PERINEAL MASSAGE - CASE STUDY 1

Leila and James

Although I taught perineal massage with words and pictures for years, late 2018 was the first time I taught a couple how to do perineal massage by physically demonstrating it on the pregnant woman, and then giving feedback when the support person gave it a try with guidance. I immediately thought we should be giving far more physical guidance to every lady who needs to learn perineal massage! There’s a lot more to that story, but this case study has a different focus.

This is the story of the case that sparked my passion for teaching pregnant women and their support person how to do perineal massage. Let’s call them Leila and James, which are obviously not their real names.

Early in 2019, we moved to Queensland so I never heard what happened to the first couple I taught. The second lady I taught had a low risk profile for pelvic floor complications during birth, and went on to have a great vaginal birth with an intact perineum and pelvic floor. I didn’t attribute this to perineal massage at all because she seemed like she would go well with birth anyway.

Leila was the 3 rd pregnant woman I taught physically. She was very different to the second lady. After a vaginal examination when she was about 30 weeks pregnant, I felt very worried for her. My thought process was: this is definitely going to turn into an emergency caesarean, or a severe tear. There is no way this baby is getting out of here with Leila intact. That is a very extreme/negative thought process for me. I had never had that thought process about any of my patients. I’m very positive about women’s ability to birth and I don’t tend to anxiety. With that in mind, you can imagine that Leila’s pelvic floor was on the very, very tight end of the normal spectrum. Tightness is only 1 factor amongst many that influence the risk of pelvic floor issues in labour, and Leila didn’t have too many of these other factors in her favour either.

Leila was hoping for a vaginal birth. She was an extremely organised person who had a good support network, and was great at doing all of the homework I gave her. I told her and James that they would need to be more devoted to her perineal massage than most, because she was less flexible (in her pelvic floor) than average. They rose to the challenge and practised virtually daily, as well as addressing all of the other unfavourable factors that were modifiable.

After 2 weeks of practice, the progress in flexibility was looking a little slow. We therefore added in an epi-no to the program. Epi-no is a tool to assist with perineal preparation for birth, but the research behind it shows no benefit. To cut another long story short, I believe there are a few occasions where epi-no’s are very useful, but they absolutely need guidance. The instructions that come with the device are very misleading in my opinion.

When Leila returned for her two weeks postnatal visit, she happily reported having:

• An amazing water birth
• No perineal tears, no episiotomy, no stitches
• A tiny vaginal graze that healed quickly

I was amazed and happy, but quite sure I would find a pelvic floor injury at the 6 week check-up when we do internal examinations. These injuries are not visible after birth when people are diagnosing perineal tears. However, when I examined her, Leila’s pelvic floor was not only intact, but had bounced back to it’s pregnant dimensions!

I was completely blown away by this outcome, and have been offering perineal massage practice to pregnant women, for whom it is relevant, ever since. Over the years, the massage strategies have been fine-tuned and adapted to the point where it should be called perineal yoga instead of perineal massage.

Of course there are never any guarantees when it comes to birth, even when people prepare as best as they can, not all factors are predictable or modifiable. Part of it comes down to luck, and connective tissue genetics, but let’s maximise our chances of good birth experiences!