Original research••

Construction of a postpartum pelvic floor rehabilitation exercise programme based on the Delphi method

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Abstract

Background Pelvic floor dysfunction (PFD) affects women’s health and quality of life seriously. Postpartum is a crucial stage and ideal opportunity for the prevention and treatment of PFD diseases. Therefore, it is essential to promote postpartum physical recovery and effectively improve the prevention and treatment effect of PFD through a simple, non-invasive and high-compliance pelvic floor rehabilitation programme during postpartum pelvic floor rehabilitation.

Methods A literature review was conducted to develop the initial list of competencies which consisted of 23 items from six models. Two rounds of Delphi Surveys were conducted, inviting experts via email to rate the importance of each item and provide qualitative comments on their ratings. Consensus was predefined as a mean score of 4.0 or above and at least 75% agreement among the participants.

Results The postnatal pelvic floor rehabilitation exercise programme developed in this study was guided by the ‘holistic pelvic floor theory’ proposed by Petros and Ulmsten. The effective recovery rate of the two rounds of expert consultation questionnaires was 100%. In the first round, some items were changed according to experts’ opinions. In the second round, the expert authority coefficient was 0.819. The Kendall coefficient of expert opinion was 0.154 (p<0.01). The final plan included 6 modules with 23 items. The postpartum pelvic floor rehabilitation exercise programme was formed, consisting of six exercises (APBKQS-exercise) such as abdominal breathing, pelvic exercise, bridge exercise, kneeling balance, quadrupedal stretching and supine hand-and-knee confrontation.

Conclusion The postnatal pelvic floor rehabilitation exercise programme constructed in this study integrates multiple exercises (APBKQS-exercise). Theexercise programme guided by the ‘holistic pelvic floor theory’ incorporates the use of Women's Active Functional Fitness Equipment (WAFF) exercise air cushions to better achieve the purpose of alleviating joint pain, loosening contracture muscles, repairing pelvic floor muscles, strengthening abdominal core strength, and recovering body shape as soon as possible.

What is already known on this topic

Postpartum is a crucial stage and ideal opportunity for the prevention and treatment of pelvic floor dysfunction diseases, and there are many ways to exercise.
Kegel exercise is currently recognised as the only first-line intervention for the prevention of urinary incontinence.
However, patients tend to feel dull and bored during the training process due to the monotonous repetition and high exercise intensity, making it difficult for patients to adhere to it.

What this study adds

It was guided by the ‘holistic pelvic floor theory’ proposed for the first time.
It includes a variety of poses, both husband and wife can participate in it, and involves the willingness of the parturient to exercise.

How this study might affect research, practice or policy

The postpartum pelvic floor rehabilitation exercise programme established in this study has the characteristics of science, rigour, simplicity, applicability and economy.
Next, it is planned to conduct multicentre studies in different levels of hospitals to benefit more patients

Introduction

Pelvic floor dysfunction (PFD) indicates the damage of the pelvic floor support structure or displacement of pelvic organs caused by various reasons, followed by pelvic organ position or function abnormalities, mainly manifested as pelvic organs prolapse, stress urinary incontinence, and faecal incontinence (FI).1 Pregnancy and childbirth are considered the primary independent risk factors for PFD.2–4 The incidence of postpartum urinary incontinence can reach 30%, the incidence of FI is up to 10%, 5and 40%–91% of primiparous women suffer from PFD-related symptoms in the first postpartum year.6 PFD not only affects women’s health and quality of life seriously,7 but also brings heavy social and economic burdens.8 9 The prevention and treatment of postpartum PFD have become a major concern of society, especially with the two-child and three-child policies in China.10

Pelvic floor rehabilitation is currently recognised as a first-line recommended preventive for PFD.1 11 Postpartum pelvic floor rehabilitation is a process in which comprehensive technologies are applied to prevent or treat pelvic floor tissues damaged during pregnancy and childbirth, with great significance to women’s health.12 During pregnancy, factors such as the increase of uterine weight, the change in the uterine position, and the change in hormone levels can lead to the relaxation of the pelvic floor supporting tissue. During delivery, the dilation of the uterine orifice, perineal tears, lateral incision, or the use of forceps could cause certain mechanical damage to the nerve, muscle, and other tissues of the pelvic floor.13 Postpartum is a crucial stage and ideal opportunity for the prevention and treatment of PFD diseases.14 Postpartum pelvic floor rehabilitation can effectively improve postpartum pelvic floor muscle strength, promote the recovery of nerve function and prevent the occurrence of postpartum PFD.15–17

At present, the main methods for postpartum pelvic floor rehabilitation therapy include electrical stimulation treatment, biofeedback therapy and pelvic floor muscle training (PFMT).18 However, the former two options are invasive treatments with expensive equipment and can only be provided by hospitals or professional medical institutions.17 Although PFMT is simple and easy to implement and does not need additional medical expenses, it still requires long-term persistence and higher maternal perseverance and presents poor maternal compliance.19 Thus, it is essential to promote postpartum physical recovery and effectively improve the prevention and treatment effect of PFD through a simple, non-invasive and high compliance pelvic floor rehabilitation programme during postpartum pelvic floor rehabilitation. This study aims to establish a set of scientific and feasible postpartum pelvic floor rehabilitation exercise programmes through literature research and the Delphi method, to provide theoretical guidance in pelvic floor rehabilitation and PFD prevention and treatment for postpartum women.

Methods

Design

This study followed the recommendations for Conducting and Reporting of Delphi Studies.20 A flow chart illustrating the Delphi process is shown in figure 1. This study did not need to seek a patient consent statement.

Figure 1

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The flow chart of the Delphi process.

Generation of the initial draft

A systematic literature search was performed using PubMed, Web of Science, the Cochrane Library, Embase, Ovid Technologies (OVID), China National Knowledge Infrastructure (CNKI) and Wanfang database from the inception of each database to May 2020. The main search terms included: ‘postpartum’, ‘PFD’, ‘rehabilitation’ and ‘exercise’. Studies published in English or Chinese and reported on postpartum pelvic floor rehabilitation exercise were considered eligible for inclusion. According to the literature review and group discussion, the research team generated an original draft of the pelvic floor rehabilitation exercise programme suitable for 42 days of postpartum, involving six modules with a total of 23 items.

Delphi process

The expert panel

All experts who participated in the Delphi Survey were recruited from different regions and institutions in China with PFD knowledge or clinical practice. Delphi Expert Group members met the following requirements: (A) At least 10 years of professional experience; (B) Engaged in diagnosis and treatment, nursing, or educational research related to pelvic floor diseases in tertiary hospitals or medical universities; (C) Intermediate and above professional titles; (D) Bachelor’s degree or above. Due to time and budget constraints, we recruited 18 team members based on the recommendation of literature.21

Data collection

In the first round, 18 experts were sent questionnaires by email, including the introduction of the survey, the content of informed consent, the draft of the postpartum pelvic floor rehabilitation exercise programme, and the personal information of experts. Experts were asked to rate each entry on a 5-point Likert Scale, from 1 (not important at all) to 5 (very important). In addition, there is a blank field next to each entry where experts can fill in specific comments or suggestions.

In the second round, the feedback from the first round was summarised and presented to the experts of the first round. Experts were invited to answer the revised questionnaire in the same manner as the first round to reach a consensus. Each round of the survey lasted 2 weeks, and an email reminder was sent to experts who had not completed the survey 3 days before the deadline.

Data analysis

We used Excel 2019 and IBM SPSS V.26.0 for statistical analysis. First, descriptive analysis was performed using frequency, proportion, mean and SD. Second, the response rate and the authority coefficient of experts were calculated to test the reliability and prediction accuracy of expert consultation results. The calculation formula for the authority coefficient (Cr) is Cr = (Cs +Ca)/2, where Cs is the familiarity coefficient and Ca is the impact coefficient of assessment.22 Furthermore, the coefficient of variation (CV) was used to measure group stability, which is defined as the consistency of responses between successive rounds of a study.23 Besides, we used Kendall’s coefficient of concordance to test the consistency of experts’ opinions. Finally, qualitative content analysis was performed to analyse the comments of the experts. These comments were discussed by the study group to modify, collapse, or exclude each competency statement based on the study aims and literature.24

Results

Sociodemographic and professional characteristics of the expert panel

In both the first and second rounds, 18 experts invited to participate in the study responded to the questionnaire, with a response rate of 100%. All the participants were female with an average age of 41.22 (SD=5.67) years and average working experience of 18.44 (SD=6.89) years. The sociodemographic and professional characteristics of the Delphi expert panel were presented in table 1.

Table 1

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Sociodemographic and professional characteristics of the expert panel

Delphi round 1

After the first round of expert consultation, a total of 6 items were revised based on expert opinions and collective discussion proposed by the research team, involving changing ‘1.3 Abdominal breathing time schedule of 2 minutes’ to ‘2–5 min’, modifying ‘2.4 Time schedule of pelvic exercise: 3–4 sets, about 5 minutes’ to ‘2–4 sets, about 3–5 min’, adding ‘Inhale to start next bridge movement’ in ‘3.3 Bridge movement’, changing ‘3.4 Time schedule: 3–4 groups, about 5 minutes’ to ‘2–4 groups, about 8 minutes’, modifying ‘4.3 Kneeling balance for 30 seconds’ to ‘gradually transition to 30 seconds’, and adding ‘complete 4–6 sets’ to ‘4.4 Hold kneel position for 30 seconds in sets’ and ‘6.4 Hold hand-and-knee confrontation for 30 seconds in sets’. After the second round of expert consultation, there was no objection to the crucial indicators of 23 items. All indicators could meet statistical standards. Meanwhile, the opinions of experts tended to be consistent.

Delphi round 2

In the second round, all items achieved consensus based on the predefined criteria and no new items were proposed. A list of 23 items in six domains was finalised (table 2, online supplemental file 1). The postnatal pelvic floor rehabilitation exercise programme developed in this study is called ‘APBKQS-exercise’ and includes the following six actions. Abdominal Breathing: relax body and take abdominal breaths; Pelvic Exercise: Sit on a yoga mat or Women's Active Functional Fitness Equipment(WAFF) mat with knees bent, sitting bones on either side of the spine, feet shoulder-width apart, hands hooked on the back of the thighs. Inhale slowly to extend the spine. Exhale and tilt the pelvis back, driving the spine backwards into a capital ‘C’; inhale and tilt the pelvis forward, driving the spine upwards to extend the spine backwards. Repeat. Bridge Exercise: Lie on your back with knees bent, feet on yoga mat or WAFF mat, pelvis in neutral position, shoulders away from ears, chin slightly tucked. Posterior pelvic tilt on exhalation→Lift the hips→Raise the waist→Lift the ribs→Lift the sternum→Body lifts in a straight line, Pubic symphysis in highest position→Inhale and hold still, exhale as the spine slowly descends in a segmental pattern until it returns to neutral position. Inhale to start the next bridge movement. Kneeling Balance: Kneel on your yoga mat or WAFF mat, keeping your body upright. Lift your feet off the floor slowly, keeping your body stable, gradually transitioning to holding for 30 s, with your core muscles tightened at all times. Quadrupedal Stretching: Kneel, keeping both knees under the hip joints, adjust the pelvis to a neutral position where the occiput, the highest point of the thoracic spine and the sacrum should be in a straight line. Inhale to extend the spine and keep the spinal pelvis stable→Exhale to extend right leg backwards→Inhale and retract→Exhale to extend left leg backwards→Inhale and retract. Same exercises for both upper limbs. Supine Hand-And-Knee Confrontation: Lie on your back on a yoga mat or WAFF mat with your hands pointing vertically to the ceiling, keeping your knees above your hips in a tabletop position, adjusting your pelvis to a neutral position with your shoulders away from your ears and your chin slightly tucked in. Place your hands on your knees, inhale in preparation, exhale as your hands and your knees resist each other and hold the counter force for 20–30 s, keeping your breath even and your core muscles tightened at all times.

Table 2

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The results of the second round of expert consultation

Discussion

The postpartum pelvic floor rehabilitation exercise programme established in this study has the characteristics of science, rigour, simplicity, applicability and economy, which are as follows: First, the response rate of the experts reflects their attention to the research, and for Delphi technology, a high response rate of more than 70% represents the rigour of the correspondence.23 The recovery rate of the two rounds of the Delphi Survey in this study was greater than 70%, indicating that the experts are highly motivated and engaged. In addition, the report shows that when the authority coefficient is greater than or equal to 0.7,22 the expert consultation results are reliable. The authority coefficient of the expert group in this survey is greater than 0.7. The consultation results are trustworthy. Second, the results of the Kendall coefficient show that the consistency of expert opinions increases, and the results can be considered credible and acceptable. From the first round to the second round, the CV of most items decreased, indicating that this Delphi Survey has reached population stability, and the consensus is meaningful.

The postnatal pelvic floor rehabilitation exercise programme developed in this study was guided by the ‘holistic pelvic floor theory’ proposed by Skilling and Petros.25 From the perspective of pelvic biodynamics, after literature research and group discussion, the postpartum pelvic floor rehabilitation exercise programme was formed, consisting of six exercises such as abdominal breathing, pelvic exercise, bridge exercise, kneeling balance, quadrupedal stretching and supine hand-and-knee confrontation. Through abdominal breathing, the parturient can reach a state of physical and mental relaxation while feeling the strength of the abdomen and contracting the abdominal muscles. The maternal can correct the pelvic inverted state caused during pregnancy and exercise the ability to control the pelvic floor muscles through pelvic exercises. Through the bridge movement, it can stimulate the hip muscles, close the vagina and lift the anus. Kneeling balance can exercise the overall balance ability of the parturient, stabilise the pelvis, strengthen both sides of the spine muscles and enhance core muscle coordination and stability. The quadruped extension emphasises core stability while moving the hip and shoulder joints. Supine hand-and-knee confrontation focuses on the exercise of the rectus abdominis muscle and can emerge from the separation of the rectus abdominis muscle during pregnancy and delivery. While the six exercises have their focuses, they can cooperate as a whole to achieve the effect of promoting the overall rehabilitation of the parturient after the delivery. The six exercise steps of the programme are progressive from easy to difficult, and mothers need to proceed step by step according to their own conditions. However, it is not suitable for severe cardiovascular disease, uncontrolled chronic hypertension, pulmonary embolism (PE), severe respiratory disease, restrictive lung disease, severe anaemia, etc. It is recommended to start exercising as soon as possible after giving birth if your physical condition permits.

With the development of technology and medical treatment, there are increasing methods of pelvic floor rehabilitation. Among them, PFMT, known as Kegel exercise, is currently recognised as the only first-line intervention for the prevention of urinary incontinence and has been written in the clinical guidelines of various countries.19 However, patients tend to feel dull and bored during the training process due to the monotonous repetition and high exercise intensity, making it difficult for patients to adhere to it.26 The postpartum pelvic floor rehabilitation exercise programme constructed in this study integrates multiple exercises, and both husband and wife can participate in it, contributing to an increase in the fun of pelvic floor rehabilitation exercises. According to the letter consultation from Delphi experts, the duration and frequency settings are also reasonable and moderate, which is highly manoeuvrable and conducive to the improvement of the willingness of the parturient to exercise.

Additionally, the postpartum rehabilitation exercise programme constructed in this study incorporates the use of WAFF exercise air cushions. WAFF is an inflatable cushion with an unstable plane designed based on ergonomic mechanics. On the whole, it enables the human body to constantly activate the feedforward mechanism of trunk stabilisation for balance maintenance. Locally, it can put muscles in a tense state of contraction, triggering a stretch reflex and activating proprioception. Yao J et al verified that WAFF exercise training can promote the separation and healing of the rectus abdominis muscle in postpartum women.27 Our postpartum exercise programme can be combined with the use of WAFF exercise air cushion to better achieve the purpose of alleviating joint pain, loosening contracture muscles, repairing pelvic floor muscles, strengthening abdominal core strength, and recovering body shape as soon as possible. Simultaneously, the implementation of this exercise programme is not entirely dependent on the use of WAFF air cushions, and exercise effects can be achieved through simple yoga mats.

This study has some limitations. Our Delphi Survey only selected 18 experts, which is not representative of the whole and is limited. In addition, these experts are from China’s more developed areas of medical treatment, and the results have a certain regional bias. In the upcoming study, we will continue to explore ways to get feedback from more experts in different regions to improve the exercise programme established in our study. Skilling and Petros showed that squatting was encouraged as a universal slow-twitch exercise. It can be used as a reference in the future exercise programme design.25 In addition, exercise programmes developed lack further testing of their true effectiveness and applicability in clinical practice. We plan to conduct a related interventional study as the next step.

Conclusion

In this study, a postpartum pelvic floor rehabilitation exercise programme including six core exercises with 23 items was constructed through literature analysis and two rounds of Delphi expert consultation. The programme has been validated to be scientific and reliable, providing practical guidance for pelvic floor rehabilitation of the parturient.