Introduction

Labor and delivery care, currently institutionalized and conducted by obstetrics professionals, follows guidelines and protocols that aim to ensure safe, humanized, and harm-free care for the mother-baby binomial. However, over the years, women’s autonomy and active participation in delivery have been reduced, with less freedom of choice over their bodies and the delivery process. ¹

Access to humanized care and safe delivery may not be available to all pregnant women, being influenced by sociocultural and economic factors or by services that institutionally prioritize cesarean sections. ² In 2019, the cesarean section rate in Brazil reached 56 % of births. In the private health sector, this number reached 88 %. ³ Although there are clinical and obstetric indications, the number of cesarean sections is disproportionate both in the public system and, especially, in the private system, including the scheduling of cesarean sections at the request of the pregnant woman. ³

Over the past three decades, the World Health Organization (WHO) has proposed strategies that are considered good practices for delivery and birth care. These strategies seek to reduce unnecessary interventions and increase women’s participation in the process. ⁴ One example is the delivery plan, a legal document encouraged by the WHO, in which the pregnant woman expresses her preferences and expectations for care during labor and delivery, such as the choice of non-pharmacological methods, freedom of movement, preferences for certain positions and the desire to be informed in advance about invasive procedures and interventions, among others. ⁽⁵

Continuous education of health professionals is essential to ensure the implementation of these good practices, including the inclusion of non-pharmacological strategies that promote greater participation of pregnant women. Strategies such as pelvic mobility exercises and integrative practices in obstetrics can positively influence delivery outcomes and increase women’s satisfaction. ^6,7

The professionals who accompany pregnant women during prenatal care are responsible for preparing them for delivery, and may suggest exercises for articulating the pelvic region, such as walking, squats, dancing, foward lunge and reverse lunge exercises, as well as activities with a Swiss ball or peanut ball, exercises to strengthen the pelvic floor muscles and perineal massage.^8,9 Some studies indicate that these exercises increase pain tolerance during labor, improve delivery dynamics and optimize contractions, cervical dilation, and baby’s descent, resulting in shorter labor time. ⁹

Among the exercises applied during labor is the Spinning Babies^® method, which includes techniques such as forward-leaning inversion to stretch the uterine ligaments and side-lying release, which relaxes the pelvic floor and relieves pain. ¹⁰ These practices are already part of the routine of some obstetric services and aim to facilitate the rotation and descent of the baby into the maternal pelvis without the need for direct manipulation, promoting a smoother evolution of labor and greater participation of the pregnant woman. However, there is little evidence in the literature about the efficacy and effectiveness of these techniques. ^10,11

A preliminary search conducted in June 2023 in the Cochrane Library, Medical Literature Analysis and Retrieval System Online (MEDLINE/PubMed) databases, and the Open Science Framework (OSF) platform found no systematic or scoping reviews that addressed these exercises and positions in labor. Considering the need to fill this gap and analyze existing studies, the present review aims to map and characterize the use of pelvic mobility exercises in labor and delivery care.

Methodology

This study followed the methodology proposed by the Joanna Briggs Institute (JBI) ¹² for scoping reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses - Extension for Scoping Reviews (PRISMA-ScR). The review was carried out in five stages: 1) definition of the review question; 2) identification of relevant studies that would enable the scope and purpose of the review; 3) selection of studies based on predefined criteria; 4) data mapping; 5) comparison, summary, and reporting of results. ¹³ The protocol for this review was registered on the Open Science Framework (OSF) platform under the DOI: 10.17605/OSF.IO/WM5JA.

The review question that guided the study was: “What is the available evidence on pelvic mobility exercises in labor and delivery?”.

The inclusion criteria were: scientific articles with different methodologies and designs (randomized clinical trials, non-randomized clinical trials, cross-sectional studies, case studies, and experience reports), editorials, research notes, dissertations, and theses, without language restrictions or time limits, published until August 28, 2024. Publications were selected based on the mnemonic strategy PCC (Participant: pregnant women or parturients, Concept: types of pelvic mobility exercises applied by health professionals in labor and delivery). The context was omitted to avoid geographic or institutional limitations. Texts not available in full, studies that did not answer the review question, and research protocols were excluded.

The initial search was performed in the MEDLINE (PubMed) and CINAHL databases to identify articles related to the topic and their Medical Subject Headings (MeSH) descriptors, with the assistance of an academic librarian. The descriptors identified were: “labor, obstetric”; “labor stage, first”; “parturition”; “labor pain”; “delivery, obstetric”; “natural childbirth”; “cesarean section”; “exercise movement techniques”; “exercise therapy”; “exercises”; “physical therapy modalities”; “patient positioning”; “pelvic floor”.

The search strategy, including all MeSH descriptors and related keywords, was adapted for each database (Table 1 . .), namely: PubMed, PubMed Central, CINAHL, Web of Science, PeDro, Scopus, BVS, and Embase. The review also included unconventional literature (grey literature) from the ProQuest Dissertations and Thesis Global repositories.

Table 1: Defining the search strategy with descriptors and keywords in each database 

After the search, all the retrieved studies were collected and exported to the Rayyan web application, and duplicates were removed. Blinding in Rayyan was activated, and two reviewers independently analyzed and selected the studies using the titles and abstracts, according to the inclusion and exclusion criteria. At the end of this stage, a third reviewer was called in to mediate any conflicts when blinding was removed.

The selected studies went on to a second stage of screening and full reading, being analyzed according to the eligibility criteria. After reading, disagreements were resolved through discussion and consensus among the three reviewers.

The final sample was coded, and the extracted information was recorded in a spreadsheet in Microsoft^® Word 2019, containing: order number, database, type of publication, title, authors, year of publication, objective, study design, country of origin, sample characteristics, description of the pelvic mobility exercises evaluated in the labor and delivery, professionals who performed the evaluations and the results described.

For data analysis, the frequency and focus of interest of each publication were considered, with a descriptive approach, in light of the key concepts of the present review on pelvic mobility exercises in labor and delivery care.

Results

A total of 2,341 studies were identified, of which 1,051 were duplicates. Of the remaining 1,290, 1,243 were excluded because they did not meet the eligibility criteria. Thus, after reading 47 studies in full, 11 were selected because they met the established criteria and answered the research question. In addition, one additional publication was included, extracted from the references of the primary texts. Therefore, the final sample of this review consisted of 12 studies. The publication selection process is illustrated in the flowchart below (Figure 1)

Figure 1: Selection flowchart according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses - Extension for Scoping Reviews (PRISMA-ScR) criteria. Source: Prepared by the authors, based on PRISMA-ScR. 

Among the included studies, seven were published in the last five years (2019 to 2024), ^{8,9,14,15,17,20,21} two between 2014 and 2018, ^19,23 and the others between 1997 and 2013. ^16,18,22) The studies were published in English, ^{8,14,15,16,17,18,19,21,22,23} Portuguese ⁹ and Spanish,⁽²⁰ six from Brazil, ^{(8,9,14,15,18,23} two from the United States ^21,22 and the others from Canada,¹⁶ Norway, ¹⁷ India, ¹⁹ and El Salvador. ²⁰

Although these are not recommended categorizations for scoping reviews, the risks of bias and the level of evidence of the studies were verified. The JBI Appraisal Tools were used to analyze the methodological quality and risk of bias. ²⁴ The JBI Appraisal Tools allowed us to identify low risks of bias in the selected studies, with nine ^{8,9,14,15,17,18,19,21,23)} considered to be of high quality, two ^16,22 of moderate quality, and one ²⁰ of low quality. The Agency for Healthcare Research and Quality criteria were used to identify the level of evidence, with three studies ^5,17,23 classified as level of evidence II, one ¹⁹ as level III, another ⁹⁾ as level V, and seven ^{8,14,16,18,20,21,22)} as level VI.

The total population of the included studies was 936 participants. Three literature review studies ^18,21,25 did not discriminate the sample of the studies evaluated, and two^21,22 studies were based on expert opinions. Study samples were selected based on the following inclusion criteria: low-risk pregnant women, ^15,18,19,23 nulliparous/primiparous women, ^17,18,23 and yoga practitioners. ¹⁴ One study established cervical dilation between 3 and 8 cm as the criterion, ¹⁵ while another considered dilation between 4 and 5 cm. ⁽²³

Among the professionals who carried out the evaluations, four studies involved nurses, ^9,15,19,22 one had an obstetric nurse, ⁸ another had a midwife, ¹⁴ two had physiotherapists, ^18,23 and the others did not identify the professionals. ^16,17,20,21 The other data and the summary of the included studies are described in Table 2 . .

Table 2: Summary of studies included in the review  

^Note: PME: Pelvic mobility exercises; PF: Pelvic floor; SD: Standard deviation; EG: Experimental group; CG: Control group; DPP: Delivery preparation program; N/A: Not applicable; VAS: Visual analogue scale, graduated from 0 to 100 mm (millimeters); MD: Mean difference; CI: Confidence interval.

Based on the established search strategy, the following practices were selected and evaluated: pelvic floor exercises with a Swiss ball, ^{9,15,18,20,23} aerobic exercises, ¹⁷ walking, ^8,18 squatting, ⁸ freedom of movement and upright positions, ¹⁶ yoga, ¹⁴ dancing, ²¹ abdominal muscle training exercises, ²² and pelvic floor muscle training exercises. ^9,18,19,22 In six studies (Table 3), ^{8,9,15,20,21,23} the exercises were characterized. Some mentioned the intervention performed, but did not provide details about the exercise.^{14,16,17,18,19,22}

Table 3: Characterization of labor exercises 

Discussion

This scoping review aimed to map the published evidence on pelvic mobility exercises in assisting labor and delivery, which help to optimize the rotation and descent of the baby in the maternal pelvis, in addition to providing greater freedom of movement for the woman.

The results of the studies evaluated indicated that the main outcomes include a reduction in labor time, due to increased uterine contractions and accelerated cervical dilation, ^{9,17,20,21,23} and decreased pain and anxiety. ^{9,14,15,19,20,21,22,23} A clinical trial with aerobic exercises ¹⁷ showed a reduction of 186 minutes, and another with exercises on the Swiss ball ²³ of 72 minutes in the time of the first period and 18 minutes in the second period (expulsive); the others did not quantify the labor time. ^{8,9,14,15,16,18,19,20,21,22}

Three studies related pelvic mobility exercises (aerobic or Swiss ball movements) to increased vaginal deliveries; in one study ¹⁷, the vaginal delivery rate was 85.7 % versus 62.3 % in women without exercise (p = 0.051); in another study ²³, the rate was 80 % versus 65 % (RR 1.23, 95 % CI 0.93 to 1.62); and in another ⁹, this information was not clear. No study reported complications or undesirable effects in their samples.

Exercises using the Swiss ball were the most evaluated in the selected studies, which have variations that work the pelvic joints, favoring the evolution of labor. Some variations include the woman sitting with the ball resting next to her body, which provides relaxation and stretching; sitting on the ball resting on a front bar, performing forward and backward movements, lateral movements to the right and left, and/or propulsion and rotation movements; standing, resting on the ball on a hard surface at trunk level; or in a four-legged position with the trunk resting on the ball. ⁽²⁰

Using different positions and movements with the Swiss ball during labor helps to engage, descend, and rotate the fetal head. When combined with upright positions, the ball can help align the mother’s and baby’s bodies, correct fetal presentation, reduce labor time, and improve pain control, avoiding invasive procedures. ^9,15,20,23 In one study, ¹⁵ parturients were instructed to perform propulsion and rotation movements on a Swiss ball, with or without the use of a hot bath. In both scenarios, an acceleration of cervical dilation and a reduction in the time of the active phase of labor were observed.

Upright positions, Swiss ball exercises, and shower bathing were considered low-cost non-pharmacological strategies in the evaluated studies, promoting relaxation of the pelvic floor muscles, comfort, and greater pain control for parturients. ^9,15 Other authors²⁵ also described that upright positions, walking and shower bathing resulted in reduced pain and were associated with an increase in the number of vaginal deliveries. ⁹

The combination of Swiss ball exercises, lumbosacral massage, and breathing techniques has been identified as an important strategy to reduce pain, fear, and anxiety in parturients. ^9,23 However, the isolated use of lumbosacral massage, ^23,25,26 or combined with breathing techniques and pelvic floor muscle relaxation, has also been shown to be effective in reducing pain levels. ^9,19 These strategies are frequently used in labor care and are considered highly effective in reducing analgesic use and avoiding early analgesia. ⁽²³

In one study, ⁸ obstetric nurses reported encouraging freedom of movement, promoting pelvic joint exercises, such as hip swaying with a sense of the free pelvis, demonstrating circular movements to the left and right, forward and backward, and laterally (asking the parturient to imagine how a sieve moves), walking, squats, pelvic rocking (horseback type) and the four-support position during the expulsive period, described as promoting the woman’s autonomy and ensuring safe and respectful care. However, a review ¹⁶ recommended caution in the use of birthing chair in upright positions, due to the increased risk of perineal edema.

Another study ¹⁸ implemented a delivery preparation program, including stretching exercises, Swiss ball exercises, walking, pelvic floor muscle training, breathing, and relaxation techniques. This study ¹⁸ showed that pregnant women had greater control and confidence in using these strategies as labor progressed. The delivery preparation program,¹⁸ which integrated pelvic mobility exercises and dance practice ²¹ (a combination of pelvic and body movements), associated these activities with the reduction of pain and fear, in addition to increasing women’s satisfaction during labor and delivery.^18,21 The practice of dance during pregnancy is recommended because it strengthens the pelvic floor muscles, which can reduce postpartum complications, such as urinary incontinence and organ prolapse. ⁽²¹

The World Health Organization (WHO) and the Brazilian Ministry of Health (MS) recommend freedom of movement and upright positions during labor and delivery, as well as the adoption of non-pharmacological methods for pain relief, as they provide comfort, humanize delivery care, and reduce unnecessary interventions. ⁽²⁷

A study carried out by experts ²² described the training of the abdominal muscles and pelvic floor, with exercises that combine the contraction of the transverse abdominal muscle and the relaxation of the pelvic floor, in addition to breathing with an open glottis to facilitate labor. This strategy, using exhalation with an open glottis, leads to the lifting of the diaphragmatic muscle, abdominal contraction, and relaxation of the pelvic floor, which promotes the relaxation of the soft tissues and uterine ligaments, helping the baby to descend. Training the abdominal muscles is also associated with the prevention of lower back pain and abdominal diastasis. ^(22,28

The practice of yoga was evaluated in a study ¹⁴ in which the authors reported several benefits for pregnant women during labor and delivery, such as breathing control, reducing anxiety, stress, and pain, as well as strengthening the pelvic floor muscles. Some yoga postures act on the joints, ligaments, and soft tissues of the hip region, ²⁹ increasing pelvic diameters, which can favor the evolution of labor and reduce stressful factors for the parturient, as well as avoiding unnecessary interventions. ⁽¹⁴

Two studies ^9,16 evaluated another strategy: perineal massage for the prevention of lacerations during delivery and the reduction of episiotomy. One of the studies showed a lower incidence of lacerations, ¹⁸ while the other did not find significant results, ¹⁶ although it recommended the practice for women who wished it and the performance of timely episiotomy. Episiotomy is a surgical incision made in the vulvoperineal region to enlarge the opening at the time of the baby’s head passage. However, routine use of episiotomy does not reduce the risk of severe perineal trauma or the risk of stress urinary incontinence, and it also increases blood loss. ³⁰ Another recommendation for reducing perineal trauma is to maintain physiological pushing with the glottis open during the expulsion, a practice that also avoids prolonging this phase. ⁽¹⁶

Women in labor need adequate care and appropriate management of environmental factors in order to meet their needs and provide a better delivery experience. Obstetricians can use less invasive and non-pharmacological strategies to reduce the time of the active phase of labor or the expulsive period, provide greater control of pain, fear and anxiety, and favor vaginal delivery. The studies included in this review highlight these practices and can stimulate discussions about the care provided in obstetric centers, in addition to suggesting good practices that can be implemented.

Vaginal delivery is associated with better safety indicators compared to cesarean section, such as reduced post-delivery complications, strengthening of the mother-baby bond, lower risk of infections, contribution to the baby’s cardiac and respiratory stabilization and greater participation of the woman in the birthing process. ⁽³¹ However, professionals must ensure maternal and fetal safety parameters during care, while valuing the woman’s wishes and anxieties regarding her delivery, promoting humanized care and avoiding unnecessary interventions, especially the indiscriminate practice of cesarean sections.

The limitations of this review may be related to the heterogeneity of the included studies, due to different pelvic mobility exercises and study designs, which made it difficult to summarize the results. Another limitation was the small number of publications with pelvic mobility exercises applied and with outcomes in labor and delivery; thus, most of the studies selected in the databases presented only results of exercises to prepare for delivery in prenatal care and were not eligible for this scoping review.

Although it is not a general rule for scoping reviews, the prevalence of studies classified with levels of evidence between III and VI, according to the GRADE system, ³² is considered a low recommendation for care practice. However, most of the studies evaluated (75 %) ^{8,9,14,15,17,18,19,21,23} were considered of high quality by the JBI Appraisal Tools, therefore, with a low risk of bias. Exercises have also been shown to be a safe form of delivery care, since they did not negatively interfere with maternal and perinatal parameters.

This study mapped different pelvic mobility exercises indicated for labor and delivery. These strategies are widely used in obstetric centers and delivery homes, especially by obstetric nurses, midwives, and physiotherapists, which makes the discussion relevant for clinical and obstetric practice. However, this work also highlights gaps in the literature on care practices, such as the set of exercises called Spinning Babies^{® (10,11} or the De Gasquet Method^®, ³³ developed by the physician and yoga teacher Dr. Bernadette de Gasquet, which proposes a holistic approach involving different positions associated with breathing for pregnancy, labor and delivery. Therefore, there is a need for high-quality randomized clinical trials and/or new research in the literature so that these strategies can be included in institutional protocols.

Final Considerations

Pelvic mobility exercises are essential for women’s active participation in labor and delivery, as well as helping to reduce invasive and pharmacological procedures and increasing women’s satisfaction. Among the exercises identified in this scoping review are: pelvic exercises with a Swiss ball, aerobic exercises, walking, squats, freedom of movement and upright positions, yoga, dance, and abdominal and pelvic floor muscle training. These practices showed a relationship with a reduction in the duration of labor and the expulsion period, as well as promoting greater control of pain, anxiety, and fear. Pelvic exercises under the Swiss ball and aerobic exercises were associated with an increase in the vaginal delivery rate.

The results demonstrated the potential of different strategies, without causing adverse harm to delivery care. However, there is still a gap concerning some exercises and positions used in the routine of obstetric centers in Brazil and other countries, which were not found in this review. This may be related to the databases used or the lack of published studies on these strategies, indicating the need for future investigations in the literature.