Perineal massage

Antenatal perineal massage (APM) or birth canal widening (BCW) is the massage of a pregnant woman's perineum around the opening to the vagina, performed anywhere in the 4 to 6 weeks before childbirth and usually on 4-6 separate occasions. The practice aims to more gently mimic the massaging action of a baby's head on the opening to the birth canal prior to birth, which enables some of the hard work of labour to be done before the start of labour. The intention is to attempt to prevent tearing of the perineum during birth, and reduce the need for an episiotomy or an instrument (forceps or vacuum extraction) delivery.

Description

The Oxford Radcliffe NHS Trust Document "Antenatal Perineal Massage" 2011 describes the use of the pregnant mother's thumbs being placed just inside the birth canal, whilst she stands with one foot supported on the toilet. She pulls backwards towards her spine, whilst relaxing her pelvic floor, progressively increasing the pressure under her finger tips until this starts to feel uncomfortable. On the next occasion she uses both thumbs pulling backwards and then sideways, thumbs away from each other, to enlarge the 2 cm diameter opening of the birth canal progressively over time to 10 cm. It is not possible to stretch this opening further causing damage, because this will be limited by the distance between the bony walls of the pelvis.

Purposes

The goal of APM is to prevent the baby's head from undergoing excessive strain during the last 30 minutes of labour. It seeks to train the mother to relax her pelvic floor to allow the baby's head to pass through the opening, to stretch the two fibrous layers within the Uro-Genital Membrane, a triangular shaped muscular shelf at the front half of the opening of the bony pelvis, through which the 2 cm diameter birth canal and urethra pass, and to transform the fat packed rigid skin at the opening to the birth canal into paper thin stretchy elastic skin, all without using the baby's head.

If the external skin (perineal skin) opening has been stretched before birth, to 10 cm, then there is no reason to perform an episiotomy to increase the diameter of the opening of the birth canal. Tearing is less likely as the external skin at the opening has been stretched already and is lax, whilst the underlying muscular pelvic floor has not been damaged. Episiotomy permanently damages the pelvic floor muscle, as the episiotomy cuts through the nerve supply to this muscle, so the larger part of the pelvic floor muscles atrophies and becomes replaced by scar tissue, increasing the mother's chance of developing a prolapse in the future. Antenatal Perineal Massage does not damage the pelvic floor, so protects against a prolapse.

History

Antenatal Perineal Massage or Pre-birth Obstetric Massage (Birth Canal Widening) has been used for many generations both by Chukchi Eskimos in Siberia and by African tribal people. Using an index finger and progressing to index, middle and ring finger massage, performed by the pregnant mother's spouse, after sexual intercourse, when the mother is relaxed has also been described enabling the father to take an active role in aiding the birth. Glass bottles of increasing sizes have also been used as the instrument of massage.

The German obstetrician Mr Welheim Horkel, when visiting a medical mission in the mid-1980s, learned that African tribes used gourds of increasing sizes as instruments of massage, with mothers aiding their daughters' labours in this way.

West Berkshire England performed an Antenatal Massage trial in 1984, and many small trials have been performed worldwide since. Cochrane Collaborate Reports since 2006 have advised that women should be informed that episiotomy is avoidable if they employ digital Antenatal Perineal Massage.

Effectiveness

Randomized clinical trials of perineal massage have shown its effectiveness in reducing class two and three level tears to be around 5 to 7 percent, against not doing the massage. Third degree tears involve damage to the purse string arrangement of muscle around the anus, which results in loss of control over large bowel contents (faecal incontinence) to a greater or lesser degree.

Antenatal Perineal Massage affords mothers worldwide, irrespective of income, the opportunity to shorten the critical last 30 minutes of labour. Mothers with a narrowed opening in their bony pelvis, whether from being born with an abnormally narrow pelvis, from previous fracture or from deformity secondary to infection in the bone (osteomyelitis), may need surgical intervention, as indicated by a failure to progress either when the baby's head fails to enter the bony pelvis or develops fetal distress.

See also

• Kegel exercises