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 practicing 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- or 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 practiced 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 be gently expelled from the vagina. A randomized controlled trial on this product showed that antenatal use of the Epi-No® device is unlikely to be clinically beneficial in the prevention of intrapartum levator ani damage or anal sphincter and perineal trauma as diagnosed with ultrasound imaging (Atan et al. 2016).
It has been shown that almost 60% of women who have never given birth report some pelvic floor symptoms (Durnea et al 2014) and clinically it can be observed that many women present with high tone and sometimes painful pelvic floor at this stage. 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 extend to manual therapy of the deep 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 program for daily practice.