Knowing how to do it was never the hard part. Staying with it is, and that part can be fixed.
More than half of the women who start perineal massage stop within three weeks. Three weeks, not three months.
I wasn't surprised when I read that. I've been a midwife for over 35 years. I've sat with thousands of women through their preparation for birth and through the birth itself, and I'm still doing it. In all that time I have almost never met a woman who gave up because she didn't understand what she was supposed to do.
By 35 weeks most women have heard of perineal massage at least once. Their midwife mentions it, it comes up in a birth class, a friend brings it up over coffee. Explaining the technique takes four or five minutes and any midwife can do it. What nobody prepares her for is week two, when it stops being interesting and turns into one more thing she has to remember at eleven at night.
Why it stops
When I go through the routine with a woman I watch her face while I'm talking. Three or four times a week, about seven minutes, through roughly the last six weeks. Somewhere in the middle of that sentence her expression shifts, and I understand it. She's 35 weeks pregnant. She isn't sleeping, her back hurts, there's a hospital bag half packed and a car seat nobody has installed, and here I am handing her homework.
Then there's the couple side of it, which gets ignored too often. Plenty of couples plan to do this together and it sounds lovely when you're planning it. In practice one of them remembers on a Tuesday night when the other is already asleep. It becomes a negotiation. Then it becomes a small resentment, and a thing that was meant to be close and quiet turns into a conversation about whose job it was to remember. I've had women tell me plainly that they'd rather let it go than raise it with their partner again.
And underneath all of it sits the doubt. Am I doing this often enough. Am I even in the right place. Nobody is watching, nobody tells her she's doing it well, so she has no way to know. In my experience that's what really ends it, more than the tiredness does.
What I tell women now
Somewhere along the way I stopped handing out instruction sheets and started talking about something else: how to make this small enough that it survives a bad week.
The first thing is to attach it to something you're already doing. This is the one that changes the most, and it's the one nobody mentions. If it depends on you deciding each evening, you'll lose it by the second week, because the deciding is the hard part, not the seven minutes. Do it after your shower. Do it once you're already in bed. The women who are still going at 39 weeks are usually the ones who never had to make the choice in the first place.
Start earlier than you think you need to. Most guidance points to somewhere around 34 or 35 weeks, and there's a practical reason for that beyond the physiology. Starting at 38 means building a brand new habit in the two most exhausting weeks of the whole pregnancy, which is when nothing new sticks.
Aim for three times a week, and please don't aim for perfect. Two evenings a week for six weeks will serve you better than seven days in a row followed by nothing at all. If you miss a few days you haven't ruined it. You pick it up at your next shower and carry on.
And get the counting out of your head. Keeping track of how many times you've done it this week, watching the clock, wondering if you're in the right spot. That's the load that turns seven minutes into a chore, and it has nothing to do with the massage itself.
The part I'm biased about
Which brings me to something I should say plainly, because I'd rather say it than have you notice it: I designed the tool I'm about to describe. Take that into account.
I didn't set out to build a product. I set out to fix the thing I watched go wrong every single week. When I made Perimom there was nothing else like it, because nothing on the market had been built for what I was asking women to do.
A lot of devices have appeared since. What most women don't realize: plenty of them were made for pelvic floor work, and the words “perineal massage” went on the box afterwards. So it's easy to end up holding something that looks right and was never designed for this, and a tool that fights you is exactly the kind you stop using.
What I was trying to remove, one by one, were the reasons women quit.
- I gave the tool a curve because I was tired of watching women fold themselves in half trying to get around a third-trimester bump. If reaching is comfortable you'll do it again tomorrow.
- The handle is shaped so your hand isn't aching by minute five, which sounds like a detail until you remember that discomfort is the most common reason women stop.
- There's a channel built in to hold the oil, so you're not dealing with a mess on your sheets every time, and one more small excuse to skip tonight disappears.
- Women have always done this massage with a thumb, and that isn't a coincidence, it's what the body responds to. So I shaped the tip the same way, smooth and rounded, to move in a U along the lower opening where perineal massage belongs. Most other devices come to a point, because they were made for internal pelvic floor work. Of everything on this list, that's the difference I'd argue about hardest.
- Then there's the remembering. I can't sit in the room with every woman, so I built an app to do the part I'd normally do. It counts your sessions so you always know where you stand. You put your headphones in, press play, and I talk you through the seven minutes with some music behind it.
One last thing, and it's the least glamorous. Every Perimom is inspected and polished by hand before it leaves us, one at a time. Nothing is stamped out by the thousand and boxed untouched, so there are no rough seams or hard edges, none of the nooks and crannies you get on something mass-produced. It sounds like a small thing until you remember what it's used for and how close to the skin it sits.
What I care about after 35 years
I no longer believe the goal is perfect technique. The goal is a woman who shows up for herself two or three times a week for six weeks, imperfectly, and nobody was helping with that part.
So if you're pregnant and weighing this up, don't buy the most impressive-looking thing you can find. Pick whatever you'll still be reaching for in week two, and keep the routine as small as you can live with.
I'm still on the ward and I'm still going through this with women, one at a time. After 35 years I have no plans to stop.
— Vered (Rose)
Vered (Rose) Dalal is a midwife of more than 35 years, a doula, and the founder of Perimom. She still works on the ward, preparing women for birth one at a time.
Notes and sources
- About that number: in a study of first-time mothers who were taught perineal massage and asked to practice three times a week, only about half kept it up for three weeks, and counting every woman who started, fewer than a third did (Takeuchi and Horiuchi, Women and Birth, 2016).
- On the guidance: antenatal perineal massage is part of the Royal College of Obstetricians and Gynaecologists' perineal care bundle, which is why midwives are asked to raise it with women from around 35 weeks.
- Disclosure: the author is the founder of Perimom. All photographs are supplied by the author.