Does pelvic floor muscle contraction early after delivery cause perineal pain in postpartum women?

doi:10.1016/j.ejogrb.2016.11.009

European Journal of Obstetrics & Gynecology and Reproductive Biology

Volume 208, January 2017, Pages 1-5

https://doi.org/10.1016/j.ejogrb.2016.11.009 Get rights and content

Abstract

Objective

Pelvic floor muscle training is effective and necessary in the prevention and treatment of pelvic floor dysfunction during pregnancy and after childbirth. But because of the high prevalence of perineal pain observed in women after childbirth, many women and caregivers fear to start pelvic floor muscle training immediately after childbirth. However, it is unknown whether pelvic floor muscle contractions (PFMC) provoke perineal pain in women shortly after childbirth. Therefore, the main objective is to study whether PFMC performed immediately after childbirth is painful or not.

Study design

Observational longitudinal study. Perineal pain was assessed (1–6 days and 9 weeks postpartum) using a visual analogue scale (VAS 0–10) during PFMC and during several activities of daily living (ADL), during micturition and defecation. Descriptive statistics, Wilcoxon and McNemar tests were used.

Results

A total of 233 women participated (148 primiparous and 85 multiparous). Immediately postpartum the prevalence and intensity of pain during ADL (73%; VAS 4.9 (±2.3)), micturition (47%; VAS 3.4 (±1.7)) and defecation (19%; VAS 3.6 (±2.2)) were significantly higher (all p < 0.000) than during PFMC (8%; VAS 2.2 (±0.9)). At 9 weeks postpartum, 30% experienced perineal pain during sexual intercourse (VAS 4.6 +/− 2.3) and 18% during defecation (VAS 4.7 +/− 2.3), but none during PFMC.

Conclusion

Perineal pain is highly prevalent immediately after childbirth during ADL, micturition and defecation, but not during PFMC (only 8%). In case perineal pain occurs during PFMC, the intensity of pain is low (VAS 2). These results show that fear of perineal pain should not discourage women to start pelvic floor muscle training shortly after childbirth.

Introduction

Pregnancy and childbirth are main risk factors for pelvic floor dysfunction such as urinary incontinence (UI), anal incontinence, pelvic organ prolapse and sexual problems [1], [2].

Pelvic floor muscle training (PFMT) is known to be effective in the prevention and treatment of pelvic floor dysfunction during pregnancy and after childbirth [3], [4], and therefore has an important role in the peripartum period. Muscular reinforcement during perineal rehabilitation reduces urinary stress incontinence and anal incontinence [5]. PFMT after delivery should at first be focused on restoring voluntary contraction of the weakened musculature [6].

Pregnancy and delivery are also the most common risk factors for perineal pain in the early postpartum period. Perineal pain is defined by the International Continence Society as the complaint of pain felt between the posterior fourchette (posterior lip of the introitus) and the anus [7], [8]. Some researchers define perineal pain in a broader region: as any pain occurring in the perineal body, the area of muscular and fibrous tissue, which extends from the symphysis pubis to the coccyx [9]. Recent research found a high prevalence of perineal pain postpartum, ranging from 74% to 90%, with 37% reporting moderate or severe pain [10], [11]. Evidence shows that perineal tissue damage is the most important risk factor for perineal pain postpartum. Perineal tissue damage can occur with diverse birth interventions including episiotomy, forceps, vacuum extraction, prolonged expulsive period and newborn characteristics including birth weight [12], head circumference and position of the baby at birth [13], [14].

Perineal pain can impact a woman’s daily activities including sleep patterns, urinary and bowel function and practical care of her infant [15], [16]. Although preventive PFMT has an important role in peripartum pelvic floor dysfunction, the prevalence of perineal pain during PFMT after delivery has never been studied before. Recent research revealed that PFMT started early after obstetrical anal sphincter injuries (within 30 days) reduces anal incontinence significantly compared to PFMT given within 6–8 weeks postpartum [6]. But many women and caregivers are cautious or even restrained to start PFMT early after childbirth because of the pain they complain about.

The aim of this study is to investigate whether and to which extent pelvic floor muscle contraction (PFMC) provokes perineal pain in women shortly after delivery and nine weeks later. Secondary we will register which activities of daily living provoke perineal pain shortly after delivery and nine weeks later. And also the influence of parity, delivery methods, newborn anthropometric characteristics, pain medication and prepartum pelvic floor dysfunction on the prevalence of perineal pain will be investigated.

Section snippets

Design

Observational longitudinal survey. Study subjects were recruited within 1–6 days after delivery at the maternity ward, University Hospital Antwerp. A good knowledge of the Dutch, French or English language was a prerequisite for inclusion. Exclusion criteria were the presence of an indwelling bladder catheter. Written informed consent was obtained from all participating women. The study was approved by the local ethics committee (BE300201318334).

Questionnaire immediately after delivery

The date of delivery, characteristics of the

Results

Two hundred thirty-three women (148 primiparous and 85 multiparous) participated in the study (M 2.4 ± 1.2 days postpartum) immediately after delivery. Hundred ninety-nine of them agreed to participate also in the second part of the study, approximately nine weeks after delivery. Eight women were excluded for the second part because they were not able to perform an analytic PFMC immediately after childbirth. Mean age of the participants was 30.4 ± 4.4 years old; characteristics are presented in

Comment

The results of this study indicate that pelvic floor training shortly after delivery is not painful in most women, even if many report pain during ADL, micturition or defecation. Those women who experienced pain reported a lower level of pain during PFMC than during ADL, micturition and defecation. Perineal pain, immediately after delivery was significantly more prevalent in primiparous women and women with perineal trauma. None of the participants felt any pain during a PFMC performed at nine

Conflict of interest

The authors declare that there is no conflict of interests regarding the publication of this paper.

Financial disclaimer/conflict of interest

None.

Contribution to authorship

H Neels: Project development, data collection, management data analysis, manuscript writing.

S De Wachter: Project development, manuscript editing.

JJ Wyndaele: Project development, manuscript writing/editing.

M Wyndaele: management data analysis, manuscript editing.

A Vermandel: Project development, manuscript writing/editing.

Acknowledgements

The authors would like to thank all the women who participated in this study and all pelvic floor therapists. Gratitude also to Dr. K. Wouters for her advice and help in the statistical analysis and to Dr. G. Hatfield and Mrs. P. Hatfield for their editing as native speakers.

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A women-centred exploration of postpartum perineal pain when the perineum is diagnosed as intact: A French Gadamerian research study
2024, Midwifery
Postpartum perineal pain is a frequent symptom (90%) with consequences on postnatal health regardless of whether the perineum remains intact. The impact of that pain on both short and long-term health has been studied and literature suggests midwives have a role to play in addressing this issue. However, the determinants of perineal pain when no lesions are identified are under researched and there is little understanding of women's views on this topic.
The aim of the study was to gain an understanding of postpartum perineal pain when the perineum is considered to be intact. The objectives were
•To gain an understanding of postpartum pain and its consequences on health and well-being
•To explore women's views and understanding of perineal pain postpartum
•To gain an understanding of the determinants of postpartum perineal pain when no anatomic lesion is diagnosed.
A Gadamerian hermeneutic approach was used to achieve a shared understanding of the issue. Participants were recruited from two maternity hospitals in the French area of Vaucluse. All women aged 18 to 45 years old, having given birth vaginally to a single live child and diagnosed with an intact perineum, were invited to participate in face-to-face interviews. Eleven participants were interviewed once, six of whom agreed to a second interview which took place over the telephone due to Covid lockdown.
The findings identified three major themes 1. Can't honestly call it pain, 2. Reassurance in normality, 3. Managing the unexpected. The use of the word pain to describe perineal sensations in postpartum was questioned by the participants, who used inner resources to deal with these sensations. Fostering self-confidence, having the possibility to explain the sensations and qualifying them as normal were some approaches women usedto manage their postpartum perineal sensations in a positive manner.
Pelvic-floor function, dysfunction, and treatment
2021, European Journal of Obstetrics and Gynecology and Reproductive Biology
Citation Excerpt :
Pelvic floor dysfunctions are associated with delivery. Fear of perineal pain should not discourage women from starting PFM training shortly after childbirth [33]. PF exercise and perineal massage may prevent episiotomies and tears in primiparous women [34].
The pelvic floor functions as a holistic entity. The organs, bladder, bowel, smooth and striated muscles, nerves, ligaments and other connective tissues are directed cortically and reflexly from various levels of the nervous system. Such holistic integration is essential for the system’s multiple functions, for example, pelvic girdle stability, continence, voiding/defecation, and sexuality. Pelvic floor dysfunction (PFD) is related to a variety of pelvic pain syndromes and organ problems of continence and evacuation. Prior to treatment, it is necessary to understand which part(s) of the system may be causing the dysfunction (s) of Chronic Pelvic Pain Syndrome (CPPS), pelvic girdle pain, sexual problems, Lower Urinary Tract Symptoms (LUTS), dysfunctional voiding, constipation, prolapse and incontinence. The interpretation of pelvic floor biomechanics is complex and involves multiple theories. Non-surgical treatment of PFD requires correct diagnosis and correctly supervised pelvic floor training.
The aims of this review are to analyze pelvic function and dysfunction. Because it is a holistic and entirely anatomically based system, we have accorded significant weight to the Integral Theory’s explanations of function and dysfunction.
Early postpartum biofeedback assisted pelvic floor muscle training in primiparous women with second degree perineal laceration: Effect on sexual function and lower urinary tract symptoms
2021, Taiwanese Journal of Obstetrics and Gynecology
Citation Excerpt :
No women in the PFMT group complained of pain or discomfort during the muscle contractions. A study was conducted to evaluate whether pelvic floor muscle contractions starting immediately after childbirth will cause perineal pain [22]. This study concluded that women experience less pain (VAS: 2.2) during pelvic floor muscle contraction compared with other activities of daily living and during micturition at 1–6 days postpartum.
To evaluate the short-term effect of routine early postpartum electromyographic biofeedback assisted pelvic floor muscle training on sexual function and lower urinary tract symptoms.
From December 2016 to November 2017, primiparous women with vaginal delivery, who experienced non-extended second-degree perineal laceration were invited to participate. Seventy-five participants were assigned into a pelvic floor muscle training (PFMT) group or control group. Women in the PFMT group received supervised biofeedback-assisted pelvic floor muscle training at the 1st week and 4th week postpartum. Exercises were performed at home with the same protocol until 6 weeks postpartum. The Pelvic Organ Prolapse Urinary Incontinence Sexual Questionnaire (PISQ-12) and the Urinary Distress Inventory short form questionnaire (UDI-6) were used to evaluate sexual function and lower urinary tract symptoms respectively at immediate postpartum, 6 weeks, 3 months, and 6 months postpartum.
Forty-five women (23 in PFMT group,22 in control group) completed all questionnaires at 6 months postpartum. For overall sexual function and the three sexual functional domains, no statistically significant difference was found in PISQ scores from baseline to 6 weeks, 3 months, and 6 months postpartum between the PFMT and control groups. For postpartum lower urinary tract symptoms, all symptoms gradually improved over time for both groups without a statistically significant difference between groups.
Our study showed that supervised biofeedback-assisted pelvic floor muscle training started routinely at one week postpartum did not provide additional improvement in postpartum sexual function and lower urinary tract symptoms.
Role of the different physiotherapy modalities in women with dyspareunia: a literature review
2020, Clinica e Investigacion en Ginecologia y Obstetricia
El objetivo de este trabajo es evaluar la literatura científica actual sobre el papel de las modalidades de fisioterapia en mujeres con dispareunia, independientemente de su causa. La búsqueda se realizó en las bases de datos Medline, Pubmed, Cinahl, Scopus y Web of Science. Después de tener en cuenta los criterios de inclusión y exclusión fueron seleccionados 12 artículos para la realización de la revisión. El tratamiento se lleva a cabo con dilatadores, biofeedback, ejercicios de fortalecimiento, técnicas de relajación y estiramientos entre otros. Dichas intervenciones, tienen períodos de tiempo variables y utilizan múltiples escalas y cuestionarios. La fisioterapia del suelo pélvico se utiliza como herramienta para el tratamiento de la dispareunia pero los resultados se deben tomar con precaución. Se necesitan ensayos clínicos controlados aleatorizados con tamaños muestrales más grandes que aumenten la calidad de la literatura científica.
A review of the current scientific literature was performed on the role of physiotherapy modalities in women with dyspareunia, regardless of the cause. The search for article was carried out in Medline, PubMed, Cinahl, Scopus, and Web of Science databases. After taking into account the inclusion and exclusion criteria, 12 articles were selected for the creation of the literature review. The reviewed articles describe different interventions, such as the use of vaginal dilators, biofeedback, strengthening exercises, relaxation techniques, and stretching exercises, among others. Furthermore, these interventions were carried out during varying periods of time, and multiple scales and questionnaires were used. Pelvic floor physiotherapy is used as a tool for the treatment of dyspareunia but the results should be taken with caution. Randomised controlled clinical trials with larger sample sizes that increase the quality of the scientific literature are needed.
Musculoskeletal Pelvic Pain and Sexual Function in the First Year After Childbirth
2019, JOGNN - Journal of Obstetric, Gynecologic, and Neonatal Nursing
Citation Excerpt :
We found no differences between participants with pain and those without pain based on mode of birth, episiotomy, or laceration history. In a recent European study, researchers explored the relationship between pelvic floor muscle contraction and perineal pain immediately after childbirth (first 48 hours after giving birth) and at 9 weeks postpartum (Neels, De Wachter, Wyndaele, Wyndaele, & Vermandel, 2017). Findings from physical examinations and questionnaires to assess pain of women in the early postpartum period indicated that perineal pain was most common during micturition, defecation, and activities of daily living, but not during pelvic floor muscle contraction.
To characterize sexual function in women with and without musculoskeletal pelvic pain during the first year after childbirth.
Cross-sectional descriptive study.
Outpatient women’s health clinic in a Midwestern U.S. academic medical center.
Women who gave birth to singleton infants within the past year.
Women were recruited from various outpatient settings. We obtained baseline demographic variables and used selected components from the Wilson and Cleary Health-Related Quality of Life model. Participants completed questionnaires related to sexual health, pain symptoms, and general quality of life. They were asked to indicate their pain on a pain diagram and to quantify it with the use of a numeric rating scale (NRS). Examiners used validated examination techniques to assess pelvic floor muscle tenderness, strength, and pelvic girdle pain. Participants who reported pelvic pain and had at least one positive physical examination finding were classified in the pain group.
Forty-five participants completed the study, and 20 participants were in the pain group. Most participants with pain had pelvic girdle pain (n = 15) and pelvic floor myofascial pain (n = 20). Participants with pain reported less sexual satisfaction (t[43] = 2.84, p = .007) and reduced quality of life (t[36] = 5.25, p < .001) compared with participants without pain.
Participants who experienced musculoskeletal pelvic pain in the first year after childbirth were significantly more likely to report problems with sexual function compared with their counterparts without pain.
Common errors made in attempt to contract the pelvic floor muscles in women early after delivery: A prospective observational study
2018, European Journal of Obstetrics and Gynecology and Reproductive Biology
Citation Excerpt :
Although they could disturb the woman’s sensory awareness and the proprioception of the PFM [13]. It has been shown that an early start of PFMC after delivery is advisable to prevent and treat PFD [15]; and performing PFMC immediately after childbirth does not cause any burden or pain [16]. The aims of this study are to examine COMMOV performed in addition to or instead of the PFMC immediately after childbirth, to investigate whether they influence the performance of a PFMC, and whether verbal feedback is effective to unlearn COMMOV.
The ability to perform a correct pelvic floor muscle contraction (PFMC) is necessary to start pelvic floor muscle training after delivery. COMMOV are "c"ontractions of "o"ther "m"uscles (m. rectus abdominus, the gluteal muscles, and the adductors), and other "mov"ements (pelvic tilt, breath holding, and straining) performed in addition to or instead of the PFMC. COMMOV are probably the most common errors in attempt to contract the pelvic floor muscles during the first days after delivery. The aims of this study were to observe the prevalence of COMMOV, to investigate whether COMMOV influence the ability to perform a PFMC, and whether verbal instructions are effective to unlearn the COMMOV postpartum.
A Prospective Observational Study was performed in women during the first through sixth day postpartum. PFMC and COMMOV were evaluated with visual observation. Women who did not show correct isolated PFMC received verbal instructions and were re-evaluated. Interobserver variability and agreement were calculated. Chi-square, Kappa, Risk Ratio, and McNemar were used.
A total of 382 women participated, 2.36 (±1.2) days postpartum. Twohundred sixteen, 57%, CI (52–62%), showed COMMOV. The chance to perform a correct PFMC was 2.65 times higher without COMMOV (p = 0.0001). Verbal feedback was effective (57% reduced to 3%) to abandon COMMOV during PFMC.
COMMOV are common errors performed during attempts to contract the pelvic floor muscles after delivery. They can reduce the ability to contract the pelvic floor muscles, but can easily been unlearned with visual observation and verbal feedback.

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Full length articleDoes pelvic floor muscle contraction early after delivery cause perineal pain in postpartum women?

Abstract

Objective

Study design

Results

Conclusion

Introduction

Section snippets

Design

Questionnaire immediately after delivery

Results

Comment

Conflict of interest

Financial disclaimer/conflict of interest

Contribution to authorship

Acknowledgements

Eur J Obstet Gynecol Reprod Biol

Midwifery

Am J Obstet Gynecol

Lancet

Am J Obstet Gynecol

Eur J Obstet Gynecol Reprod Biol

Int J Gynaecol Obstet

Am J Obstet Gynecol

Eur J Obstet Gynecol Reprod Biol

Eur J Obstet Gynecol Reprod Biol

Eur J Obstet Gynecol Reprod Biol

The prevalence of pelvic floor disorders and their relationship to gender, age, parity and mode of delivery

BJOG

Graphic integration of causal factors of pelvic floor disorders: an integrated life span model

Am J Obstet Gynecol

Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women

Cochrane Database Syst Rev

Effect of pelvic floor muscle training during pregnancy and after childbirth on prevention and treatment of urinary incontinence: a systematic review

Br J Sports Med

Full length article
Does pelvic floor muscle contraction early after delivery cause perineal pain in postpartum women?