We often don't think of doing anything for our perineum prior to birth, we don't look past what our doctor or midwife can do for us to help us avoid an episiotomy. One of the biggest factors in preventing tears (and possible episiotomy) can be a daily 5 minute session of vaginal stretching starting 5 weeks before your due date. Its purpose is to encourage elasticity and help the mother learn to relax and feel comfortable with the sensation of stretching and burning which occur as the baby's head distends the perineum. In addition, perineal massage may have the effect of focusing the mother's determination, giving the mother something proactive to do as she waits for the birth to begin. The better you prepare your perineal tissues for the stretching of birth, the less likely they will tear, and the better they will heal. Mothers with a more conditioned perineum are less likely to tear or get an episiotomy. Perineal massage has been particularly effective in women over the age of 20 and in women having their first baby, but it is something that can't hurt to try with subsequent children. Pelvic floor exercises (kegals!) should also continue through these last weeks of your pregnancy as well, so that elasticity, not laxness, is encouraged.
Vaginal stretching should not be started too early in the pregnancy. The hormones will not have sufficiently softened the tissue. it will be more traumatic, than helpful.
A hot bath before each session will soften the tissues. To begin, have the partner place lubricated fingers in both sides of the vaginal opening to the depth of the deep transverse muscle: about 3 to 4 cm. The mother tightens her muscles around the fingers to assure that the proper landmark is identified. Now the stretcher directs bilateral pressure down and outward toward each ischial tuberosity or "sit bone" (at about 4 and 8 o'clock) while the mother consciously exaggerates the relaxation of her muscles. When she begins to feel stretching or burning discomfort, the partner holds the stretch for thirty seconds to a minute and then relaxes tension. To minimize shoulder discomfort for partners doing the stretching with two hands, cross the forearms at the wrists. The stretch can then be held longer and more steadily.
To lubricate fingers, use either a water-based product (K-Y jelly) or pure vegetable oil. If you tend to be troubled by yeast infections, use the water-based lubricant. Petroleum-based products (mineral oil or petroleum jelly) should not be used. They clog pores and leach vitamins from the tissue.
Some woman have previous scars that are thick or painful. They can massage a mixture of vitamin E and Evening Primrose oils from opened capsules into the scar tissue during stretching. This helps make the scar more flexible.
If the partner is unwilling or unavailable, the woman can stretch her vagina herself. Either squatting, or lying down with her legs up, she reaches around under her thighs on either side and stretches down and out with her index fingers. Or, she can reach between her legs and stretch with her thumbs. Many women find hot baths are the perfect place to practice.
Massage alone will not protect your perineum. Perineal integrity has more to do with race, parity, age, and overall state of health than it does to perineal massage but that doesn't mean you can't benefit from it. Warm compresses between pushes and perineal stretching during active labor can help. Water birth outcomes have been seen to be preferable in the preservation of intact perineum. Slow controlled delivery is also key to an intact perineum and reduced incidence of laceration. The baby must not suffer any form of fetal distress and the mother and partner must listen closely to the midwife or health care provider on when to push and when to stop pushing. Choosing a position for birth that is more upright (kneeling, squatting, sitting) will allow the perineum to evenly distribute the pressure. If you choose a side lying position this will also prevent enormous amounts of strain on the perineum. Lying flat on your back creates the most stress on the perineum, making a tear or episiotomy almost impossible to avoid.
Always keep in mind that birth is unpredictable by nature. Tears do often happen, and episiotomies sometimes become necessary, even during the most prepared of births.
CAUTION: Check with your care provider before beginning perineal massage. Avoid if you have a history of preterm labor, premature rupture of membranes, a vaginal infection, if the massage induces contractions, or if the procedure makes you sore or uncomfortable. Avoid the the urinary opening to prevent urinary tract infections (at the top of the vaginal opening). Do not massage the perineum if you have active herpes lesions, this can cause the lesions to spread.