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MATERNAL AND NEONATAL HEALTH

Analysis of pelvic floor musculature function during pregnancy and


postpartum: a cohort study
(A prospective cohort study to assess the PFMS by perineometry and digital vaginal palpation
during pregnancy and following vaginal or caesarean childbirth)

Adriana de Souza Caroci, Maria Luiza Gonzalez Riesco, Wesllanny da Silva Sousa, Ana Carolina
Cotrim, Edinéia Maria Sena, Nelly Lima Rocha and Cintia Najara Caroci Fontes

Aim. To compare the measurements of women’s pelvic floor musculature strength (PFMS) during pregnancy and postpartum
period.
Background. Pregnancy and childbirth can have an influence on the muscles and pelvic floor and can cause morbidities of
women’s genito-urinary tract.
Design. A prospective cohort study.
Methods. There were included 226 primigravidae women, attended by community health services in the city of Ita-
pecerica da Serra, Sao Paulo, Brazil. The participants were followed in four stages: (1) within 12 weeks of pregnancy; (2)
between 36–40 weeks of pregnancy; (3) within 48 hours after childbirth; (4) 42-60 days after childbirth. Data were
collected from February 2007–August 2008. The pelvic floor musculature strength was evaluated by perineometry and
digital vaginal palpation in stages 1, 2 and 4. The final sample included 110 women who completed all four stages of
the study.
Results. The pelvic floor musculature strength of the women did not change significantly during pregnancy or after
delivery (ANOVA : p = 0Æ78). In all three examined stages, a low-intensity pelvic floor musculature strength was prevalent
(in mmHg: stage 1 = 15Æ9; stage 2 = 15Æ2, stage 4 = 14Æ7), with scores from 0–3 on the Oxford scale. The pelvic floor
musculature strength did not differ in relation to maternal age, skin colour, conjugal status, dyspareunia, stool char-
acteristics, type of delivery, or conditions of the perineum. An interaction between maternal nutritional state and
newborn’s weight may affect the pelvic floor musculature strength (MANOVA : p = 0Æ04).
Conclusion. Pregnancy and childbirth did not reduce significantly pelvic floor musculature strength. The perineometry and
digital vaginal palpation used to assess the pelvic floor musculature strength were well accepted by the women.
Relevance to clinical practice. In clinical practice, digital vaginal palpation is effective for supporting the diagnosis of
urinary, intestinal and sexual dysfunctions. Perineometry use is particularly important together with the performance of
perineal exercises with biofeedback in the treatment these disorders.

Authors: Adriana de Souza Caroci, MSc, PhD, RNM, Lecturer, of São Paulo; Nelly Lima Rocha, RN, Midwifery Advanced Program
Adventist University Center of São Paulo; Maria Luiza Gonzalez Student, Adventist University Center of São Paulo; Cintia Najara
Riesco, MSc, PhD, RNM, Associate Professor, School of Nursing of Caroci Fontes, RN, Midwifery Advanced Program Student, Adventist
Universidade de São Paulo; Wesllanny da Silva Sousa, RN, University Center of São Paulo and Nurse, Renal Care Medical
Midwifery Advanced Program Student, Adventist University Center Center, São Paulo, Brazil
of São Paulo and Nurse, Family Health Program of Iaciara, Goiás; Correspondence: Maria Luiza Gonzalez Riesco, Associate Professor,
Ana Carolina Cotrim, RN, Nursing Advanced Program Student, School of Nursing, Universidade de São Paulo, São Paulo, Brazil.
Educational Institute of São Paulo; Edinéia Maria Sena, RN, Telephone: +55-11-30617607.
Midwifery Advanced Program Student, Adventist University Center E-mail: riesco@usp.br

2424  2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 2424–2433
doi: 10.1111/j.1365-2702.2010.03289.x
Maternal and neonatal health A cohort study of pelvic floor musculature function during pregnancy and postpartum

Key words: childbirth, lacerations, midwifery, nursing, pelvic floor, perineum

Accepted for publication: 7 April 2010

teristics, type of delivery, condition of the perineum and the


Introduction
newborn’s weight.
A loss or reduction in perineal muscle tone is very common
among women who have given birth vaginally (Hay-Smith
Methods
et al. 2002). This change can lead to genito-urinary and anal
dysfunction, which has a negative effect on women’s sexual,
Design
physical, social and psychological health (Wyman et al. 1990,
Norton et al. 2006). Pregnancy and vaginal birth can cause A prospective cohort study examining women’s PFMS
stress urinary incontinence (UI) and damage to the pelvic floor during pregnancy and following vaginal or caesarean child-
(PF). The main studies in this area have concentrated on birth was conducted. PFMS was evaluated by perineometry
investigating the mechanisms that cause PF trauma and on and digital vaginal palpation.
appropriately evaluating the symptoms contributing to this
clinical picture (Fitzpatrick & O’Herlihy 2001). Longitudinal
Setting
studies have long been recommended to evaluate the effects
of pregnancy and childbirth on UI and PF function (Kolbl Data concerning pregnant women, childbirth and postpartum
2001). period were collected in five community health services
Evaluation of pelvic floor musculature strength (PFMS) (CHS) and in two public hospitals in Itapecerica da Serra,
after childbirth forms a key part of the evidence used by Brazil. In CHS, nurse-midwives initiate prenatal care and
studies and research. Such studies were enabled by the subsequent consultations involve doctors. Nurse-midwives
development of methods and equipment that have improved are responsible for uncomplicated births, while doctors
this evaluation and, consequently, the accuracy of diagnosis attend to deliveries involving dystocia and caesareans. These
(Fitzpatrick & O’Herlihy 2001). PF musculature can be services offer coverage to a population of approximately
classified into different functional levels, and PFMS evalua- 187,000 inhabitants.
tion should be conducted based on a gynaecological exam-
ination using different methods, such as electromyography,
Ethical considerations
perineometry, digital vaginal palpation, vaginal cones, ultra-
sonography and manometry (Fitzpatrick & O’Herlihy 2001, This study was approved by the Committee for Research
Kolbl 2001, Fleming et al. 2003, Herbison et al. 2002, Ethics and authorised by the appropriate authorities at the
Dumoulin et al. 2004, Menta & Schirmer 2006, Örnö et al. locations where it was carried out. Women were admitted to
2008, Braekken et al. 2009). Besides pregnancy and vaginal the study after receiving oral and written information from
birth, parity, perineal trauma and other mechanic, endocrine the researchers and giving voluntary written consent. The
and neural factors can contribute to the reduction in the study’s outline was reviewed with participants before they
PFMS (Fitzpatrick & O’Herlihy 2001, Coletti et al. 2005, signed consent forms. The researchers had no ties to the
Norton et al. 2006, Zanetti et al. 2007, Castro et al. 2008, manufacturers or distributors of the equipment used in this
Örnö et al. 2008, Voorham-van der Zalm et al. 2008, study.
Braekken et al. 2009). To summarise, the hypothesis inves-
tigated in this study was that pregnancy and childbirth reduce
Population and sample size
women’s PFMS.
The inclusion criteria were to be nulliparous in the first
12 weeks of pregnancy. The exclusion criteria were as
Aim
follows: multiple pregnancy; previous abdominal or urogen-
The aim of this study was to compare the measurements of ital surgery; use of hormone therapy; diseases that might
women’s PFMS during pregnancy and postpartum period interfere with PFMS; resistance to digital vaginal palpation or
based on the following factors: maternal age, skin colour, insertion of a perineometer into the vagina; difficulty in
conjugal status, dyspareunia, nutritional state, stool charac- understanding Portuguese or in communicating.

 2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 2424–2433 2425
A de Souza Caroci et al.

The sample size was calculated based on the study of were given instructions about perineal exercises to strength-
Menta and Schirmer (2006). Assuming 5% probability for en PF musculature and were encouraged to perform them;
the occurrence of Type I error and a test power of 80%, it they were taken to referral services in the event of
was determined that 136 pregnant women were needed. complications. The trial profile shows the study’s sequence
Taking into consideration that this was a longitudinal study (Fig. 1).
with different stages of data collection, the possibility that
some women might not participate in the full course of the
Procedures used to measure PFMS
study was considered. Thus, to obtain the estimated sample
size, the recruitment of participants was increased by 50%, The measurement of PFMS was performed by only one
with the aim being to recruit 204 women. researcher, in all participants and all stages. Before starting
To guarantee the estimated sample size, 226 pregnant data collection, the researcher received specialised training by
women were enrolled. As the number of women who nurses, physiotherapists, doctors and manufacturers of the
dropped out of the study was higher than expected, the equipment used. Two methods of measuring PFMS were used
researchers performed a comparative analysis between on all participants: perineometry and digital vaginal palpa-
women included in the final sample and those who quit the tion. For the perineometry, PFMS was measured with an
study. The homogeneity of both groups suggests that the electronic perineometer. For digital vaginal palpation, PFMS
effect of the loss did not greatly influence the results of was classified according to the Oxford scale (Bø & Larsen
the final sample of the 110 women in the cohort. 1990).
The sequence for applying these methods was randomised,
by means of an electronically produced random numeral
Data collection
table. Opaque envelopes were used; these were opened only
Data were collected in four stages. Stages 1, 2 and 4 involved at the moment that PFMS was measured and contained the
consultations, interviews, physical examinations and PFMS sequence of methods to be used. Thus, digital vaginal
measurements. The same procedures were performed in stage palpation might precede perineometry or vice versa to avoid
3, except for omission of the PFMS measurement. Stages 1–4 any trending in the data.
were as follows:
• Stage 1 was conducted with women during the first
The Oxford classification scale
12 weeks of pregnancy. A subsequent doctor’s appoint-
ment and the next return visit with the researcher for the • Grade 0 – no contractions;
second stage of the study were established. • Grade 1 – flicker of muscular contraction;
• Stage 2 was conducted when the women were between 36– • Grade 2 – low intensity but sustained contraction;
40 weeks pregnant. • Grade 3 – moderate contraction, with an increase in
• Stage 3 was conducted with postpartum women up to intravaginal pressure, squeezing of fingers and with a slight
48 hours after childbirth. The researcher was in daily elevation of the vaginal wall;
contact with the hospitals to find out when participants of • Grade 4 – satisfactory contraction, which pushes against
the study were admitted. PFMS was not evaluated because the examiner’s fingers, with elevation of the vaginal wall in
of the discomfort this might have produced after childbirth the direction of the pubic symphysis;
and because this data could be evaluated at a later time. An • Grade 5 – strong contraction, firm compression of the
appointment was made for the mother to return to the examiner’s fingers with a positive movement in the direc-
CHS. tion of the pubic symphysis.
• Stage 4 was conducted with the women in the period of
42–60 days after childbirth.
Equipment
The researcher made her telephone number available to
these women, in case they needed it and so they could The study used a Quark electronic perineometer, model
advise her when they were admitted to hospital. Two days Perina 996-2 (Quark Medical Products, Piracicaba, SP,
before the date scheduled for stages 2 and 4, participants in Brazil), which registers the potential action of PF muscle
the study were contacted by phone or by telegram to contractions and translates their intensity from visual signals
confirm their attendance at the CHS. If they missed their based on a graduated numerical scale that ranges from
appointments, the researcher made a home visit to collect 0–46Æ4 mmHg. This model is a biofeedback device to be
the data. After all of the data were collected, the women inserted into a woman’s vagina and it measures the PFMS. It

2426  2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 2424–2433
Maternal and neonatal health A cohort study of pelvic floor musculature function during pregnancy and postpartum

Data concerning pregnancy, childbirth and postpartum period were collected in


5 CHS and in 2 public hospitals in Itapecerica da Serra, Brazil

Inclusion criteria: primigravidae women with


no more than 12 weeks of pregnancy

Exclusion criteria: multiple pregnancy; previous


abdominal or urogenital surgery; the use of hormone
therapy; diseases that might interfere with PFMS;
resistance to digital vaginal palpation or the insertion of
a perineometer into the vagina; difficulty in
understanding Portuguese or in communicating

Pregnant women were enrolled n = 226, stage 1

Pregnant women between 36 and 40 weeks n = 128


stage 2

• Pacient record • Pacient record


up to 48 hours after • Interview
• Interview
childbirth n = 134, stage 3, hospital
• Physical • Physical examination
examination • PFMS

42 to 60 days after childbirth n = 124, stage 4

Women that finished the four stages of the


study n = 110
Figure 1 Trial profile study’s sequence.

has an electronic display, a pressure transducer and a vaginal ble with rest (on the electromyograph scale of between
probe. When the contraction varies from 1Æ6–14Æ4 mmHg, 0–10 lV).
the bar of LEDs is illuminated in green, in orange from 16Æ0–
30Æ4 mmHg and in red from 32Æ0–46Æ4 mmHg.
Procedures used to prepare women for measuring PFMS
The vaginal probe is elastic and inflatable, allowing greater
by two methods
adaptation, perception and comfort. The surface of the tube
with rubber rings favours its keeping in the vagina. The 1 The woman was placed in a gynaecological position, with
perineometer selected for this study met all the required the genital region and the lower limbs uncovered but
safety norms for electromedical equipment and is registered protected with a sheet;
with the Brazilian Ministry of Health. 2 The electromyograph’s four electrodes were connected
This apparatus registers, indistinctly, all increases in over the reto-abdominal muscles (two electrodes on the
intracavity pressure, meaning that it does not differentiate right side and two on the left, between the upper border of
between muscle contractions of the perineum and of the the pubis and the umbilical region);
abdomen. Therefore, a surface electromyograph (Lynx 3 The operator put on surgical gloves;
brand, model Bio-ADS1200; Lynx Electronic Technology, 4 The operator taught each woman how to make contrac-
São Paulo, SP, Brazil) was used to monitor abdominal tions as if she were ‘holding in’ urine, using only the PF
relaxation during PFMS measurement. The electromyograph muscles and avoiding the contraction of the muscles of the
has the function of indicating the differentiation between abdomen, thighs and buttocks.
these muscles and it detects, through external electrodes, the
electrical activity of the muscle during rest and contraction, Perineometry
using computer-linked software. The computer screen shows 5 The pressure level of the scale was zeroed;
muscular activity graphically. The PFMS, measured by the 6 The elastic probe was covered with an unlubricated, dis-
perineometer, was recorded only when the electromyograph posable condom;
register indicated abdominal musculature activity compati- 7 Lubricate the condom with lubricant;

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A de Souza Caroci et al.

8 The probe was introduced 3-4 cm into the vagina; dyspareunia and stool characteristics. Regarding the condi-
9 The woman was instructed to relax her PF muscles; tion of the perineum and newborn’s weight, a comparison of
10 The woman was asked to hold and maintain, for as long the PFMS measurements in stage 4 was made, using one-
as possible, a voluntary contraction of the perineal mus- factor ANOVA (Costa Neto 1992).
cles around the vaginal probe, in a sequence of three A multivariate analysis of variance (MANOVA ) was per-
sessions, with an inter-session interval of 15 seconds; formed to verify whether the variables, when combined,
11 The vaginal probe was maintained in position intra- show interactions or differences not found in the univariate
vaginally during the PFMS measurement and intervals; analysis. The statistical F associated with Wilks’ Lambda
12 The greatest force of the voluntary contraction by the PF values was adopted (Hair Junior et al. 1998, Ferrán Aranz
muscles was recorded; 2001). When the combination of variables showed an
13 The woman was allowed to rest for one minute before interaction (p < 0Æ05), ANOVA and Tukey’s HSD test were
beginning digital vaginal palpation (in case this had not performed to identify how this interaction occurred and
already been performed, in accordance with the ran- discriminate the differences in the means of PFMS (Dawson
domisation). & Trapp 2003). All tests were performed using the statistical
packages SAS System for Windows V9 (SAS Institute Inc.,
Digital vaginal palpation Cary, NC, USA) and SPSS for Windows v13.0 (SPSS Inc.,
5 The two distal phalanges of the pointer and middle fingers Chicago, IL, USA).
were introduced into the vagina, using lubricant;
6 The woman was asked to make a voluntary contraction of
Results
the perineal muscles around the fingers of the examiner and
to hold it as long as possible, in a sequence of three ses- Of the 226 women enrolled, 116 failed to participate to
sions, with an inter-session interval of 15 seconds; completion. Thus, the sample of women who finished the
7 The examiners fingers were kept in the vagina during the four stages of the study was 110. The average age of the
PFMS measurement and intervals; women was 21Æ4 (SD 5Æ1). The women began prenatal care at
8 The highest classification level for contraction reached was an average gestational age of 9Æ4 weeks (SD 2Æ2). The women
recorded, using the Oxford scale; reached stage 2 of the study at an average gestational age of
9 The woman was allowed to rest for one minute before 36Æ5 weeks (SD 0Æ8). First sexual intercourse took place at an
beginning perineometry (if this had not been performed average age of 17Æ3 years (SD 4Æ0). The average length of
previously, in accordance with the randomisation). active sex life was 3Æ1 years (SD 2Æ8). The average frequency
of sexual activity was 2Æ5 times per week (SD 1Æ6). At the
start of pregnancy, 25 (22Æ7%) women were low weight and
The study’s variables
65 (59Æ1%) presented appropriate weight. At the end of
The following variables were examined: PFMS (PF muscle pregnancy, 18 (16Æ4%) of the women were low weight and
tone, evaluated during contraction); maternal age; skin 57 (51Æ8%) presented appropriate weight.
colour; conjugal status; weight; height; body mass index; PFMS can be classified according to intensity as follows: no
classification of nutritional state (low weight, appropriate contraction (0Æ0); slight contraction (1Æ6–16Æ0 mmHg); mod-
weight, overweight, obesity) (Atalah et al. 1997); gestational erate contraction (17Æ6–3Æ0 mmHg); normal contraction
age; dyspareunia; stool characteristics; type of delivery; (33Æ6–46Æ4 mmHg) (Barbosa et al. 2005). The ANOVA indi-
newborn’s weight; condition of the perineum during delivery cated that the perineometry measurements in stages 1
(episiotomy, intact perineum or first to forth degree perineal (15Æ9 mmHg), 2 (15Æ2 mmHg) and 4 (14Æ7 mmHg) did not
lacerations). differ between the stages (p = 0Æ78). Low-intensity (slight)
muscular contractions were most prevalent from the start of
pregnancy through the postpartum period. The study also
Data analysis
verified that the frequency of moderate intensity contractions
Descriptive and comparative statistical analyses were carried declined over time. It should be noted that in those cases
out. Two-tailed tests (chi-square and Student’s t-test) were where the PFMS value was higher than 0Æ0, but the surface
used, and the significance level was set at 5% (p < 0Æ05). electromyograph indicated contractive activity of the abdom-
Two-way analyses of variance (ANOVA ) was used for multiple inal muscle, an absence of contraction was scored.
comparisons of the PFMS measurements in stages 1, 2 and 4, Among all the women, 73 (66Æ4%) had vaginal deliveries
regarding the variables of age, skin colour, conjugal status, and 37 (33Æ6%) delivered by caesarean section. The

2428  2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 2424–2433
Maternal and neonatal health A cohort study of pelvic floor musculature function during pregnancy and postpartum

frequency of perineal trauma (episiotomy or spontaneous the descriptive data for the factors analysed, as well as the
laceration) among the women with vaginal deliveries was respective p-value for each factor.
93Æ2%. All women who suffered perineal trauma received The comparison of perineometry averages with the nutri-
perineal sutures. Neonates’ birth weights varied from 2245– tional state of the women did not reveal any statistically
4650 g, with a mean birth weight of 3205 g (SD 466Æ3). significant differences (Table 2). There was no statistically
The two-way ANOVA with one of the factors correspond- significant difference in the comparison of perineometry
ing to each of stages 1, 2 and 4 and the other corresponding averages after childbirth among women who had vaginal
to maternal age, skin colour, conjugal status, dyspareunia deliveries and caesarean sections or among those with
and stool characteristics revealed no significant differences episiotomy, intact perineum or perineal laceration. Equally,
between the factors or between the stages and the factors. In the average PFMS after delivery did not differ statistically
analysing each stage on its own, the average perineometry did regarding the newborn’s weight (Table 3).
not show any statistically significant differences among the The results of MANOVA showed no significant interactions
women according to their age group, white or non-white skin among the means of the perineometry for most of the
colour, whether or not they lived with their partners, whether analysed combinations, considering that p < 0Æ05. Never-
or not they complained of dyspareunia and whether they theless, the combination between the newborn’s weight and
regularly presented dried out stool or not. Table 1 synthesises the mother’s nutritional state may influence the PFMS

Table 1 Means of perineometry of stages 1, 2 and 4

Perineometry (mmHg)

Stage 1 Stage 2 Stage 4

Variable n (%) mean (SD) mean (SD) mean (SD) p-value*

Age (years) Age Stage · age


14–20 50 (45Æ5) 16Æ2 (11Æ1) 16Æ2 (12Æ3) 17Æ2 (10Æ9) 0Æ12 0Æ82
20–30 49 (44Æ5) 15Æ8 (10Æ9) 15Æ1 (12Æ4) 14Æ4 (11Æ0)
30–39 11 (10Æ0) 14Æ1 (1Æ1) 12Æ5 (12Æ2) 11Æ3 (10Æ4)
Skin colour Skin colour Stage · skin colour
White 29 (26Æ4) 16Æ2 (11Æ4) 16Æ5 (12Æ6) 16Æ3 (11Æ2) 0Æ88 0Æ37
Not white 81 (73Æ6) 15Æ7 (11Æ0) 14Æ6 (12Æ3) 13Æ7 (11Æ0)
Conjugal status Conjugal status Stage · conjugal status
Living with partner 67 (60Æ9) 16Æ1 (11Æ0) 14Æ2 (12Æ4) 13Æ4 (10Æ9) 0Æ37 0Æ60
Not living with partner 43 (39Æ1) 15Æ4 (10Æ9) 16Æ5 (12Æ3) 15Æ9 (11Æ0)
Dyspareunia Dyspareunia Stage · dyspareunia
Yes 26 (23Æ6) 14Æ8 (10Æ9) 11Æ9 (12Æ5) 12Æ3 (10Æ8) 0Æ07 0Æ77
No 84 (76Æ4) 16Æ2 (10Æ9) 16Æ1 (12Æ3) 15Æ0 (11Æ0)
Stool characteristics Stool characteristics Stage · stool characteristics
Dried out 40 (36Æ4) 16Æ4 (11Æ0) 15Æ0 (12Æ4) 13Æ4 (11Æ0) 0Æ68 0Æ64
Not dried out 70 (63Æ6) 15Æ6 (11Æ0) 15Æ2 (12Æ3) 15Æ0 (10Æ9)

*ANOVA .

Table 2 Means of perineometry of stages 1 and 2

Perineometry (mmHg) Stage

Stage 1 Stage 2 1·2

Nutricional state n (%) Mean (SD) n (%) Mean (SD) p-value*

Low weight 25 (22Æ7) 14Æ6 (11Æ3) 18 (16Æ4) 16Æ7 (12Æ3) 0Æ58


Appropriate weight 65 (59Æ1) 16Æ4 (10Æ9) 57 (51Æ8) 14Æ2 (12Æ3) 0Æ29
Overweight 14 (12Æ7) 18Æ0 (11Æ2) 20 (18Æ2) 13Æ4 (12Æ3) 0Æ24
Obesity 6 (5Æ5) 10Æ4 (11Æ4) 15 (13Æ6) 19Æ2 (12Æ8) 0Æ10

*Student’s t-test.

 2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 2424–2433 2429
A de Souza Caroci et al.

Table 3 Means of perineometry of stage 4 Discussion


Perineometry (mmHg) Stage 4 There was a high percentage of loss of the study population
Variable n (%) mean (SD) p-value (51Æ3%), which can be attributed to the longitudinal nature
of the study. However, as the variables analysed when
Type of delivery
Spontaneous 73 (66Æ4) 13Æ7 (10Æ1) 0Æ16*
comparing the group of dropouts with the study sample
Caesarean 37 (33Æ6) 16Æ9 (13Æ0) indicated homogeneity between both groups, the likelihood
Condition of the perineum that the results were skewed by those who dropped out of the
Episiotomy 48 (65Æ8) 13Æ2 (10Æ7) 0Æ67 cohort is reduced.
Intact and 1st degree 18 (24Æ6) 13Æ7 (9Æ0) To obtain a more precise PFMS variation, it is important to
laceration
follow the women before, during and after the pregnancy,
2nd degree laceration 7 (9Æ6) 16Æ9 (9Æ0)
Newborn’s weight evaluating parity, type of delivery, perineal conditions,
<2500 6 (5Æ4) 16Æ0 (12Æ5) 0Æ65 genito-urinary and intestinal tract symptoms, as well as sex
2500–3500 76 (69Æ1) 15Æ0 (11Æ0) life. When evaluating the effects of pregnancy on perineal
>3500 28 (25Æ5) 12Æ5 (10Æ9) muscle function by measuring PFMS, some studies have
*Student’s t-test. concluded that pregnancy is associated with a reduction in

ANOVA . PFMS (Fleming et al. 2003). This reduction may occur
because during pregnancy progesterone increases, smooth
Table 4 Multivariate analysis of variance of the means of perine- muscle relaxes, conjunctive tissue is altered, the uterus raises
ometry (mmHg) of stages 1, 2 and 4
abdominal pressure and because of prior anatomical defects
Wilks’ (Valadares 2002).
Perineometry and combined variables Lambda F p-value* The average PFMS of the participants in this study was
Age · nutritional state (stage 2) 0Æ87 0Æ93 0Æ54 between 14Æ7–15Æ9 mmHg, which can be classified as a slight
Age · type of delivery 0Æ98 0Æ44 0Æ85 contraction. These results showed that PFMS decreased,
Age · condition of the perineum 0Æ87 0Æ57 0Æ89 slightly, over the course of pregnancy, and this reduction was
Type of delivery · nutritional 0Æ90 1Æ24 0Æ27 maintained up to the end of the postpartum period. However,
state (stage 2)
there were no statistically significant differences among the
Type of delivery · condition of the 1Æ00 – –
stages, probably because the participants were primigravidae
perineum
Type of delivery · newborn’s weight 0Æ97 0Æ90 0Æ45 women. If there is a reduction in PFMS in each pregnancy,
Condition of the perineum · nutritional 0Æ74 0Æ68 0Æ88 even one of low intensity, over the course of various
state (stage 2) pregnancies, this reduction could become exacerbated, caus-
Condition of the perineum · newborn’s 0Æ83 1Æ35 0Æ22 ing morbidities.
weight
Given the above results, we can suppose that if PFMS does
Newborn’s weight · nutritional state 0Æ80 1Æ86 0Æ04
(stage 2) not recover fully, these women might present morbidity in the
genito-urinary tract in future. Therefore, it is fundamental
*MANOVA .

that health professionals who treat women ask them to bring
ANOVA (p < 0Æ02); Tukey’s HSD (p < 0Æ02).
up any genito-urinary tract complaints. On the other hand,
(p = 0Æ04). In this situation, obese women with babies over the parameters adopted to classify PFMS intensity in women
3500 g showed higher means of perineometry than those without clinical symptoms may be open to debate (Fischer &
with appropriate weight and babies over 3500 g (p < 0Æ02) Linde 1997, Fitzpatrick & O’Herlihy 2001, Cammu et al.
(Table 4). 2004, Diokno et al. 2004, Belo et al. 2005, Castro et al.
As indicated in Table 5, PFMS evaluated in stage 4 by 2008). Further studies of PFMS measurement are necessary
digital vaginal palpation did not show any statistically and important to establish a profile of PFMS during
significant variation in terms of delivery type, presence of pregnancy and after childbirth.
episiotomy, or birth weight of around 3500 g. In this stage, The fact that PFMS in the majority of women involved in
the majority of the women presented vaginal contraction this study was classified as slight or moderate from the start
varying from none to low intensity (grades 0 to 2). PFMS was of pregnancy, regardless of the influence of pregnancy or
considered satisfactory or strong (grades 4 or 5) in 13Æ7 and delivery, can also be attributed to their difficulty in identi-
24Æ3% of the women with vaginal delivery and caesarean fying the perineal muscles and to a lack of practice in
sections, respectively. exercising them (Oliveira et al. 2007).

2430  2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 2424–2433
Maternal and neonatal health A cohort study of pelvic floor musculature function during pregnancy and postpartum

Table 5 Vaginal digital palpation of stage 4

Vaginal digital palpation (stage 4)

Oxford scale grade

0–2 3 4 and 5 Total

Variable n % n % n % n % p-value*

Type of delivery
Spontaneous 39 53Æ4 24 32Æ9 10 13Æ7 73 100 0Æ38
Caesarean 17 46Æ0 11 29Æ7 9 24Æ3 37 100
Total 56 50Æ9 35 31Æ8 19 17Æ3 110 100
Condition of the perineum
With episiotomy 25 52Æ1 16 33Æ3 7 14Æ6 48 100 0Æ98
Without episiotomy 14 56Æ0 8 32Æ0 3 12Æ0 25 100
Total 39 53Æ4 24 32Æ9 10 13Æ7 73 100
Newborn’s weight (g)
£3500 41 50Æ0 27 33Æ0 14 17Æ0 82 100 0Æ91
>3500 15 53Æ6 8 28Æ6 5 17Æ8 28 100
Total 56 50Æ9 35 31Æ8 19 17Æ3 110 100

*Chi-square test.

This being the case, women should be taught the factors study. In addition, third- and fourth-degree perineal lacer-
related to PFMS reduction and a supervised programme of ations can damage the anal sphincter muscles and the nerves
exercises to strengthen the PF should be implemented of the pudenda (Fitzpatrick & O’Herlihy 2001); however,
during prenatal consults so that they can know how to none of the women in this study suffered such severe
properly identify their PF muscles (Zanetti et al. 2007). It is degrees of laceration. Although some studies associate UI
worth pointing out that all the women evaluated in stage 4 and anal incontinence with PF damage inflicted during
of the study were instructed, verbally and in writing, about vaginal delivery (Dannecker & Anthuber 2000, Voorham-
how to perform a programme of perineal exercises. van der Zalm et al. 2008), more longitudinal studies are
The average PFMS in this study may be different from needed to evaluate the effects of pregnancy and delivery on
that of other similar studies (Barbosa et al. 2005, Menta & genito-urinary tract incontinence and on PF function (Kolbl
Schirmer 2006, Oliveira et al. 2007) because it used surface 2001).
electromyography to evaluate abdominal muscle activity and Postpartum PFMS showed no statistically significant asso-
not clinical inspection. This procedure was essential, as the ciation with the conditions of the perineum during vaginal
women had difficulty in distinguishing between contractions delivery, independent of whether the perineum remains
of the muscles of the abdomen and those of the perineum intact, or whether there are first- and second-degree lacera-
(Nagib et al. 2005). During data collection, one researcher tions or episiotomy. These results are consistent with other
proceeded with PFMS measurement, while another read the findings (Menta & Schirmer 2006). However, Leeman et al.
results on the electronic visor of the perineometer and the (2007) contended that PFMS six weeks after delivery was
electromyograph screen. In this way, we sought to avoid reduced in women with second-degree lacerations, compared
the possibility that the results of the perineometry might to those who had an intact perineum (53 against 28%,
influence the researcher when performing digital vaginal p = 0Æ03). The results of this study showed that type of
palpation. delivery did not significantly disrupt average PFMS or Oxford
In this study, as in some others, the maternal age, skin scale. Other studies, by contrast, have shown that vaginal
colour and conjugal status had no influence on the PFMS delivery can cause PF damage (Dannecker & Anthuber 2000,
values during pregnancy or postpartum (Menta & Schirmer Fitzpatrick & O’Herlihy 2001, Hay-Smith et al. 2002, Souza
2006, Oliveira et al. 2007), in spite of some authors having 2002, Norton et al. 2006).
suggested that these variables could interfere with PFMS A study that analysed the influence of delivery type on
(Allen et al. 1990, Klein et al. 1997). Regarding the nutri- PFMS using digital vaginal palpation and perineometry in a
tional state and the newborn’s birth weight, the interaction cohort of 30 women who had never been pregnant and 64
of these variables can affect the PFMS, as indicated in this first-time mothers (32 postcaesarean and 32 postvaginal

 2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 2424–2433 2431
A de Souza Caroci et al.

delivery) between four and six months after delivery does not require special equipment, but the professional, who
concluded that vaginal and caesarean delivery both reduced uses it, must be adequately prepared to assess the PFMS. In
PFMS; however, PFMS was lower among women who had clinical practice, this method is effective to support the
vaginal births in comparison with those who had caesareans diagnosis of urinary, intestinal and sexual dysfunctions.
or who had never been pregnant. The authors suggested that Regarding perineometry, its use is particularly important
routine episiotomy and not just vaginal delivery could together with the performance of perineal exercises with
decrease PFMS, because all women who had vaginal births biofeedback in the treatment of these disorders.
underwent episiotomy (Barbosa et al. 2005).
One important aspect that should be mentioned is the fact
Acknowledgements
that the participants in this study readily accepted both
methods of PFMS evaluation. Of all of the women enrolled This work was supported by the State of São Paulo Research
in our study, only four (1Æ8%) refused to continue in the Foundation (FAPESP), São Paulo (SP), Brazil. We also thank
study. The methods used to evaluate PFM were selected School of Nursing of the Universidade de Sao Paulo and
because they are the most widely used in clinical practice Adventist University Center of Sao Paulo.
(Coletti et al. 2005).
To summarise, the results of PFMS evaluation during
Source of support
pregnancy and postpartum vary rather reasonably among
the studies. We consider that this variation is mainly because This study was partially funded by the State of São Paulo
of the different inclusion criteria, population following Research Foundation (FAPESP), São Paulo (SP), Brazil. This
along the study and the PFMS measuring methods. funding involved resources for the purchase of equipment and
It is worth reiterating that the sample estimate was not supplies, transportation, statistical analysis and technical
reached because of loss of follow-up of women. Thus, this training scholarships.
limitation should be considered when interpreting the results
of this study. Although our sample size is greater than that of
Contributions
similar studies, a larger n would allow more accurate
analysis of the interaction between the variables that Study design and manuscript preparation: ASC, MLGR; data
influence the PFMS. Therefore, the researchers of this study collection and analysis: ASC, MLGR, WSS, ACC, EMS,
recommend that more studies be performed that follow NRL, CNCF.
women for a longer period after delivery to evaluate genito-
urinary tract symptoms, sexual dysfunction and PFMS
Conflict of interest
variation.
None.

Conclusion
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