The effect of antenatal pelvic floor muscle training on labor and delivery outcomes: a systematic review with meta-analysis

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).

Influence of pelvic floor muscle training alone or as part of a general physical activity program during pregnancy on urinary incontinence, episiotomy and third- or fourth-degree perineal tear: Systematic review and meta-analysis of randomized clinical trials

INTRODUCTION

The complex process of pregnancy and childbirth significantly influences the well-being of both mother and child. Today all pregnant women without medical contraindications are recommended to start or continue regular aerobic and strength training for at least 150 min per week to prevent pregnancy-related diseases and conditions. Urinary incontinence in pregnancy, episiotomy and third- or fourth-degree perineal tear during labor can greatly impact womens' health, quality of life and ability to be physically active. The aim of this study was to examine the efficacy of pelvic floor muscle training (PFMT) during pregnancy in the prevention of urinary incontinence, episiotomy, and third- or fourth-degree perineal tear.

MATERIAL AND METHODS

A systematic review and meta-analysis (CRD42022370600) was performed. Only randomized clinical trials published between 2010 and 2023 were included. The following databases were examined: EBSCO (including Academic Search Premier, Education Resources Information Center, MEDLINE, SPORTDiscus and OpenDissertations databases), Clinicaltrials.gov, Web of Science, Scopus, Cochrane Database of Systematic Reviews and Physiotherapy Evidence Database (PEDro). Three meta-analyses to investigate the effect of PFMT exclusively or implemented as a section within a physical activity program during pregnancy on urinary incontinence, episiotomy, and third- or fourth-degree perineal tear were conducted.

RESULTS

Thirty studies were analyzed (N = 6691). An effective preventive action of PFMT was found for urinary incontinence (z = 3.46; p < 0.0005; relative risk [RR] = 0.72, 95% confidence interval [CI]: 0.59, 0.87, I2 = 59%) and third- or fourth-degree perineal tear (z = 2.89; p = 0.004; RR = 0.50, 95% CI: 0.31, 0.80, I2 = 48%) but not for episiotomy (z = 0.80; p = 0.42; RR = 0.95, 95% CI: 0.85, 1.07, I2 = 75%).

CONCLUSIONS

PFMT during pregnancy proves to be an effective preventive intervention for reducing the risk of urinary incontinence and the occurrence of third- or fourth-degree perineal tears. These findings highlight the importance of incorporating PFMT into antenatal care and training programs to improve maternal well-being and overall childbirth outcomes.

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.

The effect of pelvic floor muscle-strengthening exercises on low back pain: a systematic review and meta-analysis on randomized clinical trials

BACKGROUND

Low back pain is a musculoskeletal disorder (MSD), and Kegel exercise is considered as one of the non-surgical management methods. Therefore, the present systematic review and meta-analysis aimed to estimate the results of randomized clinical trials (RCT) about the effect of pelvic floor muscle-strengthening exercises on reducing low back pain‏.‏ METHODS: The present study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline (2020) to January 2022. The relevant studies were searched in the MagIran, SID, PubMed, Embase, Web of Science (WoS), Scopus, ClinicalTrials.gov databases and Google Scholar motor engine using related MeSH/Emtree terms, which were combined with free text word. The heterogeneity of the studies was checked using I² statistic.

RESULTS

Finally, 19 RCTs with a sample size of 456 subjects in the intervention group and 470 in the control group were included in the meta-analysis. The low back pain intensity in the intervention group decreased up to 1.261 ± 0.213 (SMD ± 95% CI) with I² = 87.60 more than that in the control group (P <0.001). The low back pain intensity in postpartum women decreased up to 1.614 ± 0.312 (95% CI) followed by pregnant women as 1.282 ± 0.479 (SMD ± 95% CI) more than that in other populations. But due to high the heterogeneity in all sub-groups (I² > 80%) this result should be considered with caution. Meta-regression analysis showed the effect of pelvic floor muscle-strengthening exercises increased by increasing the year of publication, quality assessment score of the article, and the number of weeks of intervention (P<0.05).

CONCLUSION

Based on the results of the present meta-analysis, pelvic floor muscle-strengthening exercises significantly reduce the low back pain intensity. Therefore, these exercises can be regarded as a part of a low back pain management plan.

The effect of antenatal pelvic floor muscle exercise on sexual function and labour and birth outcomes: A randomised controlled trial

BACKGROUND

Pelvic floor muscle exercises (PFME) are recommended for treatment of urinary incontinence with less evidence available about the effect on female sexual function (FSF) and childbirth.

AIM

To investigate the effect of antenatal PFME on FSF during pregnancy and the first three months following birth as a primary outcome, and on labour and birth outcomes as a secondary outcome.

METHOD

200 nulliparous women were randomised to control (n = 100) and intervention (n = 100) groups. The women in the intervention group (IG) undertook PFME from 20 weeks gestation until birth and had routine antenatal care, while those in the control group (CG) received routine antenatal care only. The Female Sexual Function Index (FSFI) was used to measure FSF at 36 weeks gestation and three months postnatal. Baseline characteristics and childbirth data were also collected and analysed using SPSS.

RESULTS

There were no statistically significant differences between the two groups in terms of FSF scores during pregnancy and on childbirth outcomes. Sexual satisfaction was slightly higher in the CG [Mean ± SD, CG: 4.35 ± 1.45 vs. IG: 3.70 ± 1.50, (P = 0.03)] at three months after birth. However, 50% of women adhered to the PFME, and 40% of women did not resume sex by three months after the birth.

CONCLUSION

Though some trends were observed, the results showed no effect of PFME on sexual function or labour and birth outcomes. This needs to be interpreted considering the 50% adherence to PFME. More research is recommended.

Preliminary Effectiveness of mHealth App-Based Pelvic Floor Muscle Training among Pregnant Women to Improve Their Exercise Adherence: A Pilot Randomised Control Trial

This pilot randomised control trial (RCT) aimed to evaluate the feasibility and preliminary effectiveness of conducting a full-powered trial for a newly developed pelvic floor muscle training (PFMT) app among pregnant women with urinary incontinence (UI) in Malaysia. This was a prospective, single-centre, single-blind, parallel, randomised controlled, pilot feasibility study—the Kegel Exercise Pregnancy Training app (KEPT app) trial. In total, 26 pregnant women with urinary incontinence from an urban healthcare clinic were recruited and randomly assigned to either intervention or waitlist control group. The intervention group received the KEPT app, while the control group received usual antenatal care (waitlist control). Of the 26 pregnant women, 16 (61.5%) completed the two-month follow-up. The recruitment rate was 54.2%, and the retention rate was 62.5% in the intervention group and 60% in the control group. There was a significant difference between intervention and control groups’ baseline measurement in the severity of UI (p = 0.031). The app improved their knowledge (p = 0.011) and self-efficacy (p = 0.038) after the first month and attitude (p = 0.034) after two months of intervention, compared with the control group. This study supports the feasibility of our future cluster RCT. The KEPT app demonstrates a promising effect in improving PFMT attitude and self-efficacy and potentially enhancing exercise adherence among pregnant women with UI. Trial registration: This study was prospectively registered on ClinicalTrials.gov on 19 February 2021 (NCT04762433).

Promotion on labor process and relief of the low back pain by relaxing pelvic muscle with Shangliao (BL 31) point injection in women using epidural analgesia during labor: A randomized, controlled, clinical trial

BACKGROUND

The purpose of this study was to explore the effects of combing Shangliao point injection with epidural analgesia on labor pain and birth process in women with low back pain and the possible mechanisms.

METHODS

93 consecutive women were randomized to receive either Shangliao point injection combined with epidural analgesia or epidural analgesia. Another 14 women were recruited to explore the mechanisms and the transperineal ultrasound was performed accordingly.

RESULTS

The main result duration from epidural analgesia to baby delivery was significantly shorter in epidural analgesia and saline injection group than that in epidural analgesia group 307.0 (175.0-445.0) min VS 369.0 (254.0-563.0) min (P = 0.02). The verbal numerical rate scaling score in low back during the first contraction was significantly decreased 5.0 (4.0-7.0) after Shangliao point injections (P < 0.001). The consumption of ropivacaine per hour was significantly less in epidural analgesia and saline injection group than in epidural analgesia group (-0.4 mg, 95%CI: -0.1 to -1.8; P = 0.03). The angle of progression and anteroposterior diameter of the levator hiatus at rest and during valsalva were significantly increased after shangliao point injection (7.10°, 95%CI, 1.50~12.70; P = 0.02); (9.10°, 95%CI, 3.60~14.58; P < 0.01); (0.27 cm, 95%CI, 0.03~0.51; P = 0.03); (0.30 cm, 95%CI, 0.13~0.48; P < 0.01).

CONCLUSIONS

Shangliao point injection could shorten the time to baby delivery and rapidly relieve low back pain in addition to epidural analgesia, that may attribute to its function of relaxing the pelvic floor muscles and promote fetal head progress.

Narrative review of pelvic floor muscle training for childbearing women-why, when, what, and how

INTRODUCTION AND HYPOTHESIS

Urinary incontinence (UI) is prevalent during pregnancy and postpartum. UI in pregnancy strongly predicts UI postpartum and later in life. UI reduces women's wellbeing and quality of life and presents a significant burden to healthcare resource.

METHODS

A narrative review summarizing quantitative and qualitative evidence about pelvic floor muscle training (PFMT) for prevention and treatment of UI for childbearing women.

RESULTS

There are clinically important reductions in the risk of developing UI in pregnancy and after delivery for pregnant women who start PFMT during pregnancy, and PFMT offers additional benefits preventing prolapse and improving sexual function. If women develop UI during pregnancy or postpartum then PFMT is an appropriate first-line treatment. For novice exercisers, a programme comprising eight contractions, with 8-s holds, three times a day, 3 days a week, for at least 3 months is a reasonable minimum and 'generic' prescription. All women need clear accurate verbal instruction in how to do PFMT. Incontinent women, and women who cannot do a correct contraction, require referral for pelvic floor rehabilitation. Behavioural support from maternity care providers (MCPs)-increasing women's opportunity, capability, and motivation for PFMT-is as important as the exercise prescription.

CONCLUSION

PFMT is effective to prevent and treat UI in childbearing women. All pregnant and postpartum women, at every contact with a MCP, should be asked if they are continent. Continent women need exercise prescription and behavioural support to do PFMT to prevent UI. Incontinent women require appropriate referral for diagnosis or treatment.

Protocol of a Single-Blind Two-Arm (Waitlist Control) Parallel-Group Randomised Controlled Pilot Feasibility Study for mHealth App among Incontinent Pregnant Women

Background: The delivery of pelvic floor muscle training (PFMT) through mHealth apps has been shown to produce promising results in improving pelvic floor muscle strength and urinary incontinence (UI). However, there is limited evidence on mHealth apps designed for pregnant women who are at high risk of developing UI. This pilot study aims to evaluate the feasibility of conducting an effectiveness trial for a newly developed PFMT app among pregnant women in Malaysia. Methods: This is a prospective, single-centre, single-blind, randomised controlled pilot feasibility study: The Kegel Exercise Pregnancy Training app (KEPT-app) Trial. Sixty-four incontinent pregnant women who attended one primary care clinic for the antenatal follow-up will be recruited and randomly assigned to either intervention or waitlist control group. The intervention group will receive the intervention, the KEPT-app developed from the Capability, Opportunity, Motivation-Behaviour (COM-B) theory with Persuasive Technology and Technology Acceptance Model. Discussion: This study will provide a fine-tuning for our future randomised control study on the recruitment feasibility methods, acceptability, feasibility, and usability of the KEPT-app, and the methods to reduce the retention rates among pregnant women with UI. Trial registration: This study was registered on ClinicalTrials.gov on 19 February 2021 (NCT04762433) and is not yet recruiting.

The marathon of labour-Does regular exercise training influence course of labour and mode of delivery?: Secondary analysis from a randomized controlled trial

OBJECTIVES

Today all pregnant women are recommended to participate in moderate intensity aerobic and resistance-based physical activity/exercise ≥150 min/week. However, there are still controversies and scant knowledge on the role of regular exercise on delivery outcomes, including mode of delivery and length of active labour. In addition, nutritional counselling have often been examined together with exercise, which may independently effect the outcomes. Hence, the aims of the present study were to investigate the sole effect of supervised group exercise, including pelvic floor muscle training on course of labour and mode of delivery.

STUDY DESIGN

A single blind, randomized controlled trial, performed in the municipality of Oslo, Norway. Out of 105 healthy, inactive nulliparous women, initially enrolled (gestation week 17.7 ± 4.2) to study the effect regular aerobic exercise (60 min 2/week) on health benefits for both mother and her baby, 90 (85.7%) completed postpartum follow-up (7.7 ± 1.7) on labour outcomes (exercise: 43 and control: 47). Data were collected via standardized interviews and birth partographs from hospital records, reported on the postpartum visit (weeks after labour 7.6 ± 1.6). The primary investigator was unaware of the original randomization at the time of the interviews. The principal analysis was done on an intention to treat basis (ITT). For the planned subgroup analyses (per protocol), acceptable intervention adherence was defined as attending ≥ 80% of the recommended exercise program (≥ 19 exercise sessions).

RESULTS

There were no differences between the exercise and control groups in induction of labour, use of analgesia, duration of active labour or prolonged labour, according to ITT. Per protocol analyses, showed a shorter duration of total active labour in the exercise group (6.8 ± 5.5 h) than the control group (9.8 ± 5.4 h), with a mean between group difference of 3.1 h (95% CI 0.31-5.9, p = 0.029). Rate of normal vaginal delivery was 85.7% among adherent participants and 62.3% in the control group (p = 0.051).

CONCLUSIONS

Regular exercise during pregnancy decreased duration of total active labour and showed a trend towards more normal vaginal deliveries among participants who adhered to the prescribed program.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00617149.

A protocol for developing, disseminating, and implementing a core outcome set (COS) for childbirth pelvic floor trauma research

Background

More than 85% of women sustain different degrees of trauma during vaginal birth. Randomized controlled trials on childbirth pelvic floor trauma have reported a wide range of outcomes and used different outcome measures. This variation restricts effective data synthesis, impairing the ability of research to inform clinical practice. The development and use of a core outcome set (COS) for childbirth pelvic floor trauma aims to ensure consistent use of outcome measures and reporting of outcomes.

Methods

An international steering group, within CHORUS, an International Collaboration for Harmonising Outcomes, Research and Standards in Urogynaecology and Women’s Health, including academic community members, researchers, healthcare professionals, policy makers and women with childbirth pelvic floor trauma will lead the development of this COS. Relevant outcome parameters will be identified through comprehensive literature reviews. The selected outcomes will be entered into an international, multi-perspective online Delphi survey. Subsequently and based on the results of the Delphi surveys consensus will be sought on ‘core’ outcomes.

Discussion

Dissemination and implementation of the resulting COS within an international context will be supported and promoted. Embedding the COS for childbirth pelvic floor trauma within future clinical trials, systematic reviews, and clinical practice guidelines is expected to enrich opportunities for comparison of future clinical trials and allow better synthesis of outcomes, and will enhance mother and child care. The infrastructure created by developing a COS for childbirth pelvic floor trauma could be leveraged in other settings, for example, advancing research priorities and clinical practice guideline development.

Urinary incontinence among pregnant women in Southern Brazil: A population-based cross-sectional survey

Urinary incontinence (UI) is a common condition that causes significant harm to the well-being and quality of life of pregnant women. This cross-sectional population-based study aimed to estimate the prevalence and identify factors associated with the occurrence of UI during pregnancy in women living in the municipality of Rio Grande (RS), Southern Brazil, between January 1 and December 31 of 2016, and included all puerperae living in this municipality that had a child in one of the two local maternity hospitals. The previously trained interviewers used a single standardized questionnaire, within 48 hours after delivery to retrieve information on maternal demographic, behavioral and reproductive/obstetric history, as well as socioeconomic status of the household and care received during pregnancy and childbirth. The multivariate analysis followed a previously defined hierarchical model using Poisson regression with robust variance adjustment and prevalence ratio (PR) as a measure of effect. As a result, 2,716 puerperae were identified, of which 2,694 (99.2%) participated in this study. The prevalence of urinary incontinence in the gestational period was 14.7% (95%CI: 13.4%-16.1%). After adjusted analysis, the likelihood of UI occurring varied significantly as per women's characteristics. For example, the PR for the occurrence of UI among women over 30 years of age was 2.05 (95% CI: 1.39-3.01) compared to adolescents. In two other groups of women who had their first pregnancy before the age of 20 or after the age of 30, the PR for UI was 1.36 (95% CI: 1.04-1.76) and 1.59 (95% CI: 1.01-2.51), respectively, when compared to those who became pregnant for the first time between 20 and 29 years of age. Finally, in two other groups of women, namely, those who reached 90 kg and over at the end of pregnancy and those who performed regular physical exercise and reported frequent urinary urgency, the PR was 2.49 (95% CI: 1.74-3.57), and 2.90 (95% CI: 2.10-4.00) compared to those who did not exercise and did not report urinary urgency, respectively. The authors concluded that UI showed a high prevalence in the study population. The identified risk factors can be well administered at primary health care level. The recommendation of regular physical exercise in pregnancy must be reviewed and better investigated with more robust designs because of possible facilitators for the occurrence of UI in this period.

The effect of antenatal pelvic floor muscle exercises on labour and birth outcomes: a systematic review and meta-analysis

INTRODUCTION AND HYPOTHESIS

The current data on the effectiveness of antenatal pelvic floor muscle exercises (PFME) on childbirth outcomes are limited. Therefore, in this study the effect of antenatal PFMEs on labour and birth outcomes was assessed by undertaking a meta-analysis.

METHODS

Databases were systematically searched from 1988 until June 2019. Randomised controlled trials (RCTs) and quasi-experimental studies were included. The methodological quality of studies was assessed using Cochrane Collaboration tools. The outcomes of interest were: duration of first and second stage of labour, episiotomy and perineal outcomes, mode of birth (spontaneous vaginal birth, instrumental birth and caesarean section) and fetal presentation. The mean difference (MD) and risk ratio RR) with the corresponding 95% confidence intervals (CIs) were calculated to assess the association between PFME and the childbirth outcomes.

RESULTS

A total of 16 articles were included (n = 2,829 women). PFME shortened the duration of the second stage of labour (MD: -20.90, 95%, CI: -31.82 to -9.97, I²: 0%, p = 0.0002) and for primigravid women (MD: -21.02, 95% CI: -32.10 to -9.94, I²: 0%, p = 0.0002). PFME also reduced severe perineal lacerations (RR 0.57, 95% CI: 0.38 to 0.84, I²: 30%, p = 0.005). No significant difference was seen in normal vaginal birth, caesarean section, instrumental birth and episiotomy rate. Most of the studies carried a moderate to high risk of bias.

CONCLUSION

Antenatal PFME may be effective at shortening the second stage of labour and reducing severe perineal trauma. These findings need to be interpreted considering the included studies' risk of bias. More high-quality RCTs are needed.

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.

Third- and fourth-degree tears: A review of the current evidence for prevention and management

BACKGROUND

Third- and fourth-degree tears are associated with significant pain, discomfort and impact on quality of life and intimate relationships. Australian women experience comparatively higher rates of third- and fourth-degree tears relative to countries of similar economic development.

AIMS

We aimed to conduct a comprehensive review of the literature, published over the past five years, to identify the best ways to prevent and manage third- and fourth-degree perineal tears in Australian maternity centres.

MATERIALS AND METHODS

We searched the literature using the Cochrane Database of Systematic Reviews, EMBASE, MEDLINE, Maternity and Infant Care Database and Google Scholar for articles published since 2013 using key search terms. A review of reviews was undertaken given the extensive amount of literature on this topic.

RESULTS

Twenty-six systematic reviews were identified. The most common risk factors reported in the literature for third- and fourth-degree tears included primiparity, mother's ethnicity, large for gestational age infants and certain interventions used in labour and birth, such as instrumental deliveries. Preventive practices with varying degrees of effectiveness and often dependant on parity included: antenatal perineal massage, different maternal birthing positions, water births, warm compresses, protection of the perineum and episiotomy for instrumental births.

CONCLUSIONS

Third- and fourth-degree perineal tears are associated with immediate and long-term implications for women and health systems. Evidence-based approaches can reduce the number of women who sustain a severe perineal tear and alleviate the associated disease burden for those who do.

Is Physical Activity Good or Bad for the Female Pelvic Floor? A Narrative Review

More women participate in sports than ever before and the proportion of women athletes at the Olympic Games is nearly 50%. The pelvic floor in women may be the only area of the body where the positive effect of physical activity has been questioned. The aim of this narrative review is to present two widely held opposing hypotheses on the effect of general exercise on the pelvic floor and to discuss the evidence for each. Hypothesis 1: by strengthening the pelvic floor muscles (PFM) and decreasing the levator hiatus, exercise decreases the risk of urinary incontinence, anal incontinence and pelvic organ prolapse, but negatively affects the ease and safety of childbirth. Hypothesis 2: by overloading and stretching the PFM, exercise not only increases the risk of these disorders, but also makes labor and childbirth easier, as the PFM do not obstruct the exit of the fetus. Key findings of this review endorse aspects of both hypotheses. Exercising women generally have similar or stronger PFM strength and larger levator ani muscles than non-exercising women, but this does not seem to have a greater risk of obstructed labor or childbirth. Additionally, women that specifically train their PFM while pregnant are not more likely to have outcomes associated with obstructed labor. Mild-to-moderate physical activity, such as walking, decreases the risk of urinary incontinence but female athletes are about three times more likely to have urinary incontinence compared to controls. There is some evidence that strenuous exercise may cause and worsen pelvic organ prolapse, but data are inconsistent. Both intra-abdominal pressure associated with exercise and PFM strength vary between activities and between women; thus the threshold for optimal or negative effects on the pelvic floor almost certainly differs from person to person. Our review highlights many knowledge gaps that need to be understood to understand the full effects of strenuous and non-strenuous activities on pelvic floor health.

[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).

Systematic review of pelvic floor interventions during pregnancy

BACKGROUND

Pelvic floor interventions during pregnancy could reduce the impact of pregnancy and delivery on the pelvic floor.

OBJECTIVE

To determine the effects of pelvic floor interventions during pregnancy on childbirth-related and pelvic floor parameters.

SEARCH STRATEGY

PubMed, Embase, and LILACS were searched for reports published during between 1990 and 2016 in English, Spanish, or Portuguese. The search terms were "pregnancy," "pelvic floor muscle training," and related terms.

SELECTION CRITERIA

Randomized controlled trials with healthy pregnant women were included.

DATA COLLECTION AND ANALYSIS

Baseline and outcome data (childbirth-related parameters, pelvic floor symptoms) were compared for three interventions: EPI-NO (Tecsana, Munich, Germany) perineal dilator, pelvic floor muscle training, and perineal massage.

MAIN RESULTS

A total of 22 trials were included. Two of three papers assessing EPI-NO showed no benefit. The largest study investigating pelvic floor muscle training reported a significant reduction in the duration of the second stage of labor (P<0.01), and this intervention also reduced the incidence of urinary incontinence (evaluated in 10 trials). Two of six trials investigating perineal massage reported that a lower rate of perineal pain was associated with this intervention.

CONCLUSION

Pelvic floor muscle training and perineal massage improved childbirth-related parameters and pelvic floor symptoms, whereas EPI-NO showed no benefit.

Do female elite athletes experience more complicated childbirth than non-athletes? A case-control study

OBJECTIVE

Previous studies have suggested that female athletes might be at higher risk of experiencing complications such as caesarean sections and perineal tears during labour than non-athletes. Our aim was to study delivery outcomes, including emergency caesarean section rates, length of the first and second stages of labour and severe perineal tears, in first-time pregnant elite athletes compared with non-athletes.

METHODS

This is a retrospective case-control study comparing birth outcomes of primiparous female elite athletes engaging in high-impact and low-impact sports compared with non-athletic controls. The athletes had prior to birth competed at a national team level or equivalent. Participant characteristics and frequency of training for at least 3 years before a first pregnancy were collected via a self-administered questionnaire. Information on delivery outcome was retrieved from the Icelandic Medical Birth Registry.

RESULTS

In total, 248 participated, 118 controls, 41 low-impact and 89 high-impact elite athletes. No significant differences were found between the groups with regard to incidence of emergency caesarean section or length of the first and second stages of labour. The incidence of third-degree to fourth-degree perineal tears was significantly higher (23.7%) among low-impact athletes than in the high-impact group (5.1%, p=0.01), but no significant differences were seen when the athletes were compared with the controls (12%; p=0.09 for low-impact and p=0.12 for high-impact athletes).

CONCLUSION

Participation in competitive sports at the elite level was not related to adverse delivery outcome, including length of labour, the need for caesarean section during delivery and severe perineal tears.

Regular exercisers have stronger pelvic floor muscles than nonregular exercisers at midpregnancy

BACKGROUND

Today all healthy pregnant women are encouraged to be physically active throughout pregnancy, with recommendations to participate in at least 30 minutes of aerobic activity on most days of the week in addition to performing strength training of the major muscle groups 2-3 days per week and also pelvic floor muscle training. There is, however, an ongoing debate whether general physical activity enhances or declines pelvic floor muscle function.

OBJECTIVES

The objectives of the study were to compare vaginal resting pressure, pelvic floor muscle strength, and endurance in regular exercisers (exercise ≥30 minutes 3 or more times per week) and nonexercisers at midpregnancy. Furthermore, another objective was to assess whether regular general exercise or pelvic floor muscle strength was associated with urinary incontinence.

STUDY DESIGN

This was a cross-sectional study at mean gestational week 20.9 (±1.4) including 218 nulliparous pregnant women, with a mean age of 28.6 years (range, 19-40 years) and prepregnancy body mass index of 23.9 kg/m² (SD, 4.0). Vaginal resting pressure, pelvic floor muscle strength, and pelvic floor muscle endurance were measured by a high-precision pressure transducer connected to a vaginal balloon. The International Consultation on Incontinence Questionnaire Urinary Incontinence Short Form was used to assess urinary incontinence. Differences between groups were analyzed using an independent-sample Student t test. Linear regression analysis was conducted to adjust for prepregnancy body mass index, age, smoking during pregnancy, and regular pelvic floor muscle training during pregnancy. The significance value was set to P ≤ .05.

RESULTS

Regular exercisers had statistically significant stronger (mean 6.4 cm H₂O [95% confidence interval, 1.7-11.2]) and more enduring (mean 39.9 cm H₂Osec [95% confidence interval, 42.2-75.7]) pelvic floor muscles. Only pelvic floor muscle strength remained statistically significant, when adjusting for possible confounders. Pelvic floor muscle strength and not regular general exercise was associated with urinary continence (adjusted B, -6.4 [95% confidence interval, -11.5 to -1.4]).

CONCLUSION

Regular exercisers at midpregnancy have stronger pelvic floor muscles than their sedentary counterparts. However, pelvic floor muscle strength and not regular general exercise was associated with urinary incontinence. There is a need for additional studies in elite athletes and women performing more strenuous exercise regimens.

Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women

BACKGROUND

About one-third of women have urinary incontinence and up to one-tenth have faecal incontinence after childbirth. Pelvic floor muscle training (PFMT) is commonly recommended during pregnancy and after birth for both prevention and treatment of incontinence.This is an update of a review previously published in 2012.

OBJECTIVES

To determine the effectiveness of pelvic floor muscle training (PFMT) in the prevention or treatment of urinary and faecal incontinence in pregnant or postnatal women.

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register (16 February 2017) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised or quasi-randomised trials in pregnant or postnatal women. One arm of the trial included PFMT. Another arm was no PFMT, usual antenatal or postnatal care, another control condition, or an alternative PFMT intervention.

DATA COLLECTION AND ANALYSIS

Review authors independently assessed trials for inclusion and risk of bias. We extracted data and checked them for accuracy. Populations included: women who were continent (PFMT for prevention), women who were incontinent (PFMT for treatment) at randomisation and a mixed population of women who were one or the other (PFMT for prevention or treatment). We assessed quality of evidence using the GRADE approach.

MAIN RESULTS

The review included 38 trials (17 of which were new for this update) involving 9892 women from 20 countries. Overall, trials were small to moderate sized, and the PFMT programmes and control conditions varied considerably and were often poorly described. Many trials were at moderate to high risk of bias. Other than two reports of pelvic floor pain, trials reported no harmful effects of PFMT.Prevention of urinary incontinence: compared with usual care, continent pregnant women performing antenatal PFMT may have had a lower risk of reporting urinary incontinence in late pregnancy (62% less; risk ratio (RR) for incontinence 0.38, 95% confidence interval (CI) 0.20 to 0.72; 6 trials, 624 women; low-quality evidence). Similarly, antenatal PFMT decreased the risk of urinary incontinence 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; moderate-quality evidence). There was insufficient information available for the late (more than six to 12 months') postnatal period to determine effects at this time point.Treatment of urinary incontinence: it is uncertain whether antenatal PFMT in incontinent women decreases incontinence in late pregnancy compared to usual care (RR 0.70, 95% CI 0.44 to 1.13; 3 trials, 345 women; very low-quality evidence). This uncertainty extends into the mid- (RR 0.94, 95% CI 0.70 to 1.24; 1 trial, 187 women; very low-quality evidence) and late (RR 0.50, 95% CI 0.13 to 1.93; 2 trials, 869 women; very low-quality evidence) postnatal periods. In postnatal women with persistent urinary incontinence, it was unclear whether PFMT reduced urinary incontinence at more than six to 12 months' postpartum (RR 0.55, 95% CI 0.29 to 1.07; 3 trials; 696 women; very low-quality evidence).Mixed prevention and treatment approach to urinary incontinence: antenatal PFMT in women with or without urinary incontinence (mixed population) may decrease urinary incontinence risk in late pregnancy (26% less; RR 0.74, 95% CI 0.61 to 0.90; 9 trials, 3164 women; low-quality evidence) and the mid-postnatal period (RR 0.73, 95% CI 0.55 to 0.97; 5 trials, 1921 women; very low-quality evidence). It is uncertain if antenatal PFMT reduces urinary incontinence risk late postpartum (RR 0.85, 95% CI 0.63 to 1.14; 2 trials, 244 women; low-quality evidence). For PFMT begun after delivery, there was considerable uncertainty about the effect on urinary incontinence risk in the late postnatal period (RR 0.88, 95% CI 0.71 to 1.09; 3 trials, 826 women; very low-quality evidence).Faecal incontinence: six trials reported faecal incontinence outcomes. In postnatal women with persistent faecal incontinence, it was uncertain whether PFMT reduced incontinence in the late postnatal period compared to usual care (RR 0.68, 95% CI 0.24 to 1.94; 2 trials; 620 women; very low-quality evidence). In women with or without faecal incontinence (mixed population), antenatal PFMT led to little or no difference in the prevalence of faecal incontinence in late pregnancy (RR 0.61, 95% CI 0.30 to 1.25; 2 trials, 867 women; moderate-quality evidence). For postnatal PFMT in a mixed population, there was considerable uncertainty about the effect on faecal incontinence in the late postnatal period (RR 0.73, 95% CI 0.13 to 4.21; 1 trial, 107 women, very low-quality evidence).There was little evidence about effects on urinary or faecal incontinence beyond 12 months' postpartum. There were few incontinence-specific quality of life data and little consensus on how to measure it. We found no data on health economics outcomes.

AUTHORS' CONCLUSIONS

Targeting continent antenatal women early in pregnancy and offering a structured PFMT programme may prevent the onset of urinary incontinence in late pregnancy and postpartum. However, the cost-effectiveness of this is unknown. Population approaches (recruiting antenatal women regardless of continence status) may have a smaller effect on urinary incontinence, although the reasons for this are unclear. It is uncertain whether a population-based approach for delivering postnatal PFMT is effective in reducing urinary incontinence. Uncertainty surrounds the effects of PFMT as a treatment for urinary incontinence 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 are at risk factor for urinary incontinence. 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 faecal incontinence or costs and it is important that both are 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.

Influence of a pelvic floor training programme to prevent perineal trauma: A quasi-randomised controlled trial

BACKGROUND

perineal injury is common after birth and may be caused by tears or episiotomy or both. Perineal massage has been shown to prevent episiotomies in primiparous women. On the other hand, pelvic floor exercises might have an influence by shortening the first and second stages of labour in the primigravida.

AIM

the aim of this study was to investigate the effects of a pelvic floor training following a birth programme on perineal trauma.

DESIGN

a single-blind quasi-randomized controlled trial with two groups: standard care and intervention.

SETTING

a tertiary, metropolitan hospital in Seville, Spain.

PARTICIPANTS

women (n=466) who were 32 weeks pregnant, having a singleton pregnancy and anticipating a normal birth were randomised. Women in the experimental groups were asked to perform a pelvic floor training programme that included: daily perineal massage and pelvic floor exercises from 32 weeks of pregnancy until birth. They were allocated to an intervention group by clusters (antenatal education groups) randomized 1:1. The control group had standard care that did not involve a perineal/pelvic floor intervention. These women were collected in a labour ward at admission 1:3 by midwives.

RESULTS

outcomes were analysed by intention-to-treat. Women assigned to the perineal/pelvic floor intervention showed a 31.63% reduction in episiotomy (50.56% versus 82.19%, p<0.001) and a higher likelihood of having an intact perineum (17.61% versus 6.85%, p<0.003). There were also fewer third (5.18% versus 13.12%, p<0.001) and fourth degree-tears (0.52% versus 2.5%, p<0.001). Women allocated to the intervention group also had less postpartum perineal pain (24.57% versus 36.30%, p<0.001) and required less analgesia in the postnatal period (21.14% versus 30.82%, p<0.001).

CONCLUSIONS

a training programme composed of pelvic floor exercises and perineal massage may prevent episiotomies and tears in primiparous women. This programme can be recommended to primiparous women in order to prevent perineal trauma.

KEY CONCLUSION

the pelvic floor programme was associated with significantly lower rates of episiotomies and severe perineal trauma; and higher intact perineum when compared with women who received standard care only.

IMPLICATIONS FOR PRACTICE

the programme is an effective intervention that we recommend to all women at 32nd week of pregnancy to prevent perineal trauma.