Impact of verbal instructions on pelvic floor contraction in the immediate postpartum

Introduction: Pregnancy predisposes the emergence of pelvic floor dysfunctions (PFD), postpartum being the opportune moment to assess these muscles. Objective: To investigate the effect of instructions and verbal feedback on the contraction capacity of pelvic floor muscles (PFM) in postpartum women. Methods: Quasi-experimental study with 109 women in the immediate vaginal postpartum at a reference maternity hospital in Fortaleza, Ceará state, Brazil. PFM were visually inspected using the visual contraction scale (0 = no visible contraction; 1 = weak visible contraction; 2 = visible contraction with perineal elevation), in addition to observing the use of accessory muscles and movements. Assessments occurred in consecutive moments: 1 – PFM contraction at a verbal command; 2 – contraction after instructions on structure, function and correct contraction; and 3 – contraction after feedback on the use of accessory muscles and reinforcement of correct contraction. Cochran’s Q test and a 5% significance level were used to compare the outcomes between different moments. Results: At the first assessment, 15.6% of the postpartum women did not exhibit visible PFM contraction (grade 0). Of these, 70.5% changed their contraction grade after instructions and feedback. At the end, 45.9% of women correctly contracted their PFM with perineal elevation (grade 2) (p < 000.1). The use of accessory muscles (abductors, abdominals and gluteal) declined after instructions and feedback (p < 000.1). Perineal trauma, forceps delivery, previous information and fear of feeling pain were not associated with contraction grade. Conclusion: Instructions and verbal feedback are useful tools for correct PMF contraction in the immediate postpartum.


Introduction
During pregnancy, hormonal and biomechanical changes, such as a gain in body mass and enlarged uterus, raise the pressure on pelvic floor muscles (PFM).
Especially in primiparous women, there is an increase in urethral mobility, changes in muscle tone and activity, heightening the risk of pelvic floor dysfunctions (PFD), such as urinary incontinence (UI) and pelvic organ prolapse. 1,2 As described in the literature, approximately 30% of women have difficulty in perceiving and activating these muscles when asked for the first time during a physical examination of PFM. 3,4 Given that changes in PFM strength and function occur during the gestational period, and that the perineal region in the postpartum is in a congestive and edematous state, this difficulty may be exacerbated. Pelvic floor muscle training (PFMT) is recommended as first-line treatment, but also as a preventive strategy for UI, thus it is important to assess these muscles correctly. 5 Assessment and subsequent PFMT after delivery may result in a faster and more effective recovery in preventing and treating PFD. 6 Correct PFM contraction is defined as an approximation between the vagina and anus, with cranial displacement of the central tendon of the perineum, without using the accessory muscles.
Due to pain and/or vaginal bleeding, vaginal palpation and manometry may be uncomfortable in the immediate postpartum. 7 In addition to these methods, visual inspection is one of the ways to conduct this assessment.
The perineal region can be observed to determine the contraction or not of PFM, as well as the use of accessory  ("urge to urinate" and "fallen bladder", for example).
The participant was then asked to "contract their vagina muscles, pulling inward and upward". Next, the women were asked to contract again, performing three rapid consecutive contractions, and were then reassessed using the visual scale. In order to classify the contraction grade, the last contraction was considered, taking the effect of learning the movement into account. Data collection was carried out by a single examiner, a physiotherapist with experience in the area and at the maternity hospital, who conducted a pilot test before the study. The pilot test was performed with ten women by two researchers, the examiner and a supervisor with extensive experience in women's health physiotherapy.
The researchers simultaneously assessed the pilot test participants until they reached agreement on the contraction grade and use of accessory movements.
These subjects were not included in the research sample. The adductor, abdominal and gluteal muscles were the most recruited during PFM contractions, but instructions and mainly verbal feedback at assessment 2 resulted in decreased use of all the accessory muscles and movements evaluated (p < 0.001) ( Table 2). At assessment 1, only three (2.7%) women obtained grade 2 and did not use any accessory muscle or movement, while in the second and third assessments, these numbers were four (3.6%) and 29 (26.6%) women, respectively (data not presented in the tables).
There was no association between episiotomy, use of forceps, previous information on PFM and fear of feeling pain during contraction and contraction grade according to the scale applied at assessment 1 (Table 3).
It is important to note that no adverse event occurred during or after assessments.
With respect to statistical analysis, the data were

Results
Most of the 109 women included (n = 48) were aged between 18 and 25 years, with an average of 24.3 years Record the contraction grade (0, 1 or 2).
Record the use of accessory muscles and movements.
Command: "Contract your vagina as if you were trying to hold your urine". Command: contract your vagina muscles, pulling inward and upward".

PFM contractions.
Instructions on anatomy, function and correct PFM contraction.
Command: "Now contract only your vagina muscles".

PFM contraction.
Individualized feedback on accessory muscles and movements.
Record the use of accessory muscles and movements.
Record the use of accessory muscles and movements.
Note: PFM = pelvic floor muscles.   grade 2) to analyze the difference in contraction grades between the assessments. Pelvic mov. = pelvic movement. however, a scale with high interrater reliability was used (k = 0.832), 7 which can be applied in different environments by different professionals, in addition to being a simple low-cost assessment method.
We highlight the originality and contribution of this study, which allows broadening the approaches in the All authors approved the final version.