الفهرس 
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Abstract
Pregnancy more than childbirth appears to contribute to altered long term pelvic floor function in later life due to the hormones of pregnancy. This hormone has been associated with relaxation and structural effects on the connective tissue of the pelvic floor during the third trimester and childbirth. These effects reduce the strength of the pelvic floor to help ease the birthing process. Evidence also shows that some obstetric factors may cause partial damage to the pelvic floor nerves in some women particularly the pudendal nerve that can cause weakness of the pelvic floor muscles and relaxation of the external urethral sphincter, resulting in urinary incontinence.
The leading health indicators from the Healthy People (2010) recommend that increasing physical activity is one of the greatest priorities for enhancing women’s health. In pregnancy, an association has been found between exercise and gestational diabetes, pre-eclampsia and excessive weight gain. For a normal and healthy pregnancy, the current American College of Obstetrics and Gynecology (ACOG)guidelines promote pre-pregnancy exercise activities to be continued during pregnancy and recommend that sedentary women should start exercising during pregnancy. According to the present guidelines, pregnant women are encouraged to exercise moderately for a minimum of 15 minutes, 3–5 times a week. However, studies have found that almost 60% of pregnant women are sedentary, compared with30% in the general adult population. In particular, studies have shown that the proportion of women exercising decreases from the second to the third trimester.
Strengthening pelvic floor muscles during pregnancy can help the muscles control well during labor and delivery. Toning all of these muscles will also minimize two common problems during pregnancy: bladder control and hemorrhoids. Pelvic floor training exercises are also recommended after pregnancy to promote perineal healing, regain bladder control, and strengthen pelvic floor muscles.
This study aimed to:
Evaluate the effect of implementing the exercise program during the third trimester of pregnancy on the course of labor and birth outcome.
Materials and methods:
The study was conducted in private clinic as well as Walee- El-ahad private hospital.Subjects: A purposive sample of pregnant women was selected from the mentioned settings according to Epi-info. The 80 subjects were divided randomly to two equal groups, study and control (40 for each).
Tools
Four tools were designed, validated, developed and utilized by the researcher to collect the necessary data.
Tool- I : Basic data structured interview schedule
This tool was developed by the researcher to collect the necessary data from pregnant women. It included four parts:
1- Socio-demographic characteristics such as: age, religion, level of education; occupation….. etc.
2- Reproductive history such as gravidity, parity, type of previous deliveries as well as complications of previous pregnancies and deliveries…..etc.
3- History of current pregnancy such as; whether it was planned or not, weeks of gestation; as well as number of antenatal visits…..etc.
4- Clinical assessment sheet:It included baseline data such as vital signs, abdominal palpation for determination of fundal level, weeks of gestation ……etc.
Tool II- Pelvic floor muscles strength test (vaginal manometer):
It is a device for measuring pelvic floor muscle strength and endurance. The woman is kept in a gynecological position while a rubber coated transducer covered with a condom is introduced 2-3 cm into the vaginal introits. Next, the transducer is inflated and the apparatus is set to 0. The patient is asked to inhale and perform maximum contraction of the pelvic floor muscles while exhaling which corresponds to the readings in the ammeter attached to the transducer.
Tool III: Visual analogue scale:
It was originally developed by Melzack & Katz (1999), and then revised for its reliability & validity by Al ghadir (2018). This tool was adopted & translated to Arabic language by the researcher. It was used by the researcher to determine the severity of labor pain before and after intervention. It is a self- reported 10 cm straight line which represents the pain intensity, the two opposite ends representing no pain to pain as bad as it could be in between these two phrases, words like mild pain, moderate pain, severe pain, very severe pain are assigned to each 2 cm distance respectively. 1 to 3= mild pain, 4 to 6= moderate pain, 7 to 9= severe pain, 10= worst possible pain.
Tool IV: Maternal course of labor and its outcome assessment checklist:- it entailed two sections:
Section I: Maternal course of labor and its outcome assessment checklist, which involved mode of delivery, occurrence of perineal trauma and the level of pain as well as onset and duration of labor (duration of each stage and total labor duration).
Section II: Fetal course of labor and its outcome assessment checklist, which entailed presence of fetal distress, fetal problems, in addition to the first and fifth minute APGAR score.
On admission at delivery ward the subjects were assessed by the researcher for their physical condition and pain intensity (during active phase of the first stage and second stage) using tool I part ’4’ &III. After delivery, course of labor and birth outcome assessed for both groups using tool IV.
Tools were validated by of jury of (3) experts in the field. Their suggestions and recommendations were taken into consideration.
A pilot study was carried out on 8 pregnant women to ensure the clarity and applicability of the tools, identify obstacles and problems that may be encountered as well as to estimate the time needed for data collection. Accordingly, the necessary modifications were made. Women participating in the pilot study were excluded from the study sample.
Finally, after collecting the necessary data, data was revised, categorized, coded, computerized, tabulated and properly analyzed.
The main findings of the present study were:
Subjects’ demographic data:
The present study revealed: no statistically significant differences between the study and control groups regarding their socio-demographic characteristics.
Subjects’ reproductive history:
• Slightly than one third (32.5%) of the study group compared to one- quarter (32.5%) of the control group had three times and more pregnancy.
• Only (0.0 % %2.5% respectively) of the study and control groups were delivered three times and more.
• More than three- quarters (87.5%) of both study and control group had no history of abortion.
• All(100 %& 100% respectively) of the study and control group had no history of stillbirth.
• Only (2.5%) of the study group versus none (0.0%) of the control group had three children.
• The male sex was observed (47.5% and 52.5%, respectively) between the two groups with no statistically significant differences between them with respect to the previously mentioned items.
History of current pregnancy:
• The majority (92.5%, 85%, respectively) of the study and control group had planned and wanted pregnancy.
• The mean pregnancy weeks were evident in close proportions between the two study groups and the control group (31.35 ± 1.59 and 31.67 ± 2.26, respectively).
• The majority of the study group (80%) compared to (82.5%) of the control group had started their initial visit during the first trimester of pregnancy.
• About (62.5%) of the study group compared to approximately two-thirds (67.5%) of the control group had received less than four antenatal visits.
• Both the entire study and control group had minor discomforts during their pregnancies.
Clinical assessment data:
• The mean of weight, heightandbody mass index among the study group(80.08 ± 12.68, 159.93 ± 3.19 &31.28 ± 4.68) compared to the control group (82.48 ±12.65, 161.05±5.10 &31.89±5.02), respectively.
• All of the study and control groups had a fetal cephalic presentation, fetal longitudinal lie with complete flexion attitude in their grips.
• One- half of both study group and control group had a left occiput anterior, another half had right occiput anterior in their lateral grips.
• All of the study and control groups their pulses ranged between (60-100 b/m), their blood pressure (120/80mmhg), and their temperature ranged from (36.5 to 37.5 c) and their respiration ranged between (16 to 20 c /m).
• The fetal heart rate among all of the study and control groups ranged from (120-160 b/m).
Pelvic floor muscles strength test (vaginal manometry):
Pelvic floor muscles strength at pre, two months and on admission in 1,st stages of labor after intervention (experimental group)
• Before intervention: approximately two thirds (32.5%&30%) of the study group had suffered from weak pelvic floor muscles strength.
• After two months: about (52.5% and 7.5%) of study group had either strong or powerful pelvic floor muscles contraction, the difference was statistically significant (p=0.001).
• On admission to the first stage of labor : more than one - half (57.5%) of them had strong contraction in 1st stage of labor
• About one - fifth (22.5% &20.0%) of study subject had either powerful or week contraction, the difference was statistically significant(p=0.001).
Pelvic floor muscles strength at pre, two months and on admission in 1ststages of labor after intervention (control group)
• Before the intervention: 35.0% & 40 % &25.0 % and none of the entire control group, respectively had weak, strong or powerful contractions during pelvic floor muscles strength test.
• Two months and on admission into the first stage of labor:
About four fifths (50 % &32.5 % and 32.5 %&47.5, respectively). Slightly, less than One fifth,(15.0% and 17.5%, respectively).
• No statistically significant difference was observed over time.
Pelvic floor muscles strength before, two months and at admission in 1st stages of labor after intervention (both groups):
• Before the intervention: slightly less than two- thirds (32.5%&30%) of the study group compared to (35%& 40%) of the control group had a week pelvic floor contraction with no statistically significant difference between them ( p=0.447).
• After two monthsabout (52.5%) of the study group compared to only (15%) of the control group had a strong pelvic floor muscle contraction. The differences was statistically significant between both groups (p=0.001).
• On admission in the first stage of labor about (22.5 %,) of the study group compared to (2.5%)of the control group had a powerful pelvic floor muscle contraction. The differences between groups was statistically significant (p=0.001*).
Pain intensity,on admission, in 1st, 2nd and 3rd stages of labor after intervention (experimental group):
• On admissionabout (65.0%, 20% and 10 %), of them had moderate, severe or worse pain,respectively.
• At 1st and 2ndstages of labor: Three- quarters or more (75.0% & 82.5%, respectively) of the study group had moderate pain intensity.The difference was statistically significant (p=0.059&p=0.014),respectively.
• At 3rd stages of labor: about (20.0% &0.0%), of the study group had severe or worse pain, respectively. The difference was statistically significant (p=0.001).
Pain intensity,on admission, in 1st, 2nd and 3rd stages of labor after intervention(control group)
• On admission: about 20.0%, 47.5% and 32.5 %, respectively of them had moderate, severe or worse pain on admission.
• In 1st,2ndand 3rd stages of labor:controlgroup has worse pain intensity (52.0% & 85.0%), respectively,the difference as statistically significant (p=0.005 & p= 0.001),respectively.
• Severe pain at 1st and 2ndstages of labor ofthe control group about (27.5 % & 5%), the difference was statistically significant (p= 0.001).
Pain intensity, at admission, in 1st, 2nd and 3rd stages of labor after intervention (both group):
• On admission: about (10 %, 7.5%, 5.0% and 0.0%) of the study group compared to (32.5%, 52.5%, 85.0% and5.0%), respectively of the control group had a worse level of pain.
• In 1st, 2nd and 3rd stages of labor: about (75% & 12.5%) of the study group had moderate to severe pain compared to (20% & 27.5%) of the control group, respectively. The difference was statistically significant (P=0.001),respectively.
Maternal course of labor and its outcome:
• Statistically significantdifference was found between the study and control group about the type of delivery (p=0.029).
• Progression of labor, none (0%) of the study group compared to (12.5%) of the control group had received induction during their labor.
• Duration of second, there was significance differences between the study& control groups (p=0.001).
• No significant differences was found between two groups regarding the duration of first stage.(p = 0.108)
• About mean score of the total duration of stages of laborthestudy group was lower (5.20 ± 1.97) than the control group (6.09±2.01) with a significant difference between both groups (p=0.048).
• The vast majority (97.4% &97.5%) of the study group compared to (75%&89.3%) of the control group had no perineal laceration during delivery and no complication during childbirth.
Fetal course of labor and its outcome:
• Apgar scoringat1stminute: about(100.0%& 00.0%) of the study compared to (90.0 %& 10%) of control group had (7-10) &(4 - 6),respectively.
• There was significant difference between the study and control groups (p=0.040).
• Apgar scoring AT5thminute, (100 %)of study group had (7-10) scoresas(97.5%) of the control group had (7-10).
• Fetal complications none (0%) of the study group compared to (10%, 2.5% &2.5%, respectively) of the control group, with no statistically significant difference.
Correlation between occurrence and degree of perineal laceration and pelvic floor muscles strength
• There is a statistically negative correlation between the study group pelvic floor muscles strength at pre -program, two months after implementation and at admission to the1st stage of labor & the occurrence of perineal laceration (r = -0.207*, p= 0.081 & r = -0.255 p= 0.031* & r = -0.258*, p=0.029* respectively). That is to say occurrence of perineal laceration decreases as pelvic floor muscle strength increase.
Based on the findings of this study, the following recommendations are suggested:
1. In service training program should be carried out for nurses who are working in antenatal clinics to upgrade their knowledge regarding the importance of exercises during pregnancy.
2. Enforce good postpartum care with more emphasis an importance of pelvic floor muscles exercise.
3. Continuous monitoring of maternity nurses’ performance by nursing supervisors about their role in educating and training the pregnant women about the stretching and pelvic floor muscles exercise.
For further researches
• Replication of the same study in different Egyptian governorates especially rural and Upper Egypt to compare and validate the present study findings.
• Investigate barriers against practicing the pelvic floor muscles exercise during pregnancy.