If you’re in your third trimester you may or may not have heard of perineal massage but what exactly is it?
The perineum is the small amount of tissue that runs from the vagina to the anus. It’s made up of skin, muscle and fascia and is divided into three main sections. The bulbospongiosis (bulbo) muscle which is a part of the pelvic floor and is a circular muscle at the entrance of your vagina. Then there is the perineal body the tissue between the vagina and anus. And then two circular muscles that surround the anus – the internal and external anal sphincter.
In a first degree tear it is mostly bulbo affected, a second degree tears through to the perineal body, a third degree tears to the external anal sphincter and a fourth degree tear through to the internal anal sphincter.
Now the reason that a third and fourth degree tear can cause problems is because they affect the deep anal sphincter muscles which are required for voluntary control of your bowels. In some cases women may experience some degree of faecal incontinence until strength is restored. Now NO ONE wants to be shitting themselves after birth (literally) and for this reason your midwife or obstetrician will closely monitor your risk during your birth and may suggest an episiotomy.
This is where they create an angular incision to prevent tearing. So imagine your vagina and your anus as two circles and then a body of tissue running in between called the perineal body, then there’s two circles around your anus, the internal and external anal sphincter. So if you tear all the way from your vagina to your anus, that is going to create tearing through those muscles. However, if there is an incision completed to the diagonal, it will avoid the circles around your anus, this is why an obstetrician or midwife may suggest an episiotomy.
Perineal massage is a method of preparing the outlet of the birth passage for the stretching and pressure sensations during the birth of your baby. Perineal massage can help to decrease the risk of episiotomy or perineal tears. Let’s talk about how this works?
Firstly everyone has different elasticity in their connective tissue and different flexibility in their muscles. If you’ve ever been to a yoga class and looked around the room you would know this. Some women are quite hyper-mobile and can bend into all sorts of shapes and other women are quite naturally tight and stiff – part of this is genetics and a part of this comes down to use it it or loose it.
Think about the difference in flexibility in the pelvis of a 20-year old yoga teacher vs a 35 year old office worker. We loose flexibility all over our body as we age – you probably find it harder to sit on the floor now than you did when you were 12. We also loose flexibility if we don’t use it. This applies equally to the pelvic floor as well as the muscles connecting within close proximity to the perineum such as the inner thigh and deep hip muscles.
Fortunately during pregnancy your body produces hormones which help to increase the flexibility in muscles and connective tissue but you might also see how beneficial yoga, perineal massage and hip opening stretches can to prepare for birth!
Now the pelvic floor and perineum are very complex muscles because they are highly innervated by nerves and closely connected to our emotional brain – this is what stimulates organism and arousal. However, it is also a common place were we hold tension and fear, much like people hold tension in their jaws and neck when they are stressed the pelvic floor is another common place we hold tension. As a pelvic floor physio, I see so much variety in pelvic floor tightness and tone – ranging from a good ability to contract and relax to women who don’t know how to switch there pelvic floor off and who have a very tight pelvic floor!
The pelvic floor also, much like any other muscles in our body, tightens and contracts in response to trauma, this might be from direct impact ie. falling on your bottom snowboarding, or sexual trauma, or an indirect response to pain such as a pain from recurrent thrush, UTI’s or endometriosis.
If you imagine that your giving birth and your baby’s head starts crowning all of a sudden there is quite significant pressure down on the pelvic floor requiring the pelvic floor and perineum to stretch significantly. So when you first start to get this stretching sensation, a message will be sent to the brain to look for what has happened in the past, is there danger or threat?
Now, if you have had any sort of trauma, ie. endometriosis and recurrent painful periods. It could be recurrent thrush infections or urinary tract infections causing the general irritation around the vulva. It might be a history of sexual trauma or falling off a bike or a horse, or even falling snowboarding straight onto your bottom, where you’ve had that direct trauma to the coccyx and it’s caused that tightening of the muscles around the area but also the pelvic floor.
Then this messages it’s going to be sent back to your brain. A pain signal is then going to be sent back to the pelvic floor to contract and protect. And this all comes down to pain physiology.
I’ll use a story of Lorimer Mosely a pain researcher to explain this. Lorimer was walking through the bush in Australia and felt something brush up against his leg, a message got sent to his brain. “What’s happened like this in the past, Is there any reason to respond with threat or pain?” His brain assumes it’s just a twig and responds with no pain. Then looks down at his leg only to realise that he has been bitten by a snake, he gets rushed to hospital, given an anti-venom and he thankfully survives. But you a year later, he is again, walking through the bush and feels something brush up against his leg, again message gets sent to his brain “What’s happened like this in the past, Is there any reason to respond with tightness, with trauma, with pain, with threat?!” He drops to the ground in excruciating pain, crying in pain and absolute agony. And then he looks down only to discover it was just a twig.
So you can start to see how past experience, past trauma, fear or tension in the pelvic floor can have an impact during childbirth.
So what does perineal massage do?
Perineal massage helps to ensure your pelvic floor and perineum has good flexibility and ability to stretch during labour without tearing. It also works to ensure you’ve addressed any protective tightening or pain responses that may occur BEFORE birth. It physically stretches the muscles but it also allows the brain to be rewired so that the stretching sensation is not perceived as threat or pain! When you do perineal massage you can use techniques like imagery, breath work and graded exposure to reduce pain and threat. So the first time you release the perineal massage it might be painful but as you continue to apply gentle pressure the pain should significantly reduce so that it is just a gentle stretching sensation!
Identifying the state of YOUR pelvic floor with a trained physiotherapist can help you to ensure you are able to properly contract AND RELAX these muscles and also to identify if they are tight and teach you perineal massage techniques. It’s important to understand that everyones pelvic floor is so different! My recommendation is actually just gain awareness of your pelvic floor as early on as possible in pregnancy or even preconception, it’s so beneficial to have an understanding of what your baseline pelvic floor tone is because some women have a very overactive pelvic floor, especially those with predisposing factors like endometriosis or urinary tract infections, or a history of sexual trauma, or, other women have a hypertonic pelvic floor, because they may hold a lot of stress and tension in their pelvic floor and for other women it is under-active!
Book your physiotherapy appointment to find out more about your pelvic floor tone and learn exactly how to perform perineal massage