Effects of pelvic floor myofascial manipulation intervention on primiparas and neonates during the second stage of vaginal delivery
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- Published online on: November 8, 2023 https://doi.org/10.3892/etm.2023.12292
- Article Number: 5
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Copyright: © Chen et al. This is an open access article distributed under the terms of Creative Commons Attribution License.
Abstract
Introduction
Vaginal delivery is the natural delivery process after the pregnancy period, and is the preferred mode of delivery for most mothers (1-3). However, the pain during childbirth and the long labor duration causes not only physical fatigue of the puerpera but also many adverse psychological emotions, such as fear and anxiety of a potential perineum tear, thereby affecting the normal force of the puerpera during labor, prolonging the labor duration and increasing the amount of labor bleeding (4). The continuous exertion of the mother during the second stage of labor puts pressure on the perineal body locally. If the labor process is prolonged or the fetus is stuck during the delivery after entering the pelvis, the risk of episiotomy or tearing of the perineum will be increased, and even worse, there is an increased risk of suffocation and dystocia for the newborn (5).
The pelvic myofascia is subjected to orthostatic pressure for several months during pregnancy. During labor, persistent tension and contraction of pelvic floor muscle fibers cause spasms, and the fascial matrix transmits the tension produced by the muscle, resulting in increased fascial tension and ischemia (6). For increased pelvic muscle tone, physical therapy has been the first-line treatment, and trigger point injections have been employed to release the myofascial tension (7,8). During vaginal delivery, the injections can be challenging due to the danger of injuring the surrounding tissue or possibly the fetus. Thus further research into a non-invasive way to decrease myofascial tension during labor is required.
Thiele massage is a maneuver to lessen pain during childbirth by massaging posterior pelvic floor muscles via the rectum (7), which has been shown to benefit women who have interstitial cystitis and increased pelvic muscle tone (9). A previous study explored transvaginal pelvic floor fascia manipulation and revealed that this method increases the pain threshold of myofascial receptors, while reducing the sensitivity to pain (10). Additionally, Li (11) reported that it can improve the physical and mental adaptability of the puerpera to painless delivery, thereby reducing the labor time and the rate of cesarean section (12). However, its effects on other delivery-related issues and neonatal outcomes remain unknown. Thus, the present study aimed to investigate the effect of pelvic floor myofascial manipulation on primiparas and neonates during the second stage of vaginal delivery.
Patients and methods
Patient selection
A total of 60 primiparas who were expecting to deliver at the Department Obstetrics, The Second Affiliated Hospital of Hainan Medical College (Haikou, China) between October 2021 and January 2022 were enrolled. The inclusion criteria were as follows: i) Women at full-term pregnancy admitted for vaginal delivery; ii) women without gestational hypertension or diabetes (the diseases increasing the risk of delivery complications); and iii) women without pelvic bony or anatomical abnormalities that could influence manual therapy. The exclusion criteria were as follows: i) Breech or transverse fetal positions, which significantly increased delivery complications; ii) abnormal fetal heart rate or spontaneous rupture of the fetal membrane, which increased the likelihood of cesarean section delivery; iii) women who needed emergent cesarean section delivery after failure of vaginal delivery; iv) women who had major depression or a psychotic episode and did not cooperate with therapy instructions; and v) women who dropped out due to personal choices or other emergencies.
The included women were given 5-digit random numbers. An online random number table was used to randomly allocate the women to an experimental group and a control group. During the intervention period, a total of 4 cases dropped out, 2 from each group. Finally, 28 cases were included in each group. This study was approved by the Ethics Committee of the Second Affiliated Hospital of Hainan Medical College (approval no. H20171201-1), and all participants/their guardians provided written informed consent.
General labor care
Women in the control group received standard care. Primiparas were continuously monitored for fetal heart rate during labor. All women included were in active labor. During the first stage of labor, primiparas were encouraged to ambulate more. Furthermore, birthing appliances, such as rocking chairs, birthing balls and birthing stools, were suggested to assist in labor to promote the descent of the fetal head and relieve pain. The second stage of labor was defined as the period from the beginning of complete dilation and erasure of the cervix to the end of the baby's delivery. The labor evaluation included the determination of the fetus's cephalic position and a cervical check using a bedside ultrasound, both of which were performed by a junior and a senior attending obstetrician. After entering the second stage of labor, primiparas were given low-flow oxygen inhalation and instructed to perform breathing exercises during uterine contractions, and their fetal heart rates and amniotic fluid conditions were closely monitored. Upon the complete dilation of the cervix, the primiparas were instructed to grab the bedpost with both hands, stirrup the feet on the delivery bed, inhale deeply to hold a breath and then force this held breath downward as if relieving a bowel movement. The primiparas were placed in a semi-recumbent position on a bed, with their feet apart and on the pedals, while their legs were abducted and flexed to the sides of the abdomen. During the contractions, primiparas were instructed to hold their legs with both hands, lift their heads slightly, tighten their chins, keep their eyes on the navel and hold their breath downwards. Notably, they were allowed to relax in the interval between contractions. The perinea of the primiparas were protected when the fetal heads were exposed at 3 to 4 cm dilation. The midwives placed themselves in a semi-squat position and used their left hand to properly depress the occiput of the fetal head when instructing the mother to exert force, so that the biparietal diameter of the fetal head was slowly delivered. When the occiput of the fetal head was exposed on the pubic arch, the mother was instructed to direct her held breath slightly downwards during the interval between contractions, and the midwife assisted the fetal head to stretch up with her left hand to ensure the slow delivery. In the next contraction, the midwife used the thenar muscle of the right hand to hold the perineum and the left hand to pull the fetal neck down. The first shoulder was thus delivered. The midwife then dragged the baby's neck up and over the second shoulder. Finally, the midwife relaxed her right hand and used both hands to assist in delivering the fetus.
Pelvic floor myofascial manipulation
Women in the experimental group received pelvic floor myofascial manipulation during the second stage of labor along with the standard care. This intervention was performed by the senior attending obstetrician to ensure consistency. At first, gentle pressure was applied externally to the pubic symphysis and perineum muscles and tendons (superficial transverse perineal muscle, central perineal tendon, bulbocavernosus muscle and ischiocavernosus muscle). Later, a sterile gloved index or middle finger was placed in the vagina to palpate the boney structures (sacrum and coccyx) and identify pelvic floor muscles and tendons (iliococcygeus, ischicoccygeus, obturator internus and levator ani tendon), as well as trigger points. At last, gentle pressure was given to massage the trigger points and muscles at each spot to reduce muscle tension and alleviate pain for 15-20 min.
Evaluation indicators
The duration of the second stage of labor, the forced breath-holding time and the postpartum hemorrhage volume in 2 h for both groups were evaluated.
The pain level in the second stage of labor was assessed using the Pain Visual Analogue Scale (VAS) (13). The survey data were collected 30 min after delivery. The pain level was marked on a scale of 1 to 10, with 0 indicating no pain and 10 indicating intolerable, extreme pain.
The degree of perineal laceration was classified as perineal integrity (without laceration), I˚, II˚, III˚ and IV˚ lacerations. Perineal integrity refers to the integrity of the perineal skin and vaginal mucosa without laceration. I˚ laceration refers to the tear of the perineal skin and vaginal entrance mucosa, with little bleeding. II˚ laceration indicates that the laceration has reached the fascia and muscular layer of the perineal body, involving the mucosa of the posterior vaginal wall, extending to the grooves on both sides of the posterior vaginal wall and tearing upwards. The anatomical structure is difficult to identify, and there is a lot of bleeding. III˚ laceration refers to the laceration extending deep into the perineum, with rupture of the external anal sphincter, but an intact rectal mucosa. IV˚ laceration refers to complete penetration of the anus, rectum and vagina, exposure of the rectal lumen and severe tissue damage, with possibly some bleeding.
Fatigue degree of the primipara was assessed using the Multi-Dimensional Fatigue Inventory (MFI-20), which consists of five dimensions, namely mental, activity, overall, motivatio and physical, each with four entries. For a Likert 5-point scale, 1 point denotes complete compliance and 5 points mean complete non-compliance. The total score ranges from 20 to 100 points, with higher scores representing higher fatigue degree in primiparas (14).
Neonatal outcome indicators included fetal distress, abnormal umbilical cord, abnormal amniotic fluid and neonatal asphyxia. Data collection was performed within 1 h of delivery. The neonatal outcomes were also assessed by the Apgar score. Evaluation criteria were as follows: 1 min after birth, the newborns were scored from five aspects: Heart rate, respiration, muscle tone, laryngeal reflex and skin color, with a score of 0-2 out of 10 for each item. A score of 8-10 points represents normal newborns, 4-7 points represents mild neonatal asphyxia and 0-3 points represents severe asphyxia.
Statistical analysis
Categorical variables of the included women were expressed as frequencies, and these data were analyzed using the χ2 test or Fisher's exact test. Continuous variables with normal distribution were expressed as the mean ± standard deviation and the comparison between groups was performed using the independent samples t-test. All statistical analyses were performed using IBM SPSS Version 26 (IBM Corp.), and a two-sided P-value of <0.05 was considered to indicate a statistically significant difference.
Results
Demographics
A total of 56 women were finally included in this study, with 28 patients each in the control and experimental groups. Women in the control group were aged between 16 and 34 years, with a mean age of 27.32 years. Women in the experimental group were aged between 21 and 34 years, with a mean age of 27.14 years. Comparing the age, gestational time and body mass index of the patients in the two groups, no significant differences were found (P>0.05), as shown in Table I.
Comparison of the stage of labor between the two groups
As shown in Table II, the duration of the second stage of labor, the forced breath-holding time and the postpartum hemorrhage volume in 2 h in the experimental group were lower than those in the control group, and the differences were statistically significant (P<0.05).
Comparison of the laceration rate and episiotomy rate between the two groups
In the control group, there were 13 women with I˚ vaginal tears and 5 with II˚ vaginal tears. In the experimental group, there were 13 women with first-degree vaginal tears and one with II˚ vaginal tears. The laceration ratio in the experimental group was 50.00%, which was lower than that in the control group (64.29%), but the difference was not significant different (P>0.05). One woman from the experimental group and four women from the control group required an episiotomy, as shown in Table III.
Comparison of VAS scores, multidimensional fatigue scale scores and Apgar scores between the two groups
As shown in Table IV, the pain VAS scores, multidimensional fatigue scale scores and Apgar scores of the experimental group were significantly lower than those of the control group, and the differences were all statistically significant (P<0.05).
 | Table IVComparison of visual analog scale scores, multidimensional fatigue scale scores, and Apgar scores between the two groups. |
Comparison of neonatal outcomes between the two groups
The experimental group exhibited a much lower incidence of neonatal adverse outcomes compared with the control group, and the difference between total incidence rates was statistically significant (3.57 vs. 10.71%; P<0.05; Table V).
Discussion
Pelvic floor myofascial manipulation has been reported to effectively reduce postpartum hemorrhage volume, avoid the need for a blood transfusion and help the mother's body to recover quickly (15). The procedure also shortens the duration of the second stage of labor, reduces the incidence of urinary incontinence and improves pelvic floor symptoms (16). In the present study, it was found that after pelvic floor myofascial manipulation intervention, the duration of the second stage of labor, the forced breath-holding time and the bleeding volume at 2 h postpartum were significantly lower in primiparas in the experimental group compared with those in control group. In some parturients, the fetal head enters the pelvic cavity and is stuck close to the pubic symphysis. Pelvic floor myofascial manipulation, which releases tight muscles and fascia and expands the pelvic cavity, means that the fetal head of the fetus can smoothly descend and the stage of labor is shortened. Accordingly, pelvic floor myofascial manipulation can adjust the fetal position to a certain extent, reduce the risk of dystocia, and benefit both the mother and the newborn.
Pelvic floor muscle tension will increase for a variety of reasons (such as pregnancy, childbirth and inflammation), and muscle hypertonia will not be relieved immediately. Therefore, perineal damage can easily occur during childbirth, increasing the probability of lateral cutting or tearing (17). In the present study, the proportion and degree of episiotomies or tears were decreased by pelvic floor myofascial manipulation during the second stage of labor. However, these indications showed no significant difference with those in the control group, which may be related to the small sample size. In addition, the intervention of pelvic floor myofascial manipulation can help mothers to speed up blood flow, reduce the release of pain-causing factors from related tissues and ultimately reduce the sensitivity of the mothers to pain (18), thereby reducing the pain, helping the fetal head descend and shortening the time of the second stage of labor (19,20). The present study also found that the pain VAS and fatigue scores of the pregnant women in the experimental group were significantly lower than those in the control group.
Labor pain is a medical pain with a high pain index, which is mainly caused by factors such as uterine paroxysmal contractions, fetal compression of the birth canal and the body's neuroendocrine response (21). Labor pain can promote the secretion of catecholamines and other stress products in the maternal body, increase the blood pressure and heart rate, slow down uterine contractions, decrease placental blood flow and prolong cervix dilation time, all of which affect the entire delivery process and raise the risk of adverse maternal and infant damage (22). After the intervention of pelvic floor myofascial manipulation in the second stage of labor, the parturient experienced reduced pain and fatigue, a somewhat improved mood and maintained physical strength. This contributed to a shorter duration of labor and enhanced delivery outcomes. At the same time, it is also conducive to stabilizing the fetal heart rate, lowering the risk of neonatal asphyxia, reducing the poor prognosis of neonates and achieving a good neonatal outcome (23). As an important manifestation of neonatal outcome, neonatal asphyxia primarily results from ischemia and hypoxia or acidosis due to the failure of the normal respiratory function of newborns during delivery. In severe cases, it can lead to systemic organ damage and significantly increase neonatal disability or mortality (24). Disturbances in gas exchange or blood circulation between the mother and the fetus can result in fetal distress and fetal asphyxia. The fetal distress may be transformed into intrapartum asphyxia or postpartum asphyxia, which poses a serious threat to the quality of life or safety of the newborns (25). A prolonged labor is primarily to blame for adverse outcomes such as urinary retention and neonatal asphyxia in mothers and infants (26). In this study, newborns were scored 1 min after birth in terms of five aspects (heart rate, respiration, muscle tone, laryngeal reflexes and skin color) and umbilical artery blood. One of the newborns in the control group presented with a heart rate <100/min, a weak cry, slightly flexed limbs and umbilical artery blood pH <7.1, so it was assessed as mild asphyxia (27). However, whether the experimental group in this study did not have the aforementioned problems due to the intervention performed, and whether the control group had other causes of prolonged labor leading to mild asphyxia, needs to be verified in future clinical trials with larger samples and more data. The present findings indicated that pelvic floor myofascial manipulation could shorten the duration of the second stage of labor, relieve the pain, and decrease the amount of bleeding during delivery. Additionally, the intervention assists the parturient in passing through the second stage of labor in a better mental and physical state. However, when performing the intervention, the force and the stimulation should not be excessive, and the course of action should vary depending on the state of the maternal pelvic floor. The stimulation time should also not be excessively prolonged. More importantly, surgery should intervene promptly if the fetal position cannot be adjusted during the process or there is an indication for cesarean section.
There are still several limitations to the present study: i) The study was conducted in only one hospital in China with a relatively small sample size; ii) the manipulation is hard to standardize; iii) whether pelvic floor myofascial manipulation will benefit pregnant women with hypertensive disorder and diabetes remains to be explored; and iv) follow-up information (e.g. the health of mothers and babies) after delivery is lacking. In our future study, a large sample randomized clinical trial with an improved blinding and randomization process will be conducted to provide more reliable evidence for peripartum care.
In conclusion, pelvic floor myofascial manipulation during the second stage of labor for primipara undergoing vaginal delivery can shorten the duration of the second stage of labor and reduce blood loss during labor. For neonates, this intervention helps lower the incidence of neonatal adverse outcomes. In light of these effects, pelvic floor myofascial manipulation can be a potential adjuvant therapy during labor for better maternal and neonatal outcomes. Standardization of this technique and future clinical trials to further evaluate the effects of this non-invasive manual therapy are needed.
Acknowledgements
Not applicable.
Funding
Funding: This study was supported by Hainan Nature Project (grant no. 820MS145) and the Project of Hainan Provincial Health Commission (grant no. 21A200225).
Availability of data and materials
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Authors' contributions
YQC, ZWW and HYJ conceived and designed the study. HCL, JW, JZQ, JHL and DQW were responsible for provision of the study materials or patients. HCL, JW, JZQ, JHL and DQW collected and assembled the data. Data analysis and interpretation was performed by HYJ. YQC, ZWW and HYJ confirm the authenticity of all the raw data. All authors helped write the manuscript. All authors have read and approved the manuscript.
Ethics approval and consent to participate
This study was approved by the Ethics Committee of the Second Affiliated Hospital of Hainan Medical College (Haikou, China; approval no. H20171201-1), and all patients/their guardians provided written informed consent.
Patient consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
References
|
Samara1 B and Sabella AR: The knowledge and attitudes of Palestinian women towards different childbirth delivery options. Clin Exp Obstet Gynecol. 48:138–143. 2021. | |
|
Mujezinović F, Anzeljc V, Sobočan M and Takač I: Do women in Slovenia prefer vaginal birth after prior caesarean and what hinders its successful outcome? Clin Exp Obstet Gynecol. 48:607–614. 2021. | |
|
Alkhazal BAH, Halawani MA, Alsahabi IO and Abduljabbar HSO: The preferred mode of delivery among primigravida Middle Eastern Women. A questionnaire based study. Clin Exp Obstet Gynecol. 48:567–571. 2021. | |
|
Kang F, He J, Shi H, Guo F and BAI Z: Application of nursing intervention based on transtheoretical model and stages of change in breastfeeding for primiparas. Chin J Prac Nur. 430–435. 2019. | |
|
Xie Y, Dai X and Xiong X: Observation on the effect of pelvic rocking auxiliary intervention in the first stage of labor to promote labor in primipara. J Nurses Training. 54–56. 2018.(In Chinsese). | |
|
Zou C, Min M and Yu L: Analysis of the effect of biofeedback combined with myofascial manipulation on postpartum pelvic myofascial pain. Maternal & Child Health Care of China. 3540–3541. 2020.(In Chinsese). | |
|
Lewis GK, Chen AH, Craver EC, Crook JE and Carrubba AR: Trigger point injections followed by immediate myofascial release in the treatment of pelvic floor tension myalgia. Arch Gynecol Obstet. 307:1027–1035. 2023.PubMed/NCBI View Article : Google Scholar | |
|
Dessie SG, Von Bargen E, Hacker MR, Haviland MJ and Elkadry E: A randomized, double-blind, placebo-controlled trial of onabotulinumtoxin A trigger point injections for myofascial pelvic pain. Am J Obstet Gynecol. 221:517.e1–517.e9. 2019.PubMed/NCBI View Article : Google Scholar | |
|
Oyama IA, Rejba A, Lukban JC, Fletcher E, Kellogg-Spadt S, Holzberg AS and Whitmore KE: Modified Thiele massage as therapeutic intervention for female patients with interstitial cystitis and high-tone pelvic floor dysfunction. Urology. 64:862–865. 2004.PubMed/NCBI View Article : Google Scholar | |
|
Chen J, Zhu L and Pang H: Manual massage combined with biofeedback treatment for myofascial pelvic pain syndrome-17 cases cohort report. Chin J Pract Gynecol Obstet. 547–549. 2018.(In Chinsese). | |
|
Li Fe: Effect of standard management of new labor in painless delivery on maternal and child outcomes. Chin Modern Med. 132–134. 2019.(In Chinsese). | |
|
Fang L, Chen R and Lu Y: Effect of standard management of new labor in painless delivery on maternal and child outcomes. Jilin Medical Journal. 1815–1816. 2022.(In Chinsese). | |
|
Czech I, Fuchs P, Fuchs A, Lorek M, Tobolska-Lorek D, Drosdzol-Cop A and Sikora J: Pharmacological and non-pharmacological methods of labour pain Relief-establishment of effectiveness and comparison. Int J Environ Res Public Health. 15(2792)2018.PubMed/NCBI View Article : Google Scholar | |
|
Ji C, Chen Y and Huang W: Application of Multidimensional Fatigue Scale (MFI-20) in Patients with Rheumatoid Arthritis. Smart Healthcare. 22–23. 2021. | |
|
Salık F and Bıçak M: Can requirement for blood transfusion be predicted before delivery? Analysis of risk factors for blood transfusion in patients with postpartum hemorrhage. Clin Exp Obstet Gynecol. 48:572–573. 2021. | |
|
Schreiner L, Crivelatti I, de Oliveira JM, Nygaard CC and Dos Santos TG: Systematic review of pelvic floor interventions during pregnancy. Int J Gynaecol Obstet. 143:10–18. 2018.PubMed/NCBI View Article : Google Scholar | |
|
Jones K, Webb S, Manresa M, Hodgetts-Morton V and Morris RK: The incidence of wound infection and dehiscence following childbirth-related perineal trauma: A systematic review of the evidence. Eur J Obstet Gynecol Reprod Biol. 240:1–8. 2019.PubMed/NCBI View Article : Google Scholar | |
|
Chun-Hong WU, Yang CC, Yan LI, et al: Effect of intrapartum intervention on outcome and pelvic floor function of primiparous women. Journal of Regional Anatomy and Operative Surgery. 794–798. 2019.(In Chinsese). | |
|
Chen T and Wan L: Analysis on the effect of nursing intervention for primipara breast-feeding based on the theory of behavioral staged transformation. China Medical Herald. 173–176. 2020.(In Chinsese). | |
|
Wang L, Yu D and Li mY: Effect of perinatal emotional assessment and management on postpartum depression and delivery outcome in primiparas. Chinese Journal Of Family Planning & Gynecotokology. 74–76. 2019.(In Chinsese). | |
|
Madden K, Middleton P, Cyna AM, Matthewson M and Jones L: Hypnosis for pain management during labour and childbirth. Cochrane Database Syst Rev. 2016(CD009356)2016.PubMed/NCBI View Article : Google Scholar | |
|
Jiang XM, Huang XX and Jin LX: Analysis of the changing trend of vaginal delivery pain and its influencing factors. China Journal of Modern Medicine. 54–59. 2018.(In Chinsese). | |
|
Lu C, Gong H and Kang JM: Effects of Intraspinal Anesthesia Analgesia on Delivery Outcome and Neonatal Prognosis. Shenzhen Journal of Integrated Traditional Chinese and Western Medicine: 14-15 (In Chinsese). | |
|
Chen JP, Tan KH and Yuan HC: Predictive value of aEEG, cord blood pH and neonatal Apgar score for neonatal asphyxia outcome. Hainan Medical Journal. 342–343. 2022.(In Chinsese). | |
|
Xing MM and Wei G: Analysis of the influencing factors of asphyxia in term singleton. Modern Preventive Medicine. 2971–2975. 2020. | |
|
Chen ZX, Hu YM and Hou XY: Pregnancy and neonatal outcomes of primipara at different painless delivery times. Modern Hospital. 1111–1112. 2021.(In Chinsese). | |
|
Committee of Neonatology, Chinese Medical Doctor Association. Recommendations for the diagnosis and classification of neonatal asphyxia. Chinese Journal of Contemparary Pediatrics. (1)2013.(In Chinsese). |
