to our clients that perineal massage is well-suited for and choose to perform it.

Clinically, we’ve found perineal massage to ease tension and help relax tight pelvic floor muscles, similar to how massage would help any other muscle in the body. Additionally, it can also help teach your body to release tension and relax while experiencing the feeling of the stretch. This can help to mimic the feeling of  the baby’s head stretching the perineum, so that you can practice relaxing your body in response to a stretch rather than tensing.  

Is this something you do during pregnancy or is it something your provider does during the pushing stage of labor? 

As pelvic floor therapists, perineal massage is something we will do for you during birth preparation sessions during your third trimester, as well as teach you and/or your partner to perform it at home. We usually recommend pregnant people start sometime between 34 and 36 weeks and perform up until the date of delivery. The maximum amount of time to spend on perineal massage is 10 minutes, no more than 2 to 3 times per week. 

 Some OBGYNs and midwives do perineal massage during the pushing stage of labor, but this is something an individual will typically include in their birth plan on whether or not they would like it performed during labor. 

Does it hurt? What tips do you have to get through any discomfort?

Perineal massage should not hurt, in fact, the pressure should be firm but gentle -- enough to cause a stretching sensation, but not cause any pain. If it is too uncomfortable, we recommend to reduce your pressure until it is tolerable and then focus on your breath. You should be in a reclined and relaxed position, without any muscles in your body holding tension. If it is difficult to reach, we recommend using a pelvic wand, like this one from intimate rose or having your partner do it for you. Several visual cues we like to use are: “Imagine the area softening and melting like butter” or “Imagine your vulva as a flower blooming open as you inhale”. It is also helpful if you focus on letting go of your jaw, face and shoulders. This will also help to relax your pelvic floor. 

Can you tell us more about your pelvic floor therapy in general? Why would pregnant people benefit from seeing you before childbirth?

Pelvic floor therapy is the treatment and prevention of pelvic floor dysfunction, which involves a range of issues that includes (but is not limited to): peeing in your pants when you laugh or sneeze, pain with intercourse, vaginal heaviness from pelvic organ prolapse, hemorrhoids, etc. During pregnancy, people are more prone to pelvic floor issues due to dynamic physical changes that happen in the body due to carrying the weight of the baby and the increase of the hormone, relaxin, which causes all the ligaments in our body to become very loose.

These pelvic floor issues are all things that many people are told are normal just because they are pregnant or have had a baby. And unfortunately many people end up living with and silently suffering from these issues for most of their lives because they don’t know that there is help for it. Although pelvic floor dysfunction is common, it is NOT normal because something can be done to prevent it and treat it! Pelvic floor therapy to prepare for a life-changing event such as childbirth is so important for our pelvic health and longevity.

Additionally, we can treat any pregnancy aches and pains through bodywork and exercise to help you feel stronger and more comfortable during pregnancy leading up to your date of delivery. In addition to perineal massage, we recommend pelvic floor stretches that can also help your pelvic floor to relax in preparation for birth. You can get our free handout here. 

What is one thing you wish all pregnant people knew before childbirth?

Just like training your body for a marathon, you CAN prepare your body for childbirth and prepare your body to have a better postpartum recovery.

At Empower Physical Therapy, we offer birth preparation sessions to address any pregnancy pains and help prepare your body for birth. If you are pregnant and in San Diego, we’d love to be a part of your prenatal journey! Reach out to us and book a free phone consult to see if you would benefit from pelvic floor therapy. 

**The information in this blog post is for educational purposes only and is not individual medical advice or meant to create a doctor-patient relationship. 

You can learn more about Dr. Ivy Colbert and her practice, Empower Physical Therapy, located in North County San Diego here.