ICS 2022: Effective Pelvic Floor Muscle Exercises In Antenatal Care: Design And Development Of A Training Package For Community Midwives In The United Kingdom

(UroToday.com) This study aimed to develop a comprehensive training package for midwives and resources for pregnant women, to support the teaching of an antenatal pelvic floor muscle exercise (PFME). The presentation was on the feasibility of such training tested in a pilot randomized controlled trial. The study comprised four iterative phases of intervention development, including a stakeholder event and multiple patients and public involvement and engagement (PPIE) activities. The PPIE advisory group included women with young children, with meetings held in the community.

  • Phase 1: focus groups with women and midwives. Women who were pregnant or had given birth within the previous 12 months, and midwives providing antenatal care were invited to take part in separate focus groups in three sites in England. Data were analyzed using thematic analysis.
  • Phase 2: development of a training program including intervention mapping. Data from phase 1 and from previous studies in this research program were mapped to the Behavior Change Wheel (BCW) informed by the Capability-Opportunity-Motivation and Behavioral Skill (COM-B) model, Theoretical Domains Framework and Behavior Change Technique (BCT) taxonomy (v1) and used to develop the intervention. Extensive input from PPIE and stakeholder consultations included PPIE advisors trying out mobile phone Apps to support PFME and stakeholders considering training needs and service provision.
  • Phase 3: practice training event. A member of the research team delivered the draft training package in person to a cohort of midwives. Midwives rated their confidence before and after training regarding pelvic floor knowledge and teaching PFME using a 5-point Likert questionnaire (0= not at all confident, 4=completely confident) designed for the study. After training, participants were asked to provide feedback on intervention format, content, and methods of delivery in one of two discussion sessions. Participants completed an anonymous evaluation questionnaire with options to rate the training and provide free text comments.
  • Phase 4: intervention refinement findings from Phase 3 and further PPIE helped refine format and content of the intervention package. Additional refinements due to the COVID-19 pandemic was moving the training delivery to online.
Midwives were provided with a training handbook, session slides, summary leaflets, and additional resources about PFME and urinary incontinence (UI). Training included 5 steps for implementing PFME into antenatal clinical practice:

  1. Raise the topic of PFME early in pregnancy
  2. Screen for UI at each appointment
  3. Teach PFME at 16 weeks gestation; and throughout pregnancy
  4. Prompt/remind women about how to perform PFME
  5. Refresh women’s understanding of PFME and refer on to specialist services if required.
Women received information about PFME and how to perform a correct PFM contraction, stickers to use as prompts/reminders for PFME, and an app decision card, with QR code, with details of three high-rated smartphone apps chosen by PPIE advisors to support PFME.

Following training, participants reported an increase in total confidence relating to PFME from 2.70 before training to 3.68 after training, indicating potential for the training program to address some of these challenges.

Midwives participating in the practice training event (n=18) found it useful, with positive ratings for content and delivery. Post-training qualitative feedback noted the importance of taking the lead regarding PFME, but lack of time, confidence, and skills to raise the issue presented challenges for implementing PFME in practice. The midwives raised concerns including time constraints of antenatal appointments, information overload for the women, continuity of care, the need to establish PFME champions within midwifery teams, and obtaining buy-in from senior midwives / clinical managers to support implementation and delivery.

After refinements of the training package and resources, this approach is now being tested in a feasibility and pilot RCT.

Presented by: Sarah Dean, University of Exeter Medical School, United Kingdom

Written by: Diane Newman, DNP, CRNP, FAAN, BCB-PMD, Urologic Nurse Practitioner, Adjunct Professor of Urology in Surgery, Senior Research Investigator, Perelman School of Medicine, University of Pennsylvania during the International Continence Society Annual Meeting, September 7-10, 2022, Vienna, Austria.


  1. Woodley S, Lawrenson P, Boyle R, Cody J, Mørkved S, Kernohan A, Hay-Smith E.J.C. (2020) Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women. Cochrane Database of Systematic Reviews. doi/10.1002/14651858.CD007471.pub4/full
  2. Terry R, Jarvie R, Hay-Smith J, Salmon V, Pearson M, Boddy K, MacArthur C, Dean S. (2020). “Are you doing your pelvic floor?” An ethnographic exploration of the interaction between women and midwives about pelvic floor muscle exercises (PFME) during pregnancy. Midwifery, 83 DOI: 10.1016/j.midw.2020.102647
  3. Salmon VE, Hay-Smith EJC, Jarvie R, Dean S, Terry R, Frawley H, Oborn E, Bayliss SE, Bick D, Davenport C, MacArthur C, Pearson M. and on behalf of the APPEAL study. (2020). Implementing pelvic floor muscle training in women's childbearing years: A Critical Interpretive Synthesis of individual, professional, and service issues. Neurourol Urodyn Feb;39(2):863-870.  doi: 10.1002/nau.24256.