This was supposed to be an article about how to use the ancient art of perineal massage to prevent tearing in childbirth. I even made an overly-detailed infographic on how to do perineal massage that you can reference and share.
After I made the infographic I looked at it and thought, “My obsession with the perineum is weird. It’s a tiny bit of tissue. What’s the story here?”
This no longer an article on how to do perineal massage. This is an article on “what’s the story here?” and why we are so obsessed with tearing in childbirth.
Perineal massage is a modern practice that is intended to prevent or minimize tearing your perineum in childbirth. Your perineum is the bridge of tissue between your vagina and your bum.
Perineal massage is common enough in the birth world. More than half of my clients ask me about it.
I used to think that when I talked about perineal massage with folks I was giving them a useful tool to prepare for birth. After giving birth I realize that the current interest in managing the outcome of this little 2 x 2 cm chunk of flesh — which usually tears spontaneously in birth and heals beautifully on its own without our help — speaks to a larger cultural story of controlling what little we can in childbirth.
Yep. I’ll say it again. The focus on preventing tearing your perineum reflects our culturally engrained practice of zeroing in on little things we can control in one the great mysteries of this life, childbirth.
Meddling with the perineum also reflects the current fashion for birthing lying down with your crotch at your midwife or doctor’s eye level as they are often staring at it for hours on end and wondering how they can help!
Drawing on old midwifery and obstetrical texts I’ll show that we’ve been managing this little piece of tissue for three centuries, about as long as we’ve been giving birth lying down rather than upright.
Perineal massage is just one part of a long legacy of trying to affect birth outcomes by controlling the perineum – the little bit of the birth canal we can actually see. This legacy also includes rituals like episiotomy, shaving, draping, and the application of chlorhexidine.
I hope that by placing perineal massage in its historical context I can help parents and birth workers think critically about their own practice and be wary of the influence of trends on their birth and life.
WHAT IS PERINEAL MASSAGE
Perineal massage is when you manually stretch the opening of your vagina before giving birth so that the muscles are looser when your baby’s head passes over them during crowning. That way the muscles stretch but don’t tear. It’s like warm up for birth.
Perineal massage is a common idea today. There are likely handouts in your midwife’s office on how to do it. There is even a Cochrane review – the highest level of evidence-based medicine involving the most powerful studies to date – that shows that perineal massage before birth reduces the incidence of tearing in childbirth.
You can do perineal massage with a bottle of olive oil and your hands or, if you are more comfortable with technology, there is a device you can purchase for $200 that will inflate like a balloon inside your vagina and do the stretching for you. It’s called the Epi-No. I have to guess that this stands for Episiotomy, No!
“Before my birth I could reach setting 7,” I heard one client say to another about the Epi-No. From across the waiting room, “Wow! I couldn’t get to 7 until my second child.”
The website touts the Epi-No as an alternative to the ancient “African” practice of inserting gourds of increasingly large diameter into your vagina to prepare to give birth. I think that the marketing strategy is to equate African and gourds with natural and natural with better.
While the natural African gourd story is one way to think about the Epi-No, there is another way to see it: for $200 you can manage your perineum yourself rather than have your midwife or doctor do it — as if to say, “you can either stretch it yourself or have your midwife or doctor cut an episiotomy.”
But why does your perineum need to be managed at all? Where did this story of the managed perineum come from? Why can’t we just have free-range perineums!
JOURNEY FROM INNOCENCE TO EXPERIENCE
I should have known many years ago that perineal massage was about managing birth anxiety when I was trying to figure out what to tell people when they asked me how to do perineal massage.
I knew that the authors of the Cochrane review admitted that though perineal massage reduces tearing there is “considerably heterogeneity” amongst the trials included as to what a perineal massage actually is, meaning we think it helps but no one really knows how to do it.
When I was a student midwife a client asked me how to do perineal massage. I had read it described many different ways. One finger covered in oil inserted up to the nail bed and rubbed back and forth sideways (ouch). Two fingers up to the second knuckle. EIGHT FINGERS up to the third knuckle (all the way in)! Lights dimmed. Lights off. Vaseline. Vitamin E Oil. Chanting. Anne Frye, Constance Sinclair, Ina May – they all had their own way.
I wanted to explain this spectrum of approaches to my client but I knew she wouldn’t care for my book report and just wanted a practical suggestion so I said words to the effect of, “have your partner stick two oiled fingers in your vagina and press down until it’s uncomfortable. Do yoga breathing until it’s comfortable. Repeat a few more times, three days a week, until birth.”
I said “press down on your vagina” because after birth I was usually suturing a thick band of muscle at the base of the vagina. Generally 3-4 stitches, not a lot, and six weeks later their vagina usually looked like nothing had happened.
I decided to wait and see how things went with my client that week before recommending eight fingers all the way in.
At her next visit the client complained that her vagina was unbearably itchy. On assessment the tissue was red, raw, scratchy – if I hadn’t known she was stretching it I would have erroneously treated for yeast. “Let’s take a break on the massage,” I recommended. She went into labour and gave birth a few days later. No tearing.
LIKE BITING YOUR CHEEK
The tissue of the vagina is so resilient, stretchy, and healthy it oughtta be a World Wonder. It doesn’t need a lot of help to heal after birth. A midwife mentor of mine once told me something like,
“Evolution has made the tissue in your vagina so vascular [good blood supply] that it heals beautifully, as quick as when you accidentally bite your cheek. You could put two pieces of perineum on opposite sides of this room [*gestures dramatically across the classroom*] and by the end of six weeks they would have found each other and healed together.”– a wise midwife mentor
WHAT DOES THE RESEARCH SAY ABOUT TEARING
Tearing is common in childbirth with ~75% of folks giving birth having some type of tear to their perineum, labia, or vagina.
Of the folks who tear, most will have a small tear limited to the skin and muscle of their vagina. A rare few will have a tear that extends to their anal sphincter. In my career I’ve seen five tears extend to the bum and three of these have been related to forceps or vacuum use – not spontaneous, straightforward births. Like vaginal tears, tears that extend to the bum generally heal beautifully.
It used to be routine for physicians to cut the perineum open with scissors rather than let it tear on its own. Routine! We’ll explore how this came to be shortly.
There appears to be no advantage to suturing vaginal tears compared to leaving them alone.
Stitches have the disadvantage of being associated with more pain reported in the first three months postpartum and less success with breastfeeding. Having got a few stitches in my birth I can attest to the fact that the most painful part of my whole recovery was the way the stitches pulled on my tissue while I tried to sit up and breastfeed.
So if there is no benefit to suturing vaginal tears why do we do it? I sense a big reason is medico-legal: one of the top complaints to our midwife college is from people displeased with not being sutured. This is likely cultural – of course a wound is going to heal poorly if we expect people to be back to running their house within a few days of giving birth.
75% of people tear spontaneously in childbirth.
These tears happen mostly in the perineum but can also elsewhere in the birth canal like on the walls of the vagina, the labia, and on the anal sphincter.
Vaginal tissue heals beautifully on its own, especially with rest.
Given the information above it sounds the body has birth and recovery figured out on its own. And yet we meddle with gourds, balloons, oiled fingers, and scissors. What gives?
I TEST-DRIVE THE EIGHT-FINGER PERINEAL MASSAGE
Years later I find myself pregnant for the first time and weeks away from giving birth. I decide to do perineal massage so I can show up to my birth loose and limber. I imagine that I am taking part in an ancient ritual.
It has not yet crossed my mind that I could be very nervous about giving birth and focusing all my neuroses on this little piece of tissue as a socially acceptable way of coping. My poor little perineum!
I have caught the babies of about 200 people by the time I give birth. I have looked at these people’s perineums after birth and put stitches in some and no stitches in others. I have not noticed a difference in the quality of healing – generally folks feel good around six weeks postpartum when I discharge them and great a few months later when I bump into them on the street. (“How is your perineum?” is one of my standard greetings.)
One night when I am very pregnant I set up the bedroom of my tiny apartment in the sky for perineal massage. Dim lights, a bowl of warm water, grapeseed oil. My husband uses the water and a compress to warm my vagina up and inserts his index fingers, well-oiled and up to the middle knuckle. He presses down. It feels terrible. There is a lot of moaning and complaining and yoga breathing. After a few minutes I can relax my shoulders and then my body. I try to be extra productive with this time by visualizing my birth like an athlete before a race. After ten minutes I’ve had enough.
We repeat this every couple of days for weeks leading up to my birth. By three weeks he can easily stretch the muscles around the base of my vagina with eight fingers. Eight! It is a sweaty, terrible affair but this is birth dammit and I’m going to show up ready!
A few days before giving birth I visit a very experienced pelvic floor physiotherapist. She puts her hand inside my vagina and tells me she is softening the muscles around the birth canal. She informs me that she is paving the way.
“We are now going to practice perineal massage to help your tissue prepare for birth,” she looks at my sympathetically, “tell me if it’s too much.” I groan. I feel some fidgeting around my vagina but nothing more. I peek around my belly at her. She has one finger inside my vagina up to her nailbed, less than the first knuckle. She is stretching the skin but not the muscle I’ve been working on further back. This is her perineal massage. “Your tissue is incredible.”
I think to myself, “one finger or eight, we are all making this up.”
DOES PERINEAL MASSAGE WORK? I GIVE BIRTH
I give birth three days past my due date. There are a few days of early labour, six hours of good hard rockin’ labour, and then three big pushes. It is a lovely birth. His head is 38 cm! That’s very, very big.
My perineum — the muscles we stretched with eight fingers before the birth – does not tear. The stretches did their magic.
I tear in a part of my vagina I could never had stretched – way up high inside on a wall. My baby is born sucking his wrist with his left hand up around the side of his head like Lady Gaga vogueing. This presentation is normal but a little annoying – it increases the diameter of baby that needs to fit through your pelvis by a few centimeters so the biggest part is now head + hand rather than just a head. We call this birth pose a “nuchal arm,” nuchal being Latin for relating to the neck. As he descends his fingers tear a wall of my vagina a little. This is par for the course with a nuchal arm. It feels like biting your cheek.
My midwife throws a few stitches up there while I breastfeed my baby. I get up and pee, go home, and pass out in my own bed.
I lay in bed for two weeks while my husband runs the house – our version of an old-fashioned lying in period. It is the best time ever. My biggest complaint is that I can feel my stitches pulling sharply when I sit up to breastfeed. I push my midwife to take them out sooner than she would like and I feel instantly better.
Over the next few weeks I try to do a little more around the house. When it feels like my vagina is going to fall out of my body I take it as a cue to get back in bed. My baby seems to prefer bed anyway. It’s a great system. By six weeks postpartum my whole pelvic area feels better than ever.
LIFE WITH A BABY: WHAT PERINEUM?
Once my baby starts rolling I am so busy being his mom that I quickly forget about my perineum, the little chunk of tissue I used to project all my hopes and dreams on.
Someone asks me to write a blog about perineal massage. As I make my detailed infographic it hits me: I sound crazy. Putting eight fingers in your vagina and reefing on it in the weeks before giving birth is crazy. I start to really think about my obsession with preventing tearing. What am I trying to control? Everyone knows birth is a miraculous mystery beyond control.
MY DEGREE IN MEDIEVAL STUDIES COMES IN HANDY: A HERSTORY OF THE PERINEUM
During naptime I do a literature search on the herstory of the perineum. It turns out some very bright people have also wondered why we’re so obsessed with managing the perineum in birth. Let me tell you about what my favourite one came up with.
Midwife Wise Woman Hannah Dahlen PhD has written on the herstory of the perineum in childbirth. Starting with Soraneous in the first century AD she closely reads midwifery and obstetrical literature and shows that the world took a truly hands-off approach to the perineum until the mid-18th century and then, as male midwives, forceps, and giving birth lying down became common, we became overly interested in the perineum. Probably in part because we started spending so much time staring at it.
Dahlen theorizes that there existed a “social model” of perineal care until the mid-18th century. Folks thought about this bit of tissue in birth about as much as they did in daily life – we don’t look at people’s perineums normally so why would we at birth? Soraneous advises midwives words to the effect of “don’t stare, it’s rude”: “beware of fixing her gaze steadfastly on the genitals of the labouring woman, lest being ashamed, her body become contracted.” At this time most people seem to give birth upright so you don’t even really see it.
In the mid-18th century we see a shift to a “surgical model” of managing the perineum. This “surgical model” emerges out of cultural shifts like the advent of the male midwife, forceps, and giving birth lying down. I imagine if you are a man holding scissors and forceps (essentially salad tongs that reach up, grab, and pull the baby out) and you’re staring at a bulging perineum for three hours while a woman huffs and puffs trying to push her baby out lying down in front of you, it’s hard not to fiddle and snip.
Dahlen contrasts the writings of two male midwives in the mid 18th century to that of female midwives like Justine Siegemund half a century earlier to show the evolution from a social model to a surgical model.
Justine Siegemund, a midwife writing in the 1690s, advocates for a hands off approach to a woman’s “secrets” [genitals]:
You certainly should not stretch or dilate anything with your fingers. This is a common mistake This sharp stretching injured the woman’s belly [genitals] and causes swelling before the child gets that far and comes forth. Thus the pain of the child’s passing through is all the greater because of the swelling and the injured belly.Justine Siegemund, 17th century midwife
Dahlen notes that Madame du Coudray, a famous French midwife writing a little after Siegemund, also advises against “too much vaginal meddling. The best thing is to wait patiently, alert to all cues.”
Seventy years later male-midwife John Havie publishes a tract detailing hands-on management of the perineum unlike anything in print before:
… every pain must be attended to; and as soon as the pain has acted long enough to render the perineum tight, the further action of that pain must be totally prevented by the palm of the left hand applied over a warm clean cloth against the perineum with a proper force.John Havie, 18th century male-midwife
Paired with the writing of Sir Fielding Ould we see an emerging interest in what Dahlen’s called “the mechanics of birth” and a surgical understanding of the perineum. Ould is attributed with the first description of an episiotomy in 1742:
. . . so that the Head after it has passed the Bones, thrusts the Flesh and Integuments before it, as if were contained in a Purse; in which condition if it continues long, the Labour will become dangerous, by the Orifice of the womb contracting about the Child’s Neck; wherefore it must be dilated if possible by the fingers, and forced over the Child’s Head; if this cannot be accomplished, there must be an Incision made towards the Aus with a Pair of crooked Probe- Scissors. The Business is done at one Pinch, by which the whole Body will easily come Forth.Sir Fielding Ould, 18th century male-midwife
Ould’s understanding of the perineum as a “purse” and baby extracting with scissors as “business” is a whole other metaphor to unpack, but not today…
Ould and Havie’s passages reflect the start of the surgical model of the perineum in which the perineum is a site to be actively managed in birth. This model spiralled over the next three centuries and took many forms like ritual draping, shaving, and the application of disinfectant like chlorhexidine.
Drawing on examples from 20th century obstetrical literature Dahlen shows that birth workers continue to be obsessed with thinking about the perineum as a site of pathology best managed with surgery. They just can’t leave it alone! In the 1950s Williams Obstetrics begins referring to the baby’s head as a battering ram and the vagina as a locked door, which an episiotomy can help to open. This metaphor sticks for six editions.
In the active birth movement of the late 1970s and early 80s consumers begin to resist surgical management of their births and reclaim their perineums. It was a groovy time. Michael Klein’s landmark 1992 trial, which showed episiotomy to cause the very problems in was meant to prevent, including pain and trauma to your bum, buoyed consumers’ efforts.
While the work of these activist consumers means we might not do as many episiotomies today, we still obsess about managing the perineum in birth… likely because of the legacy of centuries of characterizing the perineum as a pathology best managed with surgery.
In my own practice as a midwife I have not, as pre-surgical model midwives suggest, avoided “too much vaginal meddling” and watched and waited, “alert to all cues.” I sat at the end of the bed, stared at people’s perineums while they pushed and tried to help the perineum stretch with my fingers. Why did I do that?! I encouraged people to stretch their perineums with their fingers or with balloons before they gave birth. I carried the anxiety about control born out of the legacy of the surgical model but my worries took the form of socially acceptable “natural” approaches to management like massage, stretching, and prenatal pelvic floor physiotherapy.
No more! Knowledge is power. No more.
I have suggested that perineal massage is a small part of the legacy of three centuries of thinking about the perineum as a site of pathology best managed with surgery.
Starting with my adventures as a student midwife trying to figure out how to counsel folks on perineal massage, pausing to review perineal anatomy and physiology – which works great on its own — and then winding through my experience as a pregnant person doing perineal massage, I show that for me perineal massage was a way to channel my anxiety about control and birth onto the teeny tiny bit of birth canal that is visible to the world.
Using Hannah Dahlen’s PhD research on the herstory of the perineum I show that our understanding of the perineum’s function and normalness/pathology has changed over time from social to surgical to today’s social/surgical blend.
I hope that in reading this article birthing folks and birth workers will be critical of how trends affect their birth and practice. I’m going to start being more attentive to how long I am staring at someone’s perineum for and how that might make me meddle too early. Maybe I’ll even take a chapter from wise old Soraneous: “don’t stare, it’s rude.”
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
Dahlen H et al. From social to surgical: Historical perspectives on perineal care during labour and birth. Women and Birth (2011)24, 105-111.
Elharmeel SMA, Chaudhary Y, Tan S, Scheermeyer E, Hanafy A, van Driel ML. Surgical repair versus non‐surgical management of spontaneous perineal tears. Cochrane Database of Systematic Reviews 2010, Issue 6. Art. No.: CD008534. DOI: 10.1002/14651858.CD008534.
Frye A. Healing Passage: A Midwife’s Guide to the Care and Repair of the Tissues Involved in Birth. 6th ed. Labrys Press. 2010.
Klein MC et al. Does Episiotomy Prevent Perineal Trauma and Pelvic Floor Relaxation? First North American Trial of Episiotomy. Inaugral Issue: OnLine Journal of Current Clinical Trials American Association Advancement Sciences. 1992. 1:July 1 (Doc 10)