Perineal massage no longer recommended?

[NJ*Doula]

I had my 10 week checkup today. We went over my birth plan again, because this was my second visit, and I saw a different midwife last time (there are three in the service, and they like to give you the chance to get to know them all). The one I saw today, Cindy, saw my mention of doing perineal massage in the later months of pregnancy, and told me I shouldn't. She said that she has not recommended it for 10 years, because it does more harm than good and damages the perineal tissue. She also said she has had a very low tear rate, and credits it in large part to this policy. Now, I got a good feeling from this midwife, and I like and trust her, so I'll be doing what she says. I just wanted to get your collective take on this and see who still recommends it and who doesn't, and why?

[Jane]

Hasn't been shown to change outcomes in clinical trials, so I don't recommend it. Done properly, it's involved and painful, so I can't recommend something that doesn't help and does hurt.

[sevenkids]

I've never recommend it either; until labour, the hormones that allow those tissues to nicely stretch are absent.
One of my preceptors used to recommend it, but more often than not, the women stopped doing it after a few tries because of the discomfort involved.

IMO, the best preventatives for tears are good nutrition, good hydration, and good genetics. The best perineal "massage", if any, is done by the baby's slowly descending head, and mom's own hands as the head emerges.

[mwherbs]

I don't think that there are studies on prepratory massage- if you want to and think it helps then do it--- there is some info on women who have sex more frequently have less friable tissues-- I am not going to tell a woman to keep hands off or partner's hands off and that it can make for more tearing because that is not true forceable -painful overstretching or any unwanted touching- is one thing but something that you are comfortable with then why not...
the recent studies on it's use in labor are equal- done or not done similar results I have had women want hands right there and some counter pressure- and others who don't want to be touched-- just up to mom what she wants and feels most comfortable to her--

[SublimeBirthGirl]

It's always seemed counterintuitive to me. I did my own counterpressure with my 2nd and that worked out very nicely. I wanted to with my first but I was surrounded by people and too self-conscious. I think most women who are 100% comfortable will do their own support if it's needed and will do it just right.

[mwherbs]

so I went and looked at the lit to see what all there is- if I had missed something on prep-- and here is a new one--

1: MCN Am J Matern Child Nurs. 2007 May-Jun;32(3):158-64.

Getting through birth in one piece: protecting the perineum.

Hastings-Tolsma M, Vincent D, Emeis C, Francisco T.

Nurse Midwifery, University of Colorado at Denver & Health Sciences Center, CO,
USA. [e-mail]

PURPOSE: To identify factors related to perineal trauma in childbirth,
replicating the work of . STUDY DESIGN AND METHOD: A retrospective descriptive analysis of pregnancy and birth data recorded into the Nurse Midwifery Clinical Data Set for women (N = 510) with a singleton pregnancy and largely uncomplicated prenatal course. Prenatal care occurred at four prenatal clinics with births at a tertiary care facility during 1996-1997, with care provided by nurse midwifery faculty. Multivariate statistics detailed clinical characteristics associated with perineal trauma. RESULTS: Episiotomy was related to parity, marital status, infant weight, fetal bradycardia, prolonged second stage labor, and lack of perineal care measures. Factors related to laceration were age, insurance status, and marital status. For all women, laceration was more likely when in lithotomy position for birth (p = .002) or when prolonged second stage labor occurred (p = .001). Factors that were protective against perineal trauma included massage,
warm compress use, manual support, and birthing in the lateral position. found that ethnicity and education were related to episiotomy and that warm compresses were protective. In this study, use of oils/lubricants increased lacerations, as did lithotomy positioning. Laceration rates were similar in both studies. Episiotomy use was lower in this study. CLINICAL IMPLICATIONS: Side-lying position for birth and perineal support and compress use are important interventions for decreasing perineal trauma. Strategies to promote perineal integrity need to be implemented by nurses who provide prenatal education and care for the laboring woman.

PMID: 17479052 [PubMed - indexed for MEDLINE]

[onlyboys]

Are we talking about perineal massage before labor or during? I'd like to know, because the birth center I teach at wants it taught. If there's any studies, I'd love to see them.

The center has a very low tear rate, and the women who have spoken to me of perineal massage were positive about it. I've also never seen massage during pushing, they are hands off.

[Veritaserum]

I found prenatal perineal massage, done by myself, to be beneficial in that I learned how to relax through those stretching sensations rather than freak out and push harder.

My best second stage, though, was when I did my own perineal support. That was great!

[BeckiCNM]

Here's a good evidence based review article on the topic from the ACNM journal- will need to register for medscape (free) - http://www.medscape.com/viewarticle/558117

Here's the abstract in case the link doesn't work:

Minimizing genital tract trauma and related pain following spontaneous vaginal birth.

Albers LL, Borders N.

University of New Mexico College of Nursing, Albuquerque, NM 87131-5688, USA. [e-mail] <[e-mail]>

J Midwifery Womens Health. 2007 May-Jun;52(3):246-53.

Genital tract trauma is common following vaginal childbirth, and perineal pain is a frequent symptom reported by new mothers. The following techniques and care measures are associated with lower rates of obstetric lacerations and related pain following spontaneous vaginal birth: antenatal perineal massage for nulliparous women, upright or lateral positions for birth, avoidance of Valsalva pushing, delayed pushing with epidural analgesia, avoidance of episiotomy, controlled delivery of the baby's head, use of Dexon (U.S. Surgical; Norwalk, CT) or Vicryl (Ethicon, Inc., Somerville, NJ) suture material, the "Fleming method" for suturing lacerations, and oral or rectal ibuprofen for perineal pain relief after delivery. Further research is warranted to determine the role of prenatal pelvic floor (Kegel) exercises, general exercise, and body mass index in reducing obstetric trauma, and also the role of pelvic floor and general exercise in pelvic floor recovery after childbirth.

Basically, two studies showed benefit from late pregnancy massage, but no benefit has been shown for massage in labor. This article doesn't include Dr. Tolsma's research.

[Reha]

Just thought I would post and link to Sara Wickham's article (one of them) on perineal tearing.

[lorijds]

I personally don't think it is that helpful--rather, there are other things to do that are more comfortable and less painful and involved than preparatory, late pregnancy perineal massage, things that are just if not more helpful.

The one exception to this, I think, is for women who have been sexually traumatized. In my very limited experience, many of these women said that the preparatory perineal massage helped them have a more positive birth experience. Being the one in control of the massage and the stretching sensations made them feel less frightened and they felt like they were less likely to have negative associations with past traumas during labor. It also gave them an idea of what to expect in terms of sensation.

This is not a large sample of women, just a few, who gave me that feedback. But it was enough to make me decide to mention preparatory perineal massage in class. I know a lot of women don't share their history of sexual abuse, so I always mention in class the above comments and give a brief run down of the theory behind it, and pass out a handout on how to do it. It takes all of one or two minutes to discuss. Just enough time for women who may feel like they would benefit from it to get some info, not enough time that it distracts significantly from class or takes time away from teaching other preparatory or labor techniques that I personally feel are more likely to help more women have fewer tears and a better birth experience.

[ldsapmom]

I love our own Pamamidwife's viewpoint on this, and her article that was published in Midwifery Today. http://www.midwiferytoday.com/articles/honoring.asp

As a breastfeeding counselor, the information today tells us our nipples do not need to be "prepared" for breastfeeding; I always kind of felt there was something odd about PM, and like the breasts, wouldn't the body take care of it if mom follows her own cues?

[pamamidwife]

what's interesting is how many providers say it's not necessary prenatally then do it during the birth. Hands off, hands off! but, I'm biased, of course. I don't like someone reaming my girlie bits when there's a head coming out. In fact, I don't want anyone's hands there at all!

[Veritaserum]

Originally Posted by lorijds

The one exception to this, I think, is for women who have been sexually traumatized. In my very limited experience, many of these women said that the preparatory perineal massage helped them have a more positive birth experience. Being the one in control of the massage and the stretching sensations made them feel less frightened and they felt like they were less likely to have negative associations with past traumas during labor. It also gave them an idea of what to expect in terms of sensation.

Hmm.... Interesting. Holds true for me....

Good point about not needing to prepare nipples for breastfeeding, too.

[mwherbs]

when catching my own baby I did my own guarding and moving of tissues because it felt good- although I did not do prep-perineal massage I have worked with different midwives over the years that have recommend it and they have had not that many tears- and I have worked with mws who had lots of tears- and I have had mixed results myself-- as for prenatal perineal massage there is some evidence and it all seems to match up that yep there is some use for first time moms at least.
differences we have from animals- the first things that come to mind- their vaginal openings are usually out in the air all the time uncovered- and many animals lick as they give birth-- something we would be hard pressed to accomplish-- as for nipples and prep- some women who have inverted nipples are better served to do some prep- like wearing the breast cups-- to help draw the nipples out better and loosen the adhesions--
I would also like to know what is so "natural" about never touching your own parts, before or during birth

[ldsapmom]

My own opinion is, it IS natural to touch your own body during birth, whether guarding, guiding, or just feeling. It ISN'T natural to have a care provider trying to stretch, pull, and manually "open" you.

As far as the breast analogy, I was meaning the old adage that nipples needed to be "toughened up" to get used to a baby's suck. In the case of inverted nipples, yes, prenatal assistance can be of benefit, but that is not to say, across the board, every woman should use hobbits before birth. Some women do benefit from and require perineal touch from a caregiver, but in general, if a woman is able to tune into her own body and follow its cues, not only would she be hard-pressed to tell a caregiver when and what kind of support she needs, she probably wouldn't need much!