Aspects of Pelvic Floor Protection in Spontaneous Delivery – a Review

Abstract

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

Key words

vaginal delivery - pelvic floor protection - pelvic floor rehabilitation - urinary incontinence - pelvic organ prolapse - faecal incontinence - pregnancy

Publication History

Received: 29 January 2021

Accepted after revision: 17 May 2021

Article published online:
05 April 2022

• References/Literatur

• 1 Handa VL, Harris TA, Ostergard DR. Protecting the pelvic floor: obstetric management to prevent incontinence and pelvic organ prolapse. Obstet Gynecol 1996; 88: 470-478
• 2 Jelovsek JE, Chagin K, Gyhagen M. et al. Predicting risk of pelvic floor disorders 12 and 20 years after delivery. Am J Obstet Gynecol 2018; 218: 222.e1-222.e19
• 3 Delancey JO, Kane Low L, Miller JM. et al. Graphic integration of causal factors of pelvic floor disorders: an integrated life span model. Am J Obstet Gynecol 2008; 199: 610.e1-610.e5
• 4 Huebner M, Brucker SY, Tunn R. et al. Intrapartal pelvic floor protection: a pragmatic and interdisciplinary approach between obstetrics and urogynecology. Arch Gynecol Obstet 2017; 295: 795-798
• 5 Angelescu K. Inanspruchnahme von Leistungen der Hebammenhilfe durch GEK-versicherte Schwangere 2008 bis 2009. Eine explorative Analyse von Routinedaten einer gesetzlichen Krankenkasse. Universität Bremen 2012. Accessed November 15, 2020 at: http://nbn-resolving.de/urn:nbn:de:gbv:46-00102787-10
• 6 Sandall J, Soltani H, Gates S. et al. Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database Syst Rev 2016; (04) CD004667
• 7 Bihler J, Tunn R, Reisenauer C. et al. The preferred mode of delivery of medical professionals and non-medical professional mothers-to-be and the impact of additional information on their decision: an online questionnaire cohort study. Arch Gynecol Obstet 2019; 299: 371-384
• 8 Borrelli SE, Walsh D, Spiby H. First-time mothersʼ expectations of the unknown territory of childbirth: Uncertainties, coping strategies and ‘going with the flow’. Midwifery 2018; 63: 39-45
• 9 Cerruto MA, DʼElia C, Aloisi A. et al. Prevalence, incidence and obstetric factorsʼ impact on female urinary incontinence in Europe: a systematic review. Urol Int 2013; 90: 1-9
• 10 Wesnes SL, Rortveit G, Bo K. et al. Urinary incontinence during pregnancy. Obstet Gynecol 2007; 109: 922-928
• 11 Metz M, Junginger B, Henrich W. et al. Development and Validation of a Questionnaire for the Assessment of Pelvic Floor Disorders and Their Risk Factors During Pregnancy and Post Partum. Geburtshilfe Frauenheilkd 2017; 77: 358-365
• 12 MacArthur C, Glazener C, Lancashire R. et al. ProLong study group. Exclusive caesarean section delivery and subsequent urinary and faecal incontinence: a 12-year longitudinal study. BJOG 2011; 118: 1001-1007
• 13 Oberwalder M, Connor J, Wexner SD. Meta-analysis to determine the incidence of obstetric anal sphincter damage. Br J Surg 2003; 90: 1333-1337
• 14 Gyhagen M, Bullarbo M, Nielsen TF. et al. Prevalence and risk factors for pelvic organ prolapse 20 years after childbirth: a national cohort study in singleton primiparae after vaginal or caesarean delivery. BJOG 2013; 120: 152-160
• 15 Gyhagen M, Bullarbo M, Nielsen TF. et al. The prevalence of urinary incontinence 20 years after childbirth: a national cohort study in singleton primiparae after vaginal or caesarean delivery. BJOG 2013; 120: 144-151
• 16 Siahkal SF, Iravani M, Mohaghegh Z. et al. Maternal, obstetrical and neonatal risk factorsʼ impact on female urinary incontinence: a systematic review. Int Urogynecol J 2020;
• 17 Solans-Domènech M, Sánchez E. Espuña-Pons M; Pelvic Floor Research Group (Grup de Recerca del Sòl Pelvià, GRESP). Urinary and anal incontinence during pregnancy and postpartum: incidence, severity, and risk factors. Obstet Gynecol 2010; 115: 618-628
• 18 Blomquist JL, Munoz A, Carroll M. et al. Association of Delivery Mode With Pelvic Floor Disorders After Childbirth. JAMA 2018; 320: 2438-2447
• 19 Wilson D, Dornan J, Milsom I. et al. UR-CHOICE: can we provide mothers-to-be with information about the risk of future pelvic floor dysfunction?. Int Urogynecol J 2014; 25: 1449-1452
• 20 Schreiner L, Crivelatti I, de Oliveira JM. et al. Systematic review of pelvic floor interventions during pregnancy. Int J Gynaecol Obstet 2018; 143: 10-18
• 21 Hill AM, McPhail SM, Wilson JM. et al. Pregnant womenʼs awareness, knowledge and beliefs about pelvic floor muscles: a cross-sectional survey. Int Urogynecol J 2017; 28: 1557-1565
• 22 Franklin E. Beckenboden Power. München: Kösel; 2008
• 23 Heller A. Geburtsvorbereitung Menne-Heller Konzept. Stuttgart: Thieme; 1978
• 24 Chen I, Opiyo N, Tavender E. et al. Non-clinical interventions for reducing unnecessary caesarean section. Cochrane Database Syst Rev 2018; (09) CD005528
• 25 OʼKelly SM, Moore ZE. Antenatal maternal education for improving postnatal perineal healing for women who have birthed in a hospital setting. Cochrane Database Syst Rev 2017; (12) CD012258
• 26 Daly D, Cusack C, Begley C. Learning about pelvic floor muscle exercises before and during pregnancy: a cross-sectional study. Int Urogynecol J 2019; 30: 965-975
• 27 Ruckhaberle E, Jundt K, Bauerle M. et al. Prospective randomised multicentre trial with the birth trainer EPI-NO for the prevention of perineal trauma. Aust N Z J Obstet Gynaecol 2009; 49: 478-483
• 28 Kamisan Atan I, Shek KL, Langer S. et al. Does the Epi-No((R)) birth trainer prevent vaginal birth-related pelvic floor trauma? A multicentre prospective randomised controlled trial. BJOG 2016; 123: 995-1003
• 29 Shek KL, Chantarasorn V, Langer S. et al. Does the Epi-No Birth Trainer reduce levator trauma? A randomised controlled trial. Int Urogynecol J 2011; 22: 1521-1528
• 30 Labrecque M, Eason E, Marcoux S. Randomized trial of perineal massage during pregnancy: perineal symptoms three months after delivery. Am J Obstet Gynecol 2000; 182 (1 Pt 1): 76-80
• 31 Eogan M, Daly L, OʼHerlihy C. The effect of regular antenatal perineal massage on postnatal pain and anal sphincter injury: a prospective observational study. J Matern Fetal Neonatal Med 2006; 19: 225-229
• 32 Demirel G, Golbasi Z. Effect of perineal massage on the rate of episiotomy and perineal tearing. Int J Gynaecol Obstet 2015; 131: 183-186
• 33 Mei-dan E, Walfisch A, Raz I. et al. Perineal massage during pregnancy: a prospective controlled trial. Isr Med Assoc J 2008; 10: 499-502
• 34 Holst L, Haavik S, Nordeng H. Raspberry leaf–should it be recommended to pregnant women?. Complement Ther Clin Pract 2009; 15: 204-208
• 35 Beer AM, Adler M. Leitfaden Naturheilverfahren für die ärztliche Praxis. München: Urban & Fischer; 2012
• 36 Büthe K, Franke T, Hillen K. Geburtsvorbereitung des Perineums. Die Hebamme 2020; 33: 30-38
• 37 Salvesen KA, Stafne SN, Eggebo TM. et al. Does regular exercise in pregnancy influence duration of labor? A secondary analysis of a randomized controlled trial. Acta Obstet Gynecol Scand 2014; 93: 73-79
• 38 Dias A, Assis L, Barbosa A, Santini A, Picelli-Dias F. Effectiveness of perineal exercises in controlling urinary incontinence and improving pelvic floor muscle function during pregnancy. Neurourology and Urodynamics 2011; 30: 968
• 39 Pelaez M, Gonzalez-Cerron S, Montejo R. et al. Pelvic floor muscle training included in a pregnancy exercise program is effective in primary prevention of urinary incontinence: a randomized controlled trial. Neurourol Urodyn 2014; 33: 67-71
• 40 Stafne SN, Salvesen KA, Romundstad PR. et al. Does regular exercise including pelvic floor muscle training prevent urinary and anal incontinence during pregnancy? A randomised controlled trial. BJOG 2012; 119: 1270-1280
• 41 Sut HK, Asci O, Topac N. Sleep Quality and Health-Related Quality of Life in Pregnancy. J Perinat Neonatal Nurs 2016; 34: 302-309
• 42 Leon-Larios F, Corrales-Gutierrez I, Casado-Mejia R. et al. Influence of a pelvic floor training programme to prevent perineal trauma: A quasi-randomised controlled trial. Midwifery 2017; 50: 72-77
• 43 Fritel X, de Tayrac R, Bader G. et al. Preventing Urinary Incontinence With Supervised Prenatal Pelvic Floor Exercises: A Randomized Controlled Trial. Obstet Gynecol 2015; 126: 370-377
• 44 Mathe M, Valancogne G, Atallah A. et al. Early pelvic floor muscle training after obstetrical anal sphincter injuries for the reduction of anal incontinence. Eur J Obstet Gynecol Reprod Biol 2016; 199: 201-206
• 45 Jahdi F, Sheikhan F, Haghani H. et al. Yoga during pregnancy: The effects on labor pain and delivery outcomes (A randomized controlled trial). Complement Ther Clin Pract 2017; 27: 1-4
• 46 Barimani M, Forslund Frykedal K, Rosander M. et al. Childbirth and parenting preparation in antenatal classes. Midwifery 2018; 57: 1-7
• 47 Salvesen KA, Morkved S. Randomised controlled trial of pelvic floor muscle training during pregnancy. BMJ 2004; 329: 378-380
• 48 Boyle R, Hay-Smith EJ, Cody JD. et al. Pelvic floor muscle training for prevention and treatment of urinary and fecal incontinence in antenatal and postnatal women: a short version Cochrane review. Neurourol Urodyn 2014; 33: 269-276
• 49 Hay-Smith J, Morkved S, Fairbrother KA. et al. Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women. Cochrane Database Syst Rev 2008; (04) CD007471
• 50 Sobhgol SS, Smith CA, Dahlen HG. The effect of antenatal pelvic floor muscle exercises on labour and birth outcomes: a systematic review and meta-analysis. Int Urogynecol J 2020;
• 51 Morkved S, Bo K. Effect of pelvic floor muscle training during pregnancy and after childbirth on prevention and treatment of urinary incontinence: a systematic review. Br J Sports Med 2014; 48: 299-310
• 52 Bo K, Fleten C, Nystad W. Effect of antenatal pelvic floor muscle training on labor and birth. Obstet Gynecol 2009; 113: 1279-1284
• 53 Wesnes SL, Lose G. Preventing urinary incontinence during pregnancy and postpartum: a review. Int Urogynecol J 2013; 24: 889-899
• 54 Glazener C, Elders A, MacArthur C. et al. ProLong Study Group. Childbirth and prolapse: long-term associations with the symptoms and objective measurement of pelvic organ prolapse. BJOG 2013; 120: 161-168
• 55 Huebner M. Vitamin D: another piece of the puzzle in pelvic floor protection. BJOG 2020;
• 56 Stafne SN, Morkved S, Gustafsson MK. et al. Vitamin D and stress urinary incontinence in pregnancy: a cross-sectional study. BJOG 2020;
• 57 Huang J, Zang Y, Ren LH. et al. A review and comparison of common maternal positions during the second-stage of labor. Int J Nurs Sci 2019; 6: 460-467
• 58 Mändle C, Opitz-Kreuter S. Lehrbuch der praktischen Geburtshilfe. Stuttgart: Schattauer; 2014
• 59 Aasheim V, Nilsen ABV, Reinar LM. et al. Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database Syst Rev 2017; (06) CD006672
• 60 Trochez R, Waterfield M, Freeman RM. Hands on or hands off the perineum: a survey of care of the perineum in labour (HOOPS). Int Urogynecol J 2011; 22: 1279-1285
• 61 Foroughipour A, Firuzeh F, Ghahiri A. et al. The effect of perineal control with hands-on and hand-poised methods on perineal trauma and delivery outcome. J Res Med Sci 2011; 16: 1040-1046
• 62 Mayerhofer K, Bodner-Adler B, Bodner K. et al. Traditional care of the perineum during birth. A prospective, randomized, multicenter study of 1,076 women. J Reprod Med 2002; 47: 477-482
• 63 Bulchandani S, Watts E, Sucharitha A. et al. Manual perineal support at the time of childbirth: a systematic review and meta-analysis. BJOG 2015; 122: 1157-1165
• 64 Naidu M, Sultan AH, Thakar R. Reducing obstetric anal sphincter injuries using perineal support: our preliminary experience. Int Urogynecol J 2017; 28: 381-389
• 65 Ali-Masri H, Hassan S, Fosse E. et al. Impact of electronic and blended learning programs for manual perineal support on incidence of obstetric anal sphincter injuries: a prospective interventional study. BMC Med Educ 2018; 18: 258
• 66 Seehafer P. Warme Kompressen für den Damm: Evidenzbasiert, doch wenig angewendet. Deutsche Hebammenzeitschrift 09/2019.
• 67 Magoga G, Saccone G, Al-Kouatly HB. et al. Warm perineal compresses during the second stage of labor for reducing perineal trauma: A meta-analysis. Eur J Obstet Gynecol Reprod Biol 2019; 240: 93-98
• 68 Akbarzadeh M, Vaziri F, Farahmand M. et al. The Effect of Warm Compress Bistage Intervention on the Rate of Episiotomy, Perineal Trauma, and Postpartum Pain Intensity in Primiparous Women with Delayed Valsalva Maneuver Referring to the Selected Hospitals of Shiraz University of Medical Sciences in 2012–2013. Adv Skin Wound Care 2016; 29: 79-84
• 69 Dahlen HG, Homer CS, Cooke M. et al. Perineal outcomes and maternal comfort related to the application of perineal warm packs in the second stage of labor: a randomized controlled trial. Birth 2007; 34: 282-290
• 70 Essa R, Ismail N. Effect of second stage perineal warm compresses on perineal pain and outcome among primiparae. J Nurs Educ Pract 2015; 6: 48
• 71 Gupta JK, Sood A, Hofmeyr GJ. et al. Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database Syst Rev 2017; (05) CD002006
• 72 Thies-Lagergren L, Kvist LJ, Christensson K. et al. No reduction in instrumental vaginal births and no increased risk for adverse perineal outcome in nulliparous women giving birth on a birth seat: results of a Swedish randomized controlled trial. BMC Pregnancy Childbirth 2011; 11: 22
• 73 Nieuwenhuijze MJ, de Jonge A, Korstjens I. et al. Influence on birthing positions affects womenʼs sense of control in second stage of labour. Midwifery 2013; 29: e107-e114
• 74 Gareberg B, Magnusson B, Sultan B. et al. Birth in standing position: a high frequency of third degree tears. Acta Obstet Gynecol Scand 1994; 73: 630-633
• 75 Edqvist M, Hildingsson I, Mollberg M. et al. Midwivesʼ Management during the Second Stage of Labor in Relation to Second-Degree Tears-An Experimental Study. Birth 2017; 44: 86-94
• 76 Olson R, Olson C, Cox NS. Maternal birthing positions and perineal injury. J Fam Pract 1990; 30: 553-557
• 77 Altman D, Ragnar I, Ekstrom A. et al. Anal sphincter lacerations and upright delivery postures–a risk analysis from a randomized controlled trial. Int Urogynecol J Pelvic Floor Dysfunct 2007; 18: 141-146
• 78 WHO. WHO recommendations: intrapartum care for a positive childbirth experience. 2018 Accessed October 26, 2020 at: https://www.who.int/reproductivehealth/publications/intrapartum-care-guidelines/en/
• 79 Jesacher K. Kritik an strikter Anleitung zu forciertem Pressen und Rückenlage der Gebärenden. Die Hebamme 2016; 29: 160-165
• 80 Caughey AB. Is there an upper time limit for the management of the second stage of labor?. Am J Obstet Gynecol 2009; 201: 337-338
• 81 American College of Obstetricians and Gynecologists (College); Society for Maternal-Fetal Medicine. Caughey AB, Cahill AG, Guise JM. et al. Safe prevention of the primary cesarean delivery. Am J Obstet Gynecol 2014; 210: 179-193
• 82 Gimovsky AC, Berghella V. Randomized controlled trial of prolonged second stage: extending the time limit vs. usual guidelines. Am J Obstet Gynecol 2016; 214: 361.e1-361.e6
• 83 Rouse DJ, Owen J, Savage KG. et al. Active phase labor arrest: revisiting the 2-hour minimum. Obstet Gynecol 2001; 98: 550-554
• 84 Henry DE, Cheng YW, Shaffer BL. et al. Perinatal outcomes in the setting of active phase arrest of labor. Obstet Gynecol 2008; 112: 1109-1115
• 85 Zipori Y, Grunwald O, Ginsberg Y. et al. The impact of extending the second stage of labor to prevent primary cesarean delivery on maternal and neonatal outcomes. Am J Obstet Gynecol 2019; 220: 191.e1-191.e7
• 86 Marsoosi V, Jamal A, Eslamian L. et al. Prolonged second stage of labor and levator ani muscle injuries. Glob J Health Sci 2014; 7: 267-273
• 87 Pardo E, Rotem R, Glinter H. et al. Recovery from pelvic floor dysfunction symptoms in the postpartum is associated with the duration of the second stage of labor. Arch Gynecol Obstet 2019; 300: 127-133
• 88 Low LK, Zielinski R, Tao Y. et al. Predicting Birth-Related Levator Ani Tear Severity in Primiparous Women: Evaluating Maternal Recovery from Labor and Delivery (EMRLD Study). Open J Obstet Gynecol 2014; 4: 266-278
• 89 Lal M, Pattison HM, Allan TF. et al. Postcesarean pelvic floor dysfunction contributes to undisclosed psychosocial morbidity. J Reprod Med 2009; 54: 53-60
• 90 Schwarz C. Die Erlaubnis zum Nichtstun. Deutsche Hebammenzeitschrift 09/2014.
• 91 Bader W, Aigmueller T. Leitlinie zum Management von Dammrissen III. und IV. Grades nach vaginaler Geburt. AWMF 015/079. 2020. Accessed October 20, 2020 at: http://www.awmf.org/leitlininen/detail/II/015-079.html
• 92 Carroli G, Mignini L. Episiotomy for vaginal birth. Cochrane Database Syst Rev 2009; (01) CD000081
• 93 Jiang H, Qian X, Carroli G. et al. Selective versus routine use of episiotomy for vaginal birth. Cochrane Database Syst Rev 2017; (02) CD000081
• 94 Fodstad K, Staff AC, Laine K. Effect of different episiotomy techniques on perineal pain and sexual activity 3 months after delivery. Int Urogynecol J 2014; 25: 1629-1637
• 95 Sultan AH, Thakar R, Ismail KM. et al. The role of mediolateral episiotomy during operative vaginal delivery. Eur J Obstet Gynecol Reprod Biol 2019; 240: 192-196
• 96 DeLancey JO. Episiotomy: whatʼs the angle?. Int J Gynaecol Obstet 2008; 103: 3-4
• 97 Eogan M, Daly L, OʼConnell PR. et al. Does the angle of episiotomy affect the incidence of anal sphincter injury?. BJOG 2006; 113: 190-194
• 98 Harvey MA, Pierce M, Alter JE. et al. Society of Obstetricians and Gynaecologists of Canada. Obstetrical Anal Sphincter Injuries (OASIS): Prevention, Recognition, and Repair. J Obstet Gynaecol Can 2015; 37: 1131-1148
• 99 Kapoor DS, Thakar R, Sultan AH. Obstetric anal sphincter injuries: review of anatomical factors and modifiable second stage interventions. Int Urogynecol J 2015; 26: 1725-1734
• 100 Jango H, Langhoff-Roos J, Rosthoj S. et al. Modifiable risk factors of obstetric anal sphincter injury in primiparous women: a population-based cohort study. Am J Obstet Gynecol 2014; 210: 59.e1-59.e6
• 101 Laycock J, Jerwood D. Pelvic Floor Muscle Assessment: The PERFECT Scheme. Physiotherapy 2001; 87: 631-642
• 102 Harvey MA. Pelvic floor exercises during and after pregnancy: a systematic review of their role in preventing pelvic floor dysfunction. J Obstet Gynaecol Can 2003; 25: 487-498
• 103 Klinger H. Verbessert sich die Funktion des Beckenbodens durch Rückbildungsgymnastik?. Die Hebamme 2007; 20: 251-255
• 104 Meyer S, Hohlfeld P, Achtari C. et al. Pelvic floor education after vaginal delivery. Obstet Gynecol 2001; 97 (5 Pt 1): 673-677
• 105 Morkved S, Bo K. The effect of post-natal exercises to strengthen the pelvic floor muscles. Acta Obstet Gynecol Scand 1996; 75: 382-385
• 106 Sacomori C, Zomkowski K, Dos Passos Porto I. et al. Adherence and effectiveness of a single instruction of pelvic floor exercises: a randomized clinical trial. Int Urogynecol J 2020; 31: 951-959
• 107 Benjamin DR, Frawley HC, Shields N. et al. Relationship between diastasis of the rectus abdominis muscle (DRAM) and musculoskeletal dysfunctions, pain and quality of life: a systematic review. Physiotherapy 2019; 105: 24-34
• 108 Pascoal AG, Dionisio S, Cordeiro F. et al. Inter-rectus distance in postpartum women can be reduced by isometric contraction of the abdominal muscles: a preliminary case-control study. Physiotherapy 2014; 100: 344-348
• 109 Benjamin DR, van de Water AT, Peiris CL. Effects of exercise on diastasis of the rectus abdominis muscle in the antenatal and postnatal periods: a systematic review. Physiotherapy 2014; 100: 1-8
• 110 Eggenschwiler R. Clinical Assessment von Hebammen. Die Hebamme 2015; 28: 57-59
• 111 Franz A. PT und Hebamme: Konkurrenten?. Physiopraxis 2004; 2: 10-11
• 112 Baessler K, Heihoff-Klose A, Boelke S. et al. Does an early postpartum pessary treatment lead to remission of pelvic organ prolapse after vaginal birth? A pilot study. AUGS/IUGA Scientific Meeting. Int Urogynecol J 2019; 30: 219-380
• 113 Beilecke K, Tunn R. Ein neues Konzept in der postpartalen Pessartherapie. gynäkologie + geburtshilfe 2017; 22: 30-32