Antenatal Perineal Massage & Pelvic Floor Preparation

Antenatal digital perineal massage reduces the likelihood of perineal trauma (mainly episiotomies) and the reporting of ongoing perineal pain.Women should be made aware of the likely benefit of perineal massage and provided with information on how to massage (Beckmann & Stock 2013).This is based on a review including four studies (2497 women) comparing digital perineal massage with control. Antenatal digital perineal massage was associated with an overall reduction in the incidence of trauma requiring suturing and women practising perineal massage were less likely to have an episiotomy. These findings were significant for women without previous vaginal birth only.No differences were seen in the incidence of first- or second-degree perineal tears or third-/fourth-degree perineal trauma. There was a reduction in the incidence of pain at three months postpartum in women who had previously given birth vaginally. No significant differences were observed in the incidence of instrumental deliveries, sexual satisfaction, or any type of incontinence for women who practised perineal massage compared with those who did not massage.The basic perineal massage technique is the woman or partner performs daily 5-10 minute perineal massage from 34 weeks. One to two fingers are introduced 3-4 cm in vagina, applying alternating downward and sideward pressure using sweet almond oil (Labreque 1994). Other descriptions are to perform massage for 4 minutes 3-4 times per week from 34 weeks, 5cms into the vagina and sweeping downward from 3 o clock to 9 o clock (Shipman 1997).The EPI-NO has been designed to assist women with antenatal perineal release and it is recommended to use it from 37 weeks. It is recommended to insert the balloon 2/3rds into the vagina and to contract and relax the muscles against the balloon, which provides resistance. It should then slowly be inflated to the point of stretching and comfort each day and the muscles are stretched more. After the stretching phase the pelvic floor muscles are relaxed to allow the inflated balloon to gently expel itself from the vagina. Initial studies on this product showed some reduction in risk of birth injury but this was not conclusive (Shek et al. 2011).At www.milltownphysiotherapy.com we teach breathing release for the pelvic floor from 34 weeks gestation and gradually increase to include perineal massage, connective tissue manipulation of the external perineum and manual therapy of the pelvic floor muscles. We recommend 3-4 sessions as needed with a chartered physiotherapist with a special interest in women’s health depending on the resting position and tension of the pelvic floor. We teach a home exercise programme for daily practice. Recent studies have shown that almost 60% of women who have never given birth present with pelvic floor symptoms so it is reasonable to assume that many women will present with pelvic floor tension before they start into their pregnancy (Durnea et al 2014). References: Beckmann MM, Stock OM. Antenatal perineal massage for reducing perineal trauma. Cochrane Database of Systematic Reviews 2013, Issue 4. Art. No.: CD005123. DOI:10.1002/14651858.CD005123.pub3.Durnea CM Khashan AS Kenny LC et al An insight into pelvic floor status in nulliparous women Int Urogynecol J (2014) 25:337–345Labrecque M, Marcoux S, Pinault JJ, et al. Prevention of perineal trauma by perineal massage during pregnancy: a pilot study. Birth 1994;21(1):20–5.Shek KL, Chantarasorn V, Langer S. & et al. Does the Epi-No® Birth Trainer reduce levator trauma? A randomised controlled trial. Int Urogynecol J (2011) 22:1521–1528Shipman MK, Boniface DR, Tefft ME, McCloghry F. Antenatal perineal massage and subsequent perineal outcomes: a randomised controlled trial. British Journal of Obstetrics and Gynaecology 1997;104 (7):787–91.