The Effects of the Pilates Method on Pelvic Floor Injuries During Pregnancy and Childbirth: A Quasi-experimental Study
Phase: NA
Conditions: Pregnancy, Perineum; Injury, Pilates Method, Episiotomy Wound
Sponsor: University of Huelva

 
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The Effects of the Pilates Method on Pelvic Floor Injuries during 
Pregnancy and Childbirth: A Quasi-experimental Study 
 
 
NCT:……………………………… 
 
Data: 10/10/2018 
 
 

 
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INTRODUCTION 
It is well known that female pelvic floor weakness and/or pelvic floor dysfunction 
(PFD) can have both structural and functional effects, such as urinary 
incontinence, bowel incontinence, pelvic organ prolapse, and dyspareunia 
and/or sexual dysfunction (Bozkurt et al., 2014, Pierce et al., 2015, Hyakutake 
et al., 2016, Neels et al., 2016). One of the main risk factors associated with 
pelvic dysfunction is the reproductive process, including pregnancy and birth. 
During this process both modifiable and non-modifiable risk factors for PFD can 
be identified. Chief among the former are the pregestational and full-term body 
mass index (BMI), weight gain, smoking, the type of birth, the use of forceps, 
the duration of the first and second stages of birth, the practice of episiotomy 
and the use of epidural anaesthesia. Among the non-modifiable risk factors 
(also known as risk indicators), are age at maternity, position of the foetus and 
circumference of the newborn’s head, the weight of the newborn, and the 
presence/existence of perineal injury, chiefly those which can affect the anal 
sphincter (Bozkurt et al., 2014, Hyakutake et al., 2016). 
Of all these factors, vaginal birth is the chief modifiable risk factor for developing 
pelvic floor dysfunction, as women in this group are 2.8 times more likely to 
suffer stress urinary incontinence, and 5.5 times more likely to suffer a prolapse 
of the pelvic organs, in comparison with those who give birth via caesarean 
section. These risks increase with instrumental delivery, which seems to be 
related to the fact that the incidence of injury to the anal musculature is higher in 
this procedure (Howard & Makhlouf, 2016). 
Among the non-modifiable obstetric risk factors, chief is perineal trauma, 
whether spontaneous or induced (second degree tears or obstetric anal 
sphincter injuries), which represents one of the most frequent complications 
associated with birth (85% of puerperal women) (León-Larios et al., 2017), and 
has a clear influence in the subsequent appearance of PFD (Bose et al., 2017, 
León-Larios et al., 2017). 
Although in recent years the practice of routine episiotomies has decreased in 
Spain, the percentage remains above the recommendations of the WHO (WHO 
1999, Escuriet et al., 2015) at around 40.2% (León-Larios et al., 2017). Within this 
average there is a disparity between the public and private systems, whereby, 
according to Escuriet et al. (2015), there has been an increase in the number of 

 
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episiotomies in private hospitals. In a study carried out in the United Kingdom, 
Smith et al. (2013) found a difference in the frequency of episiotomies between 
primiparae and multiparae, and also in the different degrees of perineal tearing, 
with the most frequent being second degree tears in both uniparity and 
multiparity contexts Smith et al.,2013, Zimmo et al., 2017). 
In addition, the risk of suffering more serious perineal trauma, specifically fourth 
degree tears affecting the anal sphincter and recta mucosa is three times 
greater among primiparae than multiparae (León-Larios et al., 2017, López et al., 
2014, OMS 1999). 
Perineal wounds suffered during birth significantly increase the risk of PFD, with 
a consequent impact on the female population of physical and emotional 
discomfort, depression, social isolation, avoidance of healthy physical activity, 
and reduction in productivity and quality of life, and a resultant increase in the 
demands on the health service (Smith et al., 2013, Bozkurt et al., 2014, Pierce 
et al., 2015, Hyakutake et al., 2016). 
Primary prevention of PFD is therefore essential, and the following interventions 
have been shown to be effective: (i) perineal massage during pregnancy (from 
week 34) ) (Oblasser et al., 2016), which has been found to diminish the 
number of episiotomies in primiparae, shorten the first and second stages of 
labour, and to reduce postpartum pain in multiparae (León-Larios et al., 2017); 
(ii) weight management and prevention of constipation through the promotion of 
a suitable diet and by doing physical exercise adapted to pregnancy (Davidson 
et al., 2000, Kyvernitakis et al., 2015); and (iii) pelvic floor strengthening 
exercises, which help to reduce discomfort (mainly among primiparae) and 
reduce the risk of urinary incontinence in the third trimester of the pregnancy 
and after childbirth (Hyakutake et al., 2016, León-Larios et al., 2017). 
With respect to exercises for strengthening the pelvic floor, the most common 
are hypopressive abdominal exercises and the Pilates Method (PM), which 
focus on developing the musculature of the transverse abdominis and pelvis in 
order to decrease intra-abdominal pressure (Kyvernitakis et al., 2015). The 
latter method is an exercise programme holistically encompassing body and 
mind in a combination of eastern and western techniques, and incorporating 
movements drawn from traditional and Swedish gymnastics, rehabilitation 
techniques, martial arts, yoga and dance (Llewellyn et al., 2017). 

 
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Background 
Pilates is based on the six fundamental principles of breath, concentration, flow, 
precision, centring and control. It aims for an equilibrium in musculature by 
reinforcing weak muscles and stretching tight ones, with an emphasis on 
control, strength, and flexibility. It focuses particularly on the core – the 
abdominal muscles, vertebral column and pelvic floor, and is thus instrumental 
in improving body alignment and good posture across the range of movements 
habitually carried out in daily activities (Guzmán et al., 2013, Shaban et al., 
2014, Llewellyn et al., 2017, Navarro & Luján, 2017). Advocates also note that 
practitioners gain a greater self-awareness of their body image, their range of 
motion and personal health (Almagiá, 2003), among other benefits (Culligan et 
al., 2010, Cruz-Ferreira et al., 2011, Shaban et al., 2014). For this reason, 
Pilates is often recommended generally as a treatment for alleviating back pain 
(Boix-Vilella et al., 2017). 
Given the marked increase in practising Pilates during pregnancy (Wells et al., 
2012, Shaban et al., 2014, Llewellyn et al., 2017), various studies have been 
carried out to evaluate its effectiveness. These include the effect of Pilates in 
antenatal classes for reducing anxiety about giving birth and in terms of its 
overall perinatal outcome and the benefits of a Pilates-based exercise 
programme during pregnancy and birth (Sarpkaya et al., 2018). Also notable in 
this regard are studies demonstrating the role of Pilates in reducing lumbar pain 
during the third trimester Maczka & Sass, 2017, Rogríguez-Díaz et al., 2017). 
With regard to the specific relation of Pilates with PFD, Dias et al. (2017) found 
a positive impact on the pelvic floor musculature during pregnancy (Oktaviani, 
2017), while Muniz de Souza et al. (2017) concluded that the method was a 
valid means of helping to prevent the dysfunction (Dias et al., 2017).  
The starting hypothesis of this study is that the incidence of perineal wounds 
during childbirth to be lower among those participating in a specially designed 
Pilates program. 
 
 
 
 
 

 
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THE STUDY 
Aim 
The aim of this study is to evaluate the influence of Pilates sessions during 
pregnancy on the incidence and degree of intrapartum perineal injuries. 
 
Design 
A multicentre quasi-experimental study, will be carry out between November 
2018 and December 2019 in health centres (HCs) pertaining to two distinct 
health districts 
 
Participants 
A convenience sample of pregnant women attending antenatal classes at health 
centres in two distinct districts, and meeting the following inclusion criteria: 
(i) being registered on an antenatal programme (AP); (ii) giving written consent 
of participation; (iii) the pregnancy being a singleton; (iv) the pregnancy being 
low risk; (v) there not being any contraindications for physical exercise (vi) being 
at least 18 years old. 
Women who have missed antenatal appointments, had difficulty in speaking or 
understanding Spanish, had given birth by caesarean section or declined to 
participate will be excluded from the study. 
 
Interventions 
The study will be carry out in two stages: the first involved finding Pilates 
trainers to deliver the sessions, while the second collated participant data from 
both the experimental and control groups. The first phase took place in 
November 2018, with the collaboration of two trainers in Huelva and one in 
Seville, all with the same training background. The second phase will be carried 
out between December 2018 and December 2019 in the corresponding health 
centres in Huelva and Seville. 
In order to eliminate potential bias as a result of the antenatal classes being 
deliver by health professionals of different categories, only those health centres 
where classes are deliver by a midwife were selected for the study. The women 
participat in the corresponding antenatal classes at the respective centres were 

 
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then will be invit to participate in the study either to the experimental group (AC 
+ PM) or in the control group (AC only). 
 
Experimental group 
The experimental group will be receiver two one-hour Pilates sessions per week 
over a period of 4 weeks (Table 1). In addition, the participants will be receiver 
their usual antenatal classes at their respective health centres in accordance 
with the Comprehensive Healthcare Programme for Pregnancy, Childbirth, and 
Postpartum (CHPPCP) from the Andalusian Regional Government (Aceituno et 
al. 2014). 
 
Control group 
The control group will be receiver solely the antenatal clases at their 
corresponding centres as programmed (Table 2). 
 
Sample size 
A minimum sample size of 36 women will be project, for a confidence level of 
95% and a power of 80%, considering 49% avoiding episiotomy in the control 
group in comparison with 98% in the experimental group (Rodríguez et al., 
2017), and divided according to a ratio of 2 women in the control group for 
every woman in the experimental group. This number will be increas in case 
any women dropped out, such that the final number of participants will be 72, of 
which 24 wil be form the experimental group and 48 the control. 
 
Data Collection 
Outcomes 
The dependent variables wwill be age (years), blood pressure (mmHg), weight 
(kg), BMI (kg/m2), starting level of physical activity, and tobacco use. These 
variables will be all measured by experienced personnel at the start of the 
experimental phase, at two weeks, and again at four weeks after the treatment 
for both groups had been completed. 
Variable relating to childbirth will be measured between the eighth and tenth 
day after birth by telephone interview and review of hospital medical history. 
The number of weeks of pregnancy at birth will be measur on a discrete 

 
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quantitative scale. Labour onset (spontaneous, stimulated, induced), type of 
delivery (spontaneous, assisted delivery with forceps, Thierry’s spatulas or 
vacuum extraction, caesarean section), the use of intrapartum pharmacological 
analgesia (none, epidural anaesthesia, sedatives, nitrous oxide), type of 
episiotomy (not required, median, lateral, medio-lateral) will be measur by 
nominal scales, while the degree of perineal tear will be evaluat on an ordinal 
scale (no injury, degree I: injury to perineal skin; degree II: injury to perineal skin 
and muscle; degree III: injury to perineal skin, muscle and anal sphincter; 
degree IV: injury to perineal skin, muscle, sphincter and anorectal mucosa). 
Weight (kg) and height (cm) will be record during the routine antenatal 
appointments at the health centres using stadiometers with weight scale 
function. The level of physical activity will be measur using the International 
Physical Activity Questionnaires (IPAQ) (Craig et al. 2003). 
 
Ethical considerations 
The study will be carry out in keeping with the principles enshrined in the 
Declaration of Helsinki (1964), the Convention for the Protection of Human 
Rights and Dignity of the Human Being with regard to the Application of Biology 
and Medicine (1997), the Universal Declaration on the Human Genome and 
Human Rights (1997), and also complied with the requirements stipulated by 
Spanish Law 3/2018 of the 5th December in the area of biomedical research, 
data protection and bioethics. Approval from the bioethics committee of the 
Andalusia Health Service (SAS) will be also obtain. Only data for which 
informed consent had been given in writing will be use. 
 
Data analysis 
The quantitative variables will be present with the mean and standard deviation, 
while the qualitative data will be give in frequencies and percentages. 
In order to measure the goodness of fit of the quantitative data to a normal 
distribution, a Lilliefors corrected Kolmogorov-Smirnov test will be use. Bivariate 
analysis will be carry out with Student’s t-test for the comparison of two means. 
In the case of the qualitative data, the Chi-square test will be use, except when 
Fisher's exact test was required. Likewise, for the analysis of three or more 
means, a repeated measures ANOVA will be use to evaluate the effects of the 

 
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treatment in the two groups, at baseline, three and five weeks. Correlation 
between the quantitative variables will be verific using the Pearson coefficient 
correlation (r). Finally, in order to allow for the possibility that the data did not 
meet the criterion of normality or homoscedasticity, non-parametric versions of 
the tests above will be also carry out. 
Binary logistic regression models adjusted for various qualitative and 
quantitative predictive variables will be calculat in order to determine 
association of the variables with perineal trauma in childbirth. 
The Odds Ratios (ORs) will be determiner with a confidence interval of 95%. 
The goodness of fit tests (–2 log likelihood, goodness of fit statistic, Cox and 
Snell R2, Nagelkerke R2 and Hosmer–Lemeshow) will be calculate to evaluate 
the overall fit of the model. 
In all statistical analyses, alpha will be set to below 5% / the significance level 
was established at 5% (p<0.05) and a confidence interval of 95% will be 
comput. All statistical calculations will be made using IBM SPSS Statistics 
version 25.0. 
 
References 
Aceituno L. et al. Proceso Asistencia Integrado embarazo, parto y puerperio 
[Internet]. 3ª Ed. Sevilla: Consejería de igualdad, salud y políticas sociales; 
2014 [citado 2019 Jun 17]. Disponible:  
https://www.juntadeandalucia.es/export/drupaljda/salud_5af1956fa966b_embar
azo_parto_puerperio_septiembre_2014.pdf. 
Aguiar M., Farley A., Hope L. et al. (2019). Birth-Related Perineal Trauma in 
Low- and Middle-Income Countries: A Systematic Review and Meta-analysis. 
Matern Child Health J, 23, 1048. Doi.org/10.1007/s10995-019-02732-5. 
Almagiá E. (2003). Influencia del estado emocional en la salud física. Terap 
psicol, 21(1), 38. 
Boix-Vilella S, León-Zarceño E. & Serrano-Rosa M.A. (2017). Evidencias de la 
práctica Pilates sobre la salud mental de personas sanas. Rev Univ. 
Salud,19(2), 301-308. DOI: http://dx.doi.org/10.22267/rus.171902.92. 
Bose P., Haxton T., Harding C., & Lead M.W. (2017). Episiotomy and perineal 
repair guideline (GL836). Royal Berkshire NHS Foundation Trust. 

 
9 
 
Bozkurt M., Yumru A.E. & Şahin L. (2014). Pelvic floor dysfunction, and effects 
of pregnancy and mode of delivery on pelvic floor. Taiwan J Obstet Gynecol., 
53(4), 452-458. https://doi.org/10.1016/j.tjog.2014.08.001. 
Craig C.L. et al. (2003). International Physical Activity Questionnaire: 12-
Country Reliability and Validity. Med. Sci. Sports Exerc., 35 (8), 1381-1395. 
Cruz-Ferreira A, Fernandes J. Laranjo L., Bernardo L.M. & Silva A. (2011). A 
systematic review of the effects of pilates method of exercise in healthy people. 
Arch Phys Med Rehabil, 92 (12), 2071-2081. 
Culligan P.J., Scherer J., Dyer K., Priestley J.L., Guingon-White G., Delvecchio 
D., & Vangeli M. (2010). A randomized clinical trial comparing pelvic floor 
muscle training to a Pilates exercise program for improving pelvic muscle 
strength. Int Urogynecol J., 21(4), 401-408. 
D’Souza J.C., Monga A. & Tincello D.G. (2019). Risk factors for perineal trauma 
in the primiparous population during non-operative vaginal delivery. Int 
Urogynecol J., 1-5. doi: 10.1007/s00192-019-03944-7. 
Davidson K., Jacoby S., & Brown M.S. (2000). Prenatal perineal massage: 
preventing lacerations during delivery. JOGNN/ NAACOG., 29(5), 474-479. 
Dias N.T., Ferreira L.R.; Fernándes M.G.; Resende A.P. & Pereira-Baldon V.S. 
(2017). A Pilates exercise program with pelvic floor muscle contraction: Is it 
effective for pregnant women? A randomized controlled trial. Neurourolog 
Urodyn, 9999, 1-6. https://doi.org/10.1002/nau.23308. 
Dieb A.S., Shoab A.Y., Nabil H. et al.(2019). Perineal massage and training 
reduce perineal trauma in pregnant women older than 35 years: a randomized 
controlled trial. Int Urogynecol J, 1-7. Doi.org/10.1007/s00192-019-03937-6. 
Escuriet R., Pueyo M.J., Perez-Botella M., Espada X., Salgado I., Gómez A., et 
al. (2015). Cross-sectional study comparing public and private hospitals in 
Catalonia: is the practice of routine episiotomy changing?. BMC Health Services 
Research, 15, 95. http://dx.doi.org/10.1186/s12913-015-0753-z. 
Graham I.D., Carroli G., Davies C. & Medves JM. (2005). Episiotomy rates 
around the world: an update. Birth, 32(3), 219-223. 
Guzmán P., Díaz A.M., Gómez D., Guzmán R. & Guzmán A. (2013). Actuación 
del fisioterapeuta en el tratamiento integral de la embarazada. Nure 
Investigación, 2(63), 1-8. 

 
10 
 
Howard D. & Makhlouf M. (2016). Can pelvic floor dysfunction after vaginal birth 
be prevented?. M. Int Urogynecol J, 27(12), 1811-1815. 
https://doi.org/10.1007/s00192-016-3117-2. 
Hyakutake M.T., Han V., Cundiff G.W., Baerg L., Koenig N.A., Lee T. & 
Geoffrion R. (2016). Pelvic Floor Health Education: Can a Workshop Enhance 
Patient Counseling During Pregnancy?. Female Pelvic Med Reconstr Surg, 
22(5), 336-339. 
Jansson M.H., Nilsson K. & Franzén K. (2019). Development and validation of a 
protocol for documentation of obstetric perineal lacerations. Int Urogynecol J, 
30, 2069–2076. Doi.org/10.1007/s00192-019-03915-y. 
Jiang H., Qian X., Carroli G. & Garner P.. (2017). Selective versus routine use 
of episiotomy for vaginal birth. Cochrane Database of Systematic Reviews. 
Issue 2. Art. No.: CD000081. DOI: 10.1002/14651858.CD000081.pub3. 
Kyvernitakis I., Köhler C., Schmidt S., Misselwitz B., Großmann J., Hadji P. & 
Kalder M. (2015). Impact of maternal body mass index on the cesarean delivery 
rate in Germany from 1990 to 2012. J Neonatal Perinatal Med., 43(4), 449-454. 
Latorre G.F., de Fraga R., Seleme M., Mueller C. & Berghmans, B. (2019). An 
ideal e‐health system for pelvic floor muscle training adherence: Systematic 
review. Neurourology and urodynamics, 38(1), 63-80. 
Leon-Larios F., Corrales-Gutierrez I., Casado-Mejía R. & Suarez-Serrano C. 
(2017). Influence of a pelvic floor training programme to prevent perineal 
trauma: A quasi-randomised controlled trial. Midwifery (50), 72-77. 
Llewellyn H., Konstantaki M., Johnson M.I. & Francis P. (2017). The Effect of a 
Pilates Exercise Programme on Perceived Functional Disability and Pain 
Associated with Non-Specific Chronic Low Back Pain. MOJ Yoga & Physical 
Ther, 2(1): 00013. DOI: 10.15406/mojypt.2017.02.00013. 
López M., Palacio M., del Pino M., Puig M., Bataller E. & Espuña M. Protocolo: 
lesiones 
perineales 
de 
origen 
obstétrico. 
Diagnóstico, 
tratamiento 
y 
seguimiento. Servei de Medicina Maternofetal. Barcelona. Institut Clínic de 
Ginecologia, Obstetrícia i Neonatologia, Hospital Clínic de Barcelona. 2014. 
Mączka M. & Sass A. (2017). Pilates and mobilization methods in therapy for 
low back pain among pregnant women. J Exerc Sci Fit., 7(8), 473-488. 
Navarro C.L. & Luján M.I. (2017). Nuevos sistemas de comunicación del 
método Pilates en embarazo y puerperio. Rev. Esp. Comun. Salud, 8(1), 20-28. 

 
11 
 
Neels H., Wyndaele J.J., Tjalma W.A., De Wachter S., Wyndaele M. & 
Vermandel A. (2016). Knowledge of the pelvic floor in nulliparous women. J. 
Phys. Ther. Sci,. 28(5), 1524-1533. 
Oblasser C., Mccourt C., Hanzal E. & Christie J. (2016). Vibrating vaginal balls 
to improve pelvic floor muscle performance in women after childbirth: a protocol 
for a randomised controlled feasibility trial. Journal of Advanced Nursing, 72(4), 
900–914. doi: 10.1111/jan.12868. 
Oktaviani I. (2017). Pilates workouts can reduce pain in pregnant women. 
Complementary therapies in clinical practice. 
https://doi.org/10.1016/j.ctcp.2017.11.007. 
Organización Mundial de la Salud. (1999). Cuidados en el parto normal: una 
guía práctica. Rev Hosp Mat Inf Ramón Sardá, 18, 78-80. 
Pierce H., Perry L., Gallagher R. & Chiarelli P. (2015). Pelvic floor health: a 
concept 
analysis. 
Journal 
of 
Advanced 
Nursing, 
71(5), 
991–
1004.doi:10.1111/jan.12628. 
Rise E., Bø K. & Nystad W. (2019). Is there any association between abdominal 
strength training before and during pregnancy and delivery outcome? The 
Norwegian Mother and Child Cohort Study. Brazilian journal of physical therapy, 
23(2), 108-115. 
Rodríguez-Díaz L,; Ruiz-Frutos C., Vázquez-Lara J.M., Ramírez-Rodrigo J., 
Villaverde-Gutiérrez C, & Torres-Luque G. (2017). Effectiveness of a physical 
activity programme based on the Pilates method in pregnancy and labour. 
Enferm Clín (English Edition), 27(5), 271-277. 
Sarpkaya D.S., Yalvaç M. & Vural G. (2018). The effect of pregnancy Pilates-
assisted childbirth preparation training on childbirth fear and neonatal 
outcomes: a quasi-experimental/quantitative research. Qual Quant., 1-13. 
https://doi.org/10.1007/s11135-018-0682-0. 
Shaban M.M., Bassiouny Y.A., Elzahaby I.M. & Hassan A.A. (2014). Body mass 
index and labour outcome in Egyptian women. J Obstet Gynaecol, 34(3), 248-
250. https://doi.org/10.3109/01443615.2013.844113. 
Smith L.A., Price N., Simonite V. & Burns, E.E. (2013). Incidence of and risk 
factors for perineal trauma: a prospective observational study. BMC Pregnancy 
and Childbirth, 13:59. 

 
12 
 
Uccella S., Manzoni P., Marconi N., Toscani C., Biasoli S., Cianci S., et al. 
(2019). Impact of Sport Activity and Physical Exercise on Obstetrical and 
Perineal Outcomes at Delivery: A Prospective Study. American journal of 
perinatology, 36 (S 02), S83-S90. 
Verghese, T.S., Champaneria, R., Kapoor, D.S., Latthe & P.M. (2016). Obstetric 
anal sphincter injuries after episiotomy: systematic review and meta-analysis. 
Inter Urogynecol J, 27 (10), 1459-1467. 
Waddington H., Aloe A.M., Becker B.J., Djimeu E.W., Hombrados J.G., Tugwell 
P. et al. (2017). Quasi-experimental study designs series paper 6: risk of bias 
assessment. Journal of clinical epidemiology, 89, 43-52. doi: 10.1016/j.jclinepi. 
Wells C.; Kolt G.S. & Bialocerkowski A. (2012). Defining Pilates exercise: a 
systematic review. Complement Ther Med, 20(4), 253-262. 
Zimmo K. et al. (2017). Diagnosis and repair of perineal injuries: knowledge 
before and after expert training- a multicentre observational study among 
Palestinian 
physicians 
and 
midwives. 
BMJ 
open, 
7(4), 
e014183. 
http://dx.doi.org/10.1136/bmjopen-2016-014183.