Pelvic floor awareness and the positive effect of verbal instructions in 958 women early postdelivery

Abstract

Introduction and hypothesis:
It is uncertain how reliable a personal belief is about the ability to do pelvic floor muscle (PFM) contractions early postdelivery and how instructional feedback affects pelvic floor muscle contraction (PFMC) performance. We hypothesize that many women do not have a reliable idea about PFMC and that instructional feedback can help improve their control.

Methods:
Prospective observational study in 958 women (median 30 years) early postdelivery PFMC was evaluated with visual observation: an inward movement of the perineum was accepted as sign of good contraction. The women who could not show PFMC three consecutive times got verbal instructions, and re-evaluation was afterward.

Results:
In 500 women, no inward movement of the perineum was observed: 275 women (29%) showed no movement at all, and 225 women (24%) showed some movement but no inward displacement. In 33.4%, the personal conviction to be able or not to perform PFMC proved false. After verbal instructions, 74% improved their PFMC.

Conclusions:
The belief of doing correct PFM contraction was false in at least one of five postpartum women. Verbal instructions have a positive effect on performing PFMC in 73.6% of women.

Full text

ORIGINAL ARTICLE
Pelvic floor awareness and the positive effect of verbal instructions
in 958 women early postdelivery
Alexandra Vermandel &Stefan De Wachter &
Tessi Beyltjens &Diona D’Hondt &Yves Jacquemyn &
Jean Jacques Wyndaele
Received: 23 December 2013 /Accepted: 9 July 2014
#The International Urogynecological Association 2014
Abstract
Introduction and hypothesis It is uncertain how reliable a
personal belief is about the ability to do pelvic floor muscle
(PFM) contractions early postdelivery and how instructional
feedback affects pelvic floor muscle contraction (PFMC) per-
formance. We hypothesize that many women do not have a
reliable idea about PFMC and that instructional feedback can
help improve their control.
Methods Prospective observational study in 958 women (me-
dian 30 years) early postdelivery PFMC was evaluated with
visual observation: an inward movement of the perineum was
accepted as sign of good contraction. The women who could
not show PFMC three consecutive times got verbal instruc-
tions, and re-evaluation was afterward.
Results In 500 women, no inward movement of the perineum
was observed: 275 women (29 %) showed no movement at
all, and 225 women (24 %) showed some movement but no
inward displacement. In 33.4 %, the personal conviction to be
able or not to perform PFMC proved false. After verbal
instructions, 74 % improved their PFMC.
Conclusions The belief of doing correct PFM contraction was
false in at least one of five postpartum women. Verbal instruc-
tions have a positive effect on performing PFMC in 73.6 % of
women.
Keywords Aware nes s .Pelvic floor .Pelvic floor muscle
contraction .Verbal instructions
Abbreviations
PFM Pelvic floor muscles
PFMC Pelvic floor muscle contraction
PFMT Pelvic floor muscle training
UI Urinary incontinence
Introduction
Female urinary incontinence (UI) is a widespread problem,
with a high prevalence in pregnancy and postpartum.
Thirty-two to 64 % of women report UI during pregnancy
[1], with a reported postpartum prevalence of 56 % and
47 % at 6 weeks and 6 months [2]. Several published
guidelines recommend pelvic floor muscle training
(PFMT) as first-line treatment but also as a prevention
strategy for UI in women [3,4]. Hay-Smith t al. empha-
size the importance of correct assessment of pelvic floor
muscle contraction (PFMC) prior to starting PFM training
(PFMT) [5], which seems a necessity, as up to 30 % of
women are unable to perform a correct voluntary PFMC
[6]. The objectives of this study were to correlate
women’s impression of their ability to perform PFMC cor-
rectly with what is actually observed by a trained pelvic floor
physiotherapist and to evaluate the effect of verbal instruc-
tional biofeedback to correct PFMC in women who are unable
to perform one correctly.
Materials and methods
Design
This was a prospective repeated-measures observational study
of almost 3 years assessing women in their first week
A. Vermandel :S. De Wachter :T. Beyltjens :D. D’Hondt :
Y. Jacquemyn :J. J. Wyndaele
University Antwerp Faculty of Medicine and Health Sciences,
Antwerp University Hospital, Antwerp, Belgium
A. Vermandel (*)
Department of Urology, University of Antwerp, Wilrijkstraat 10,
2650 Edegem, Belgium
e-mail: alexandra.vermandel@uza.be
IntUrogynecolJ
DOI 10.1007/s00192-014-2483-x

postpartum during their stay in the University Hospital, Ant-
werp. Good knowledge of Dutch, French, or English language
was a prerequisite for inclusion. Exclusion criteria were blad-
der catheter in situ and a newborn in critical condition. All
women who participated gave permission to be examined and
for use of their data for our study. The study was approved by
the local ethics committee of the University of Antwerp.
Questionnaire
Data were obtained from the women and their medical
records, including age, parity, neonate birth weight, type
of delivery (cesarian or vaginal), use of epidural anes-
thesia, episiotomy, occurrence of perineal tear (grade 1–
3), and presence of UI before and during pregnancy.
Women were asked by the physiotherapist about their
knowledge regarding location and function of the PFM
(score: 0=no knowledge; 1 =knowledge). Furthermore,
they were asked if they had any experience with PFM
exercises (score: 0= no experience; 1=experience). Par-
ticipants with no knowledge or experience were briefly
informed about the location and function of PFM. Par-
ticipants with knowledge of PFM and experience with
PFM exercises were asked if they considered themselves
able to perform correct PFMC if asked to (score: 0=
unable; 1= doubtful; 2=able).
Procedure
Women were seen within the first week postpartum by a
specialized physiotherapist who evaluated them in the
supine position. All were asked to perform three PFMC
in a row and were graded upon visual observation. The
highest-grade contraction was noted. A normal PFMC
was defined as ventral and inward displacement of the
perineum: grade 0=no movement; grade 1=weak move-
ment; grade 2=strong inward displacement/lift of
perineum.
Participants received instructional biofeedback from the
physiotherapist regarding their attempt to contract the
PFM: correct (grade 2) or incorrect or insufficient (grade
0 or 1). Women without correct PFMC were instructed
and taught how to correctly contract a PFM [7] and were
asked to again perform three PFMCs. These three contrac-
tions were guided by the physiotherapist’s feedback. The
last contraction was graded using the same grading
system.
First, the correlation between the participant’sconvic-
tion of her ability to correctly perform PFMC was
evaluated in comparison with findings on visual obser-
vation by the physiotherapist. Second, the effect of
instructional biofeedback was evaluated by comparing
PFMC before and after biofeedback. Evolution in
observed contraction before and after instructional feed-
back was then graded:
Status quo:no change in grading
Positive evolution:from grade 0 to grade 1
Normalization: from grade 0 or 1 to grade 2
Deterioration: from grade 1 to grade 0
Statistical analysis
Statistical analysis was carried out using SPSS version 20.0
for Windows. Descriptive statistics, average± standard devia-
tion (SD), contingency tables, and nonparametric Wilcoxon
test were used. Multivariate analysis was performed using
logistic regression. Proportional odds logistic regression was
used to assess the effect of covariates on PFMC. First, simple
models were fitted to estimate the univariate relationship
between the different predictors and PFMC outcome. Then,
all covariates were entered into the multiple proportional odds
model. Odds ratios (OR) and 95 % confidence intervals (95 %
CI) were considered significant if p<0.05.
Interobserver variability
In 51 women, observation was done simultaneously by two
independent observers to determine interobserver variability.
Results
Nine hundred and fifty-eight women participated: 73.8 % (n=
707) indicated they had knowledge of the pelvic floor, where-
as 26.2 % (n=251) indicated no knowledge; 52.2 % (n=500)
had experience with PFMT and were included in the knowl-
edge group, where they represented 70.7 %. Demographic
data are presented in Table 1.
Mean age and birth weight were significantly higher in the
knowledge group. Women with UI before or during pregnan-
cy had more knowledge regarding pelvic floor function and
experience with PFM exercise. There was also a significant
difference in the number of days between delivery and obser-
vation. Other variables can be considered equal in both
groups. Differences of neonate birth weight and days before
observation gave no significant differences in observation
outcome. The data of reported knowledge of pelvic floor,
experience with PFMT, and PFMC performance on first ob-
servation are given in Fig. 1.
There was a significant difference in PFMC between
groups with or without knowledge and experience
(p<0.001). Between women who were convinced and women
who were in doubt about their ability to do a PFMC, there was
Int Urogynecol J

no significant difference (p=0.903). None of the women who
had knowledge and experience with PFMC was convinced
she was unable to perform a PFMC. In 77.6 % of women who
were convinced of their ability, we saw movement of the PFM
(grade 1 or 2). No inward perineal displacement was see in
52.2 % (n=500) of the women Evolution of PFMC after
verbal instructions and feedback in this group of women is
presented in Table 2.
No negative changes in PFM performance were seen after
instructions and feedback. There was no significant difference
in outcome between groups with or without knowledge and
experience (p= 0.380). An overview of data on PFMC perfor-
mance in the total population is given in Fig. 2.
Multiple proportional odds logistic regression showed a
negative effect of UI during pregnancy (p=0.047). Variables
such as age, days post delivery, multiple children, birth
weight, episiotomy perineal tear, epidural anesthesia, cesare-
an, UI before delivery, UI after delivery, parity, and experience
had no significant influence. Having knowledge about loca-
tion and function of the PFM had a positive effect on PFMC
(p=0.012 ,OR=1.567). Agreement between observations of
two physiotherapists was high (κ=0.892)
Discussion
A correct assessment of pelvic floor function is a prerequisite
for proper PFM treatment [5]. Nearly 75 % of participants in
this study declared to know the location and function of the
pelvic floor muscle. Furthermore, half the women had expe-
rience with PFMT, which is similar to other reports [8,9], and
emphasizes the need for better PFMT during pregnancy as
part of standard prenatal care.
More than 10 years ago, Chiarelli et al. [10] evaluated a
similar study population and concluded that a lack of knowl-
edge of PFM existed, which—although no numbers were
reported—seems to contradict with the high numbers in our
study. This may be due to the prenatal information sessions
that are organized at our institution in which attention is given
to the importance of PFMT or to the increased attention during
the last decade given to preventing UI. However, our results
on the questionnaire may overestimate the true ability to
perform PFMC correctly: ~ 55 % of women who were con-
vinced that they could perform a correct PFMC did so when
being assessed, confirming that misconceptions on the PFM
and their functions. Knowing about the function and location
of PFM was a positive predictor for PFMC. However, women
with experience in PFMT were no better at performing PFMC.
This emphasizes the importance for women to be well in-
formed prior to PFMC [10] and contradicts a previous report
stating thatwomen with experience in PFMTare more capable
of performing better PFMC [11]. However, no data are avail-
able on the methods participants were taught, e.g., by a trained
physiotherapist or by themselves.
We noticed that both knowledge and experience increased
with maternal age, and women with a history of UI symptoms
Table 1 Data on variables by
groups of knowledge and experi-
ence and no knowledge and/or no
experience
Data are numbers (%) or mean±
standard deviation
Participant variables Number Knowledge and experience
(n=500)
No knowledge and/or no
experience (n=458)
Pvalue
Mother
Age (years) 31 (± 4.7) 29 (± 5.2) p=0.000
Parity 1 230 (46 %) 261 (57 %) p=0.001
2 182 (36 %) 101 (22 %) p=0.000
3 61 (12 %) 62 (14 %) p=0.537
≥427(5%) 34(7%) p=0.200
Child
Multiple 22 (4 %) 25 (5 %) p=0.544
Birth weight (g) 3332 (± 607.7) 3178 (± 735.5) p=0.001
Delivery
Cesarean 111 (22 %) 105 (23 %) p=0.789
Epidural anesthesia 210 (42 %) 216 (47 %) p=0.109
Episiotomy 150 (30 %) 137 (30 %) p=0.977
Perineal tears 1 68 (14 %) 53 (12 %) p=0.346
2 91 (18 %) 76 (17 %) p=0.513
3 5 (1 %) 4 (1 %) p=0.839
Urinary incontinence
Before pregnancy 56 (11 %) 34 (7 %) p=0.045
During pregnancy 222 (44 %) 161 (35 %) p=0.003
Days to examination (days) 3 (± 1.1) 2 (± 1.1) p=0.034
IntUrogynecolJ

have more knowledge and experience. In this group of wom-
en, chances are greater that they have been in contact with
PFMT, which might explain why this group performed better
PFMC.
Visual observation as method to evaluate PFMC was used,
as ot os noninvasive, inexpensive, and patient friendly. Vagi-
nal palpation was not performed because of the discomfort
this might produce so soon after childbirth. Visual observation
is mentioned as an assessment method for PFM function in the
International Continence Society (ICS) Report on Terminolo-
gy [12]. However, no clear data on validity and reliability
exists on visual observation. In 1948, Kegel described
observation of a PFMC as a contraction or squeeze around
the urethral, vaginal, and anal openings and an inward lift that
could be observed at the perineum [7]. This definition is still
used in current literature and also during our research. Very
good interobserver agreement was found (κ=0.89).Inthe
group of women with experience with PFMT, 81.2 % were
convinced they would perform PFMC correctly. Research on
this topic reported that 65.7 % of women felt quite or very
certain that they could perform a correct PFMC [13]. A
different study reported that 94 % of women stated that they
could perform a correct PFMC, whereas 6 % doubted they
could [9]. Talasz et al. [11] and Henderson et al. [14]each
Table 2 Evolution of pelvic floor
muscle contraction (PFMC) after
instructions and feedback in
women with graded 0 or 1 on first
observation
Improved from grade 0 to 1,
normalized from grade 0 or 1 to 2
PFMC after instructions and feedback (n(%)
Unchanged Improved Normalized
Knowledge and experience (n=229) 60 (26.2 %) 44 (19.2 %) 125 (54.6 %)
No knowledge, no experience (n=271) 72 (26.6 %) 65 (24 %) 134 (49.4 %)
Tot al (n=500) 132 (26.4 %) 109 (21.8 %) 259 (51.8 %)
Included n=958
Knowledge and
experience
52.2% (n=500)
Convinced to be
able to do PFMC
81.2% (n=406)
No movement
22.4% (n=91)
Weak movement
22.9% (n=93)
Strong inward
displacement
54.7% (n=222)
Doubt to be able to
do PFMC
18.8% (n=94)
No movement
23.4% (n=22)
Weak movement
24.5% (n=23)
Strong inward
displacement
52.1% (n=49)
Knowledge or no
knowledge,
no experience
47.8% (n=458)
No movement
35.4% (n=162)
Weak movement
23.8% (n=109)
Strong inward
displacement
40.8% (n=187)
Fig. 1 Outcome of pelvic floor
muscle contraction (PFMC)
performance in women with or
without knowledge of the pelvic
floor and experience with PFM
training (PFMT). Values are
presented as percentages, with
numbers in brackets
Int Urogynecol J

researched PFM function in a large randomized group of
women and found normal PFMC, respectively, in 55.1 %
and 84.5 %. As opposed to our research, women in those
studies received minimal instructions before PFMC was
evaluated.
Our study shows that 47.8 % of women are capable of
performing a normal PFMC shortly after childbirth. These
divergent results make it difficult to attach value to the results
we found in women during the immediate postpartum stage.
Only knowledge of the PFM had a statistically significant
positive effect on PFMC. For factors such as type of partus,
rupture, or episiotomy—which might explain why women
show a less adequate PFMC postpartum than a random group
of women—no significant connection was found. Further-
more, verbal instructions and feedback had a marked positive
effect on PFM performance. Hederschee et al. [15]defined
PFMC feedback as a clinician-mediated method of giving
information back to the woman performing the contraction.
The same definition was used in our study. Feedback was
added to verbal instructions because simple verbal or written
instructions seemed insufficient for preparing a patient to
perform PFMC [16]. After this intervention, the physiothera-
pists observed a better outcome in 73.6 % of cases. This
method is certainly useful and also inexpensive, fast, feasible,
easy to perform, and applicable in the short postnatal period in
hospital.
The use of feedback and biofeedback on PFMT has been
studied in several incontinent women and was the subject of a
recent Cochrane review [15]. Our research investigated the
effect of feedback in 500 women in the immediate postpartum
period, when they are at risk for developing PFM dysfunction
and are therefore an important target. We observed an amelio-
ration in PFMC in 73.6 % of women, with 51.8 % of women
showing a correct PFMC. Having knowledge or experience
had no significant influence on results. Our results show a
clear effect on PFMC of verbal instructions combined with
feedback, which supports the conclusion of the Cochrane
review [17]. A recent study describes a positive effect of
elaborate verbal instructions alone enhancing PFMC by
78 % [14].
A limitation of this study is that only visual observation
was used. However, in this postnatal period, no more invasive
testing is acceptable. Observing the inward movement of
correct PFMC is the starting point for measuring PMF func-
tion [18].
Conclusion
In our study, we used visual observation only for assessing
PFMC, because vaginal palpation is not suitable at this stage
postpartum. Visual observation of PFMC is easy to perform
and is a very reliable tool by which to evaluate the function of
PFM, especially when vaginal palpation is not indicated, such
as in the immediate postpartum period. Giving instructional
biofeedback to women who are not able to perform a correct
PFMC, i.e., inward movement of the perineum, significantly
improves PFMC. Further research should involve women
who cannot produce a correct PFMC. It is important to verify
the patient’s postnatal ability to perform PFMC by doing a
short observation before starting any PFMT. Our results indi-
cate that instructional biofeedback has a positive effect on the
performance of PFMC in the majority of cases. Instructional
biofeedback has a beneficial effect in 73.6 % of women. This
method is certainly useful but is also inexpensive, fast, feasi-
ble, easy to perform, and applicable in the short postnatal
period in hospital.
Fig. 2 Pelvic floor muscle contraction (PFMC) performance in the total population at baseline and after instructions and feedback. Values are presented
as numbers of the total population (N=958). Grade 0 no movement, grade 1 weak movement, grade 2strong inward displacement
IntUrogynecolJ

Acknowledgments The authors thank all pelvic floor therapists and
women who participated in this study.
Conflicts of interest None.
References
1. Bortolini M, Drutz H, Lovatsis D (2010) Vaginal delivery and pelvic
floor dysfunction: current evidence and implications for future re-
search. Int Urogynecol J 21(8):1025–1030
2. Sangsawang B, Sangsawang N (2013) Stress urinary incontinence in
pregnant women: a review of prevalence, pathophysiology, and
treatment. Int Urogynecol J 24(6):901–912
3. Buckley BS, Lapitan MCM (2010) Prevalence of urinary inconti-
nence in men, women, and children—current evidence: findings of
the Fourth International Consultation on Incontinence. Urology
76(2):265–270
4. Thom DH, Rortveit G (2010) Prevalence of postpartum urinary
incontinence: a systematic review. Acta Obstet Gynecol 89(12):
1511–1522
5. Mascarenhas T, Coelho R, Oliveira M (2003) Impact of urinary
incontinence on quality of life during pregnancy and after childbirth.
33th annual meeting of the International Continence Society,
Florence, Italy
6. Subak LL, Brown JS, Kraus SR (2006) The “costs”of urinary
incontinence for women. Obstet Gynecol 107(4):908
7. Kegel AH (1948) Progressive resistance exercise in the functional
restoration of the perineal muscles. Am J Obstet Gynecol 56(2):238
8. Whitford HM, Alder B, Jones M (2007) A cross-sectional study of
knowledge and practice of pelvic floor exercises during pregnancy
and associated symptoms of stress urinary incontinence in North-East
Scotland. Midwifery 23(2):204
9. Hilde G, Stær-Jensen J, Engh ME (2012) Continence and pelvic floor
status in nulliparous women at midterm pregnancy. Int Urogynecol J
23(9):1257–1263
10. Chiarelli P, Cockburn J (1999) The development of a physiotherapy
continence promotion program using a customer focus. Aust J
Physiother 45:111–119
11. Talasz H, Himmer-Perschak G, Marth E (2008) Evaluation of pelvic
floor muscle function in a random group of adult women in Austria.
Int Urogynecol J 19(1):131–135
12. Haylen BT, de Ridder D, Freeman RM (2010) An international
urogynecological association (IUGA)/international continence soci-
ety (ICS) joint report on the terminology for female pelvic floor
dysfunction. Neurourol Urodyn 29(1):4–20
13. Chiarelli P, Murphy B, Cockburn J (2003) Women’sknowledge,
practises, and intentions regarding correct pelvic floor exercises.
Neurourol Urodyn 22(3):246–249
14. Henderson JW, Wang S, Egger MJ (2013) Can women correctly
contract their pelvic floor muscles without formal instruction?
Female Pelvic Med Reconstr Surg 19(1):8–12
15. Herderschee R, Hay-Smith EJC, Herbison GP (2011) Feedback or
biofeedback to augment pelvic floor muscle training for urinary
incontinence in women. Cochrane Database Syst Rev 6(7)
16. Bump RC, Hurt WG, Fantl JA (1991) Assessment of Kegel pelvic
muscle exercise performance after brief verbal instruction. Am J
Obstet Gynecol 165(2):322–327
17. Hay-Smith J, Mørkved S, Fairbrother K (2009) Pelvic floor muscle
training for prevention and treatment of urinary and faecal inconti-
nence in antenatal and postnatal women. Cochrane Database Syst
Rev 8(4)
18. Bø K, Sherburn M (2005) Evaluation of female pelvic-floor muscle
function and strength. Phys Ther 85(3):269–282
Int Urogynecol J