Perineal tearing remains one of the most common outcomes of vaginal birth, affecting approximately nine in 10 women to some degree.¹ Second degree tears occur in around 40% of primiparous births, and obstetric anal sphincter injuries (OASIS) affect approximately 3-6% of birthing women.¹ Beyond the immediate injury, perineal tearing can be linked to persistent pain, dyspareunia, and lasting pelvic floor dysfunction.

Pelvic health physiotherapists are well placed to teach perineal massage. Antenatal perineal massage is one of the few risk-reducing strategies a pregnant woman can start herself, well before labour starts. We can introduce it as part of routine prenatal pelvic floor checks: it is inexpensive, requires no special equipment, and can be taught in a single consultation. Yet one of the most common responses we hear in clinic is, “How am I meant to reach my vagina at 34 weeks pregnant?” Common barriers to antenatal perineal massage include a lack of guidance on proper technique, discomfort with self-touch, the awkwardness of using oils or lubricants, abdominal size, and finger fatigue.²

The Evidence for Antenatal Perineal Massage

A 2013 Cochrane review remains foundational and shows that antenatal perineal massage reduced perineal trauma requiring sutures in primiparous women by 10%, and reduced episiotomy rates by 17%.³ These benefits were not replicated in multiparous women, but multiparous women did show reduced perineal pain at three months postnatal.

A larger 2020 meta-analysis also showed that antenatal perineal massage reduced the rate of OASIS by 64%.² A 2024 systematic review compared antenatal perineal massage against perineal massage performed during the second stage of labour on primiparous women and showed that both forms of massage improved perineal outcomes and reduced episiotomy, but only antenatal massage significantly reduced anal incontinence at three months postpartum.⁴

It is also worth mentioning that adding antenatal pelvic floor muscle training to antenatal perineal massage seems to further improved episiotomy and perineal tear rates, postnatal perineal pain and dosage of postnatal analgesia in women above the age of 35 years old.⁵

The research is mixed or unclear on whether antenatal perineal massage has an effect on rates of urinary incontinence, dyspareunia, and levator avulsion. Furthermore, there is a wide variation on perineal massage technique in published studies.⁶

How Do We Suggest it is Performed?

Most protocols in studies begin between 34 and 36 weeks, although some start as early as 32 weeks.^4,6 Contraindications would include bleeding after 20 weeks, active infection, uncontrolled high blood pressure, or after waters break.

Instructions

1. Start with clean hands, an empty bladder, and ensure you are in a comfortable position where you can relax your pelvic floor muscles.
2. We recommend using a silicon or oil-based lubricant, as water-based lubricant can get sticky.
3. The pregnant person, her partner, or a physiotherapist inserts one or two lubricated fingers three to four centimetres inside the vagina (or to the levator ani layer) and applies pressure with straight, not hooked fingers, to ensure that both the perineal muscular layer and levator muscular layer is stretched.
4. Imagine the three prongs of a peace symbol as being your three directions: 4 o’clock, 6 o’clock, and 8 o’clock.
5. Use your finger/s to stretch each direction, holding each stretch for 90 – 120 seconds. Breathe and relax into the stretch, increasing the stretch as tolerated.
6. Move to the next direction and repeat.
7. Once the three directions have been stretched, sweep with a stretch from left to right and back again for two minutes.
8. It is normal to feel a strong or uncomfortable stretch but avoid pushing into pain that makes you contract your pelvic floor.

Positioning

If the pregnant person is doing the massage themselves, kneeling upright or forward over an exercise ball or standing with one foot up on the toilet/bathtub is usually the most effective positions.

If the partner is performing the massage, they must be clear that the pregnant woman is in control of comfort and pace. Lying down with knees bent and feet out wide, propped up with pillows behind the woman, and underneath her knees, is usually the most comfortable position for woman. The partner then rests between her legs to perform the massage.

Common feedback from physio patients is that it is much easier and more comfortable than they imagined, and often quite different to what they assumed the technique would entail.

In Summary

Antenatal perineal massage is a simple, low-cost intervention with a growing evidence base in reducing birth injury. Physiotherapists are well placed to teach this technique to pregnant women and their partners, along with other education which assists in pelvic health such as pelvic floor muscle training, general pregnancy exercise advice, and postnatal recovery education.