Systematic review of pelvic floor interventions during pregnancy

A physiatrist's role in managing unique challenges in pregnancy and delivery in a patient with incomplete lumbar SCI: a case report

INTRODUCTION

Women of childbearing age make up around 5-10% of individuals with spinal cord injury (SCI) and may face unique medical and functional complications during pregnancy, including prolonged hospitalization and increased risk of early rehospitalization due to falls.

CASE PRESENTATION

Here, we discuss a case of a young ambulatory woman with a lumbar motor incomplete spinal cord injury who underwent successful delivery via cesarean section and the role of the physiatrist in the management of the patient's antepartum, intrapartum, and postpartum complications. The patient faced significant antepartum challenges secondary to her neurogenic bladder and pelvic floor weakness, resulting in increased use of her manual wheelchair. The physiatry team assisted with the co-development of a multidisciplinary bladder plan for increased urinary frequency and urinary tract infection prevention with the patient's obstetrics physician (OB). In addition, the physiatry team assisted with the procurement of a new wheelchair suited for the patient's pregnancy and childcare needs in anticipation of decreased mobility during this time. Regarding intrapartum challenges, the physiatry team worked with the patient and her OB to develop a safe birth plan considering the method of delivery, epidural usage, and the need for pelvic floor therapy before and after childbirth.

DISCUSSION

The patient had a successful cesarean section delivery, with return to independent mobility soon after childbirth. In summary, this case demonstrates that there is a need for a multidisciplinary approach to patients with SCI during pregnancy and that the role of physiatry is critical to optimizing medical and functional outcomes.

Effects of perineal massage at different stages on perineal and postpartum pelvic floor function in primiparous women: a systematic review and meta-analysis

BACKGROUND

Perineal massage, as a preventive intervention, has been shown to reduce the risk of perineal injuries and may have a positive impact on pelvic floor function in the early postpartum period. However, there is still debate concerning the best period to apply perineal massage, which is either antenatal or in the second stage of labor, as well as its safety and effectiveness. Meta-analysis was used to evaluate the effect of implementing perineal massage in antenatal versus the second stage of labor on the prevention of perineal injuries during labor and early postpartum pelvic floor function in primiparous women.

METHODS

We searched nine different electronic databases from inception to April 16, 2024. The randomized controlled trials (RCTs) we included assessed the effects of antenatal and second-stage labor perineal massage in primiparous women. All data were analyzed with Revman 5.3, Stata Statistical Software, and Risk of Bias 2 was used to assess the risk of bias. Subgroup analyses were performed based on the different periods of perineal massage. The primary outcomes were the incidence of perineal integrity and perineal injury. Secondary outcomes were perineal pain, duration of the second stage of labor, postpartum hemorrhage, urinary incontinence, fecal incontinence, and flatus incontinence.

RESULTS

This review comprised a total of 10 studies that covered 1057 primigravid women. The results of the analysis showed that perineal massage during the second stage of labor reduced the perineal pain of primigravid women in the immediate postpartum period compared to the antenatal period, with a statistical value of (MD = -2.29, 95% CI [-2.53, -2.05], P < 0.001). Additionally, only the antenatal stage reported that perineal massage reduced fecal incontinence (P = 0.04) and flatus incontinence (P = 0.01) in primiparous women at three months postpartum, but had no significant effect on urinary incontinence in primiparous women at three months postpartum (P = 0.80).

CONCLUSIONS

Reducing perineal injuries in primiparous women can be achieved by providing perineal massage both antenatally and during the second stage of labor. Pelvic floor function is improved in the postnatal phase by perineal massage during the antenatal stage.

TRIAL REGISTRATION

CRD42023415996 (PROSPERO).

Effects of Pelvic Floor Muscle Training on Urinary Incontinence During the Third Trimester of Nulliparous Pregnant Women: a Randomized Controlled Trial

INTRODUCTION AND HYPOTHESIS

The objective was to investigate the effects of pelvic floor muscle training (PFMT) on urinary incontinence (UI) and quality of life (QoL) during the late third trimester of pregnancy.

METHODS

A total of 131 singleton nulliparous women without pre-existing UI who attended the antenatal clinic at Rajavithi Hospital between August 2019 and May 2020 were randomly allocated into PFMT (n=63) or usual care (n=68; controls). The PFMT group watched the video education and was taught to contract the pelvic floor muscle. The control group received standard routine care. Baseline characteristics were recorded. At the gestational age of 36-38 weeks before delivery, UI was evaluated using the Urogenital Distress Inventory (UDI-6), and a score of at least 16.7 was used as a cut-off for diagnosing UI. Incontinence-related QoL was evaluated by the Incontinence Impact Questionnaire (IIQ-7).

RESULTS

Baseline characteristics between groups were similar. The mean age of women in the PFMT group was 23.7 years versus 24.1 years in the control group. Pre-pregnancy body mass index was 21.1 kg/m2 and 21.3 kg/m2 in the PFMT and control groups respectively. The PFMT group reported fewer UI than the control group (20.6% vs 94.1%, p<0.001). The PFMT group also had a lower UDI-6 score (5.5 vs 27.7, p<0.001) and lower IIQ-7 score (0 vs 14.3, p<0.001) compared with the control group.

CONCLUSIONS

From this study, the PFMT program is effective at preventing UI in the late third trimester of pregnancy and improves QoL. Therefore, we encourage PFMT to be implemented in clinical practice.

Effects of pelvic floor myofascial manipulation intervention on primiparas and neonates during the second stage of vaginal delivery

A prolonged second stage of vaginal delivery increases the risk of shoulder dystocia, unnecessary episiotomies and cesarean sections. However, no standardized method has been proposed to tackle this issue. The effects of pelvic floor myofascial manipulation intervention during the second stage of labor in primiparas and its prognostic value in neonatal postpartum outcomes remain unknown. In the present study, a total of 60 primiparas who were expecting a vaginal delivery in the Second Affiliated Hospital of Hainan Medical College (Haikou, China) between October 2021 and January 2022 were selected. These women were randomly assigned to a control group (standard intrapartum care) or an experimental group (pelvic floor myofascial manipulation for 15-20 min during the second stage of labor along with standard intrapartum care) using a random number table, with 28 patients in each group. There was no significant difference in age, gestational time or body mass index between the two groups before delivery, indicating that the baseline data were comparable. The second stage of labor duration, forced breath-holding time and postpartum hemorrhage volume in the experimental group were significantly lower than those in the control group. The pain visual analog scale scores, fatigue scores and neonatal Apgar scores in the experimental group were also significantly lower than those in the control group. The rate of episiotomy in the experimental group was lower than that in the control group, but the difference was not statistically significant. In conclusion, pelvic floor myofascial manipulation intervention during the second stage of labor for primiparas with vaginal delivery can reduce the duration of the second stage of labor, the amount of bleeding during labor and the pain during labor. Meanwhile, it has the potential to improve neonatal outcomes.

Risk and protective factors for pregnancy-related urinary incontinence until 1 year postpartum: A cohort study using patient-reported outcome measures in Italy

OBJECTIVE

To investigate the epidemiology of pregnancy-related urinary incontinence (UI) and the related risk factors, focusing also on women's characteristics related to maternity pathway utilization.

METHODS

In this prospective cohort study, we used patient-reported data obtained from the systematic survey on the maternity pathway that all pregnant women in Tuscany, Italy, can join. We selected 8410 women who completed-between March 2019 and November 2022-all five follow-up questionnaires from the first trimester until 12 months postpartum, each including a UI-specific patient-reported outcome measure. We performed panel regression models to explore the related risk factors.

RESULTS

Prevalence of UI was 4.4% at the first trimester, 23.7% at the third trimester, and 15.6%, 12.6%, and 12.4% at 3, 6, and 12 months postpartum. UI occurrence and severity were higher in older, overweight/obese, and unemployed women. High-risk pregnancy and discomfort during pregnancy were risk factors. Receiving a cesarean section reduced the risk, while spontaneous tears, episiotomy, and high birth weight increased it. Women who experienced delays in pregnancy examinations because of long waiting times and women who had planned pregnancy had a higher risk, while performing during-pregnancy pelvic-floor-muscle training was protective.

CONCLUSION

Besides confirming the classic risk and protective factors for UI, we also found novel determinants related to the proper maternity pathway utilization.

Antenatal perineal massage - risk of perineal injuries, pain, urinary incontinence and dyspereunia - a systematic review

BACKGROUND

Natural childbirth is associated with the risk of damage to the perineum - a tears or a episiotomy. Adequate preparation of the woman for childbirth is essential to minimize the occurrence of perinatal injuries.

AIM

The aim of the review is to assess and analyze the impact of APM (antental perineal massage) on perinatal perineal injuries and the development of pelvic pain and other complications in postpartum women, such as dyspareunia, urinary (UI), gas (GI), and fecal incontinence (FI).

METHODS

PubMed, Web of Science, Scopus and Embase were searched. Three authors independently searched databases and selected articles for inclusion and exclusion criteria. Next one author did Risk of Bias 2 and ROBINS 1 analyze.

FINDINGS

Of 711 articles, 18 publications were left for the review. All 18 studies examined the risk of perineal injuries (tearing and episiotomy), 7 pain in postpartum period, 6 postpartum urinary, gas/fecal incontinence and 2 described dyspareunia. Most authors described APM from 34 weeks of pregnancy until delivery. There were different techniques and times for doing APM procedures.

DISCUSSION

APM has many benefits for women during labor and the postpartum period (e.g. lower rate of perineal injuries and pain). However, it can be observed that individual publications differ from each other in the time of massage, the period and frequency of its performance, the form of obtaining instruction and control of patients. These components may affect the results obtained.

CONCLUSION

APM can protects the perineum from injuries during labor. It also reduces risk of fecal and gas incontinence in postpartum period.

The effect of pelvic floor muscle training and perineal massage in late pregnancy on postpartum pelvic floor function in nulliparas: A randomised controlled clinical trial

OBJECTIVE

To evaluate the effects of pelvic floor muscle training (PFMT) and perineal massage during late pregnancy on postpartum pelvic floor function in nulliparas.

DESIGN

Randomised controlled trial.

SETTING

The Peking University First Hospital, a teaching hospital in China.

PARTICIPANTS

Two-hundred nulliparas were included.

INTERVENTIONS

Nulliparas were randomised into four groups in a 1:1:1:1 ratio. Group A, control; group B, perineal massage; group C, pelvic floor muscle training (PFMT); group D, perineal massage and PFMT. The intervention group received the corresponding intervention from 34 weeks of gestation until delivery.

MEASUREMENTS

Changes in pelvic floor function from 34 weeks of gestation to 6 weeks postpartum were assessed using pelvic floor electromyography (EMG), pelvic organ prolapse quantitation (POP-Q), and pelvic floor distress inventory-20 (PFDI-20).

RESULTS

Those with PFMT (groups C and D) had a smaller decline in pelvic floor EMG of fibre II than those without PFMT (groups A and B) [- 0.2 (- 7.1, 11.3) µV vs 6.1 (- 0.2, 15.2) µV, P = 0.040]. The same scenario was observed in the pelvic floor EMG of fibre I. The Aa point measurement differences of those with PFMT (groups C and D) were smaller than those without PFMT (groups A and B) [0.0 (0.0, 2.0) cm vs 1.0 (0.0, 3.0) cm, P = 0.006]. The same result was observed for point Ba. No difference was observed in EMG and POP-Q in nulliparas with (groups B and D) or without perineal massage (groups A and C). No differences were observed in PFDI-20 scores.

KEY CONCLUSIONS

PFMT during late pregnancy enhanced pelvic floor EMG, while perineal massage alone or PFMT combined with perineal massage did not.

IMPLICATIONS FOR PRACTICE

PFMT in late pregnancy enhances pelvic floor function.

Vulvar dermatoses: a cross-sectional 5-year study. Experience in a specialized vulvar unit

Background

Vulvar diseases are common in the general population and have a negative impact on the quality of life.

Objectives

To describe our experience as dermatologists in the management of vulvar dermatosis consultations.

Methods

A retrospective observational study was conducted with patients who attended monographic vulvar consultations over a 5-year period. Clinical information was obtained from the patient’s charts.

Results

148 women were studied. Their mean age was 43.24 years (standard deviation: 15.15 years), with ages ranging from 4 months to 80 years. 53.4% of patients took between 2 and 5 years to seek medical attention for the first time. The most frequent diagnosis was lichen sclerosus (41.9%), irritative eczema of the vulva (14.9%), and lichen simplex chronicus (10.1%). 83.8% reported anogenital itching, 66.2% pain, and 45.9% dyspareunia. The most frequently prescribed treatment was ultra-potent topical corticosteroids (clobetasol propionate; 41.2%). Patients with lichen sclerosus were significantly older than those who presented with any of the other diseases. No differences were found in terms of either the time of disease evolution or in symptom presentation.

Study limitations

Retrospective study. Vulvar diseases with an infectious cause are usually managed in primary care, therefore, were not included. All patients were recruited from a single private hospital which limits the comparisons with the public health system.

Conclusions

Vulvar diseases frequently occur and are associated with high morbidity. It is essential to promote the development of specific vulvar consultations in hospitals. Specialties such as dermatology, gynecology, urology, or physiotherapy must be part of these units.

The effect of pelvic floor muscle exercises applied during pregnancy on genito-pelvic pain level in postpartum period

INTRODUCTION AND HYPOTHESIS

The goal of the study is to determine the effect of pelvic floor muscle exercises on genito-pelvic pain levels during the postpartum period.

METHODS

The data of the study, which was carried out in a randomized controlled experimental design, were collected in the antenatal policlinic of a public hospital from June-December 2019. There were 60 pregnant women in the experimental and control groups. Pelvic floor muscle exercises were applied to the pregnant women in the experimental group from the 30th week of gestation to the 6th week postpartum. The control group was not given pelvic floor muscle exercise training, and only data collection forms were filled in. During the study, the Descriptive Form, Verbal Category Scale, Pelvic Floor Distress Inventory-20, and Labour and Postpartum Information Form were given to the pregnant women in both groups.

RESULTS

After pregnant women in the experimental group performed pelvic floor muscle exercises, pain levels were significantly lower than in the control group (p < 0.01). Pelvic Floor Distress Inventory-20 total score and sub-dimension scores of the experimental group were statistically significantly lower than in the control group (p < 0.01). In addition, a statistically significant difference was found (p < 0.01) in the postpartum 72 h findings of the experimental group in which pelvic floor muscle exercises were applied compared to the control group.

CONCLUSIONS

According to the result of the study, as the gestational weeks progress, the genito-pelvic pain increases. Pelvic floor muscle exercises applied during pregnancy prevent the development and progression of pelvic floor disorders in both the antenatal and postnatal periods.

TRIAL REGISTRATION

NCT05343520.

Validation and cross-cultural adaptation of the Brazilian Portuguese version of the questionnaire for the assessment of pelvic floor disorders and their risk factors during pregnancy and postpartum

INTRODUCTION AND HYPOTHESIS

Pelvic floor dysfunction may be treated and prevented during pregnancy and postpartum, as it decreases women's quality of life. The aim of the present study was to translate and validate the Brazilian Portuguese questionnaire for the assessment of pelvic floor disorders and their risk factors during pregnancy and postpartum.

METHODS

This is a cross-sectional study. Two translators fluent in German translated the German version of the questionnaire into English. The back translation was performed by two other translators. The final version was tested on Brazilian pregnant/puerperal women. The participants answered the questionnaire twice, with an interval of 7-10 days between sessions. They also completed the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). To evaluate the test-retest reliability, we used the intraclass correlation coefficient (ICC), Cronbach's alpha coefficient, to test the internal consistency, and Pearson's linear correlation to assess construct validity.

RESULTS

Sixty-six women were included (77% pregnant; 23% puerperal women), with a mean age of 26.5 ± 5.8 years and a body mass index of 26.4 ± 5.7 kg/cm². There were no missing ceiling or floor effects. The construct validity presented a moderate correlation with the role physical domain of the SF-36 (r = -0.48), the ICC test-retest showed good reliability of 0.72, and the internal consistency was 0.71.

CONCLUSIONS

These results provide evidence that the questionnaire for the assessment of pelvic floor disorders and their risk factors during pregnancy and postpartum is a valid and reliable instrument when utilized in Brazilian pregnant and postpartum women.

Aspects of Pelvic Floor Protection in Spontaneous Delivery - a Review

The necessity of increasingly addressing aspects of pelvic floor protection, i.e., prevention of the most frequent female pelvic floor disorders, such as urinary incontinence, faecal incontinence and pelvic organ prolapse, is the result of the steadily improving understanding of the association of pregnancy and delivery with the prevalence of these disorders. About a quarter of all women experience one or more such symptoms during their life. Apart from age and weight, pregnancies and births play an important part. While initial discussion of pelvic floor protection often focused very rapidly on the mode of delivery and elective caesarean section as a possible protective intervention, it has become apparent in the last few decades how varied and wide-ranging the options are that can be used to protect against pelvic floor disorders. The mode of delivery as such is "only" one element among numerous other considerations and has diminished markedly in importance. Interprofessionality and interdisciplinarity undoubtedly represent an important development as resulting recommendations must always be incorporated in an overall context that considers mother and child at the same time. Considering the pelvic floor only certainly does not make sense. This review article will analyze in greater detail important pre-, intra- and postpartum aspects that in their entirety can provide insight into the various aspects of pelvic floor protection. The authors regard the following article as an additional basis for discussion on achieving a sustained reduction in the incidence and prevalence of female pelvic floor disorders.

Are Perineal Massage and Instrument-Assisted Perineal Stretching With Short Protocol Effective for Increasing Pelvic Floor Muscle Extensibility? A Randomized Controlled Trial

OBJECTIVE

The purpose of this study was to compare (1) the effects of the instrument-assisted perineal stretching technique with different application protocols in combination with perineal massage and (2) the effects of the isolated techniques on the extensibility and strength of the pelvic floor muscles (PFMs).

METHODS

A randomized controlled clinical trial with parallel randomization, assessor blinding, and concealed allocation was conducted in the Campus Physical Education at the Federal University of Uberlândia in Brazil. Ninety-six pregnant women (18-40 years of age) were allocated into 4 groups: perineal massage (PnM) group (PnM protocol for 10 minutes); instrument-assisted perineal stretching with a long static protocol for 15 minutes [IStrLS group]); PnM + IStrLS group (both techniques applied in the 2 previous groups); and PnM + IStrSR group (the same techniques as used in the PnM + IStrLS group but with a short repeated protocol; 4 sets lasting 30 seconds each). Eight interventions were performed in all 4 groups twice weekly (beginning at the 34th gestational week). The primary outcome was PFM extensibility, assessed using vaginal dilator circumference, and the secondary outcome was PFM strength, assessed using vaginal manometry.

RESULTS

For the PFM extensibility variable, a significant main effect of time (F2,88 = 87.951) and group (F3,88 = 7.193) was found. Tukey post hoc test results showed that the PnM + IStrSR group presented greater extensibility than the PnM and IStrLS groups. The PnM group showed increased PFM strength after 8 sessions compared with the other groups.

CONCLUSIONS

Women who were pregnant and received the combination of perineal massage and instrument-assisted perineal stretching with short repeated application had a greater increase in PFM extensibility than perineal massage and instrument-assisted perineal stretching alone.

IMPACT

The combination of perineal massage and instrument-assisted perineal stretching techniques with a short, repeated protocol led to better PFM extensibility results than the application of the techniques alone in women who were pregnant.

LAY SUMMARY

Pregnant women can benefit from intervention using the combination of perineal massage and instrument-assisted perineal stretching techniques with a short, repeated protocol.

Patient-Reported Outcome measures for pregnancy-related urinary and fecal incontinence: a prospective cohort study in a large Italian population

OBJECTIVE

To investigate prevalence and risk factors of pregnancy-related urinary/fecal incontinence (UI/FI) in a large Italian population.

METHODS

This is a prospective cohort study analyzing patient-reported outcome (PRO) measures obtained from the systematic longitudinal survey on the maternity pathway of Tuscany from March 2019 to April 2021. Four questionnaires were completed by 6,023 women from the beginning of pregnancy until six months postpartum, each including two PRO measures - Wexner scale for FI and ICIQ-SF for UI -, and questions investigating sociodemographic/clinical factors. After assessing UI/FI prevalence at each time-point, we run panel regressions to explore the related risk factors.

RESULTS

Women reporting UI and FI were, respectively, 24.3% and 6.2% in the third trimester, and 12.6% and 4.2% six months postpartum. UI occurrence and severity were higher in highly-educated, aged > 30, and overweight/obese women. Spontaneous tears or episiotomy were risk factors for postpartum UI, while receiving cesarean-section and performing pelvic-floor-muscle-training during pregnancy were protective, mainly in specific groups. Finally, higher FI prevalence and severity emerged in overweight, aged > 40, highly-educated, non-Italian women and in those undergoing tears.

CONCLUSION

We employed PRO measures to investigate the epidemiology of pregnancy-related UI/FI and detect the main risk groups. Pelvic-floor-muscle-training may be recommended in women with peculiar sociodemographic/clinical features.

Application of pelvic floor ultrasound during pregnancy to detect patients at risk of cesarean section due to failure of labor progression in a Spanish population

OBJECTIVE

Our study is aimed at evaluating the characteristics of the pelvic floor, assessed through transperineal ultrasound, since it may influence or increase the possibility of having a cesarean delivery, with the objective of acting on those variables that can be modified during pregnancy.

STUDY DESIGN

Transperineal ultrasound was performed on 109 primiparous pregnant women in their first trimester of pregnancy, recruited between May 2018 and February 2019, with the purpose of studying the hiatus area at rest, retention and Valsalva. We have reassessed them at the end of pregnancy and delivery data were recorded. We selected 8 patients as case-study, who had cesarean section delivery due to failure of labor progression. We selected 4 control-cases for each, reaching the total of 32 controls, with similar age and body mass index, to avoid obtaining a biased result from these data.

RESULTS

In the study of hiatal areas, patients who delivered by cesarean section had a smaller hiatal area at rest, during levator ani muscle contraction and during Valsalva maneuver, at all visits. In early pregnancy, the range of the resting hiatal area was 13.8 ± 2.0 cm² for cesarean sections, compared to 16.2 ± 2.7 cm² for vaginal deliveries with an OR of 0.57 (0.34-0.95, 95% CI). For hiatal area on Valsalva, the OR was 0.55 (0.35-0.88, 95% CI). Therefore, the smaller the hiatal area, the greater the possibility of cesarean section. At the end of pregnancy, between 34 and 36 weeks of gestation, the OR of hiatal area on Valsalva was 0.78 (0.60-1.00, 95% CI).

CONCLUSION

The hiatus area measured by transperineal ultrasonography at the beginning and at the end of the pregnancy may be useful to identify the patients who are at a higher risk of cesarean delivery due to failure of labor progression.

Influence of a Virtual Exercise Program throughout Pregnancy during the COVID-19 Pandemic on Perineal Tears and Episiotomy Rates: A Randomized Clinical Trial

The complications associated with COVID-19 confinement (impossibility of grouping, reduced mobility, distance between people, etc.) influence the lifestyle of pregnant women with important associated complications regarding pregnancy outcomes. Therefore, perineal traumas are the most common obstetric complications during childbirth. The aim of the present study was to examine the influence of a supervised virtual exercise program throughout pregnancy on perineal injury and episiotomy rates during childbirth. A randomized clinical trial design (NCT04563065) was used. Data were collected from 98 pregnant women without obstetric contraindications who attended their prenatal medical consultations. Women were randomly assigned to the intervention (IG, N = 48) or the control group (CG, N = 50). A virtual and supervised exercise program was conducted from 8-10 to 38-39 weeks of pregnancy. Significant differences were found between the study groups in the percentage of episiotomies, showing a lower episiotomy rate in the IG (N = 9/12%) compared to the CG (N = 18/38%) (χ² (3) = 4.665; p = 0.031) and tears (IG, N = 25/52% vs. CG, N = 36/73%) (χ² (3) = 4.559; p = 0.033). A virtual program of supervised exercise throughout pregnancy during the current COVID-19 pandemic may help reduce rates of episiotomy and perineal tears during delivery in healthy pregnant women.

Prevalence of Perineal Tear Peripartum after Two Antepartum Perineal Massage Techniques: A Non-Randomised Controlled Trial

Perineal massage increases elasticity of myofascial perineal tissue and decreases the burning and perineal pain during labour, thus optimising child birth, although an application protocol has not been standardised yet. The objective of this study is to determine the efficiency of massage in perineal tear prevention and identification of possible differences in massage application. Total of 90 pregnant participants were divided into three groups: perineal massage and EPI-NO^® device group, applied by an expert physiotherapist, self-massage group, where women were instructed to apply perineal massage in domestic household, and a control group, which received ordinary obstetric attention. Results: The results showed significant differences among the control group and the two perineal massage groups in perineal postpartum pain. Correlations in perineal postpartum pain, labour duration and the baby's weight were not statistically significant. Lithotomy posture was significantly less prevalent in the massage group than in the other two; this variable is known to have a direct effect on episiotomy incidence and could act as a causal covariate of the different incidence of episiotomy in the groups. Perineal massage reduces postpartum perineal pain, prevalence and severity of perineal tear during delivery.

The Legacy of Pregnancy: Elite Athletes and Women in Arduous Occupations

ABSTRACT

Best-practice guidance and management of pregnant and postpartum elite athletes and women in arduous occupations is limited by the lack of high-quality evidence available within these populations. We have summarised the adaptations and implications of pregnancy and childbirth; proposed a novel integrative concept to address these changes; and made recommendations to progress research in this area.

Can pelvic floor muscle training prevent perineal laceration? A systematic review and meta-analysis

BACKGROUND

Pelvic floor muscle training (PFMT) is reportedly able to reduce risk factors for perineal trauma. However, the effects of these exercises on perineal injuries are unclear.

OBJECTIVE

To investigate the effectiveness of PFMT in the prevention of perineal laceration.

SEARCH STRATEGY

Searches were conducted in PubMed/Medline, LILACS, Scopus, Cochrane Library, Web of Science, and CINAHL. For search strategies, we combined the terms PFMT, tear, laceration, perineum, and delivery.

SELECTION CRITERIA

We included randomized controlled trials that evaluated the effectiveness of PFMT for the prevention of perineal laceration during vaginal delivery. There were no period or language limitations.

DATA COLLECTION AND ANALYSIS

We conducted data extraction and synthesis. We performed a quality appraisal, a qualitative synthesis, and for meta-analysis we used the Software R.

MAIN RESULTS

Nine studies were included. In most studies, PFMT was performed daily, with a wide range of the number of contractions and sustainability. Prevalence of perineal laceration had a wide range and information on laceration degree was limited. Meta-analysis showed that PFMT was not effective to prevent perineal laceration.

CONCLUSION

Pelvic floor muscle training does not prevent perineal laceration. Further studies are needed to investigate different protocols and interventions.

Ultrasonic Diagnosis and Analysis of the Effect of Labor Analgesia on Early Pelvic Floor Function and Pelvic Floor Dysfunction

Pelvic floor dysfunction disease (PFD) is a common pelvic organ dysfunction disease in the clinic of obstetrics and gynecology. Its cause is mainly the damage, defects and dysfunction of the pelvic floor support structure. Not only is the pathogenesis complicated, but also various symptoms coexist, which seriously affects the physical and mental health of female patients. Mechanical injury of the pelvic floor fascia tissue and levator ani muscles is the anatomical basis of PFD after birth; early postpartum pelvic floor examination and treatment can prevent and control the occurrence or development of PFD. Spinal canal anesthesia has good analgesic effect during labor and delivery, has little effect on mothers and infants, and is widely used. However, there are few domestic and foreign reports on the effect of labor analgesia on the pelvic floor. Labor analgesia relaxes the pelvic floor muscles, unblocks the birth canal, and the influence on the pelvic floor muscles is worth exploring. Based on the pelvic floor muscle strength screening to understand the changes in the function of the pelvic floor muscles, combined with the three-dimensional pelvic floor ultrasound examination, the pelvic floor structure and the levator ani muscle are clearly imaged, and the pelvic floor muscle structure is evaluated in the natural state and the analgesic muscle relaxation state. This study used a combination of the two to evaluate the effect of labor analgesia on pelvic floor function of primiparous women; provide individualized intervention treatment for high-risk groups screened; provide clinical basis for the prevention and treatment of PFD.

Pelvic-Floor Dysfunction Prevention in Prepartum and Postpartum Periods

Every woman needs to know about the importance of the function of pelvic-floor muscles and pelvic organ prolapse prevention, especially pregnant women because parity and labor are the factors which have the biggest influence on having pelvic organ prolapse in the future. In this article, we searched for methods of training and rehabilitation in prepartum and postpartum periods and their effectiveness. The search for publications in English was made in two databases during the period from August 2020 to October 2020 in Cochrane Library and PubMed. 77 articles were left in total after selection-9 systematic reviews and 68 clinical trials. Existing full-text papers were reviewed after this selection. Unfinished randomized clinical trials, those which were designed as strategies for national health systems, and those which were not pelvic-floor muscle-training-specified were excluded after this step. Most trials were high to moderate overall risk of bias. Many of reviews had low quality of evidence. Despite clinical heterogeneity among the clinical trials, pelvic-floor muscle training shows promising results. Most of the studies demonstrate the positive effect of pelvic-floor muscle training in prepartum and postpartum periods on pelvic-floor dysfunction prevention, in particular in urinary incontinence symptoms. However more high-quality, standardized, long-follow-up-period studies are needed.

Physiotherapy for Prevention and Treatment of Fecal Incontinence in Women-Systematic Review of Methods

Fecal incontinence (FI) affects approximately 0.25-6% of the population, both men and women. The most common causes of FI are damage to/weakness of the anal sphincter muscle and/or pelvic floor muscles, as well as neurological changes in the central or peripheral nervous system. The purpose of this study is to report the results of a systematic review of the possibilities and effectiveness of physiotherapy techniques for the prevention and treatment of FI in women. For this purpose, the PubMed, Embase, and Web of Science databases were searched for 2000-2020. A total of 22 publications qualified for detailed analysis. The studies showed that biofeedback (BF), anal sphincter muscle exercises, pelvic floor muscle training (PFMT), and electrostimulation (ES) are effective in relieving FI symptoms, as reflected in the International Continence Society recommendations (BF: level A; PFMT and ES: level B). Research has confirmed that physiotherapy, by improving muscle strength, endurance, and anal sensation, is beneficial in the prevention of FI, both as an independent method of conservative treatment or in pre/post-surgery treatment. Moreover, it can significantly improve the quality of life of patients. In conclusion, physiotherapy (in particular, BF, PFMT, or ES, as effective methods) should be one of the key elements in the comprehensive therapy of patients with FI.

Pelvic floor muscle training for preventing and treating urinary and faecal incontinence in antenatal and postnatal women

BACKGROUND

About one-third of women have urinary incontinence (UI) and up to one-tenth have faecal incontinence (FI) after childbirth. Pelvic floor muscle training (PFMT) is commonly recommended during pregnancy and after birth for both preventing and treating incontinence. This is an update of a Cochrane Review previously published in 2017.

OBJECTIVES

To assess the effects of PFMT for preventing or treating urinary and faecal incontinence in pregnant or postnatal women, and summarise the principal findings of relevant economic evaluations.

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, WHO ICTRP, and handsearched journals and conference proceedings (searched 7 August 2019), and the reference lists of retrieved studies.

SELECTION CRITERIA

We included randomised or quasi-randomised trials in which one arm included PFMT. Another arm was no PFMT, usual antenatal or postnatal care, another control condition, or an alternative PFMT intervention. Populations included women who, at randomisation, were continent (PFMT for prevention) or incontinent (PFMT for treatment), and a mixed population of women who were one or the other (PFMT for prevention or treatment).

DATA COLLECTION AND ANALYSIS

We independently assessed trials for inclusion and risk of bias. We extracted data and assessed the quality of evidence using GRADE.

MAIN RESULTS

We included 46 trials involving 10,832 women from 21 countries. Overall, trials were small to moderately-sized. The PFMT programmes and control conditions varied considerably and were often poorly described. Many trials were at moderate to high risk of bias. Two participants in a study of 43 pregnant women performing PFMT for prevention of incontinence withdrew due to pelvic floor pain. No other trials reported any adverse effects of PFMT. Prevention of UI: compared with usual care, continent pregnant women performing antenatal PFMT probably have a lower risk of reporting UI in late pregnancy (62% less; risk ratio (RR) 0.38, 95% confidence interval (CI) 0.20 to 0.72; 6 trials, 624 women; moderate-quality evidence). Antenatal PFMT slightly decreased the risk of UI in the mid-postnatal period (more than three to six months' postpartum) (29% less; RR 0.71, 95% CI 0.54 to 0.95; 5 trials, 673 women; high-quality evidence). There was insufficient information available for the late postnatal period (more than six to 12 months) to determine effects at this time point (RR 1.20, 95% CI 0.65 to 2.21; 1 trial, 44 women; low-quality evidence). Treatment of UI: compared with usual care, there is no evidence that antenatal PFMT in incontinent women decreases incontinence in late pregnancy (very low-quality evidence), or in the mid-(RR 0.94, 95% CI 0.70 to 1.24; 1 trial, 187 women; low-quality evidence), or late postnatal periods (very low-quality evidence). Similarly, in postnatal women with persistent UI, there is no evidence that PFMT results in a difference in UI at more than six to 12 months postpartum (RR 0.55, 95% CI 0.29 to 1.07; 3 trials; 696 women; low-quality evidence). Mixed prevention and treatment approach to UI: antenatal PFMT in women with or without UI probably decreases UI risk in late pregnancy (22% less; RR 0.78, 95% CI 0.64 to 0.94; 11 trials, 3307 women; moderate-quality evidence), and may reduce the risk slightly in the mid-postnatal period (RR 0.73, 95% CI 0.55 to 0.97; 5 trials, 1921 women; low-quality evidence). There was no evidence that antenatal PFMT reduces the risk of UI at late postpartum (RR 0.85, 95% CI 0.63 to 1.14; 2 trials, 244 women; moderate-quality evidence). For PFMT started after delivery, there was uncertainty about the effect on UI risk in the late postnatal period (RR 0.88, 95% CI 0.71 to 1.09; 3 trials, 826 women; moderate-quality evidence). Faecal incontinence: eight trials reported FI outcomes. In postnatal women with persistent FI, it was uncertain whether PFMT reduced incontinence in the late postnatal period compared to usual care (very low-quality evidence). In women with or without FI, there was no evidence that antenatal PFMT led to a difference in the prevalence of FI in late pregnancy (RR 0.64, 95% CI 0.36 to 1.14; 3 trials, 910 women; moderate-quality evidence). Similarly, for postnatal PFMT in a mixed population, there was no evidence that PFMT reduces the risk of FI in the late postnatal period (RR 0.73, 95% CI 0.13 to 4.21; 1 trial, 107 women, low-quality evidence). There was little evidence about effects on UI or FI beyond 12 months' postpartum. There were few incontinence-specific quality of life data and little consensus on how to measure it.

AUTHORS' CONCLUSIONS

This review provides evidence that early, structured PFMT in early pregnancy for continent women may prevent the onset of UI in late pregnancy and postpartum. Population approaches (recruiting antenatal women regardless of continence status) may have a smaller effect on UI, although the reasons for this are unclear. A population-based approach for delivering postnatal PFMT is not likely to reduce UI. Uncertainty surrounds the effects of PFMT as a treatment for UI in antenatal and postnatal women, which contrasts with the more established effectiveness in mid-life women. It is possible that the effects of PFMT might be greater with targeted rather than mixed prevention and treatment approaches, and in certain groups of women. Hypothetically, for instance, women with a high body mass index (BMI) are at risk of UI. Such uncertainties require further testing and data on duration of effect are also needed. The physiological and behavioural aspects of exercise programmes must be described for both PFMT and control groups, and how much PFMT women in both groups do, to increase understanding of what works and for whom. Few data exist on FI and it is important that this is included in any future trials. It is essential that future trials use valid measures of incontinence-specific quality of life for both urinary and faecal incontinence. In addition to further clinical studies, economic evaluations assessing the cost-effectiveness of different management strategies for FI and UI are needed.

Knowledge, Attitude, and Practices (KAP) Survey Towards Pelvic Floor Muscle Training (PFMT) Among Pregnant Women

Objective

To assess knowledge, attitude, and practices (KAP) of pelvic floor muscle training (PFMT) among Thai pregnant women.

Patients and Methods

One hundred and ten Thai pregnant women who attended the antenatal clinic of a tertiary care hospital were recruited. They were classified as “aware” if they could recognize PFMT. Questionnaires regarding the participants’ attitudes and practice toward PFMT were subsequently collected from “aware” group.

Results

The mean ±SD of age and gestational age were 30.5 ±5.4 years and 20.8 ±10.8 weeks, respectively. Sixty-one participants (55.5%) recognized PFMT, but only seventeen (27.9%) correctly answered all of the questions, which is classified as perceptive. There was no association between their educational level and PFMT knowledge (p = 0.63). Most of them (98.4%) understood that PFMT can be performed during pregnancy and believed that PFMT did not affect the pregnancy outcomes. However, only 10.7% of the aware women performed PFMT irregularly during pregnancy.

Conclusion

Half of the pregnant women in this study were aware of PFMT. The majority of women felt that PFMT had positive effects on their health, emotions, sex, and quality of life. Education concerning PFMT and motivation to maintain the adherence of practicing the exercises are required.

Current Resources for Evidence-Based Practice, March 2019

A review of new resources to support the provision of evidence-based care for women and infants.

[Methods of preventing perineal injury and dysfunction during pregnancy: CNGOF Perineal prevention and protection in obstetrics]

OBJECTIVE

Several interventions during pregnancy have been described that might prevent the risk of postnatal perineal injury or dysfunction; these include prenatal perineal massage, use of the Epi-No device, and pelvic floor muscle training exercises. Our objective was to evaluate the effectiveness of these different interventions during pregnancy.

METHODS

A systematic review of the literature was conducted on PubMed, including articles in French and English published before May 2018, to evaluate the effectiveness of these different interventions on perineal protection in the post-partum period.

RESULTS

Perineal massage during pregnancy diminishes the episiotomy rate (LE1) as well as post-partum perineal pain and flatus (LE2). It does not reduce the rate of either OASIS (LE1) or post-partum urinary incontinence (LE2). The Epi-No device does not provide benefits for perineal protection (LE1). Prenatal pelvic floor muscle training exercises do not reduce the risk of perineal lacerations (LE2); they reduce the prevalence of post-partum urinary incontinence at 3 to 6 months but not at 12 months post-partum (LE2).

CONCLUSION

Perineal massage during pregnancy must be encouraged among women who want it (Grade B). The use of the Epi-No device during pregnancy is not recommended for the prevention of OASIS (grade B). Pelvic floor muscle training during pregnancy is not recommended for the prevention of OASIS (grade B); moreover, its absence of effect in the medium term does not allow us to recommend it for urinary incontinence (professional consensus).