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Perineal Anatomy
“I am the floor. I am the ground. I am the base of your pleasure. I am the foundation of your well-being. I am the road that rises to meet you….I am rich. I am well supplied. I have nerve endings in abundance. I throb with blood. I am a treasure. I am the setting of the jewels. I am flexible. I stretch and bounce back. I thrive on action. Stir me. Pulse me…I am the mystical figure eight. I am infinity…the endless loop.” 1
-Susun Weed
Let’s discuss the energetic, emotional, and physical anatomy of this amazing area.
In the Indian system of mind-body medicine, Ayurveda, the perineum is also known as the “Root Chakra” (a chakra is translated as a “wheel of energy”) which is the first of seven chakras that move up the torso and head. The Root Chakra is our energetic connection to the earth, and it is this grounded energy that helps spiral our babies through our perineums and down to the earth. The color of this chakra is blood red, seen physically with powerful menstrual and birth blood that figuratively (and sometimes literally) feeds and fertilizes the earth.
Practitioners of yoga also engage bandhas, or locks, at some or all of the three major diaphragms of the body to direct life-force energy. These are the vocal, respiratory, and perineal diaphragms. The perineal lock, or “mula bandha,” directs energy upward through the body which essentially elevates the muscles of the perineum.2
In Traditional Chinese Medicine, the perineum is the first acupuncture point of the Ren meridian, aka Ren-1 or Conception Vessel -1. It is precisely at the midpoint between the posterior labial commissure and the anus in females, and is considered the most yin (or feminine) point in the human torso. It is used to treat many urogenital disorders, including pelvic organ prolapse, as well as to bring someone back to consciousness!
The perineum is also known as “Down There.” When I lived in a French-speaking country in central Africa I learned the term en-bas la-bas, which translates literally as “down there over there” – twice removed apparently! These cultural linguistic preferences show that talking about, let alone deliberately massaging, the perineum can feel awkward and foreign. Many women have also been victims of physical and sexual abuse which may intensify her trepidation to connect with this area of her body. This psycho-emotional component is very important to consider before we make a physical recommendation to “just massage your perineum a few times a week starting week 34 or 35 of pregnancy.” We’ll talk about this more when we discuss the goals of Perineal Massage.
The word perineum from the Greek means “around or near that which empties out,” much like the word perinatal means “around or near birth. “ When defining the perineum’s location, many western practitioners simply mean the skin between the anus and the genitals as a specific physical external area, but some would consider the perineum anything below the peritoneum of the abdominal cavity, with many internal physical layers of muscle and fascia (connective tissue). (Tears and other perineal trauma from the birth process can occur more superficially to the skin and mucosa, or if the laceration is more severe, to the layers of connective tissue and muscle.)
Most anatomical diagrams still show the perineal muscles as a sling or hammock holding the pelvic organs inside the body. However, recent findings from MRI photos show that the deeper muscles of the lower pelvic region are in fact a diaphragm, matching the shape of the respiratory diaphragm, meaning rounded at the top. “At resting tone, the pelvic floor is convex superiorly rather than inferiorly, and …. it is shaped like a dome, and not a basin.”3 This feels very significant to me, because it implies that the perineal muscles are more active and poised, rather than just hanging there like a hammock.
Likewise, there is controversy around the orientation of the standing female pelvis. The conventional medical model is of a passive pelvic floor that hangs between a horizontal coccyx and pubic bone. A growing minority of professionals perceive that women actually have an active pelvic gateway oriented more toward the back of her body whose main function is to complete elimination rather than keep the pelvic organs from falling out.4
Whether it be dome or bowl, tilted back or straight under, the female perineum is beautifully designed to meet, stretch, allow, open, and surrender to a flexible and moldable emerging infant. Some of the muscles that play an important role in this dance of tissue and energy are shown in the line drawing here.
The body landmarks of the perineal muscles include the pubic bone (which is where the two sides of pelvis meet in front), the coccyx (or tailbone), and the two ischial tuberosities (or the bones you can feel through your glute muscles, especially when seated upright). These round bony knobs merge with the pubic bones, forming a “V”, though it’s more of an upside down “U” in this drawing. There are many layers and muscles that act in this area. I’ve chosen to show a few, highlighting the pubococcygeal1 (or PC) or sometimes known as the bulbospongious and anal sphincter muscles.5 Notice the fascinating and functional figure eight shape.
Potential Goals of Perineal Massage
More pliable tissue or more scar tissue?
The primary goal of perineal massage is to reduce the chance of tearing during birth. How might this work? It is thought that the stretching massage action will soften the muscles, connective tissue, and skin of the area, and pliable tissue is less likely to tear. This is the same rationale behind how massage on other areas of the body might work – one would think it would apply to any area of the body with connective tissue. Also, most recommend perineal massage be performed to the edge of comfort until a burning or numbing sensation has occurred. This may help some women become more familiar with the sensation of a baby’s head crowning so that when she feels this in labor she is less likely to panic and tense up (or panic and push really hard and fast) rather than relax into it- which also my cause tearing. Some birth professionals even say the perineal massage will reduce the burning sensation during labor itself, sometimes referred to as the “ring of fire.”
These are two of the possible benefits of prenatal perineal massage. However, it is also possible that if the massage is performed too aggressively (i.e., the burning sensation – which is how most recommend to do it!) there can be damage to the perineal mucosa/tissue. There would then be scar tissue from the damage, which would create a less pliable perineum if the scar tissue did not resolve before labor! Also, I’ve been practicing massage for over a decade, and any technique that causes burning or numbness in any area of my client’s body is promptly stopped or altered. So this recommendation gives me pause.
The most commonly cited study that seems to have led to the blanket recommendation of perineal massage was done by Labrecque et al in 1999.6 It showed reduced incidence of perineal trauma in first-time mothers only (actually slightly more trauma for second-time or more moms) who performed the perineal massage. However, “perineal trauma” also included episiotomies (the surgical cut to the perineum that was formerly routine in this country, though still done today), so it’s hard to say if it was practitioner preference or the massage actually made the tissue so pliable there was no need for the episiotomy. Subject compliance is also difficult to control for: maybe the women actually did or did not perform the techniques as directed or as often as requested.
Perineal Awareness and Empowerment
A third benefit of massaging the perineum is bringing more consciousness and awareness to an area of the body whose messages many of us, at best, ignore. The vagina and perineum store possible physical and emotional trauma in their tissues, and doing some kind of internal physical touch may help to resolve or integrate those areas back into wholeness so they are less likely to hold the woman back during labor. A woman who is relaxed and surrendering to the process will have more responsive tissues and may be less likely to tear. (There is also the possibility of reactivating or even reinforcing trauma with aggressive perineal massage, so if you have any known previous abuse you might choose to seek professional guidance. Again, please discuss these concerns with your Prenatal Care Provider before proceeding.)
A woman (with or without her partner) who has explored how her own body feels, moves, and responds to touch may feel more in control and more likely to take an active role in making decisions about her body, her baby, and her birth. This may indirectly affect her chances of tearing because of interventions she may choose to forego or healthy practices she may choose to undertake. Birth is also a sexual experience. Midwives are fond of saying “The same energy that got the baby in will get the baby out.” If her perineal massage becomes more of an exploration of her sexuality, rather than some chore she has to do to keep her from tearing, she may find enjoyment in the practice and self-realization that could help her through labor. Also it is the hormones and changes in blood flow of labor that actually cause the engorgement and opening of the whole perineal area, something again more related to whole-body-mind response rather than just some tissue that needs to be stretched out.
A final important psychological element to the perineal massage debate is to consider what this recommendation may be telling some of our pregnant women subconsciously. Perhaps she hears “my body is not good enough, it will not open enough on its own so this massage needs to be done since my body can’t do it.” If you find yourself as a pregnant woman having this kind of attitude, please reconsider why and for whom you are performing perineal massage. Anything we choose to do during pregnancy may not always be comfortable, either physically or emotionally, but it should empower us, and never make us feel like our bodies are “not good enough.”
How to Massage Your Perineum
So, then, should I do perineal massage or not?
As with all choices in pregnancy, I strongly believe you should do what feels right for you. If perineal massage is not something that sounds appealing, or you try it and hate it, then I’d suggest doing something else entirely (how about belly dancing, prenatal yoga, or just walking barefoot in the sand?), or changing your approach. Maybe you feel less awkward in the shower, perhaps it feels more like a sacred practice if you light a candle, or you would prefer your partner do it? I think we should change what we call it. How about Sacred Gateway Exploration. Try and make it feel right for you.
For your Perineal Massage you might include the following:
- Create a safe environment where you won’t be interrupted.
- Wash hands thoroughly, trim fingernails.
- Use some kind of safe lubricant (coconut oil is a good choice) if desired, with a towel under her bottom to catch dripping oil.
- Place one or both hands over the vulva and perineum and honor your baby’s gateway into this world.
- Insert one or two fingers (or thumbs if that feels best) into your vagina up to one or two knuckles, whatever feels comfortable.
- Apply downward pressure (toward your anus) for a few minutes. Perhaps slide back and forth. Note any sensation.
- Apply pressure to one side and then the other for several minutes. Note sensations.
- Stop when you feel you’ve had enough.
- Place your hand over your vulva and perineum and send your gratitude again.
Notice I omitted the “apply pressure until you feel a burning sensation to ensure you are getting a good stretch” as this may possibly be creating microtears and damaging the tissue. But you may choose to do this.
There is also a wonderful tantric healing practice called Yoni Mapping.8 Rather than using the word vagina (which means “sheath”) the ancient practice of tantra yoga, also from India, describes the uterus, vagina, and vulva all as the yoni – a more sacred and spiritual term. You could essentially follow the steps listed above, but instead of just stretching the tissue from side-to-side and starting at the bottom, you create a clock around the entire vaginal opening and you start just below the pubic bone. Also, the Giver might use his/her more sensitive finger pads rather than thumbs.
Just below the pubic bone is 12 o’clock. (6 o’clock would be straight down toward the anus). Then you move to 1 o’clock and hold, noting anything that you feel physically or emotionally. Allow a lengthy pause between holds to help her enter a more meditative state. Proceed around the entire “clock” until you’ve returned to 12 o’clock again. This is a great practice to do with a partner who can respectfully note how you respond at the different “times” on a clock and go back there if you need them to. It also allows the woman to relax more and passively experience, rather than being both the Giver and the Receiver.
The massage should not be performed if
- the woman has an active vaginal infection.
- her membranes have ruptured (water broke).
- she is at risk for preterm labor, or is on bed-rest for a high risk condition.
- her partner cannot remain present or respectful.
- it doesn’t feel right to her.
Please consult with your Provider should you have concerns.
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Other Ways to Possibly Prevent Tearing
Most Prenatal Care Providers, especially those practicing within the midwifery model, would recommend good nutrition and adequate hydration to keep all the tissues of the body healthy and pliable. There is also the practice of being patient and slowing down during Pushing to allow the perineum adequate time to stretch as baby’s head emerges (crowns). Of course physical activity keeps all of our muscles and connective tissue healthy! (Did I mention yoga, dancing, walking?)
Other practices that a pregnant woman might find helpful have conflicting professional perspectives. One can practice squatting during pregnancy, which has numerous benefits and may help keep the pelvic floor functioning optimally, but some say to avoid squatting during the last few weeks of pregnancy, as it may drive a less-than-optimally positioned baby further into the pelvis. Also, there is some debate amongst birth professionals as to whether or not a woman should practice pelvic clenches, (aka kegeling) to “strengthen” the pelvic floor muscles. I look forward to exploring these topics with you in future posts!
One final note: I believe with all my heart that the Birth Journey a woman and her family are on is the perfect one. Pregnancy, labor, birth, and new family life are also an intense time of growth with important lessons to be learned if we are open to them. I think it’s important when we choose to devote our time to any prevention tactic or intervention that we ask ourselves why. Are we trying to control too much? Are we trying to bury rather than face our fears? How would we deal with a tear should it happen? How can we make tearing a sacred experience? Perhaps, tearing was just the thing to slow us down after the birth of our child so we could learn to ask for help more. Maybe the tear kept us in bed with our baby long enough to get the breastfeeding relationship going. Maybe observing how the yoni heals so miraculously after tearing teaches us the power, beauty, and dynamic nature of the body. Whether or not a pregnant woman chooses to massage her perineum before birth, I hope she honors her beliefs, her body, and her self.
Birth Blessings to you!
References
1 Weed, Susun. Down There: Sexual and Reproductive Health the Wise Woman Way. Ash Tree Publishing. 2011. pgs 3-5.
2 Kaminoff, Leslie and Matthews, Amy. Yoga Anatomy, 2nd Edition. The Breathe Trust. 2012. p. 17
3 Goldstein, Irwin. Women’s Sexual Function and Dysfunction: Study Diagnosis and Treatment. Taylor and Francis, US, 2006. p. 142
4 Kent, Christine. Saving the Whole Woman. Bridegworks, Inc. Albuquerque, NM. 2006.
5 Calais-Germain, Blandine. The Female Pelvis: Anatomy and Exercises. Eastland Press, Seattle, WA, 2003.
6 Labrecque, M., Eason, E., Marcouz, S., Lemieux, F., Pinault, J., Feldman, P. and Laperriere, L., “Randomized controlled trial of prevention of perineal trauma by perineal massage during pregnancy,” American Journal of Obstetrics and Gynecology 180, 3 (March 1999): 593.
7 Stager, Leslie. Nurturing Massage for Pregnancy. Lippicott Williams & Wilkins, 2010. pgs 138-140.
8 Devi, Kamala, and Dez Nichols, Baba. Sacred Sexual Healing. Zendow Press. 2008. p. 204-205.
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