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Current Women’s Health Reviews, 2007, 3, 55-62 55
1573-4048/07 $50.00+.00 © 2007 Bentham Science Publishers Ltd.
Pelvic Floor Muscle Training During Pregnancy and After Delivery
Siv Mørkved*
Clinical Service, St. Olavs Hospital, Trondheim University Hospital / Dept. of Community Medicine and General
Practice, Norwegian University of Science and Technology, Trondheim, Norway
Abstract: Objective: Female urinary incontinence is often considered a problem that occurs primarily during pregnancy
and after childbirth. The aim of this article is to review the literature addressing pelvic floor muscle training in the
prevention and treatment of urinary incontinence during pregnancy and after delivery.
Method: Only full publications of prospective controlled studies were included. Urinary incontinence was the primary
outcome variable and pelvic floor muscle training was the main intervention.
Results: Four randomised controlled trials (RCTs) assessing the effect of pelvic floor muscle training during pregnancy
were found. Ten articles were identified addressing the effect of pelvic floor muscle training postpartum; seven of these
presented RCTs, two presented matched controlled studies and a controlled study. Three were follow-up studies. The
interventions included pelvic floor muscle training, however, various training protocols were used. All studies, except for
two, reported statistically and clinically significant effects of the interventions, with a significant reduction in symptoms
or frequency of urinary incontinence after the intervention period. No adverse effects of the interventions were reported.
Conclusions: This review suggests that women should be encouraged to perform pelvic floor muscle training during
pregnancy and postpartum to prevent and/or treat urinary incontinence.
Keywords: Pelvic floor muscle training, physiotherapy, urinary incontinence, treatment, pregnancy, postpartum.
INTRODUCTION
As early as in 1948, the American gynaecologist Arthur
Kegel emphasised the value of pelvic floor muscle exercise
in restoring function after childbirth. He claimed that genital
relaxation after delivery was due to nerve injury, over
stretching of muscles and tearing of fascias and that the
method of restoring the condition was "tightening" of the
pelvic floor muscles [1]. Kegel [1] reported that Hippocrates
tried "oil injections, hot douches and salves" to restore the
pelvic floor muscles after birth and that Saranus attempted
support with the hand to exercise the pelvic floor muscles. In
addition, information was given concerning observations of
unusually firm perinea in South African tribes due to the
practice of the midwives who made women contract the
pelvic floor muscles around their distended fingers after birth
[1]. As a consequence of Kegel's [2] studies, women in most
industrialised countries have been encouraged to exercise the
pelvic floor muscles during pregnancy and after delivery to
strengthen the pelvic floor and to prevent and treat urinary
incontinence. Although some 50 years have passed since this
practice was introduced, the effects of such exercises have
until recently been only sparsely documented [3].
The pelvic floor muscles play an important role in
maintaining adequate pelvic support, for example to the
position and function of the bladder, uterus and rectum, and
to enable urinary continence [4-9]. Perineal injury at delivery
is a major etiological factor in the development of urinary
*Address correspondence to this author at the Dept. of Community
Medicine and General Practice, Medisinsk teknisk forskningssenter, N-7489
Trondheim, Norway; Tel: +47 73598876; Fax: +47 73597577; E-mail:
siv.morkved@ntnu.no
incontinence [9]. Thus, female urinary incontinence is a
symptom that often occurs after childbirth. Prevalence
estimates of any stress urinary incontinence during preg-
nancy and after childbirth vary between 6% [10] and 67 %
[11], and 2-3 months after delivery between 3% [12] and 38
% [13]. The variation may be explained by different popula-
tions investigated (nulliparous, parous), the use of different
definitions of incontinence (self-report, urodynamically
proven, according to new or old definitions from Inter-
national Continence Society), and that the registration of
incontinence took place at different stages of pregnancy or
postpartum.
Urinary incontinence is a chronic health complaint,
which severely reduces quality of life [14,15]. Many
sufferers report effects on their social, domestic, physical,
occupational and leisure activities [14,16,17]. Stress urinary
incontinence (the complaint of involuntary leakage on effort
or exertion, or on sneezing or coughing [18]) may lead to
withdrawal from regular physical and fitness activities
[17,19]. Such withdrawal from physical activity may be a
threat to a woman's general health and well-being because
regular moderate physical activity is important in preventing
obesity, osteoporosis, high blood pressure, coronary heart
disease, depression, and anxiety [20].
There has been considerable debate as to whether the
development of urinary incontinence is due to pregnancy
itself or to the act of childbirth [21], and the evidence is
contradictory [22-24]. Several studies suggest that elective
caesarean birth seems to reduce the risk of injury to the
pelvic floor and postpartum urinary incontinence [23]. Other
studies have reported conflicting results by showing that
56 Current Women’s Health Reviews, 2007, Vol. 3, No. 1 Siv Mørkved
elective caesarean sections are not completely protective
[21,25,26]. In addition, we have to keep in mind that
confounding factors may exist. Anatomical structures (the
size of the mother's pelvis, muscles, connective tissue) may
be a reason for offering some women caesarean sections.
The same anatomical characteristics may also protect against
urinary incontinence after delivery. No method of obstetric
perineal management has yet been demonstrated to reduce
the risk for incontinence [27]. Therefore, there is still a need
for strategies to treat and rehabilitate pelvic floor damage
related to pregnancy and delivery also to prevent urinary
incontinence later in life. The pelvic floor muscles may be
one target for intervention.
The aim of this article is to review the literature address-
ing the effect of pelvic floor muscle training in the
prevention and treatment of urinary incontinence during
pregnancy and post partum.
METHODS
A research of the following computerised databases from
1985 to 2006 was undertaken: Medline, CINAHL,
EMBASE, and The Cochrane Library Database. The search
strategy recommended by the International Continence
Society was applied. A manual search was undertaken of
identified manuscripts reporting on research studies
mentioned in the references of this literature. Only controlled
trials published as articles with sufficient data to allow
statistical analyses were included, but abstracts were
excluded. A study was included if the trial reported the
results of physical therapy (pelvic floor muscle training with
or without the use of additional biofeedback and /or
electrical stimulation). We found four studies addressing
pelvic floor muscle training during pregnancy and 10 studies
addressing pelvic floor muscle training after delivery that
meet the inclusion criteria (Table 1 and Table 2).
The methodological quality varies, and it is important to
notice that interventions used in the studies also vary.
RESULTS
Four randomised clinical trials (RCTs) assessing the
effect of pelvic floor muscle training during pregnancy were
found [28-31] (Table 1). Ten controlled studies were
identified addressing the effect of pelvic floor muscle
training postpartum [32-41] (Table 2).
During Pregnancy
Three studies included primigravid women [28, 29,30],
the fourth study pregnant parous women [31], all recruited at
20-22 weeks of pregnancy. One study was purely a
prevention study, including only women at risk of
developing urinary incontinence (with increased bladder
neck mobility) and no previous urinary incontinence [29].
Two studies included women who had not been selected on
the basis of incontinence or risk factors [28,30], and the last
study included only pregnant women with existing urinary
incontinence [31]. In all studies the interventions comprised
pelvic floor muscle training, with some differences in the
home training programme and the frequency of the follow-
up by health professionals. The training protocol in the
studies by Reilly et al. [29] and Mørkved et al. [30]
addressed close follow-up (monthly and weekly) by a
physiotherapist, while Woldringh et al. [31] used a protocol
consisting of only three follow-up sessions during
pregnancy. Clinically significant effects of the interventions,
showing a significant reduction in symptoms or episodes of
urinary incontinence after intervention, were documented in
three studies [28-30]. No adverse effects of the interventions
were reported.
However, only short-term effects (effective immediately
after cessation of the training protocol) have been
documented. Sampselle et al. [28] found that the effect of the
intervention was not present at one year follow-up study, and
Woldringh et al. [31] found no difference in urinary
incontinence between the intervention and control group
during pregnancy and at the follow-up at six and 12 months
postpartum.
After Delivery
The studies included both primi- and multiparous women
recruited from one day to three months after delivery. Seven
studies were RCTs [32-38], two matched controlled [39,40]
and one controlled study [41]. Three studies were follow-up
studies [35,37,40] (Table 2).
All studies, except for one [32], reported clinically
significant effects of the interventions, with a significant
reduction in symptoms or frequency of urinary incontinence
after the intervention period. No adverse effects of the
interventions were reported. The interventions included
pelvic floor muscle training, however, following different
training protocols. Most studies compared pelvic floor
muscle training with current standard care, allowing self-
managed pelvic floor muscle training but not introducing a
control intervention. Only Dumoulin et al. [38] introduced
an intervention in the control group (massage), and
compared the control intervention with two interventions
involving different combined pelvic floor muscle
rehabilitation interventions. The training protocols in the
studies by Mørkved & Bø [39,40], Meyer et al. [41], and
Dumoulin et al. [38] addressed close follow-up (weekly and
monthly) by a physiotherapist.
Mørkved & Bø [40] found that the effect of pelvic floor
muscle training was still present one year after cessation of
the training programme, while Chiarelli et al. [37] and
Glazener et al. [35] found no difference in urinary
incontinence between groups at one and six year follow-up,
respectively. However, Chiarelli et al. [37] reported that
continued adherence to pelvic floor muscle training at 12
months was predictive of urinary incontinence at that time,
with less urinary incontinence among women training the
pelvic floor muscles.
IMPLEMENTATION
The results of this review suggest that pregnant and
postpartum women should be encouraged to perform pelvic
floor muscle exercises to prevent and treat urinary
incontinence. The most effective interventions consist of an
Pelvic Floor Muscle Training During Pregnancy and After Delivery Current Women’s Health Reviews, 2007, Vol. 3, No. 1 57
Table 1. Studies Assessing the Effect of Pelvic Floor Muscle Exercises During Pregnancy to Prevent/Treat Urinary Incontinence
Author Design Subjects Training Protocol Drop out / Adherence Results
[Numbers and percentage (%)]
Sampselle
et al. 1998
[28]
2 arm RCT
1. Control (n=38):
Routine care
2. Intervention
(n=34): A
tailored PFMT
program.
N=72 primigravid
women recruited at
20 weeks of
pregnancy. Groups
comparable at
baseline. Single
centre, USA.
1. Control: Routine care
2. A tailored PFMT program
beginning with muscle
identification progressing to
strengthening. 30 contractions
per day at max or near max
intensity from 20 weeks of
pregnancy. Correct voluntary
PFM contraction checked.
26/72 (36%)
withdrawals
- Unsupervised PFMT
reported by 20% of
control group.
- Adverse events not
stated.
Self reported adherence.
Partial ITT analysis
Change in mean UI symptom score:
Control Intervention p
35 wk' pregnancy : 0.20 -0.02 0.07
6 wk' post partum: 0.25 -0.06 0.03
6 mo post partum: 0.15 -0.11 0.05
12 mo post partum: 0.06 0.00 0.74
PFM strength: Ns difference
Reilly
et al. 2002
[29]
2 arm RCT
1. Control
(n=129):
Routine care
2. Intervention
(n=139): 20
weeks of
intensive
PFMT
N=268 primigravid
women with
increased bladder
neck mobility
recruited at 20 weeks
of pregnancy. Single
centre, England.
1. Control: Routine antenatal care
(verbal advice).
2. Intervention: Individual PFMT
with physiotherapist at monthly
intervals from 20 weeks until
delivery, with additional home
exercises 3 sets of 8
contractions (each held for 6
seconds) repeated twice daily.
Instructed to contract the PFM
when coughing or sneezing.
Data reported for
230/268 women, 38
withdrawals or losses to
follow up.
- 51% of the women in
the control group did
unsupervised PFMT.
- Adverse events not
stated.
ITT analysis
Self reported UI at 3 months post partum:
1. Control: 36/110 (32.7%)
2. Intervention: 23/120 (19.2%)
RR (95% CI): 0.59 (0.37-0.92) p=0.023
Quality of life: Higher score in the
exercise group p=0.004
Pad test: Ns difference
Bladder neck mobility: Ns difference
PFM strength: Ns difference
Mørkved
et al. 2003
[30]
2 arm RCT
1. Control
(n=144):
Customary
information
from general
practitioner /
midwife.
2. Intervention
(n=145): 12
weeks of
intensive
PFMT
N=289 primigravid
women recruited at
20 weeks of
pregnancy. Some
women had existing
UI. Three outpatient
physiotherapy clinics
in Norway
1. Control: Customary information
from general practitioner /
midwife. Not discouraged from
PFMT. Correct PFM
contraction checked at
enrolment.
2. Intervention: 12 weeks of
intensive PFMT (in a group) led
by physio-therapist, with
additional home exercises 8-10
max contractions (each held for
six seconds) repeated twice
daily, between 20 and 36 weeks
of pregnancy. Correct PFM
contraction checked at
enrolment.
10 withdrawals (6 PFMT
and 4 controls).
- Adverse events not
stated
ITT analysis
Self reported UI at 36 weeks pregnancy:
1. Control: 74/153 (48%)
2. Intervention: 48/148 (32%)
RR (95% CI): 0.67 (0.50-0.89) p=0.007
UI at 3 months post partum:
1. Control: 49/153 (32%)
2. Intervention: 29/148 (19.6%)
RR (95% CI): 0.61 (0.40-0.90) p=0.018
PFM strength: Sign difference in favour of
the intervention group
Woldringh
et al. 2006
[31]
2 arm RCT
1. Control
(n=152):
Routine care.
2. Intervention
(n=112): Four
sessions of
individual
instructions in
PFMT
N= 316 women with
UI at 22 weeks of
pregnancy.
Multi center, The
Netherlands
1. Control: Routine care. Nearly
2/3 received some instruction on
PFMT.
2. Intervention: Three sessions of
individual therapy during week
23-30 of pregnancy and one 6
weeks after delivery, combined
with written information.
60 in the intervention
and 76 in the control
group participated
during the whole study
period.
- Adverse events not
stated
- Adherence not reported
ITT analysis
Self reported UI:
Intervention Control p
35 wk' pregnancy: 93% 88% 0.33
8 wk' postpartum: 68% 62% 0.44
6 mo postpartum: 60% 56% 0.63
12 mo postpartum: 63% 58% 0.61
1 year post partum: Negative correlation
between training intensity and severity of
UI
58 Current Women’s Health Reviews, 2007, Vol. 3, No. 1 Siv Mørkved
Table 2. Studies Assessing the Effect of Pelvic Floor Muscle Exercises Postpartum to Prevent/Treat Urinary Incontinence
Author Design Subjects Training Protocol Drop out / Adherence Results
[Numbers and percentage (%)]
Sleep &
Grant
1987
[32]
2 arm RCT
1. Control
(n=900):
Current
standard care
2. Intervention
(n=900):
Current
standard care +
individual
sessions PFMT
N=1800 postpartum
women recruited
within 24 hours of
vaginal delivery.
Single centre,
England.
1. Controls: Current standard
antenatal and postnatal care.
Recommended to do PFM
contractions as often as
remembered and mid stream
urine stop. 4 wk health diary.
2. Intervention: As above plus one
individual session daily while in
hospital with midwifery co-
ordinator. 4 wk health diary
including section
recommending a specific PFMT
task each week.
Withdrawals at 3
months: 84/900 in
control and 107/900 in
intervention group.
- At 3 months
postpartum 58% on the
exercise group and 42%
in the control group
reported that they were
doing PFMT.
- Adverse events not
stated.
Not ITT analysis
Self reported UI 3 months post partum:
1. Control: 175/793 (22%)
2. Intervention: 180/816 (22%)
RR (95% CI): 1(0.83, 1.20)
Mørkved
& Bø
1997 [39]
Mørkved
& Bø
2000
One-year
follow up
[40]
Prospective
matched controlled
1. Control (n=99):
Customary
written
postpartum
instructions
from the
hospital.
2. Intervention
(n=99): Eight
weeks of
intensive pelvic
floor muscle
training
1. Control (n=81)
2. Intervention
(n=81)
N=198 postpartum
women. The criteria
for matching: age (±
2 years), parity (1, 2,
3, 4 ≥ deliveries) and
type of delivery.
Single centre,
Norway
N=180 women one
year postpartum. All
women, who had
participated in a
matched controlled
trial were contacted
per telephone one
year after delivery.
Single centre,
Norway.
Control: Customary written
postpartum instructions from the
hospital. Not discouraged from
performing PFMT on their own.
Correct PFM contraction checked at
enrolment.
Intervention: Eight weeks of intensive
PFMT (in a group) led by
physiotherapist with additional home
exercises between 8 and 16 weeks
postpartum. Correct PFM contraction
checked.
Seven withdrawals in the
intervention group.
- 100% in the training
group and 65% in the
control group reported
that they were doing
PFMT between 8 and 16
weeks after delivery.
- Adverse events not
stated
All longitudinal changes
were conducted using a
constant sample,
including the 81
matched pairs that
attended all tests
(162/180).
- 53% in the training
group and 24% in the
control group reported
that they were doing
PFMT between 16
th
week and one year
postpartum.
- Adverse events not
stated.
Self reported UI at 16 weeks post partum:
1. Control: 28/99 (28.3%)
2. Intervention: 14/99 (14.1%)
p=0.015
Standardised pad test:
1. Control: 13/99 (13.1%)
2. Intervention: 3/99 (3.0%) p=0.009
PFM strength: Sign difference in favour of
the intervention group
Self reported UI at 12 months post
partum:
1. Control: 31/81 (38%)
2. Intervention: 14/81 (17%)
p=0.003
Standardised pad test:
1. Control: 14/81 (13%)
2. Intervention: 5/81 ( 3%)
p<0.03
PFM strength: Sign difference in favour of
the intervention group
Pelvic Floor Muscle Training During Pregnancy and After Delivery Current Women’s Health Reviews, 2007, Vol. 3, No. 1 59
(Table 2) Contd….
Author Design Subjects Training protocol Drop out / Adherence Results
[Numbers and percentage (%)]
Wilson &
Herbison
1998 [33]
2 arm RCT
1. Control
(n=117):
Standard
postnatal PFM
exercises
2. Intervention
(n=113): 12
weeks of
intensive
PFMT
N=230 women with
UI three months
postpartum
1. Control: Standard postnatal PFM
exercises
2. Intervention: Instructions by
physiotherapist (80-100 fast/slow
contractions daily) 3,4,6 and 9
months postpartum. Use of
perineo-meter to teach awareness
of pelvic floor contraction. Three
groups:
a. 39 women performed only PFMT
b. 36 women only trained with
vaginal cones 15 minutes per day
c. 38 women used both a and b
Women responding on 1
year outcome
assessment:
1. Control: 91/117
2. Intervention:
54/113
Self reported UI at 12 months post
partum:
1. Control: 69/91 (76%)
2. Intervention: 27/54 (50%)
p=0.003
Pad test: Ns difference
Perineometry: Ns difference
Glazener
et al. 2001
[34]
Glazener
et al. 2005
[35]
2 arm RCT
1. Control
(n=376): No
visit
2. Intervention
(n=371):
Advice + visits
3 Centres:
Aberdeen,
Birmingham,
Dunedin
6 year follow up
1. Control: n=253
2. Intervention:n=
263
N=747 women with
UI three months
postnatally
Mean age at entry
29.6 (SD 5.0)
N=516
Mean age at entry
30.0 (SD 4.7)
1. Control: No visit
2. Intervention: Assessment of UI,
with advice on PFMT (80-100
fast/slow contractions daily)
followed up 5, 7, and 9 months
after delivery supplemented by
bladder training if appropriate at
7 and 9 months
Lost to follow up at 12
months:
1. Control: 35%
2. Intervention: 25%
ITT analysis
Lost to follow up: 30%
Performing any PFMT:
1. Control: 50%
2. Intervention: 50%
Self-reported UI at 12 months post
partum:
Any UI:
1. Control: 169/245 (69%)
2. Intervention: 167/279 (59.9%)
p=0.037
Severe UI:
1. Control: 78/245 (31.8%)
2. Intervention: 55/279 (19.7%)
p=0.002
Severe UI at 6 years follow up:
1. Control: 99/253 (39%)
2. Intervention: 100/263 (38%)
p=0.867
Meyer
et al. 2001
[41]
Allocated to 2
groups
1. Control (n=56):
no education
2. Intervention
(n=51): 12
sessions PFMT
over 6 weeks with
physiotherapist
N=107 primiparous
women 2 months
after delivery: 9/56
controls and 16/51 in
the intervention
group had self
reported SUI. Single
centre, Switzerland.
1. Control (n=56): No pelvic floor
re-education offered from 2 - 10
months postpartum.
2. Intervention (n=51): 12 sessions
over 6 weeks with
physiotherapist. PFMT followed
by 20 minutes of biofeedback
and 15 minutes of
electrostimulation.
No withdrawals or loses
to follow up.
Adherence not reported
- Adverse events not
stated
Self reported SUI 10 months post partum:
1. Control: 8/56 (32%)
2. Intervention: 6/51 (12%)
RR (95% CI): 0.82 (0.31, 2.21)
Subjects cured:
1. Contro1: 1/51 (2%) p=1.0
2. Intervention: 10/56 (19%) p=0.02
PFM strength: Ns difference
Bladder neck position and mobility: Ns
difference
Urodynamic parameters: Ns differences
60 Current Women’s Health Reviews, 2007, Vol. 3, No. 1 Siv Mørkved
(Table 2) Contd….
Author Design Subjects Training protocol Drop out / Adherence Results
[Numbers and percentage (%)]
Chiarelli
&
Cockburn
2002
[36]
Chiarelli
et al.
2005 [37]
2 arm RCT
1. Control
(n=350): Usual
care.
2. Intervention
(n= 370):
Continence
promotion
3. Control
(n=294):
Usual care
4. Intervention
(n= 275):
Continence
promotion
N=720 postnatal
women following
forceps or ventouse
delivery, or
delivered a baby > or
= 4000g.
Age 15– 44
Multicentre (3),
Australia.
1. Control : Usual care.
2. Intervention: Continence
promotion: One contact with
physiotherapist on postnatal
ward and another at 8 weeks
postpartum (correct PFM
contraction checked at second
visit). Intervention included
individually tailored PFMT, use
of transversus abdominus
contraction, the 'Knack',
techniques to minimise perineal
descent, postpartum wound
management. Written and verbal
information.
Drop out 6% in each
group
Adherence to PFM
training:
1. Control: 57.6%
2. Intervention:83.9%
- Adverse events not
stated
IT T analysis
Drop outs: 30%
ITT analysis
Self reported UI 3 months post partum:
1. Control: 126/328 (38.4%)
2. Intervention: 108/348 (31.0%)
(95% CI 0.22% - 14.6%) p=0.044
OR of incontinence for the women in the
intervention group compared with Control
group was:
0.65 (0.46-0.91), p=0.01
Self reported UI 12 months post partum:
Ns difference between groups.
Practice of PFMT at 12 months promotes
continence at this time.
Dumoulin
et al. 2004
[38]
3 arm RCT
1. Control (n=20)
2. PFM
rehabilitation
(n=21)
3. PFM
rehabilitation +
training of deep
abdominal
muscles (n=23)
N=64 parous women
under 45 years, still
presenting symptoms
of SUI at least once
per week 3 months
or more after their
last delivery.
Recruited during
annual gynecologic
visit at an obstetric
clinic, Canada
1. Control: 8 weekly sessions of
massage
2. PFM rehabilitation: Weekly
sessions supervised by
physiotherapist for 8 weeks: 15-
minutes electrical stimulation +
25 minutes PFMT with
biofeedback + home training 5
days per week.
3. PFM rehabilitation as group 2 +
30 minutes of deep abdominal
muscle training
Drop out rate 6%
High adherence
- Adverse events not
stated
ITT analysis
Objective cure (less than 2 g urine on pad
test) after the intervention:
1. Control: 0/19
2. PFM rehabilitation: 14/20
3. PFM rehabilitation + training of
deep abdominal muscles: 17/23
Sign difference in favour of the
intervention groups (p=0.001)
Ns difference between the two
intervention groups
Incontinence Impact Questionnaire: Sign
difference in favour of the intervention
groups
PFM strength: Ns difference
ITT = intention to treat analysis, mo=month, Ns=non significant, OR=odds ratio, PC = power calculation, PFM = pelvic floor muscles, PFMT = pelvic floor muscle training,
RCT=randomised controlled trial, RR=relative risk, SD=standard deviation, SUI= stress urinary incontinence, UI=urinary incontinence, wk'= week
intensive protocol for strength training of the pelvic floor
muscles, including frequent home training sessions and close
follow-up by a skilled physiotherapist.
However, when it comes to implementing the findings,
birth attendants often address the possible negative effect
that pelvic floor muscle training during pregnancy may have
on labour. There is a myth that pelvic floor muscle training
during pregnancy may cause prolonged labour. In theory,
strong and voluminous pelvic floor muscles could obstruct
labour. An opposite theoretical assumption is that training of
the pelvic floor muscles could improve both muscle strength
and muscle awareness and produce strong, flexible and well-
controlled muscles that will facilitate labour.
In the study by Salvesen & Mørkved [42] effects of
pelvic floor muscle training during pregnancy on labour
were assessed. The main outcome measures were duration of
Pelvic Floor Muscle Training During Pregnancy and After Delivery Current Women’s Health Reviews, 2007, Vol. 3, No. 1 61
the second stage of labour (“active pushing” time) and rate
of prolonged second stage of labour (active pushing for
longer than 60 minutes). The median length of the second
stage of labour was 40 minutes in the intervention group and
45 minutes in the control group, but the difference was not
statistically significant. However, a statistically significantly
lower rate of women in the intervention group had prolonged
duration of the second stage of labour. Analysis of Numbers
needed to treat showed that pelvic floor muscle training
during pregnancy prevented prolonged second-stage of
labour in about one in eight women. In addition, fewer
episiotomies were found in the intervention group.
EXAMPLE OF A PROGRAMME FOR PELVIC
FLOOR MUSCLE TRAINING DURING PREGNANCY
AND AFTER DELIVERY
In the following, the pelvic floor muscle training
programme used in our studies will be presented as an
example of an effective protocol to treat and prevent urinary
incontinence [30,39,40,42].
The training groups followed an especially designed
weekly exercise course that included both pelvic floor
muscle and general exercises. The groups were led by a
skilled physiotherapist, and each session lasted 45-60
minutes. The pelvic floor muscle training was performed in
lying, sitting, kneeling, and standing positions with legs
apart to emphasise specific strength training of the pelvic
floor muscles and relaxation of other muscles. Between each
session of pelvic floor muscle training, general exercises
were performed to music. The physiotherapist encouraged
the women to perform near maximal pelvic floor muscle
contractions, and to hold the contraction for 6-8 seconds. At
the end of each contraction, the women were asked to add 3-
4 fast contractions. The resting period was about 6 seconds.
In addition, the women performed 8-12 equally intensive
pelvic floor muscle contractions twice per day at home. The
physiotherapists focused strongly on motivation. The pelvic
floor muscle training protocol has previously been published
by Bø et al. [43] following recommendations for general
training to increase strength of skeletal muscles [44]. The
training groups included 5-15 women, and the training
period in the postpartum training groups was 8 weeks and in
pregnant women 12 weeks. Adherence to the training
protocol was verified by the participants' training diary and
from reports from the physiotherapists who were responsible
for the group training.
CONCLUSION
According to the results of the presented review pelvic
floor muscle training during pregnancy and after delivery is
effective in reducing urinary incontinence during pregnancy
and in the immediate postpartum period. However, the
longer term effect is questionable. No adverse effect of the
pelvic floor muscle training has been reported. It appears that
the interventions including intensive and frequent strength
training of the pelvic floor muscles and close follow-up by a
skilled physiotherapist have the best effect. However,
methodological differences and differences in adherence to
the training protocols make it difficult to compare studies
and to conclude which training regimen is the most effective.
Based on the current knowledge we should advice
women to conduct pelvic floor muscle exercises systema-
tically, both during pregnancy and after childbirth. The
training has no negative side effects and is inexpensive – and
the exercises help women to take care of their own health by
themselves.
A significant public health issue would be to build
strategies for encouraging women to talk about postpartum
morbidity, and to search for effective prevention and
treatment strategies. It is essential that – as far as possible –
future services for women during pregnancy and after
childbirth are organised according to results from controlled
clinical trials.
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Received: October 27, 2006 Revised: November 29, 2006 Accepted: November 29, 2006
