Perineal Massage

What is perineal massage?

Perineal massage is the process of massaging and gently stretching the skin, fascia and muscles of the pelvic floor, the opening of the vagina and the perineum (the space between your vaginal opening and your anus). This area of your body has to significantly relax and stretch to allow your baby out! Your body is 100% capable of doing this without you interfering in any way, but think of perineal massage like stretching before running: your body is probably capable of running ‘cold’ but you’re much less likely to get injured if you stretch well beforehand. Regular perineal massage in the run up to labour (and even before you start trying to get pregnant) can help to make your birth experience as easy and pain free as possible. It can also reduce your risk of tearing, bruising or the likelihood of needing an episiotomy (an intentional cut made by your doctor from your vaginal opening into the perineum). You can do perineal massage on yourself or you can have a partner, or trained professional, do it for you. Some people choose to use a device called an ‘Epi-No’ to help stretch the perineum but I encourage hands and fingers as the far better option for mindful touch and massage!

What does 'tearing' during labour mean?

The degree of tearing of the skin, fascia or muscles of the pelvic bowl and vaginal opening during labour falls into 4 categories:

1st degree: a tear that only affects the skin and superficial tissue layer around the entrance of the vagina. They usually heal within a few days but can cause temporary pain and discomfort when you pee.

2nd degree: a tear that deepens into the muscle layer. It’s not always the external perineum muscle but can be the transverse perineal massage inside your vagina (usually caused by the baby’s shoulder). These typically require stitches and you will likely experience pain during sitting, walking, peeing, and bowel movements for at least a week. It can take 4-6 weeks to fully heal.

3rd degree: also affects the muscles around the anus – the external anal sphincter. These can require repair under anaesthesia in an operating room, not in the delivery room.

4th degree: extends through the internal anal sphincter muscle to the mucous membrane inside the rectum. As with 3rd degree, it’s advised that you avoid ‘heavy lifting’ for 4-6 weeks (which can include picking your newborn up from the floor or cot).

So, with those slightly scary definitions in place, it’s easy to see why you might like to attend to your perineum and pelvic floor before your delivery day! Bear in mind though that 3rd and 4th degree tears are very rare, affecting only about 3-4% of women. The more severe tears are most likely if the baby is in an unusual position (e.g. hand up by the head), or if you had a tear or episiotomy during a previous labour.

Third trimester preparations

What are the benefits of perineal massage?

Some studies say that perineal massage in the third trimester doesn’t really make a difference to the likelihood of tearing during labour. However, in my experience, and the experience of my wonderful friend Flo Joly de Lotbiniere (a midwife and Integral Pelvic Therapy (IPT) practitioner), it is immensely effective in helping women to prepare for the experience of birth – mentally, emotionally and physically. Flo shared with me that during her time as an NHS midwife in the UK she saw countless women suffering with tears, episiotomies and difficult births because of the lack of guidance and encouragement given around perineal massage. In contrast, in her work in the Netherlands over the past few years, she has seen zero occurrences of tearing because of the IPT and massage techniques she uses with her clients. This has meant that her clients actual experience of labour, and their post-labour recovery, have been far less stressful than they might have been. Dealing with a newborn whilst also healing from tears and stitches is not so much fun!

One of the main benefits of perineal massage is that it offers the opportunity to get used to the kind of sensations you will experience during the final stages of labour. When your baby’s head reaches the base of your vaginal canal it can be easy to freak out with the sensation of stretching, burning and pressure. This is where my midwife friend Flo sees most women disconnect from the process and their bodies during labour, unable to relax into the feeling of just allowing the baby to slowly stretch the tissues. Being a little bit more used to this sensation from perineal massage will help you to be able to slow down and be present with it (without fighting it or running away from it). This often means less of a ‘popping out’ of the baby’s head, and a sudden stretching or ripping of the tissues.

When should you start perineal massage?

You can incorporate genital massage and perineal massage into your intimate life regardless of what stage of pregnancy you’re in (and even if you have no intention of becoming pregnant). Building a relaxed and loving connection with this part of your body is beneficial in many ways, whether that’s through mindful self-touch or enjoying massage from a partner. Most ‘experts’ suggest that the third trimester is a good time to start perineal massage, and to spend some time massaging every day or every other day if you can. 

How to prepare for perineal massage - what you'll need

Perineal massage tips

It can be really nice to take a warm bath before you begin your perineal massage. This relaxes your muscles and brings blood flow to the surface of the skin, which helps the tissues to stretch, and to feel softer and more supple. If you don’t have time, or don’t have a tub, a ‘quickie’ option is to heat some water (not too hot) and soak a flannel in it, then place the flannel over your vulva and perineum to warm and soften the area. Even if you’re not doing perineal massage, I think this is such a deeply relaxing and pleasurable sensation!

Creating a nice environment or atmosphere will take your massage from something only ‘functional’ to an opportunity to relax and switch from ‘heady’ working mind to a more relaxed ‘feeling’ state. This can be as simple as putting on some soft music (check out my Spotify playlists for some inspiration), or lighting some candles in the room.

Preparing for perineal massage
Positions for perineal massage

Whether you’re receiving from a partner or massaging yourself, I suggest using lots of cushions on the bed so that you can lie back and be propped up. Placing a towel over the bed sheets is a good idea as you’ll be using some oil for the massage (a word on those later). For self-massage you can also stand with one foot raised and resting (on a chair or low table) but make sure that you are able to feel comfortable and not in danger of losing your balance! With a partner it can be nice if you sit/recline/lie at the edge of the bed and they sit comfortably on some cushions on the floor, so their shoulders are about level with your hips.

You’re going to need some oil: please don’t use any perfumed ‘massage’ oils as these can upset the delicate pH balance of the vagina. My top recommendations are simple organic coconut oil, or almond oil. You can basically use any kind of natural plant oil that you feel comfortable with. I recommend avoiding anything with lots of chemicals (like vaseline or KY Jelly).

Oils to use for perineal massage
Relaxing perineal massage

Before you start massaging or being massaged, take a couple of moments to just check in with your body and let your attention settle on your breath – let any busy thoughts from the day slow down and take a mini-pause to let any initial tension or tightness relax. It can be nice to take a few sighing breaths: inhale through the nose then let the breath sigh out in a long exhale through the mouth (with the jaw soft and the mouth in an ‘aaaah’ shape rather than lips pursed as if you’re blowing out candles). Let your attention scan through your body from the top of your head down to the tips of your toes, pausing for a second or two at each area of your body and just noticing any sensations – they might be really ‘big’ sensations like warmth, pulsing, tension, or they might be more ‘subtle’ sensations like tingling, fizzing or softness. This practice of noticing and attending to the sensations will also come in handy later on.

How to do perineal massage on yourself...

Start by softly touching and massaging your breasts, down over your belly towards your pelvis. Let your hands rest for a few moments on your hips, then stroke along the inner thighs from the knees into the groin.   

  • cupping: place your whole hand flat over your vulva, just rest and be still. The warmth and soft pressure of your palm will warm the labia and begin to relax the pelvic floor muscles. Breathe deeply, stay here for a minute or so, don’t be in a hurry.
  • finger padding: using the pads of the first 2 or 3 fingers of both hands, massage in soft circles (like a cat pawing) in the groin crease and either side of the opening of your vagina. This is great for bringing blood flow to the pelvic floor muscles. Use some oil and slide the finger pads up from the perineum towards your pubic bone with varying pressures.
  • holding at the entrance: place the pad of your thumb at the entrance of your vagina (palm facing down) and apply a little pressure downwards so your thumb goes inside. 
  • stretches: imagine a clock face, gently press your thumb down towards 6 (towards your anus) and hold for 45-60 seconds. Repeat at 7 and 5, then 8 and 4, then 9 and 3. At each point add pressure gradually, allowing yourself to slowly feel the stretch. Pause when you feel the stretchy/tingly/burning/pressure sensation and then just hold on that spot. Once it relaxes you can go a little firmer with the pressure or move on to the next spot. Start with one thumb inside, move to all the spots then add your other thumb and repeat. Remember to breathe, and make sounds: this is not just about the physical stretch remember, it is about tuning in to your body and staying with the sensation, letting your mind and body relax into it.
  • thumb slides: with the pad of your thumb facing down at the entrance of your vagina, slowly move in a ‘U’ shape (use plenty of lube/oil here) with gentle pressure. Explore this with your thumb at different ‘depths’ (i.e. just the tip of your thumb inside, all the way up to the big knuckle and other points in between).

How to do perineal massage on a partner...

Start with some nice slow, soft massage strokes for the front of the body: let the hands caress down from the heart to the pelvis, and then from the knees along the inner thighs in towards the groin. This is relaxing for the nervous system and gradually brings attention down into the genitals.

  • cupping: place your whole hand flat over the vulva, just rest and be still. The warmth and soft pressure of your palm will warm the labia and begin to relax the pelvic floor muscles. Encourage your partner to breathe deeply and let your breath sync up with hers. Stay here for a minute or so, don’t be in a hurry.
  • thumbs up: use the thumbs to massage into the groin crease and either side of the opening of the vagina. Slide the thumbs slowly up from the perineum towards the pubic bone, ask your receiver to tell you if there are any points that feel tense or painful then just hold on that point with a little pressure until it relaxes.
  • holding at the entrance: place one finger against (not inside) the entrance of the vagina. Encourage your receiver to feel that they are ‘breathing’ the finger in (rather than you ‘pushing in’). You will gradually feel the band of muscle that forms the opening of the vagina relax and almost ‘suck’ your finger in. Gently adjust your hand position so that the palm is facing down and pause for a few seconds before moving onto the next part…
  • stretches: imagine a clock face, gently press your finger down towards 6 and hold for 45-60 seconds. Repeat at 7 and 5, then 8 and 4, then 9 and 3. At each point add pressure gradually, allowing the receiver to slowly feel the stretch. Encourage your partner to say ‘pause’ when she feels the stretchy/tingly/burning/pressure sensation and then just hold on that spot (as you did with the little pressure points on the outside). Once it relaxes you can go a little firmer with the pressure or move on to the next spot. Start with one finger inside, move to all the spots then add a second finger and repeat. Encourage your partner to make sound as she exhales. This is not just about the physical stretch remember, it is about her feeling she can stay with the sensation and let her mind and body relax into it.
  • circles: with the palm facing down, using one or two fingers inside, make gentle circles with the finger pads along the back wall of the vagina and gradually move the finger out of the vagina. Pause at the entrance then slide the fingers slowly back in and repeat the circling motion. Use plenty of oil and take your time. This is particularly good for the transverse perineal muscle.
  • thumb slides: place the pad of your thumb facing down at the entrance of the vagina, slowly move in a ‘U’ shape around the band of muscle that forms the opening (use plenty of lube/oil here). Use gentle pressure, increasing gradually, and work at different depths (i.e. with just the tip of your thumb inside, all the way up to the big knuckle inside, and any point in between).

With all of these techniques it’s really nice to remember to connect with pleasure! Add in some clitoral stimulation, and touch on the rest of the body so that it’s not all ‘hard work’! Just be mindful that you don’t start to clench up into the tension-based patterns of arousal usually associated with clitoral stimulation: play with your clit but keep your pelvis, your butt and your whole body as relaxed as you can. If your body has an imprint of these stretching sensations being accompanied by pleasure, and maybe even arousal, it will be easier to override the mind ‘freaking out’ during your labour.

Common mistakes to avoid with perineal massage

  1. Don’t approach this as a mechanical exercise or a ‘tick list’. it’s possible to do yourself more damage than good by going too hard, stretching too quickly or rushing through it. Let go of the misconception that you have to ‘stretch as much as possible’ during perineal massage to avoid tearing during labour. Stay in connection with the sensations, and listen to your body. This is the same as increasing flexibility in any other muscle: stretch a little and often, go to the point that you feel the sensation and can still breathe easily. You wouldn’t expect yourself to be able to immediately fling your leg above your head in a yoga class so don’t push your pelvis and your vagina either!
  2. Don’t just do it once and expect a miracle. Three minutes per day of gentle massage and stretching is better than 30 minutes once in three weeks.
  3. Don’t forget about the rest of your body. When we experience an intense or ‘painful’ sensation in one area the reaction is never restricted to that part. There is always a referred pattern of bracing or holding that runs through the fascia and the muscles. So, be curious about your thighs, your calves and your feet; pay attention to your jaw, your neck and your hands. Do these places clench up, tighten or contract? Relax the muscles that are under your conscious control (e.g. soften your jaw, un-ball your fists, relax your thighs) and you will be helping your nervous system to get the message that it’s ok to relax the muscles that are not under your conscious control.

Treat yourself to a professional session

If you and your partner want to learn how to give perineal massage safely and effectively, or if you want to just relax and receive for yourself, then you can get in touch to book a session. I offer couples coaching sessions in-person which include a demonstration from me, and the opportunity for you to practice the techniques. Individual sessions are 90 minutes and include an initial chat about your pregnancy so far and how you’re feeling about the birth, some time spent on massage for the rest of your body, and at least 30 minutes of perineal massage – a really luxurious and relaxing experience. Please email elizabeth@touchofhappiness.co.uk to enquire and check the availability page of my website for date/time options.

With Love,

Libby

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