International Urogynecology Journal

https://doi.org/10.1007/s00192-020-04298-1

REVIEW ARTICLE

The effect of antenatal pelvic floor muscle exercises on labour

and birth outcomes: a systematic review and meta-analysis
Sahar Sadat Sobhgol 1 & Caroline A. Smith 2 & Hannah Grace Dahlen 1,3,4

Received: 31 October 2019 / Accepted: 27 March 2020

# The International Urogynecological Association 2020

Abstract
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.

Keywords Birth . Pelvic floor exercises . Pregnancy . Perineal care . Severe perineal tear . Second stage

Abbreviations Introduction
FI Faecal incontinence
PFM Pelvic floor muscle Pregnancy and birth, in particular instrumental birth and per-
PFME Pelvic floor muscle exercises ineal trauma, can negatively affect pelvic floor muscle
PFMS Pelvic floor muscle strength strength (PFMS) and lead to pelvic floor dysfunction [1, 2].
RCT Randomised controlled trial Obstetric interventions, prolonged second stage and extension
UI Urinary incontinence of episiotomy appear to be important risk factors for perineal
tears [3].
The benefits of pelvic floor muscle exercises (PFMEs) in
preventing and treating pelvic floor dysfunction during preg-
* Sahar Sadat Sobhgol
Sahar.sobhgol@y7mail.com nancy and/or the postpartum period have generally been
recognised [4]. However, there have been different views re-
1 garding the effects of antenatal PFMEs on labour and birth [5].
School of Nursing and Midwifery (SONM), Western Sydney
University (WSU), Locked Bag 1797, Penrith, NSW 2751, Australia Pelvic floor muscles help to support the weight of the baby
2 during pregnancy and to control urination. Researchers have
NICM Health Research Institute, Western Sydney University,
Locked Bag 1797, Penrith, NSW 2751, Australia suggested that PFMEs during pregnancy help to increase flex-
3 ibility, endurance and muscle control, which are necessary for
Ingham Institute, Liverpool, NSW, Australia
labour and birth [6]. PFMEs are free and have no reported side
4
NICM, Campbelltown, Australia

effects; they also can be done at any time of the day [7].
However, the current data on the influence of PFMEs on la-
bour and birth outcomes are limited and conflicting [8]. Some
studies report that PFMEs facilitate labour and birth [9],
whereas other studies report that weak or strong pelvic floor
muscles may obstruct labour [10] and some studies reported
neither a positive nor a negative effect of PFMEs on childbirth
[11]. The meta-analysis by Du et al. found that PFME short-
ened the duration of the first and second stages of labour.
However, their result was reported with high heterogeneity
for the second stage of labour [8]. As the number of RCTs
examining the effect of PFMEs on labour and birth outcomes
have increased in the last few years and the results have
remained conflicting, this meta-analysis was undertaken to
further investigate the effect of antenatal PFMEs on childbirth
outcomes.
Materials and methods
Search strategy, selection criteria and data selection
process
The following databases were searched: CINHAL,
(EBSCOhost), Health Collection, PubMed (NCBI, US
National Library of Medicine), Embase Ovid, Wiley Online
Library (John Wiley & Sons), Medline (OvidSP, Wolters
Kluwer), Cochrane, Health Source, Scopus, Wiley, Health &
Medical Complete (ProQuest), Joanna Briggs Institute and
Google Scholar. Full-text articles published between 1988
and June 2019 were included. The search was not limited to
the English language. The following key words were used in
combination: “pregnancy”, “childbirth”, “labour”, “delivery”
and “pelvic floor muscle exercises [all fields]”. The reference
lists from selected studies were also checked to identify other
studies that could have been overlooked by the electronic key
word search.
The study selection process is outlined in Fig. 1. The search
was conducted by one reviewer (Sahar Sobhgol). Decisions
regarding the inclusion of articles were made by agreement
between all of the authors. Randomised controlled trials
(RCTs) and quasi-experimental studies that met the inclusion
criteria were included in this study. The eligibility criteria are
outlined in Table 1.
Data extracted from each study included authors, journals,
year of publication, country, study objectives, population,
sampling, sample size, mean age, characteristics of interven-
tions in the training group and control groups, and outcomes.
Where necessary, the authors of articles were contacted for
more information. The outcomes of interest were duration of
first and second stages of labour, episiotomy and perineal
outcomes, mode of birth (spontaneous vaginal birth, instru-
mental birth and caesarean section) and fetal presentation.
Int Urogynecol J
In this study, episiotomy was defined as a surgical incision
to the perineum during the active pushing phase of the second
stage of labour. Vacuum extraction and/or forceps birth were
considered instrumental birth. Fetal presentation included all
types: cephalic, breech, shoulder etc. Third- and fourth-degree
perineal tears were classified separately and combined as se-
vere perineal laceration. The time from regular uterine con-
tractions to complete cervix dilation was considered the first
stage of labour. The time from complete cervical dilation up to
the birth of the new-born was defined as the second stage.
As outlined in Table 1, PFME with no adjunctive therapy
(such as perineal massage, perineal stretching before labour or
during labour, vaginal devices and fitness training) is the only
intervention of interest in this study. All types of PFM training
such as verbal or practical instruction, with or without relax-
ation or strength training, were included.
Quality assessment
The quality of the RCTs was assessed using the Standard
Methods of the Cochrane Collaboration tool [34]. This tool
includes assessment of six domains, including random se-
quence generation, allocation, blinding of outcome assess-
ment, incomplete outcome data, selective reporting and other
bias. Each category was classified as low, high or unclear risk
of bias. Data extraction was performed by one reviewer (Sahar
S. Sobhgol) and was double-checked by a second and a third
reviewer (Hannah G. Dahlen, Caroline A. Smith). All of the
authors participated in quality assessment of the studies.
Statistical analysis
RevMan 5.3 was used to analyse data. The weighted
mean differences (WMDs) and risk ratios (RRs) using
a fixed-effects model (Mantel–Haenszel) with the corre-
sponding 95% confidence intervals (CIs) were calculated
to assess the effect of PFME on childbirth outcomes. I2
and Chi2 were calculated to assess statistical heteroge-
neity. A value of greater than 30% was considered a
substantial heterogeneity in this study and a random
effects model (DerSimonian–Laird) was used to analyse
data. If I2 ≥ 30, subgroup and sensitivity analyses were
conducted to explore the possible source of between-
study heterogeneity. In the subgroup analysis, the
RCTs were classified into two groups depending on
the duration of intervention (PFMEs started from
20 weeks’ gestation until the third trimester or birth,
and PFMEs were only carried out from the third trimes-
ter until the end of pregnancy), parity (primiparous and
multiparous) and characteristics of the control groups
(no information about PFMEs at all and receiving a
range of written or verbal information or instruction).
Publication bias was assessed using funnel plots and
Int Urogynecol J

Fig. 1 Preferred Reporting Items

Addional records idenfied
for Systematic Reviews and Records idenfied through
through other sources [12-15]
Meta-Analyses (PRISMA) flow

Identification
database searching
diagram (n = 849 ) (n = 4)

Records aer duplicates removed

(n =482)

Screening Records excluded (n=442), For

Records screened reasons [general populaon,
(n =482) UI,FI, Postpartum period,
men, menopausal age]

Full-text arcles assessed

Full-text arcles excluded, with
for eligibility reasons (n = 24)
(n = 40)
One paper was published twice
Eligibility

[16]

One Opinion piece [17]

12 papers on EpiNo, perineal

massage, general exercises [18-29]

Five papers; only available in

abstract/ Not available in English,
not enough informaon, low
quality, did not meet the inclusion
16 Studies included in
criteria [13-15,30,31]
Included

qualitave and
quantave synthesis One protocol paper/the result not
available [7]
(meta-analysis)
Three papers with mixed
intervenon [6,32-34]

Egger’s test. A level of <0.05 was used to determine Trials with multiple arms were included if PFME was
whether significant difference exists. Some of the out- given to one group versus a control group and other
comes (such as fetal presentation) were reported narra- active interventions. In this case only two arms, the
tively if data could not be pooled for meta-analysis. control and PFMEs, were compared.

Table 1 Eligibility criteria

Criteria Description

Design Randomised controlled trials; and quasi-experimental studies

Participants Pregnant primiparous or multiparous women with or without pelvic floor dysfunction at
baseline
Intervention All types of antenatal PFME alone with no adjunctive therapy (such as perineal massage)
Comparators/control Control group with no treatment. Comparison group receiving only education on PFME
without supervision or follow-up, or a less intensive protocol
Main outcomes The effect of PFME on at least one labour and birth outcome including mode of birth
(spontaneous vaginal birth, instrumental birth and caesarean section), duration of
labour (first and second stages of labour), episiotomy, perineal outcomes and fetal
presentation
Exclusion criteria Studies that used other interventions (such as general exercises, perineal massage) with
no PFME programme. Observational studies, abstracts and studies with no PFME.
Studies including children and adolescents and non-pregnant women, published
guidelines and opinion pieces

Results
The first search yielded 853 papers (Fig. 1). After remov-
ing duplicates (n = 371) and screening for titles and ab-
stracts, 40 papers remained for full-text assessment. A fur-
ther 23 papers were excluded for reasons as outlined in Fig.
1, leaving 16 papers included in this study, with a total of
2,829 women included in this meta-analysis and systematic
review. Two authors were contacted for more information
[14, 35].
Quality appraisal of the included studies
Figure 2 outlines the quality assessment of the studies.
Most of the studies carried several risks of bias. Three
studies were classified as high risk for selection bias ow-
ing to a lack of reporting on allocation concealment or
randomisation [36–38]. Only four studies were at a low
risk of selection bias [9, 11, 39, 40]. All of the studies
were considered high risk in terms of performance bias, as
PFMEs cannot be hidden from the participant and the
therapist. Only five studies were classified as having a
low risk of detection bias [9, 11, 41–43]. In terms of
attrition bias, three studies were high risk [36, 40, 43].
Two studies were rated as having an unclear risk of se-
lective reporting [38, 41].
Characteristics of the studies
Three studies were undertaken in the UK [5, 42, 43], 1 was
from France [39], 1 was from Italy [3], 1 was from the
Netherlands [35], 2 were from Norway [9, 37], 2 were from
Egypt [38, 41], 1 was from Turkey [36], 2 were from Brazil
Fig. 2 Summary of risk of bias. Other bias: small studies, missing reports, no statement on intention-to-treat analysis, high statistical heterogeneity
Int Urogynecol J
[11, 40], 2 were from China [4, 44] and 1 study was from
Thailand [45] (Table 2). Included studies were published
between 1988 and 2018. In only 6 studies [3, 4, 11, 36, 37,
41] was the effect of PFMEs on childbirth outcomes
assessed as a primary outcome. The sample sizes ranged
from 20 to 300. In most of the studies (12 out of 16 stud-
ies), the population consisted of nulliparous women with a
singleton pregnancy [3–5, 9, 11, 37, 39, 40, 42–45]. In the
studies by Woldringh et al., Dönmez et al., Abd El Fatah,
and El-Shamy and Abd El Fatah both primiparous and
multiparous pregnant women were recruited [35, 36, 38,
41]. Agur et al. [5], Woldringh et al. [35] and Fritel et al.
[39] recruited women with increased antenatal bladder
neck mobility [5] or with and without urinary incontinence
at baseline [35, 39], whereas in the remaining studies low-
risk women with no previous history of pelvic floor dys-
function were recruited. The following variables were re-
moved from the final analysis in 7 studies: twin pregnan-
cies [9], preterm birth [9, 36–38], vaginal breech birth [5,
9, 36, 38], induced labour [9], planned caesarean section
[5, 9, 45], caesarean section for fetal distress [36–38], dia-
betes, hypertension and intrauterine growth restriction
(IUGR) [40].
Table 3 outlines the characteristics of PFMEs and control
groups. PFMEs were the only intervention in 14 studies. The
studies by Dönmez et al. and Abd El Fatah compared the
effects of PFME and perineal massage in two parallel groups
with control groups [36, 38]. Eight studies commenced PFME
during mid-pregnancy, from 16 to 20 weeks’ gestation [4, 5,
9, 39, 41, 43–45] and continued up to 32 weeks [38], 36 weeks
[5, 9, 39, 44, 45], or until birth [36, 37, 41, 43]. Nielsen et al.
[37], Dönmez et al. [36] and Abd El Fatah [38] commenced
the interventions during late pregnancy from 32 weeks,
Int Urogynecol J

Table 2 Characteristics of the studies included

References Population Study Dates Intervention Control Results

type (n) (n)

Dias et al [11] Nulliparous women carrying a single RCT 2007–2008 IG: 21 CG: 21 No significant difference in mode of
2011, Brazil fetus (mean age—TG: 23.1 [5.1]; CG: labour (p = 0.35), duration of the
23.7 [4.8]) second stage of labour (p = 0.38),
total duration of labour (p = 0.91),
laceration (p = 0.66)
Wang et al [4] Nulliparous women, singleton baby, RCT 2010–1011 IG: 51 CG: 55 No significant difference in terms of
2014, China normal cognitive function, no previous mode of birth (p = 0.076), perineal
childbirth, abortion, UI, pelvic surgery, laceration (p = 0.911), episiotomy rate
POP. (Age—CG: 26.58 ± 3.04; TG: (p = 0.351) and duration of the first
27.31 ± 2.94) stage of labour (p > 0.05). The second
stage of labour was significantly
shorter in the test group (p > 0.05)
Salvesen et al [9] Healthy nulliparous women >18, with RCT 1998–2000 IG: 112 CG: 108 No significant difference in terms of
2004, Norway single live fetus. No antenatal duration of the first stage of labour
complication and pain during PFMEs. (p = 0.44), emergency caesarean
(Age—IG: 28.0 ± 5.3; CG: 28 ± 5.3) section (p = 0.461), instrumental birth
(p = 0. 57), duration of the second stage
of labour (p = 0.06), third- or
fourth-degree tears (p = 0.64), a signif-
icant difference in a prolonged second
stage (≥60 min; p = 0.03) and episiot-
omy (p = 0.05) between two groups
Agur et al [5] Primigravida women with antenatal RCT NA IG: 139 CG: 129 No significant difference in duration of
2008, UK BNM on perineal ultrasound. (Age: the second stage of labour (min;
28 years [16–47]) p = 0.87), active (pushing) phase (min;
p = 0.89), prolonged active labour
(>60 min; p = 0.47), epidural
(p = 0.32), episiotomy (p = 0.41) or
perineal trauma (p = 0.21) and
Caesarean section rate and assisted
birth
Donmez et al Elementary graduate, willing to have RCT 2012–2013 30 in CG: 39 No difference in forceps and vacuum
[36] 2015, normal childbirth, with low-risk preg- massage, birth (p = 1.00), induction of labour
Turkey nancy. (Age—CG: 24.25 ± 4.15; TG: 32 in (p = 0.119), duration of induction
28.03 ± 4.15) PFMEs (p = 0.361), second stage of labour
(p = 0.1000), difficulty of the birth
(p < 0.05). A significant difference was
reported in terms of episiotomy rates,
laceration, postnatal perineal pain after
24 h and 15 days and improvement
(p < 0.05)
Ko et al [44] Low-risk primiparous women RCT 2008–2009 IG: 150 CG: 150 PFME group had lower UDI-6 and IIQ-7
2011, China scores and less self-reported UI. There
was no significant difference in terms
of vaginal birth, labour duration,
episiotomy, instrumental birth and se-
vere perineal laceration (p > 0.05)
Nielsen et al [37] 86 normal healthy primiparous. (Age: 26 RCT 1984–1985 IG: 38 CG: 39 The course of delivery showed no
1988, Norway [18–37]) difference in the second stage of
labour. Three third-degree lacerations
occurred in CG
Laura et al [3] Healthy nulliparous women. (Age: RCT NA IG: 65 CG: 62 There were significantly lower
2010, Italy 26.68 ± 4.22) episiotomy rates and fewer overall
spontaneous tears in the training group
(9.5% vs 3%, p = 0.05 and 0.5% vs
4.2%, p = 0.007). Lower rates of
urinary incontinence in IG at 6 months
after birth (26.7% vs 18.3%, p = 0.39),
with no statistical significance
 Int Urogynecol J

Table 2 (continued)

References Population Study Dates Intervention Control Results

type (n) (n)

Fritel et al [39] With singleton, uncomplicated pregnancy RCT
2015, France with or without urinary incontinence
Abd El- Fatah et Nulliparous women carrying a single
al [38] 2015, fetus. (Age >18)
Egypt
El Shamy et al Nulliparous women, singleton baby,
[41] 2017, normal cognitive function, no previous
Egypt childbirth, abortion, UI, pelvic surgery,
POP. (Age—IG: 23.2 ± 1.5; CG:
22.6 ± 0.9)
Reilly et al [43] Healthy nulliparous women, with single
2014, UK live fetus. No antenatal complications
and pain during PFME. (Age: 16–47;
median: 28)
Woldringh et al Primigravida women with antenatal
[35] 2007, BNM on perineal ultrasound. (Age—
Netherland IG: 31.9 [31.1–32.7]; CG: 32.6
[32.0–33.3])
Lekskulchai [45] Nulliparous women pregnant between 8 RCT
2014, Thiland and 12 weeks. (Age—IG:
26.95 ± 3.94; CG: 26.51 ± 5.41)
Okido et al [40] With no chronic diseases, fetuses without RCT
2015, Brazil malformations or any condition that
might prevent the execution of physical
exercise
Mason et al [42] Nulliparous with singleton pregnancy, no RCT
2010, UK previous symptoms of stress urinary
incontinence. (Age—CG: 28.2
[17–41]; IG: 28.3 [17–40])
2008–2010 IG: 140 CG: 142 There were no significant differences in
the rate of Caesarean section before
labour, during labour, spontaneous
vaginal delivery and instrumental birth
between the two groups
RCT 2015 IG: 21 CG: 21 No significant difference in type of labour
(p = 0.35), duration of the second
stage of labour (p = 0.38), total
duration of labour (p = 0.91), laceration
(p = 0.66)
RCT 2016 IG: 51 CG: 55 No significant difference in terms of
mode of birth (p = 0.076), perineal
laceration rate (p = 0.911), episiotomy
rate (p = 0.351) and the duration of the
first stage of labour (p > 0.05). The
second stage of labour was
significantly shorter in the IG
(p > 0.05)
RCT NA IG: 112 CG: 108 No significant difference in terms of the
duration of the first stage of labour
(p = 0.44), emergency caesarean
section (p = 0.461), instrumental birth
(p = 0. 57), duration of the second stage
of labour (p = 0.06), third- or
fourth-degree tears (p = 0.64). A sig-
nificant difference in a prolonged sec-
ond stage (≥60 min; p = 0.03) and epi-
siotomy (p = 0.05) between the two
groups
RCT 2000–2002 IG: 139 CG: 129 No significant difference in duration of
the second stage of labour (min;
p = 0.87), active (pushing) phase (min;
p = 0.89), prolonged active labour
(>60 min; p = 0.47), epidural
(p = 0.32), episiotomy (p = 0.41) or
perineal trauma (p = 0.21), and
Caesarean section rate and assisted
birth
NA IG: 108 CG: 111 No significant difference in bladder
symptoms, mode of birth (p > 0.05)
2007–2009 IG: 26 CG: 33 No significant difference in type of birth,
episiotomy and laceration rates
between the two groups (p = 0.05)
2005–2006 IG: 141 CG: 146 No significant difference in the various
degrees of perineal lacerations and
episiotomy rate between the control
and intervention groups (p > 0.05)

BNM bladder neck mobility, CG control group, IG intervention group, IIQ Incontinence Impact Questionnaire, NA not stated, POP pelvic organ
prolapse, RCT randomised controlled trial, TG test group, UDI urinary distress inventory, UI urinary incontinence

33 weeks and 35 weeks or until birth. The characteristics of by physiotherapists and included both verbal and practical
the PFME programme are outlined in Table 3. PFMEs varied instruction on how to perform PFMEs (Table 3). Most studies
between studies in terms of frequency of contractions and reported first individual supervised training by a physiothera-
relaxation (Table 3). PFME instructions were mainly provided pist followed by weekly or monthly follow-up with
Table 3 Characteristics of intervention and control

Studies Control Active intervention group

Intervention Intensity Frequency and duration Supervision and follow-up Length of programme
Int Urogynecol J

Abd El-Fatah [38] No intervention Perineal NA 5–10 times contractions daily, each First training was supervised using vaginal From 35 weeks until childbirth
2015, Egypt massage contraction lasting 3 s and then to palpation in addition to pamphlets.
and PFME relaxing it for 3 s Home diaries to register the duration and
frequency of exercises
Nielsen et al [37] Customary post-partum in- PFME Maximal 50 brief, maximal contractions morning and To contract the pelvic floor without using Last 8 weeks of pregnancy
1988, Norway structions to perform evening (maximum 10 min). either the abdominal muscles or the
PFME Contractions were performed after full adductor muscles of the thigh.
pulmonary expiration Abdominal muscle relaxation was tested
by manual palpation
Laura et al [3] Customary instruction on PFME NA A 12-week pelvic floor muscle training NA 12-week period during
2010, Italy PFME, routine care programme during pregnancy, super- pregnancy
vised by a physiotherapist and a midwife
Ko et al [44] Customary written PFME NA PFME course consisted of three repetitions Individually instructed by a physical 12-week period from 20 weeks
2011, China instructions of eight contractions each hold for 6 s, therapist. Correct contraction was until 36 weeks’ gestation
with a 2-min rest between repetition, assessed by observation of inward
twice daily at home movement of the perineum during
contraction. Group weekly training for
45 min in sitting and standing positions.
Compliance was monitored using diaries
Fritel et al [39] Written instruction PFME NA Eight sessions of PFME training by a Eight supervised sessions by From 6 to 8 months
2015, France midwife or physiotherapist, which took physiotherapist or midwife between the
20–30 min. Written instructions (were 6th and 8th months of pregnancy.
delivered to both control and exercise Follow-up at the 9th month of gestation,
groups) and 2 months and 12 months after birth
El-Shamy et al No instruction on PFME PFME Maximal To contract eight times, hold for 6 s, 6-s First supervised session by a 20 weeks until birth
[41] 2018, relaxation, three repetitions, 2-min rest physiotherapist. Vaginal palpation was
Egypt between sets in different positions and used. Exercise brochure and application
when coughing, to repeat twice daily, observation form to monitor compliance.
three times per week. To increase to Weekly follow-up or telephone calls up
12 at 36 weeks to birth
Lekskulchai et al The latter group received PFME NA The PFME regimen comprised a series of First session with pelvic examinations with 24–36 weeks. Not reported
[45] 2014, routine antenatal care 15 contractions each held for 5 s, with visual feedback using 2D trans perineal clearly
Thailand 5-s rest between each contraction. The ultrasound. Phone follow-up at the first
women in the PFME group were asked and second visits. Transperineal ultra-
to repeat this regimen three times after sound at 24–28 and 32–36 weeks. More
each meal follow-up at 3 to 6 months postpartum
Table 3 (continued)

Studies Control Active intervention group

Intervention Intensity Frequency and duration Supervision and follow-up Length of programme

Mason et al [42] Usual care and instruction PFME Near A 45-min physiotherapy class once a month First supervised training by a NA
2010, UK on PFME maxi- for 4 months. Bø et al [46]. protocol. physiotherapist using vaginal palpation.
mal 8–12 contractions for 6–8 s, twice daily, 45-min class once a month for 4 months
followed by four fast contractions with
breathing and relaxation exercises in
different positions in addition to back
and abdomen strength training. To do it
daily at home
Wang et al [4] PFME course without PFME NA Contracting anal and vaginal muscle for 3 s First supervised training session by a From 16 to 32 weeks and
2014, China further follow-up twice followed by five fast contractions physiotherapist. A handout given to 6 weeks postpartum
for 10–15 min two or three times a day women. Telephone follow-up every
with a 2-min rest between repetitions 2 weeks
Salvesen et al [9] Were not discouraged from PFME Intensive 8–12 intensive PFM contractions lasting for First individual supervised training and Between the 20th and the 36th
2009, Norway doing PFMEs on their 6–8 s, followed by 3–4 fast contractions weekly training by physiotherapist for week for 12 weeks (Bø et al.
own with a rest of 6 s, twice a day 60 min for 12 weeks protocol)
Agur et al [5] The usual verbal advice on PFME NA
Three repetitions of eight contractions twice First supervised PFME training and Between the 20th and the 36th
2008, UK PFME from midwives daily, and with coughing or sneezing. To monthly follow-up by physiotherapist week for 12 weeks (Bø et al.
increase to 12 contractions at 34 weeks’ protocol)
gestation
Okido et al [40] Were not discouraged to PFME Maximum Protocol Bø [46] was used. Consisted of 10 Vaginal palpation and electromyography 20–36 weeks
2015, Brazil perform PFME at home sets of contractions held for 6–8 s biofeedback were used by
followed by three fast contractions re- physiotherapist to teach PFMEs. Once a
peated in different positions. Each ses- week PFMEs supervised by
sion lasted 20 min physiotherapist. Home diaries were used
Donmez et al [36] No intervention Perineal NA Contracting for at least 3 s and relaxing for First supervised training and weekly From 33 weeks’ gestation, up to
2015, Turkey massage 3 s, do it for 5–10 times daily. follow-up at clinic from 33 weeks’ ges- childbirth
and PFME Individualised first initial training tation up to childbirth
Reilly et al [43] Verbal advice on PFMEs PFME NA Eight contractions held for 6 s, 2-min rest Physiotherapist at monthly intervals on a From 20 weeks until delivery
2014, UK from midwives. Routing for three repetitions twice daily. Contract one-to-one basis. Using diaries at home
care when coughing or sneezing. Increase to
12 at 34 weeks’ gestation
Woldringh et al Routine care. Some PFME NA Three sessions of individual PFME training Physiotherapist-led practical instruction From 23 weeks’ gestation to
[35] 2007, received some between 23 and 30 weeks’ gestation and with no vaginal palpation. 40-page 6 weeks after birth
Netherland instruction on PFMEs one session at 6 weeks after birth, handbook given to women
combined with written information
Dias et al [11] Control: no PFME Antenatal Maximal Four sets of ten PFMEs lasting 6–8 s with Weekly individual supervised PFME From 20 to 36 weeks for
2011, Brazil PFME an interval of 6 s, and a 30-s interval follow-up with physiotherapist. Home 16 weeks
between sets twice a day diary

NA not stated, PFMEs pelvic floor muscle exercises, PFMs pelvic floor muscles
Int Urogynecol J
Int Urogynecol J
physiotherapists or researchers [5, 9, 11, 35–45] or only tele-
phone follow-up (Table 3) [4]. All studies provided informa-
tion on how to perform PFMEs at home. Few studies reported
on the adherence to PFMEs in both the study and the control
group. The adherence to PFMEs in the study group ranged
from 64% [42] to around 80% [5, 9, 11, 35, 40, 41, 44]. Reilly
et al. reported that women performed various amounts of
PFMEs in the study group [43].
Control groups also varied from no intervention [11, 36,
38, 41, 44] to receiving education about PFMEs with no
follow-up [3–5, 9, 40], the usual verbal advice from midwives
[5] and written instruction (Table 3) [39]. Woldringh et al. also
found that 50% of women in the control group also performed
PFMEs [35]. Okido et al. reported that none of the women in
control group said that they did PFMEs [40]. Reilly et al.
reported that 56 women in the control group (n = 108) claimed
to have performed regular PFMEs and 37 had performed oc-
casional PFMEs [43].
The results of six studies [3, 4, 9, 36, 38, 41] showed that
PFME was effective in improving perineal healing, reduction
of episiotomy rates and perineal lacerations [3, 9, 36, 38],
mode of birth [41], duration of the second stage of labour
[4] and prolonged second-stage pushing [9]. However, the rest
of the studies did not show any effect of PFME on labour and
birth outcomes (Table 2).
Outcome measures and results
Table 4 outlines the various outcomes measures used in the
included studies to measure the outcomes. The childbirth out-
comes measured are outlined in Table 4. The REEDA scale
was used by two studies [36, 38] to assess perineal healing
after birth (Table 4).
Studies also used a variety of assessment tools to assess
pelvic floor dysfunction symptoms such as the Urinary
Distress Inventory (UDI-6), the Incontinence Impact
Questionnaire (IIQ-7) [39, 44], the International
Consultation on Incontinence Questionnaire Short Form
(ICIQ-SF), the Baessler Female Pelvic Floor
Questionnaire (FPFQ), the EuroQoL-5D and Contilife
questionnaire [42], the Bristol Female Lower Urinary
Tract Symptoms (BFLUTS) questionnaire, and the
Leicester Impact Scale (LIS). Ultrasound was used to as-
sess fetal wellbeing [45] and also bladder neck mobility by
two studies [31, 43].
Eight studies measured pelvic floor muscle strength
(PFMS) [3–5, 9, 11, 37, 41, 43], as outlined in Table 4.
Myodynamia, a Peritron, a perineometer, a vagino-
tonograph and a vaginal balloon catheter were used to as-
sess PFMS in these studies. Four studies reported that
PFMEs improved PFMS [3, 4, 37, 41]. Dias et al. reported
that there was no correlation between PFMS and childbirth
outcomes [11].
Meta-analysis results
The effect of PFMEs on the mode of birth
Using a random effects model, no significant difference was
found in the effect of PFMEs on normal vaginal birth (NVB;
12 studies; RR: 0.97, 95% CI: 0.90 to 1.05, I2: 37%, p = 0.49)
[4, 5, 9, 11, 35–37, 39–41, 44, 45] and on caesarean section (9
studies; RR: 1.04, 95%, CI: 0.77–1.41, I2: 42%, p = 0.78) [4,
5, 9, 11, 36, 39–41, 43]. To find out the source of heteroge-
neity for NVB (I2: 37%, p = 0.09), subgroup and sensitivity
analysis were performed. Heterogeneity dropped to normal
range (I2: 15%, p = 0.31) in the subgroup analysis including
only primiparous women [4, 5, 9, 11, 35, 37, 39, 40, 44, 45].
However, no significant difference was seen between groups
in terms of NVB. The same measures were applied for cae-
sarean section and heterogeneity improved to I2: 33% (p =
0.16) in the subgroup analysis including only primiparous
women; however, the difference between the two groups
remained non-significant.
Using a fixed effects model including 10 studies, no differ-
ences were found in the effect of PFME on instrumental birth
between groups (RR: 0.84, 95%, CI: 0.67 to 1.06, I2: 0%, p =
0.15) [5, 9, 11, 36–40, 43, 44].
The effect of PFME on the duration of labour
There were not enough data to assess the effect of PFME on
the first stage of labour in this study. We found no evidence of
difference in the effect of PFME on total duration of labour
(three studies) [11, 36, 44] (MD: −9.34, 95% CI: 43.80–25.13,
I2: 0%, p = 0.60) and on prolonged active pushing (three stud-
ies) [5, 9, 35] (RR:0.96, 95% CI: 0.60 to 1.53, I2: 66%, p =
0.87). The subgroup and sensitivity analysis also showed no
difference between the two groups.
In terms of the effect of PFME on the duration of the sec-
ond stage of labour, five studies [4, 11, 37, 39, 41] were
included in a fixed effects model and showed that PFMEs
shortened the duration of the second stage of labour by
−20.90 min (MD: −20.90, 95% CI: −31.82 to −9.97, I2: 0%,
p = 0.0003; Fig. 3). A subgroup analysis including three stud-
ies [4, 11, 41] also showed that PFMEs significantly reduced
the duration of the second stage of labour by −21.02 min in
primigravida women (MD = −21.02, CI 95% − 32.10 to
−9.94, I2 0%, p = 0.0002; Fig. 3).
The effect of PFME on episiotomy and perineal lacerations
No difference was found between the two groups in terms of
episiotomy rate (11 studies) [3, 5, 9, 11, 36–38, 40–43] (RR:
0.92, 95% CI: 0.83 to 1.01, I2: 2%, p = 0.09) and first- and
second-degree perineal lacerations, including three studies
[36, 38, 42] (RR: 0.95, 95% CI: 0.28 to 3.13, I2: 80%, p =
Table 4 Description of childbirth and pelvic floor muscle outcome measures and results
References
Ko et al [44] 2011, China
Wang et al [4] 2014, China
Salvesen et al [9] 2009, Norway
Agur et al [5] 2008, UK
Donmez et al [36] 2015, Turkey
Nielsen et al [37] 1988, Norway
Laura et al [3] 2010, Italy
Fritel et al [39] 2015, France
Mason et al [42] 2010, UK
Abd El-Fattah et al [38] 2015, Egypt
Outcome measure PFMS outcome measure PFMS result
Primary outcome: urinary incontinence using Not measured Not stated
UDI-6 and IIQ-7
Mode of birth, duration of labour, perineal PFMS was assessed using myodynamia at first Women in the test group had significantly better
laceration or episiotomy, weight gain of women, visit, and at 6 weeks and 3 months postpartum contraction scores at 6 weeks and 3 months
neonatal weight postpartum than those in the control group
(p < 0.05)
Mode of birth, epidural analgesia or oxytocin PFMS was assessed using a vaginal balloon PFMS was not reported
augmentation in labour, duration of labour, catheter connected to a pressure transducer
episiotomy, perineal tears and neonatal
outcomes
Duration of the second stage of labour, incidence of PFMS was measured using perineometry at PFMS was not reported
instrumental deliveries, duration of the active 20 weeks
phase of labour. Bladder neck mobility was
measured by ultrasound at 20 weeks
Duration of labour, instrumental birth, induction of PFMS was not measured PFMS was not reported
labour, epidural anaesthesia, baby outcomes.
REEDA scale was used to assess perineal
laceration
Second stage of labour, frequency of episiotomy, PFM was measured using a WISAP The course of delivery showed no difference in the
vacuum extraction, caesarean section and Apgar vagino-tonograph 4001 (Germany), which con- second stage of labour on in the frequency of
score, PFMS sists of a simple pneumatic vaginal chamber complications in Apgar scores awarded to the
operating at atmospheric pressure and connected infants (Tables 2 and 3). Three third-degree lac-
to a transducer with a printer erations occurred in non-TG and none in TG
Primary outcome: the occurrence of traumatic tears PFMS was measured PFMS was significantly higher in the training
and use of episiotomy. Secondary outcomes: group at 12 weeks after birth (p = 0.05)
PFMS and pelvic floor dysfunction (urinary and
faecal incontinence, pelvic pain)
ICIQ-SF, the primary endpoint, the Baessler FPFQ NA NA
to assess urinary and pelvic floor symptoms.
EuroQoL-5D and Contilife questionnaires were
used to assess quality of life
Urinary incontinence was measured using the Not measured Not reported
BFLUTS questionnaire, and the LIS. Perineal
lacerations including first, second, third degree,
and episiotomy rates were reported
Information on episiotomy, laceration and perineal Not measured Not measured
pain after 24 h and 15 days, wound healing after
24 h and 15 days. REEDA scale to assess the
perineum. It consists of five parameters of
wound healing. Scale was evaluated by giving a
0, 1, 2 and 3 score to each assessment. The
lowest score was 0 and the highest was 15. The
highest shows serious perineal trauma
Int Urogynecol J
Table 4 (continued)
References
El-Shamy et al [41] 2018, Egypt
Dias et al [11] 2011, Brazil
Okido et al [40] 2015, Brazil
Reilly et al [43] 2014, UK
Woldringh et al [35] 2007, Netherland
Lekskulchai et al [45] 2014, Thailand
BFLUTS Bristol Female Urinary Tract Symptoms, FPFQ Female Pelvic Floor Questionnaire, ICIQ-SF International Consultation on Incontinence Questionnaire Short Form, IIQ-7 Incontinence Impact
Questionnaire, MCA middle cerebral artery, PFM pelvic floor muscle, PFMS pelvic floor muscle strength, REEDA redness, oedema, ecchymosis, discharge, approximation, TG test group, UA umbilical
artery, UDI-6 urinary distress inventory, UI uterine incontinence, UTA uterine artery
Outcome measure
Primary outcome: PFMS at 20 and 36 weeks;
secondary outcomes were birth outcomes
Gestational age at birth, duration of second stage of PFMS was assessed using a Peritron
labour, total duration of labour, prevalence and
degree of laceration. Baby gender, weight,
length, APGAR score
The primary objective was to detect changes in
blood flow in the MCA, UA, UTA. Resting PI
was measured using Doppler ultrasound
An ultrasound scanner (Pie Medical Scanner 100,
Maastricht, The Netherlands) with a 5-MHz
curvilinear probe. Images were taken at rest and
with a standardised Valsalva manoeuvre to
measure bladder neck mobility. Questions and
1-h International Continence Society pad test
were used to assess urine leakage
The bladder diaries and validated PRAFAB score
consisting of five questions relating to the use of
protective pads or garments, the amount of UI,
frequency of UI, adjustment in daily activities
because of UI were used to assess UI and IIQ
Bladder neck position was measured using
ultrasound
PFMS outcome measure PFMS result
Measured using a Peritron to have good intra- and A significant improvement in PFMS at 36 weeks in
Int Urogynecol J
intertest reliability the intervention group
No significant difference in the mean PFMS at
36 weeks’ gestation between women who had a
vaginal birth and those who had a vaginal birth
with episiotomy (p = 0.59), forceps (p = 0.68),
caesarean (p = 0.10), vaginal birth with
episiotomy and forceps (p = 0.92). The mean of
PFMS between vaginal birth with episiotomy
and caesarean (p = 0.02) and forceps and
caesarean (p = 0.04) was significant
Not measured Not measured
PFMS was assessed at each visit by perineometry No difference in pelvic floor strength between
(Peritron, Neen HealthCare, East Dereham, UK) groups after exercise, although all those
developing postpartum stress incontinence had
significantly poorer perineometry scores than
those who were continent
Not measured Not measured
Not stated Not stated

Fig. 3 Pelvic floor muscle
exercises and duration of the
second stage of labour.
IV means Inverse variance
0.93) and (RR: 0.94, 95%, CI: 0.50 to 1.74, I2: 61%, p = 0.84)
respectively. Similarly, no effect of PFMEs was found on
third-degree tears, including four studies (RR: 0.62, 95% CI:
0.35 to 1.08, I2: 30%, p = 0.09) [36, 38, 39, 42]. This result did
not change after subgroup and sensitivity analysis for first-
and second-degree perineal laceration.
In terms of severe perineal laceration, six studies [9, 36, 38,
39, 42, 44] were included in a fixed effects model, and showed
that PFMEs significantly reduce the rate of severe perineal
trauma (RR: 0.57, 95% CI: 0.38–0.84, I2: 30%, p = 0.005;
Fig. 4).
Only two studies [36, 38] reported on the incidence of
fourth-degree perineal laceration and were included in a fixed
random model showing that PFMEs significantly reduce the
rate of fourth-degree perineal laceration (RR: 0.07, 95% CI:
0.01–0.54, I2: 0%, p = 0.01), although confidence intervals
were very wide (Fig. 5).
Only one study reported on the rate of intact perineum and
no significant difference was found between the two groups
(RR: 0.96, 95% CI: 0.73–1.27, p = 0.78) [42].
The effect of PFMEs on fetal presentation
Only one study, by Salvesen and Mørkved, reported on this
variable and found that there were 9 cases of breech presenta-
tion after 37 weeks in the control group compared with 1 in the
PFME group [9].
There was no significant publication bias, as demonstrated
by the funnel plot asymmetry and also Egger’s test (NVD [p =
Fig. 4 Pelvic floor muscle
exercises and severe perineal
laceration. M-H means Mantel-
Haentzel
Int Urogynecol J
0.368], caesarean section [p = 0.692], instrumental birth [p =
0.823], second stage of labour [p = 0.929], prolonged active
labour [p = 0.602], severe perineal laceration [p = 0.765], epi-
siotomy [p = 0.880]).
Discussion
This study was aimed at investigating the effect of antenatal
PFME on labour and birth outcomes by carrying out a sys-
tematic review and meta-analysis. Sixteen RCTs including
2,829 women were included in this systematic review and
meta-analysis. Overall, the results showed that antenatal
PFMEs are effective at reducing the rate of severe perineal
lacerations and the duration of the second stage of labour.
We found that antenatal PFMEs significantly shorten the
duration of the second stage of labour by 20.90 min overall
and by 21.02 min in primiparous women. Our findings were
associated with very low heterogeneity (I2: 0%). The study by
Du et al. found that antenatal PFMEs shortened the duration of
the second stage of labour by 10.41 min, with relatively high
heterogeneity (I2 > 50%) [8].
The mechanism that PFME may reduce the duration of the
second stage of labour is not completely clear. The pelvic
floor musculature consists of sphincters and muscles that sup-
port the pelvic organs [8]. Pregnancy and vaginal birth may
affect pelvic floor muscles negatively [1–3]. Several studies
reported that antenatal PFMEs improve PFMS during preg-
nancy [3, 4, 36, 41]. This, in turn, enhances muscle control
Int Urogynecol J
Fig. 5 Pelvic floor muscle
exercises and fourth-degree peri-
neal laceration. M-H means
Mantel-Haentzel
and flexibility, which can facilitate the descent or rotational
movements of the fetal head and subsequently shorten the
length of labour [8, 9].
This meta-analysis also showed that antenatal PFME re-
duced the rate of severe perineal trauma (third- and fourth-
degree perineal tear) significantly. This association was not
assessed in the previous meta-analysis [8]. The former meta-
analysis reported no association between antenatal PFMEs
and perineal lacerations and the episiotomy rate in general [8].
Pregnancy and childbirth, as well as obstetric interventions
(such as forceps and vacuum deliveries) are among the primary
factors leading to pelvic floor trauma. Some studies suggested
that an excessively strong pelvic floor muscle might obstruct
labour, resulting in perineal trauma and negating the beneficial
effect of antenatal PFMEs [8, 10]. However, based on the find-
ings of this study, it is possible that PFMEs improve PFMS and
flexibility, simultaneously enhancing the descent, flexion or
rotational movements of the fetal head, causing less severe
perineal laceration during birth. There are also studies indicat-
ing that antenatal PFME not only reduces perineal trauma but
also enhances perineal healing after birth [36, 38].
These findings need to be interpreted considering the var-
iation in the characteristics of the PFME programmes used in
the included studies. Even though most of the included studies
had a relatively similar approach in terms of training methods,
there were variations in the duration of PFME programmes.
There are different views about the optimal duration of PFME
programmes. It is suggested that 12 weeks of PFME training
is required to improve PFMS [45]. However, Johnson et al.
(2000) suggested that antenatal PFMEs from 35 weeks’ ges-
tation increase the tone and elasticity of the perineum and
reduce perineal trauma [47]. In this study, most researchers
commenced PFMEs mid-pregnancy (16–20 weeks’ gesta-
tion), but three studies started PFMEs in late pregnancy (33–
35 weeks’ gestation). Two studies [11, 38] found a significant
effect of PFMEs on perineal trauma when PFMEs started from
late pregnancy. The studies that commenced PFMEs during
mid-pregnancy reported different results, ranging from no ef-
fect of PFMEs on childbirth outcomes [5, 11, 37, 39, 40,
42–45] to a significant effect of PFMEs on childbirth out-
comes, such as improved perineal healing, reduction of episi-
otomy rates and perineal laceration [3, 9], mode of birth [41],
shortening the duration of the second stage of labour [4] and
shortening prolonged second-stage pushing [9]. To further
assess the effect of the duration of the PFME programme, this
factor was included in subgroup analysis in this study, as
described earlier, and no significant difference was seen.
Adherence to PFMEs is another issue in both study and con-
trol groups that could also affect the result. Adherence of 60–
80% was reported by some studies. As this item was not
reported by all studies, it could not be included in the sub-
group analysis. The variation in control groups is also another
important factor that can affect the results and has been report-
ed by few studies. This factor was included in the subgroup
analysis in this study and no significant difference was found
between the two groups.
Regarding the rest of the outcomes of interest in this study,
we did not find any difference between the two PFME and
control groups in terms of mode of birth, including spontane-
ous vaginal birth, caesarean section and instrumental birth.
Similarly, Du et al. found no effect of PFMEs on the mode
of birth [8]. Additionally, no effect of PFMEs was found on
episiotomy and first- and second-degree perineal lacerations
in this study. It was not possible to make any conclusions
about the effect of PFME on fetal presentation, duration of
first stage of labour and intact perineum owing to the lack of
information available. Only one study [9] reported that more
women in the control group had a breech presentation than in
the PFME group. More studies are needed to investigate the
effect of PFMEs on these variables.
These findings need to be interpreted with caution consid-
ering the risk of bias from the included studies. Some of the
studies had very small sample sizes [11, 41] and missing data
on the details of the PFME programme or the outcome data. In
some studies, there was insufficient detail about
randomisation, allocation concealment and blinding.
Variations in control groups and PFME programmes may also
affect the results. Lack of a standard PFME programme is a
limitation of this study. Various reported adherence to PFME
programmes could also affect the results. Only a few studies
assessed the effect of PFMEs on labour and birth as primary
outcomes. Another limitation of this meta-analysis is that few
papers were not included owing to a lack of information and to
not meeting the inclusion criteria [14, 15, 31]. Few studies

reported all the outcomes under consideration in this study.
Most of the studies carried a moderate to high risk of bias.
The strength of this study is that it included several studies
to assess the effect of PFMEs on childbirth outcomes. It also
highlighted the gap in the literature and the need for more
research. This meta-analysis also confirmed the results of a
previous meta-analysis on the effectiveness of PFMEs in
shortening the duration of the second stage of labour. It may
be suggested that antenatal PFMEs may be recommended to
women not only to prevent or treat urinary incontinence [4, 5]
but also potentially to reduce the duration of the second stage
of labour and the incidence of severe perineal laceration. The
incidence of severe perineal trauma is on the increase [36],
partly due to the higher rate of obstetric interventions, such as
induced labour and instrumental birth. PFMEs may have a
protective effect on women experiencing severe perineal
lacerations.
Future high-quality RCTs are recommended with larger
sample sizes, including both primiparous and multiparous
women, monitoring of the control group in terms of
performing any PFMEs, and assessing all clinically relevant
childbirth outcomes.
Conclusion
Antenatal PFMEs may be effective at reducing the duration of
the second stage of labour and the incidence of severe perineal
trauma. These results need to be interpreted in the context of
the study’s limitations. Antenatal PFMEs do not seem to affect
the rate of first- or second-degree perineal lacerations, episiot-
omy, NVB, instrumental birth and caesarean section. The ef-
fect of PFMEs on fetal presentation, intact perineum and du-
ration of the first stage of labour is not clear. More research is
needed in this area.
Acknowledgements The support provided by Western Sydney
University is greatly appreciated. The contribution of Dr. Steve Frost at
Ingham Research Institute is greatly appreciated.
Authors’ contributions S.S Sobhgol: data collection, quality assessment,
data analysis, writing the manuscript;C.A. Smith: quality assessment,
data analysis, reviewing, editing;H.G. Dahlen: quality assessment, data
analysis, reviewing, editing.
Compliance with ethical standards
Conflicts of interest None.
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