Rev. Latino-Am.

Enfermagem Original Article

2016;24:e2758
DOI: 10.1590/1518-8345.0926.2758
www.eerp.usp.br/rlae

Pelvic floor muscle strength in primiparous women according to the

delivery type: cross-sectional study1

Edilaine de Paula Batista Mendes2

Sonia Maria Junqueira Vasconcellos de Oliveira3
Adriana de Souza Caroci4
Adriana Amorim Francisco5
Sheyla Guimaraes Oliveira6
Renata Luana da Silva7

Objectives: to compare the pelvic floor muscle strength in primiparous women after normal
birth and cesarean section, related to the socio-demographic characteristics, nutritional status,
dyspareunia, urinary incontinence, perineal exercise in pregnancy, perineal condition and weight of
the newborn. Methods: this was a cross-sectional study conducted after 50 - 70 postpartum days,
with 24 primiparous women who underwent cesarean delivery and 72 who had a normal birth.
The 9301 PeritronTM was used for analysis of muscle strength. The mean muscle strength was
compared between the groups by two-way analysis of variance. Results: the pelvic floor muscle
strength was 24.0 cmH2O (±16.2) and 25.4 cmH2O (±14.7) in postpartum primiparous women
after normal birth and cesarean section, respectively, with no significant difference. The muscular
strength was greater in postpartum women with ≥ 12 years of study (42.0 ±26.3 versus 14.6
±7.7 cmH2O; p= 0.036) and in those who performed perineal exercises (42.6±25.4 11.8±4.9 vs.
cmH2O; p = 0.010), compared to caesarean. There was no difference in muscle strength according
to delivery type regarding nutritional status, dyspareunia, urinary incontinence, perineal condition
or newborn weight. Conclusion: pelvic floor muscle strength does not differ between primiparous
women based on the type of delivery. Postpartum women with normal births, with higher education
who performed perineal exercise during pregnancy showed greater muscle strength.

Descriptors: Muscle Strength; Perineum; Postpartum Period; Obstetric Nursing.

1
Paper extrated from Master’s Thesis “Pelvic floor muscle strength in primiparous women according to type of delivery: a cross-sectional study”,
presented to Escola de Enfermagem, Universidade de São Paulo, São Paulo, SP, Brazil. Supported by Fundação de Amparo à Pesquisa do
Estado de São Paulo, FAPESP, process # 2013/01336-2.
2
Master’s Student, Escola de Enfermagem, Universidade de São Paulo, São Paulo, SP, Brazil.
3
PhD, Associate Professor, Escola de Enfermagem, Universidade de São Paulo, São Paulo, SP, Brazil.
4
PhD, Professor, Curso de Obstetrícia, Escola de Artes, Ciências e Humanidades da Universidade de São Paulo, São Paulo, SP , Brazil.
5
Doctoral Student, Escola de Enfermagem, Universidade de São Paulo, São Paulo, SP, Brazil.
6
Master’s Student, Escola de Enfermagem, Universidade de São Paulo, São Paulo, SP, Brazil.
7
MSc, Assistant Professor, Escola de Artes, Ciências e Humanidades, Universidade de São Paulo, São Paulo, SP, Brazil.

How to cite this article

Mendes EPB, Oliveira SMJV, Caroci AS, Francisco AA, Oliveira SG, Silva RL. Pelvic floor muscle strength in primiparous
women according to the delivery type: cross-sectional study. Rev. Latino-Am. Enfermagem. 2016;24:e2758.
[Access ___ __ ____]; Available in: ____________________. DOI: http://dx.doi.org/10.1590/1518-
month day year
URL
8345.0926.2758.
2 Rev. Latino-Am. Enfermagem 2016;24:e2758.

Introduction primiparous women can prevent UI at the end of the

pregnancy and postpartum(8).
The pelvic floor muscles play an important role A cohort study performed in Australia with 1,244
in supporting the pelvic and abdominal organs and nulliparous found dyspareunia in 24% of them after
controlling urinary and fecal continence, in addition 18 months following childbirth. Obstetric interventions
to their role in the sexual function(1). Pregnancy and such as vaginal birth with vacuum extraction and
childbirth, however, influence this musculature and can emergency or elective cesarean section were associated
decrease its tone, leading to a set of problems known with the persistence of this symptom in that population
as pelvic floor dysfunction (PFD), such as urinary (OR=2.28, p 0.005; OR=2.41, p 0.001; OR=1.71,
incontinence (UI) and dyspareunia, and other conditions p=0.087, respectively)(9). Another cohort study was
that may be transient or permanent . These issues can
(2-3)
conducted with women who reported having dyspareunia
negatively impact the sexual, physical and professional or not having it. No significant difference was identified
activities of women. between the groups in relation to vaginal pressure at
Urinary incontinence is the involuntary loss of urine, rest, perineal muscle strength and vaginal endurance,
with negative impacts on women in terms of their quality six and 12 months after delivery. Also, no significant
of life, and is considered a social and hygiene problem(4). difference was identified between the groups according
In a systematic review, the combined prevalence of any to the delivery type, episiotomy, third and fourth degree
postpartum UI was 33% in all women; factors such as perineal lacerations, or weight of the newborn(10).
parity, delivery type, and exercise seem to influence The assessment of pelvic floor muscle strength
the occurrence of this problem, however the studies (PFMS) is important for the prevention, diagnosis and
are still controversial(2). The average prevalence of UI treatment of the pelvic floor dysfunction (PFD). The
in multiparous women was greater than in primiparous PFMS can be assessed at rest or during activity, by
women (36.6% vs. 28.7%). In addition, the prevalence means of resistance and muscular contraction during
of UI in the instrumental postpartum was approximately the gynecological examination, using methods such as:
twice compared to cesarean section (32% vs 15%)(2). vaginal digital palpation, perineometry, ultrasonography,
Another study found a positive correlation between electromyography, manometry, and vaginal cones(11)
normal delivery and UI, but not for cesarean section, In a study that tested the reliability of the
which was assigned as a protective factor for UI. After PeritronTM, resistance and PFMS was verified by means
aanalyzing the relationship between UI and the number of two measures on the same day, with one hour
of pregnancies and normal deliveries, the authors between them, in order to assess intra-day reliability.
concluded that the greater the number of these two After five days, a third measure was conducted to check
variables, the greater the rate of UI, showing that the between-days reliability. The authors found a high
pregnancy and normal delivery are also risk factors for level of agreement between the measurements. Thus,
UI(5). the PeritronTM can be considered a reliable method for
A cohort conducted in Sweden with 5,236 women measuring the resistance and PFMS(11).
found that vaginal birth, compared to cesarean section, Thus, the objectives of this study were: to analyze
increased the risk of UI by 275% for the period of ten PFMS in postpartum primiparous women following
years after childbirth, and in 67%, for 20 years after normal birth and cesarean section; compare the PFMS
delivery. However, the authors concluded that eight of normal birth and cesarean section postpartum women
to nine women having cesarean sections would be relating to socio-demographic characteristics, nutritional
necessary to avoid one case of UI, using the amount status, UI, dyspareunia, exercise during pregnancy,
needed to be treated(6). On the other hand, in another perineal condition, and weight of the newborn.
study no significant difference was identified between
the prevalence of UI two years after vaginal childbirth, Method
compared to cesarean section . (7)

Scientific evidence shows that exercise for pelvic This was a cross-sectional study on PFMS in

strengthening must be used and if performed early in primiparous women, 50 to 70 days after childbirth,
according to delivery type, conducted in a maternity
hospital and Basic Health Unit – Unidade Básica de

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 Mendes EPB, Oliveira SMJV, Caroci AS, Francisco AA, Oliveira SG, Silva RL. 3

Saúde (UBS) - of the municipality of Itapecerica da of a no-show, the appointment was scheduled again by
Serra, São Paulo, Brazil. phone call.
The sample was composed of women who met Step 2 consisted of the second part of the interview
the following inclusion criteria: having only one normal and the assessment of PFMS. An electronic pressure
birth or caesarean section of a full term newborn (37 to meter, the PeritronTM, model PRN09301 (Laborie,
42 weeks), single and alive with cephalic presentation Canada), was used to measure the PFMS, which
at birth; who did not undergo abdominal or urogenital consists of a silicone vaginal probe of 8 cm long and
surgery; without diseases or physical conditions that 3 cm in diameter which registers muscle contraction
could interfere with PFMS (pelvic or spinal injury, using a portable microprocessor, numerically, from
diabetes, pelvic organ prolapse, neurological disorders); 0.1 centimeters of water (cmH2O). The unit did not
without problems of communication due to hearing differentiate pelvic muscles or abdomen contractions.
limitation or speech acuity. The exclusion criteria During the evaluation of the PFMS, the movement
were: difficulty in inserting the perineometer into the of accessory muscles and the Valsalva maneuver
vagina and complications in the healing process of the were controlled by means of visual observation. The
perineal region due to local trauma. The sample size was procedure of PFMS measurement by perineometry was
calculated based on the averages of PFMS in women conducted by one of the researchers and followed the
with normal and cesarean section delivery of a previous methodology described in a published study(15). The
study . When comparing this data, the Cohen’s d effect
(13)
data registered were double entered in the Statistical
size of 0.669 was found; assuming a type I error of 5% Package for the Social Sciences (SPSS), version 22.0 for
and 90% test power, 96 mothers were required. Mac. The statistical analysis was performed by validation
The data of births registered in the hospital of the database and importing of the data into the Excel
maternity area, during the 2011-2012 period, showed application. The analysis of variance (ANOVA) was used
that for each woman having a caesarean section, three to compare the mean of PFMS between women who
childbirths occurred. Considering this distribution, 24 had normal birth and by cesarean section. The two-
post-caesarean women and 72 normal birth postpartum way analysis of variance ANOVA was used to assess
women were required. The study was approved by the the relationship of sociodemographic characteristics,
Research Ethics Committee of the school of nursing, nutritional status, UI, dyspareunia, perineal exercise
University of São Paulo (CAAE: 13545113.5.0000.5392) and weight of the newborn. For association of PFMS
and women’s participation was voluntary, after receiving with delivery and perineal condition data, the one-way
orientation and signing the Terms of Free and Informed ANOVA was applied. The significance level of 5% was
Consent. As for the device used in this study, it is important adopted for all tests.
to clarify that there is no link between the researchers
and the manufacturer. The data were collected in two Results
steps, between January and September of 2014. The
Among the 236 eligible primiparous women, 51
data collection form was adapted from a study which
refused to participate in the study because they lived
also assessed PFMS(14), and was tested prior beginning
in another municipality, 15 were not addressed due
the data collection. Two researchers previously prepared
to early hospital discharge, and one was not included
on the proper use of the perineometer performed the
because she underwent episiotomy and cesarean
data collection.
section, as well. Therefore, 169 women were recruited,
Step 1 was conducted in the hospital maternity
and of these, 73 did not attend the study sessions, and
area and consisted of recruitment, interview and data
two were considered as a loss. Thus, the final sample
collection from the medical record. Thus, a return visit
consisted of 96 primiparous women, who attended the
was scheduled after 50 and 70 days from delivery to
two steps of the study. Due to the high percentage of
the original UBS or the maternity unit where they were
losses (43.2%), a comparative analysis between the
recruited. Telephone contact was made between one and
losses and the final sample was performed, showing
two days before the appointment in order to confirm the
that the losses were random and did not influence the
presence of a woman who recently gave birth. In case
sample.

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4 Rev. Latino-Am. Enfermagem 2016;24:e2758.

Figure 1 - Flowchart of the research participants. Itapecerica da Serra, SP, Brazil, 2014

The mean age of participants was 21.7 (± 4.8) according to the type of delivery (p = 0.697). The mean
years old, minimum of 13 years and maximum of 37; values of the PFMS in relation to socio-demographic
36.5% were up to 19 years. Most women reported being variables showed significant difference only when the
mixed race (56.3%), having between nine and 11 years woman had 12 years or more of education (Table 1).
of education, living with a partner (78.1%), and being In the categories of 8 and 9 to 11 years of education,
without remunerated employment (61.5%). this difference was not significant, showing a significant
The mean PFMS among women with normal reversal, represented in the Figure 2. In terms of urinary
delivery was 24 (dp = 16.2) cmH2O , with those who had conditions, smaller values of PFMS were found after
a cesarean section at 25.4 (SD = 14.7). Although the normal birth, without significance, as demonstrated by
PFMS after cesarean section was 1.4 cmH2O higher than Table 1.
with normal delivery, the difference was not significant

Table 1 - Mean pelvic floor muscle strength according to childbirth type, sociodemographic characteristics, nutritional
status, urinary incontinence, dyspareunia, perineal exercise, perineal condition and weight of the newborn. Itapecerica
da Serra, SP, Brazil, 2014
PFMS * (cmH2O)

Variable Normal birth Cesarian section p-valor

n Mean (SD†) n Mean (SD)

Age (years) 0.390‡

≤ 19 28 26.0 (14.8) 7 21.2 (12.9)

20 - 24 28 26.4 (18.3) 9 30.4 (16.1)

25 - 29 11 21.1 (12.0) 6 23.0 (17.3)

≥ 30 5 5.5 (8.4) 2 25.2 (3.1)

Skin collor 0.406‡

Mixed 40 25.5 (15.9) 14 26.5 (15.2)

White 23 20.1 (15.6) 7 25.8 (16.4)

Black 8 30.6 (17.4) 3 19.3 (10.4)

Yellow 1 0.0 - - -

Education (years) 0.036‡

(continue...)

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 Mendes EPB, Oliveira SMJV, Caroci AS, Francisco AA, Oliveira SG, Silva RL. 5
Table 1 - (continuation)
PFMS * (cmH2O)

Variable Normal birth Cesarian section p-valor

n Mean (SD†) n Mean (SD)

≤8 10 26.8 (20.7) 6 31.5 (10.8)

9 - 11 57 21.9 (13.4) 15 25.1 (16.2)

≥ 12 5 42.0 (26.3) 3 14.6(7.7)

Marital status 0.339‡

Living with partner 55 23.1 (16.9) 20 26.8 (14.2)

Does not live with partner 10 25.9 (14.0) 1 6.7 -

No partner 7 27.7 (14.9) 3 22.3 (19.3)

Remunerated employment 0.767‡

Yes 41 24.9 (14.8) 18 24.8 (11.5)

No 31 23.3 (17.4) 6 25.6 (15.9)

Nutritional status 0.584‡

Low weight 5 23.4 (18.1) 0 -

Adequate 43 23.9 (14.8) 12 20.5 (10.0)

Overweight 20 23.1 (15.4) 7 25.6 (20.0)

Obesity 4 29.1 (34.6) 5 36.9 (11.6)

ICU during pregnancy 0.296‡

Yes 67 19.9 (20.1) 14 27.0 (14.9)

No 29 25.4 (14.5) 10 24.3 (15.0)

ICU after delivery 0.894‡

Yes 59 22.4 (20.8) 20 25.0 (14.4)

No 13 24.3 (15.2) 4 25.5 (15.1)

UI that persists for two months postpartum (n=17) 0.448‡

Yes 6 12.2 (9.9) 3 21.9 -

No 7 34.4 (24.5) 1 26.0 (17.5)

Dyspareunia (n=77) 0.361‡

Yes 30 24.3 (17.3) 10 24.8 (14.6)

No 28 21.5 (13.1) 9 29.3 (14.6)

Perineal exercise during pregnancy 0.010‡

Yes 42.6 (25.4) 2 11.8 (4.9)

No 22.6 (14.7) 22 26.7 (14.7)

Perineal condition 0.677§

Intact 11 23.5 (16.2)

First degree laceration 22 27.5(14.7)

Second degree laceration 11 21.0 (13.5)

Third degree laceration 1 8.8 -

Episiotomy 27 23.0 (15.2)

Weight of newborn 0.732‡

≤ 3,500 57 23.7 (16.4) 14 26.2 (14.7)

> 3,500 15 24.8 (16.0) 10 24.3 (15.5)

* Pelvic floor muscle strength

†Standard deviation
‡ Two-way ANOVA
§ ANOVA
|| Incontinence

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6 Rev. Latino-Am. Enfermagem 2016;24:e2758.

sociodemographic characteristics and delivery, to PFD

and perineal exercise in pregnancy. This data contributes
to the profile of the PFMS and provides indicators that
could support the option of choice for women regarding
the type of delivery.
Normal birth is seen as a factor that promotes a
weakening of the pelvic floor muscles. Thus, the choice
of the woman for caesarean section is often associated
with the prevention of morbidities related to the lost of
PFMS. However, the current study did not identify an
influence on type of childbirth and PFMS between 50 and
70 days after the childbirth. This result differs from that
Figure 2 - Interaction between education level and the
found by a study(16) that compared nulliparous women
type of delivery on pelvic floor muscle strength (PFMS).
with primiparous women after normal and cesarean
Itapecerica da Serra, SP, Brazil, 2014
section delivery, in which a decline in FMAP was identified
among primiparous women with normal birth, compared
Comparing the PFMS mean with perineal exercise
to those with a cesarean section.
during pregnancy, interaction was observed between
The normal birth increased the risk of decrease the
practicing perineal exercise and the type of childbirth
PFMS by 2.58 and 2.31 times after four and six months
(p = 0.010). Primiparous women who exercised the
postpartum, respectively, while for the cesarean section
perineum during pregnancy, and who had a normal birth,
women the risk was 1.56 and 1.37 times (at four and
showed significantly higher values of PFMS compared to
six months, respectively). This divergence of results can
women who experienced a cesarean section, as shown
be justified by the use of different devices to measure
in Figure 3.
the PFMS and the variation in the time at which the
evaluation was performed.
The great variability in the assessment periods for
PFMS complicates the comparison between the results
of this study with those of previous surveys, as the
literature suggests that the mean PFMS varies during
the puerperal period, with a tendency to increase over
time, independent of the type of birth(17). This variation
can be observed in surveys conducted with primiparous
women at 45 postpartum days, which identified PFMS
of 8.3 cmH2O and 13.7 cmH2O (postpartum normal
birth and cesarean section, respectively)(18) and higher
measures at 98 days and 12 months postpartum, 54.1
Figure 3 - Interaction between the perineal exercise
cmH2O and 59.9 cmH2O, respectively(17). That variation
in pregnancy and delivery type on pelvic floor muscle
can be observed even in studies that used devices with
strength (PFMS). Itapecerica da Serra, SÃO PAULO,
different units of measurement (13-14).
Brazil, 2014
Considering the socio-demographic characteristics
in this study, as well as in others(14-15), maternal age,
marital status, skin color and remunerated employment
In relation to the perineal condition, the PFMS
did not influence PFMS. Although some authors suggest
among primiparous women who had either an intact
that age and skin color are related to lower PFMS
perineum or an episiotomy were similar. No significant
after childbirth(19), in the current survey, a significant
differences were found between the means on PFMS
difference in PFMS was identified only in relation to
and the weight of the newborn according to the type of
education level. Primiparous women over 12 years of
childbirth, described in Table 1.
education and normal birth showed a significantly higher
Discussion PFMS value. However, these data should be viewed with
caution, as the sample size was small in that category.
This investigation sought to compare the PFMS The literature did not present studies that
according to the type of childbirth, associating the investigated the relationship of PFMS with education.
However, the authors suggest that the level of

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 Mendes EPB, Oliveira SMJV, Caroci AS, Francisco AA, Oliveira SG, Silva RL. 7

education may be associated with other factors such In this study, most primiparous women returned to
as socioeconomic condition, i.e. higher education, in sexual activity between 50 and 70 days after delivery and
general, is related to increased socioeconomic condition about half of them mentioned dyspareunia, however, as
which in turn allows access to better nutrition, physical with other studies(10,15), no difference was found in PFMS
activity, and greater access to health care among related to the type of childbirth regarding this complaint.
others . However, the socio-economic condition was
(19)
As in a prior research study(13), PFMS was not
not addressed in the current research, preventing more associated with the perineal condition during normal
comparisons. birth. But, this variable seems to be related to sexual
As for the nutritional status, although there is no dysfunction. A prospective type study, aiming to
parameters for the body mass index during the puerperal identify the extent of sexual dysfunction with three
period, according to the Atalah classification(20) for the months postpartum of normal delivery, found an
gestational period, most women in this study presented association between perineal injury and increased rate
adequate nutritional status at the time of evaluation of of dyspareunia and reduction in levels of libido, orgasm
the PFMS, and no significant differences were found in and sexual satisfaction(24). Thus, it is important to
PFMS in relation to nutritional status according to the prevent perineal trauma, because even if no influence
type of delivery. However, one study(18) that compared of this variable on PFMS is identified, it can be a
the PFMS of nulliparous and primiparous women determinant for the resumption of sexual function after
suggested that being overweight influenced the results. birth. The PFMS was not associated with the weight of
In this investigation, UI showed higher prevalence the newborn, regardless of the type of delivery. Studies
in pregnancy compared to postpartum, and most evaluating the relationship between these two variables
women complaining about UI at two months postpartum were not found. However, the literature shows that fetal
had urine loss during the pregnancy. Although gravidic weight greater than 4 kg is a predictor for urinary and
changes may contribute to UI after childbirth(21), fecal incontinence, suggesting that to prevent such
some authors present evidence that, when present in problems, normal birth of macrosomic babies should
pregnancy, this condition becomes a risk factor for its be avoided(25).
occurrence also in postpartum(7,21-22). The lack of standardized methods for assessing
Despite the fact that results showed lower values PFMS within research hinders the comparison of the
of PFMS in women with UI who were postpartum values of this variable. In this sense, the current study
after normal compared to cesarean section delivery, used a method previously employed in most current
this difference was not significant. The result of a studies(15,26) in an attempt to standardize such measures
prospective study(22) is similar to the findings of the and use it as a basis for other studies, facilitating the
present investigation. The authors concluded that PFMS comparison of results, and assisting in the evaluation of
did not interfere with the symptoms of UI, regardless of pelvic muscle tone after childbirth.
the type of delivery. Our results also provide support so that the
Few recent mothers reported doing some kind of professional can guide pregnant women about the factors
pelvic strengthening exercise during pregnancy and after that interfere with PFMS, providing one more element to
childbirth, with the most cited being Kegel exercises and support the decision-making of the woman related to
holding the ureterovesical jet. Those who had normal the type of delivery. Furthermore, the results indicate
childbirth and exercised their perineum during pregnancy that special attention should be devoted especially to
showed significantly higher values of PFMS compared pregnant women with lower education levels and with
to post-caesarean women, however it should be noted UI during pregnancy, in order to improve perineal care.
that it was not asked if the exercise was performed on a In this way, the direction to practice, or the inclusion of
regular basis or if the women received guidance on how an exercise program to strengthen the muscles of the
to do it. However, it is possible to affirm that perineal pelvic floor, in prenatal care, can have positive impact
exercise can bring benefits to those who do it. Results on PFMS after normal birth.
that reinforce this assertion were demonstrated by
Limitations
studies that evaluated the exercises both in pregnancy as
well as in the puerperium, indicating that strengthening A follow-up loss of about 40% related to the non-
of the pelvic muscles contributes to the improvement return of women to puerperal consultation was found in
of the symptoms of UI(8) and sexual function(23). Thus, this study. Thus, these participants were replaced and
the inclusion of an exercise program for prenatal care the sample reached, at the end of the survey, the number
could have beneficial effects for the strengthening of this previously established in the calculation of the sample.
musculature and prevention of UI.

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8 Rev. Latino-Am. Enfermagem 2016;24:e2758.

In addition, the comparative analysis between the losses inactive control treatments, for urinary incontinence
and the participants in the study sample showed that in women (Cochrane Review). Cochrane Database of
they differed in only three days on gestational age. Systematic Reviews. 2014;5:CD005654.
That loss can be attributed to geographical distribution 9. McDonald EA, Gartland D, Small R, Brown SJ.
between the basic health units and the residence of the Dyspareunia and childbirth: a prospective cohort study.
participants. BJOG. 2015;122(5):672-9.
Another limitation of this study could be related 10. Tennfjord MK, Hilde G, Stær-Jensen J, Ellström Engh
to the single evaluation of PFMS after childbirth, which M, Bø K. Dyspareunia and pelvic floor muscle function
precluded a determination of whether there are long- before and during pregnancy and after childbirth. Int
term influences of the type of childbirth on this type Urogynecol J. 2014;25:1227-35.
variable. 11. Rahmani N, Mohseni-Bandpei MA. Application of
perineometer in the assessment of pelvic floor muscle
Conclusion strength and endurance: a reliability study. J Bodyw Mov
Ther. 2011;15(2):209-14.
No difference was found in the PFMS of postpartum
12. Domingues RMSM, Dias MAB, Nakamura-Pereira
mothers who had normal and cesarean deliveries.
M, Torres JA, d’Orsi E, Pereira APE, et al. Processo de
Postpartum primiparous women with 12 or more years
decisão pelo tipo de parto no Brasil: da preferência
of education presented with a higher PFMS. The perineal
inicial das mulheres à via de parto final. Cad Saúde
exercises in pregnancy were associated with increased
Pública. 2014;30 Suppl:101-16.
PFMS in postpartum mothers who had a normal delivery.
13. Menta SS, Schirmer J. Relação entre a pressão
muscular perineal no puerpério e o tipo de parto. Rev
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May 13th 2015

Received: May 13th 2015

Accepted: Jan. 19th 2016

Corresponding Author:
Sonia Maria Junqueira Vasconcellos de Oliveira
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