Received: 27 November 2017 | Revised: 20 February 2018 | Accepted: 26 April 2018

DOI: 10.1002/ijgo.12513

REVIEW ARTICLE
Obstetrics

Systematic review of pelvic floor interventions

during pregnancy

Lucas Schreiner* | Isabel Crivelatti | Julia M. de Oliveira | Christiana C. Nygaard |

Thais G. dos Santos

Medical School, Obstetrics and Gynecology

Department, Pontifícia Universidade Católica
do Rio Grande do Sul, Porto Alegre, Brazil
*Correspondence
Lucas Schreiner, Avenida Ipiranga 6690,
Centro Clínico, conjunto 612, CEP 90610–
001 Jardim Botânico, Porto Alegre, Brazil.
Email: schreinerlucas@hotmail.com
This article includes a Portuguese
translation of the Abstract, available in the
Supporting Information section.
Abstract
Background: Pelvic floor interventions during pregnancy could reduce the impact of
pregnancy and delivery on the pelvic floor.
Objective: To determine the effects of pelvic floor interventions during pregnancy on
childbirth-­related and pelvic floor parameters.
Search strategy: PubMed, Embase, and LILACS were searched for reports published
during between 1990 and 2016 in English, Spanish, or Portuguese. The search terms
were “pregnancy,” “pelvic floor muscle training,” and related terms.
Selection criteria: Randomized controlled trials with healthy pregnant women
were included.
Data collection and analysis: Baseline and outcome data (childbirth-­related parame-
ters, pelvic floor symptoms) were compared for three interventions: EPI-­NO (Tecsana,
Munich, Germany) perineal dilator, pelvic floor muscle training, and perineal massage.
Main results: A total of 22 trials were included. Two of three papers assessing EPI-­NO
showed no benefit. The largest study investigating pelvic floor muscle training reported
a significant reduction in the duration of the second stage of labor (P<0.01), and this
intervention also reduced the incidence of urinary incontinence (evaluated in 10 tri-
als). Two of six trials investigating perineal massage reported that a lower rate of per-
ineal pain was associated with this intervention.
Conclusion: Pelvic floor muscle training and perineal massage improved childbirth-­
related parameters and pelvic floor symptoms, whereas EPI-­NO showed no benefit.

KEYWORDS
Pelvic floor; Pelvic floor muscle training; Perineal laceration; Perineal massage;
Physiotherapy; Pregnancy

1 | INTRODUCTION Perineal laceration during delivery is also associated with consider-

The strength of the pelvic floor muscles can decrease during preg-
nancy and after delivery, owing to physiological processes and changes
in the anatomical position of the pelvis and in the shape of the pelvic
floor muscles. This decrease in muscle strength facilitates the appear-
ance of musculoskeletal alterations, leading to urinary incontinence,
perineal laceration, and dyspareunia.1,2
able postpartum morbidity and raises the incidence of pelvic floor dys-
function. Nulliparous women are at high risk for perineal laceration.3
In the UK,4 approximately 85% of women sustain childbirth-­related
perineal trauma. Trauma can occur either spontaneously with vaginal
delivery or secondarily because of an episiotomy. It is classified accord-
ing to the anatomical structures involved, with a first-­degree tear
involving the perineal skin only; a second-­degree tear involving the

Int J Gynecol Obstet 2018; 1–9 wileyonlinelibrary.com/journal/ijgo

© 2018 International Federation of | 1
Gynecology and Obstetrics
2 | Schreiner ET AL.

perineal muscles but not the anal sphincter complex; a third-­degree
tear involving the anal sphincter; and a fourth-­degree tear involving
4
both the anal sphincter and the anorectal mucosa. First-­degree lacer-
ations sometimes do not require suturing; second-­degree lacerations
can usually be sutured easily, with local analgesia; and third-­degree
lacerations should always be sutured to prevent fistula formation and
fecal incontinence.
Common consequences of perineal laceration include perineal
pain and dyspareunia, resulting in severe impairment of sexual
function. Women with an intact perineum tend to resume inter-
course earlier and be more sexually satisfied than women who
had an episiotomy or a tear.5 Anal incontinence also has a clear
association with perineal laceration, especially when the lacera-
tion involves the anal sphincter (third-­ and fourth-­degree trauma).
Urinary incontinence, however, does not have an evident associa-
tion with perineal laceration. 6
The pelvic floor plays a major role in maintaining continence.7
This could imply that pelvic floor muscle training (PFMT) could be an
important tool for preventing pelvic muscle disorders during preg-
nancy and postpartum. The goal of PFMT is to strengthen the stri-
ated musculature, including the striated urogenital sphincter, which
is partly responsible for the occlusion of the urethra.8 The contrac-
tion of pelvic floor muscles during perineal exercises results in ele-
vation of the urethra, vagina, and rectum, resulting in stabilization
of the pelvic floor and resistance to downward movement.2,9 Pelvic
floor muscle training can reduce the risk of urinary incontinence
both in late pregnancy (≥34 weeks) and postpartum (≤12 weeks
after delivery).10–13
Perineal stretching does not seem to improve or prevent urinary
incontinence; however, it could play a role in the prevention of per-
ineal lacerations during childbirth.10,14 Prenatal perineal massage
enables the perineal tissue to expand more easily during delivery and
may therefore decrease the incidence of perineal trauma. It could be
undertaken once or twice a week by either the woman or her partner,
starting from 35 weeks of pregnancy.15 Moreover, a perineal dilator
called the EPI-­NO (Tecsana, Munich, Germany) Childbirth Trainer (an
inflatable silicon balloon coupled to a pressure-­display hand pump) has
been developed to gradually stretch the vagina and perineum in late
pregnancy, again with the aim of reducing the risk of perineal trauma
during delivery.14
The objective of the present systematic review was to assess pub-
lished randomized trials on pelvic floor interventions during pregnancy
in healthy women and evaluate the consequences for childbirth and
pelvic floor dysfunctions.
results are reported according to the Preferred Reporting Items for
Systematic Reviews and Meta-­analyses (PRISMA) statement.16 No
ethics approval was required because this was a systematic review of
previously published data.
First, two independent reviewers screened the titles and abstracts
of reports identified in the search. Second, the full texts of poten-
tially relevant papers were reviewed. Randomized controlled trials,
published between January 1, 1990, and December 30, 2016, that
enrolled pregnant women who did not have pelvic floor symptoms
before recruitment, and included a clearly described pelvic floor
intervention in at least one arm of the trial, were included. Trials
that included women with neurological disease, were published in a
language other than English, Spanish, or Portuguese, or reported no
outcomes related to the pelvic floor or childbirth (for example, scale
validation studies) were excluded.
The articles were divided into groups according to the inter-
vention used (EPI-­N O device, PFMT, or perineal massage) and
the outcome assessed (childbirth-­related parameters or pelvic
floor symptoms), and the results for each group were summa-
rized. SPSS version 17 (SPSS, Chicago, IL, USA) was available for
the statistical analysis with P<0.05 planned as the threshold for
­s tatistical significance.
3 | RESULTS
Initially, 946 articles were identified through the electronic search
(Fig. 1). The full text of 61 publications was evaluated, and 22
trials were selected for inclusion. Only a few randomized con-
trolled trials were retrieved and most compared different out-
comes. Consequently, no meta-­analysis was performed and only
a narrative summary of results was provided. The studies were
divided into subgroups according to the intervention and the
outcome studied.
Articles identified through
database search (n=946)
Articles included in title/abstract
evaluation after removal of
duplicates (n=605)
Excluded based on
inclusion criteria (n=544)

Full text articles assessed for

eligibility (n=61)
Full-text articles excluded (n=39)
Language other than English,
2 | MATERIALS AND METHODS Spanish, or Portuguese (n=10)
Did not evaluate outcomes
related to pelvic floor or childbirth
An extensive electronic systematic review was performed. The (n=25)
Included patients with
PubMed, Embase, and LILACS databases were searched for tri- neurological disease (n=4)
Randomized trials included
als with female participants using a combination of the following (n=22)
terms: “pregnancy,” “pelvic floor,” “pelvic floor muscle training,”
“physiotherapy,” and “perineal massage.” The search method and FIGURE 1 Flow diagram of study selection.
Schreiner ET AL. | 3

massage group (both P<0.05). Another study25 showed a significant

3.1 | Effect of EPI-­NO on childbirth parameters
Three randomized trials14,17,18 including a total of 1136 women
investigated the use of EPI-­NO during pregnancy. Each paper
evaluated a different outcome measure (Table 1). Only one study18
reported a significant difference between the EPI-­NO group and
the control group (intact perineum, 37.4% vs 25.7%; P=0.05). For
all other outcomes, no significant difference was found between
the groups.
3.2 | Effect of pelvic floor muscle training on
childbirth parameters
Three randomized trials9,19,20 studied the effect of PFMT on childbirth
outcomes in 439 women (Table 2). The trial with the largest study
population (n=301)20 reported a reduced duration of the second stage
of labor in the control group compared with the PFMT group (47 min
vs 38 min; P<0.01). There were no significant differences in the other
outcomes when comparing PFMT and control groups. The pelvic floor
muscle was significantly stronger among women who had cesarean
deliveries compared with those who had a vaginal delivery with episi-
otomy or a forceps delivery.
3.3 | Effect of perineal massage on
childbirth parameters
Six randomized trials15,21–25 including 1997 patients assessed the
effect of perineal massage (Table 3). Two studies21,24 identified
a significant reduction in postpartum perineal pain in the perineal
reduction in the duration of the second stage of labor associated
with perineal massage (P=0.001). There were discordant results
among the trials in terms of the reductions in episiotomy rate and
lacerations reported.
3.4 | Effect of pelvic floor muscle training on pelvic
floor symptoms
Eleven randomized trials1,7,8,13,26–32 including 2529 women evalu-
ated the effect of PFMT on pelvic floor symptoms (Table 4). The
most frequent outcomes investigated were urinary incontinence (10
trials), pelvic floor muscle strength (five trials), and anal incontinence
(two trials). The trial with the largest study population (n=855)7
found a reduction in urinary incontinence in the PFMT group com-
pared with the control group (P=0.004), with no significant differ-
ence in anal incontinence.
4 | DISCUSSION
The pregnancy–puerperium cycle is often associated with anatomi-
cal and physiological changes in the pelvic floor. Interventions during
pregnancy can reduce the occurrence of pelvic floor symptoms and
problems during childbirth resulting from these changes. The present
systematic literature review confirmed that PMFT during pregnancy
shortened the second stage of labor and reduced urinary inconti-
nence, whereas perineal massage reduced perineal pain. By contrast,
use of the EPI-­NO device tended to have no effect.

TABLE 1 Effect of EPI-­NO (Tecsana, Munich, Germany) perineal dilator use.

No. of
Study patients Comparison Outcome measures Main findings Difference between groups
14
Shek, 2011 200 EPI-­NO vs control Macroscopic pelvic No significant difference between groups P=0.19 (macroscopic
floor trauma trauma)
Pelvic floor microtrauma No significant difference between groups P=0.22 (microtrauma)
Kamisan 660 EPI-­NO vs control Levator avulsion No significant difference between groups P=0.39 (levator avulsion)
Atan,
201617
Hiatal overdistension No significant difference between groups P=0.51 (overdistension)
Anal sphincter trauma No significant difference between groups P=0.77 (anal trauma)
No significant difference between groups P=0.65 (perineal tears)
No significant difference between groups P=0.07 (anal sphincter
on ultrasonography)
Ruckhäberle, 276 EPI-­NO vs control Intact perineum (vaginal Increased frequency of intact perineum P=0.05 (intact perineum)
200918 laceration without (37.4% vs 25.7%) compared with
muscle injury) control group
Episiotomy rate No significant difference between groups P=0.11 (episiotomy)
Duration of No significant difference between groups P=0.154 (duration of
second stage second stage of labor)
Analgesic use No significant difference between groups P>0.05 (analgesic use)
Vaginal infection No significant difference between groups P>0.05 (vaginal infection)
4 | Schreiner ET AL.

TABLE 2 Effect of pelvic-­floor muscle training on childbirth parameters.

No. of
Study patients Comparison Outcome measures Main findings Difference between groups

Dias, 42 PFMT vs control Medical records: pregnancy No significant differences in pregnancy P=0.35 (type of delivery)
20119 duration at delivery, type of duration at delivery, type of delivery,
delivery, indication for cesarean indication for cesarean delivery, and
delivery, duration of the second duration of second stage of labor
stage of labor
Prevalence and degree No significant difference between groups P=0.66 (perineal lacerations
of laceration in prevalence of laceration of pelvic floor muscle)
Perineometer (Peritron, Laborie, The pelvic floor muscle was significantly P=0.02 (PFMS, vaginal
Mississauga, Canada): PFMS stronger in women with cesarean delivery with ­episiotomy
delivery compared with those who had a vs cesarean delivery)
vaginal delivery with episiotomy or a
forceps delivery
P=0.04 (PFMS, forceps
delivery vs
cesarean delivery)
Okido, 96 PFMT vs control Perineal laceration No significant difference in the prevalence P=0.66 (perineal laceration)
201519 of perineal laceration (22.5% vs 15.4%)
Doppler: pulsatility indices of the No significant differences in maternal age, P=0.65 (estimated
uterine, umbilical, and middle weight, or BMI, pregnancy duration, and fetal weight)
cerebral arteries (to evaluate estimated fetal weight
fetal risk)
Amniotic fluid index No significant difference between groups P=0.97 (amniotic fluid index)
in amniotic fluid index
Salvesen, 301 PFMT vs control Partograms: duration of the The duration of labor (measured by P>0.05 (duration of labor)
201420 second stage of labor (fully partogram) was similar in the groups,
dilated cervix) and there were no differences in
labor outcomes
In a subgroup analysis, the second stage of P<0.01 (duration of second
labor was shorter in the control group stage of labor)
(47 ± 28 min vs 38 ± 23 min)

Abbreviations: BMI, body mass index; PFMS, pelvic floor muscle strength; PFMT, pelvic floor muscle training.

Few well-­designed clinical trials have been performed to iden-
tify the benefit of currently available interventions childbirth-­related
parameters and pelvic floor symptoms. Only three trials evaluated the
benefit of the EPI-­NO device. One of these studies18 found that an
intact perineum was more common among women in the interven-
tion group than among those in the control group. However, an intact
perineum is considered a minor outcome without clinical relevance.
The two other studies14,17 compared the incidence of puborectalis
avulsion and hiatal overdistension using perineal ultrasonography, and
17
failed to show any benefit for the use of EPI-­NO. One study investi-
gated the risk of anal sphincter trauma and found no difference for this
outcome measure either.
The studies investigating PFMT were divided into two groups
according to the outcome that was being studied: childbirth param-
eters or pelvic floor symptoms. With regard to childbirth parameters,
one study20 found a significantly shorter duration of the second stage
of labor in the intervention group. Another study9 used a perineometer
to evaluate pelvic floor muscle strength after PFMT and demonstrated
a significant difference between women who had a vaginal delivery
with episiotomy or a forceps delivery and those who had a cesarean
delivery, with the latter having stronger muscle. However, the pelvic
floor muscle strength was measured between 20 and 36 weeks of
pregnancy. No data were recorded after delivery.
Concerning pelvic floor muscle symptoms, the majority of stud-
ies evaluated the effect of PFMT on urinary incontinence, and in four
of eight studies1,7,13,28 fewer patients in the training group reported
symptoms during pregnancy. However, only one of five studies30
revealed less urinary incontinence in the intervention group during
the postpartum period. One study27 compared supervised PFMT
with unsupervised PFMT and found no difference in urinary inconti-
nence either during pregnancy or postpartum (12-­month follow-­up).
The pelvic floor muscle strength was assessed in five trials,1,8,28–30
with three studies1,8,29 reporting a strength increase in the inter-
vention group. The studies that analyzed anal incontinence did not
demonstrate differences between the groups. However, the prev-
alence of this symptom is very low during first pregnancies, and
therefore larger samples are necessary to reach conclusions regard-
ing this topic.
Perineal pain is a very common issue in postpartum women, and
two trials21,25 demonstrated a benefit with perineal massage. Five
trials15,22–25 evaluated the effectiveness of perineal massage in pre-
venting perineal lacerations but none of them found a significant
TABLE 3 Effect of perineal massage.

No. of
Study patients Comparison(s) Outcome measures Main findings Difference between groups
Schreiner ET AL.

15
Mei-­dan, 2008 234 Perineal massage Medical records: episiotomy rate; rate of lacerations No significant difference in episiotomy rate P=0.83 (episiotomy rate)
vs control (perineal tear or bruise not requiring suturing
[first-­degree perineal tears]); second-­, third-­, and
fourth-­degree perineal tear rates; intact perineum;
tear location; amount of suture material required
for repair
No significant difference in overall spontaneous tear rate P=0.39 (laceration rate);
P=0.39 (tear rate)
The risk for anterior tears in the massage group was signifi- P<0.05 (tear location)
cantly higher (9.5% vs 3%); the risk for internal/external lateral
tears and posterior tears was not significantly different
No significant difference in intact perineum P=0.12 (intact perineum)
21
Labrecque, 2000 572 Perineal massage Self-­report: perineal pain, dyspareunia, sexual There were no differences between the groups at 3 mo P>0.05 (intact perineum
vs control satisfaction, urinary/flatus/anal incontinence postpartum among the participants without a previous and other perineal
vaginal delivery outcomes)
Significantly lower perineal pain among women with previous P=0.01 (perineal pain)
vaginal deliveries who underwent perineal massage
(93.6% vs 85.8%)
P>0.05 (urinary
incontinence)
Labrecque, 199422 46 Perineal massage Rate of severe laceration and episiotomy Severe lacerations and episiotomy extension were more P>0.05 (laceration and
vs control frequent in the experimental group, but the differences were episiotomy)
not significant
Shipman, 199723 682 Perineal massage Medical records: perineal trauma (“tear” refers to No significance difference in tear rates (75.1% vs 69.0%) P=0.073 (tear rate)
vs control second-­ and third-­degree lacerations and
episiotomies), type of labor
No significant difference in the rate of instrumental delivery P=0.094 (instrumental
(40.9% vs 34.6%) delivery)
Eogan, 200624 179 Perineal massage Medical records: perineal outcome (episiotomy rate; No significant difference in perineal outcome P=0.84 (perineal outcome)
vs control first-­, second-­, third-­, and fourth-­degree perineal
tear rates, intact perineum)
Subjective postpartum pain scale: postnatal perineal Significant difference in the intensity of perineal pain P=0.029 (postnatal perineal
pain on the third day postpartum pain)
Demirel, 201525 284 Perineal massage Medical records: episiotomy rate, rate of perineal Episiotomies were less common in the massage group P=0.001 (episiotomy)
during active tears, duration of second stage of labor (44% vs 99%)
labor vs control
No significant difference in the rate of lacerations (13% vs 6%) P=0.096 (laceration)
The second stage of labor was significantly shorter in the P=0.001 (duration of
|

massage group (25.33 ± 5.50 min vs 28.18 ± 6.58 min) second stage)
5
 6

TABLE 4 Effect of PFMT on the pelvic floor.

|

No. of
Study patients Comparison(s) Outcome measures Main findings Difference between groups
13
Pelaez, 2014 169 Supervised PFMT Self-­report: frequency and amount Significant difference in frequency of UI (never: 95.2% P<0.001 (frequency of UI)
vs control of UI and its impact on daily life vs 60.7% for PFMT vs control)
Significant difference in amount of leakage (none: P<0.001 (amount of leakage)
95.2% vs 60.7% for PFMT vs control)
ICIQ-­UI SF: UI at 10–14 wk and Significant difference in ICIQ-­UI SF score (1.2 vs 4.1 P<0.001 (ICIQ-­UI SF score)
36–39 wk for PFMT vs control)
P>0.05 (UI)
Bo, 201126 105 Supervised PFMT Self-­report: urinary/flatus/anal No significant difference between groups during P=0.99 (UI at 6–8 wk postpartum)
vs control incontinence pregnancy or postpartum
P=0.46 (flatus at 6–8 wk postpartum)
P=0.62 (anal incontinence at 6–8 wk postpartum)
Fritel, 201527 282 Supervised PFMT Self-­reported UIS (ICIQ-­UI SF) No significant difference in UI prevalence or in pelvic
vs unsupervised floor troubles at baseline, end of pregnancy, and
PMFT 2-­mo or 12-­mo postpartum
ICIQ-­UI SF (end of pregnancy): 2.7 vs 2.9) P=0.99 (ICIQ-­UI SF, end of pregnancy)
ICIQ-­UI SF (2 mo): 1.7 vs 2.3 P=0.26 (ICIQ-­UI SF, 2 mo)
ICIQ-­UI SF (12 mo): 1.9 vs 2.1 P=0.38 ((ICIQ-­UI SF, 12 mo)
UI prevalence (end of pregnancy): 44.6% vs 43.7% P=0.89 (UI prevalence, end of pregnancy)
UI prevalence (2 mo): 33.7% vs 38.3% P=0.48 (UI prevalence, 2 mo)
UI prevalence (12 mo): 32.3% vs 39.3% P=0.32 (UI prevalence, 12mo)
Mørkved, 200328 301 Supervised PFMT Self-­reported UI Significantly fewer women in the PFMT group had UI P=0.007 (UI during pregnancy)
vs control at 36 wk of pregnancy (32% vs 48%)
No difference in UI 3 mo after delivery P=0.18 (UI postpartum)
Vaginal balloon catheter: PFMS Significantly higher PFMS at 36 wk of pregnancy and P=0.008 (PFMS during pregnancy)
3 mo after delivery in PFMT group
P=0.048 (PFMS postpartum)
Stafne, 20127 855 Supervised PFMT Self-­report: urinary and anal Significant reduction in UI with PFMT (42% vs 53%) P=0.004 (UI)
vs control incontinence at 32–36 wk
No significant difference in anal incontinence P=0.18 (anal incontinence)
1
Assis, 2015 87 Supervised PFMT Voiding diary: UI Significant difference in UI (6.9% vs 6.9% vs 96.6%) P<0.001 (UI)
vs unsupervised
PFMT vs control
Perimetry: PFMS Significant difference in PFMS (0.8 vs 1 vs 1.7) P<0.001 (PFMS)
Sut, 201629 60 Supervised PFMT Perimetry: PFMS Significant decrease in PFMS during pregnancy in P<0.001 (PFMS)
vs control control group (3.0 ± 2.5 vs −2.2 ± 5.2)
Schreiner ET AL.

(Continues)
 Schreiner ET AL.

TABLE 4 (Continued)

No. of
Study patients Comparison(s) Outcome measures Main findings Difference between groups

UDI-­6, IIQ-­7, and OAB-­q: UI No significant difference in urinary symptoms at P>0.05 (urinary symptoms)
36–38 wk of pregnancy
Reilly, 200230 268 Supervised PFMT Self-­report: UI Significant reduction in postpartum UI at 3 mo P=0.023 (stress incontinence)
vs control (19.2% vs 32.7%)
Perimetry: PFMS No significant difference in pelvic floor strength P=0.38 (PFMS)
Perineal ultrasound: bladder neck No significant difference in bladder neck mobility P=0.28 (bladder neck mobility)
mobility
Mason, 201031 286 Supervised PFMT Self-­report: UI No significant difference in stress incontinence at P>0.05 (stress incontinence)
vs control 20–36 wk of pregnancy and 3 mo postpartum
BFLUTS, LIS, and bladder diary No significant difference in incontinence episodes and P>0.05 (postpartum incontinence symptoms and
degree of bother by symptoms postpartum degree of bother by symptoms)
Oliveira, 20078 46 PFMT vs control Ortiz scale and perineometry: PFMS Significant increase in PFMS during pregnancy in P<0.001 (increase in PFMS during pregnancy)
PFMT group (47.4% vs 17.3%)
Sangsawang, 70 Supervised PFMT Self-­report: UI (frequency) Significantly lower frequency of severe UI at 38 wk of P<0.001 (severe UI frequency)
201632 vs control pregnancy for PFMT vs control (27.3% vs 53.3%)

Abbreviations: PFMT, pelvic floor muscle training; UI, urinary incontinence; ICIQ-­UI SF, International Consultation on Incontinence Questionnaire-­Urinary Incontinence Short Form; UIS, urinary incontinence
severity; PFMS, pelvic floor muscle strength; UDI-­6, Urogenital Distress Inventory 6; IIQ-­7, Incontinence Impact Questionnaire 7; OAB-­q, Overactive Bladder Questionnaire; BFLUTS, Bristol Female Lower
Urinary Tract Symptoms Questionnaire; LIS, Leicester Impact Scale; EP, end of pregnancy.
|
7
8 |
difference between the intervention and control groups. Perineal
massage during active labor was associated with a lower rate of episi-
otomies in one trial25; however, neither the participants nor the inves-
tigators were blinded to the intervention. The other four trials15,22–24
found no difference in episiotomy rates.
The limitations of this systematic review were that it did not
include articles in languages other than English, Spanish or Portuguese
(such as French or Chinese), meaning some papers could not be ana-
lyzed; further the review lacked a meta-­analysis owing to the clinical
trials included utilizing several different outcomes.
In conclusion, use of the EPI-­NO device was not superior to the
usual recommended prenatal follow-­up for reducing pelvic floor
lesions. However, several clinical trials showed evidence that PFMT
shortens the second stage of labor and reduces the risk of urinary
incontinence during pregnancy. Therefore, PFMT should be taught
routinely during prenatal care should be and practiced at home during
pregnancy. Perineal massage reduced the risk of postpartum perineal
pain and could also shorten the second stage of labor. The combined
use of interventions that have proven beneficial has not been studied
and should be evaluated in the future.
AUTHOR CONTRI BUTI O N S
LS contributed to the development of the review methods, con-
ducting an independent literature search, reviewing abstracts and
full text articles, and writing the manuscript. IC contributed to the
development of the review methods and revising the manuscript.
JMdO contributed to the development of the review methods
and revising the manuscript. CCN contributed to the develop-
ment of the review methods, conducting an independent literature
search, reviewing abstracts and full text articles, and revising the
manuscript. TGdS contributed to the development of the review
methods, reviewing abstracts and full text articles, and revising
the manuscript.
CO NFLI CTS OF I NT E RE S T
The authors have no conflicts of interest.
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S U P P O RT I NG I NFO R M AT I O N
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File S1. Portuguese translation of abstract.