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Pelvic Floor Training in Pregnancy: Is It Really Worth It?

Team Ri-Hub15 min lettura

Revisione clinica: Daniele Carretto, Fisioterapista (Albo 2019) · Pubblicato il 30 luglio 2026

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At the antenatal class you were told in twenty seconds: "and remember, do your Kegels". Nobody explained to you which muscles, how many times, from when and whether it really makes a difference or whether it is one of those phrases said to everyone out of caution.

Here is the answer straight away, because the evidence here is among the best in all of physiotherapy: yes, it makes a difference, under one condition, which is the one almost nobody mentions. Training the pelvic floor in pregnancy works very well to prevent urine leakage if you do not yet have any; if the leakage is already there, the same studies become much more lukewarm. Two different questions, two different answers: confusing them is the easiest mistake on this topic.

The two numbers not to confuse

The reference source is the 2020 Cochrane review: 46 controlled studies, 10,832 women in 21 countries. It did the right thing, separating women according to how they were before starting.

Who trains in pregnancy What happens to urine leakage
Continent women (prevention), late pregnancy 62% less (RR 0.38; 95% CI 0.20–0.72; 6 studies, 624 women)
Continent women, 3 to 6 months after birth 29% less (RR 0.71; 95% CI 0.54–0.95; 5 studies, 673 women)
Already incontinent women (treatment), late pregnancy no evidence of effect
Already incontinent women, 3 to 6 months after birth no evidence of effect (RR 0.94; 95% CI 0.70–1.24; 1 study, 187 women)

Two details to read carefully. The first: that 29% at three to six months after birth is classified by the authors as high quality evidence, which is rare in rehabilitation and makes a future reversal unlikely. The second: in women who are already incontinent the effect is not small, it is absent.

Another review, published in the British Journal of Sports Medicine in 2018, on 24 studies and 15,982 women, confirms it: antenatal training halved the likelihood of incontinence during pregnancy (OR 0.50; 95% CI 0.37–0.68; 15 randomised studies, 2,764 women) and also reduced it after birth (OR 0.63; 95% CI 0.51–0.79; 10 studies, 1,682 women). Then comes the sentence that should be at the top of every antenatal class: when the data are split by continence at the start, exercise was effective in preventing incontinence in continent women, but was not therapeutic in those who already had it.

The general picture, covering what it is, when to train it, and when strengthening it is the wrong answer, is in Pelvic floor: what it is for and when to train it. Here we are talking about the window of pregnancy, the one with the best numbers.

What the 62% means in practice

The Norwegian study behind much of this data helps translate it: 301 healthy nulliparous women, half on an intensive 12-week programme supervised by physiotherapists, half receiving routine information.

At 36 weeks, 32% of the training group reported leakage, against 48% of controls. Three months after birth, 20% against 32%. The authors translated it as honestly as possible: training prevented incontinence in about one woman in six during pregnancy and in one in eight after birth.

One in six does not mean "it works for everyone": five out of six do the exercises without a benefit that can be attributed to them. But for an intervention that costs nothing and can be done while you wait for the bus, a figure like this is one many treatments would envy. As for risks: in the Cochrane review, across 46 studies, the only adverse events reported were two women out of 43 who, in a single study, stopped because of pelvic floor pain.

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If you already leak (and in pregnancy it is very common)

You are not an unusual case: in a Norwegian study of 300 nulliparous women between the eighteenth and twenty-second weeks, 35% already reported urine leakage before any birth. After birth, a 2023 meta-analysis (32 studies, 28,303 women) estimates an incidence of 26%.

That training does not come out as "therapeutic" does not mean you have to live with it. It means three concrete things:

  • a generic programme is not enough. The same exercises recommended to everyone, without anyone checking how you contract, are the route that does not work in the studies;
  • you need to understand what kind of leakage it is. On effort, from sudden urgency, or both: these are different mechanisms and the work changes;
  • if you are still continent, the most worthwhile time is now. If you are no longer continent, the work continues after birth, and that is a different game: we covered it in Urine leakage after birth: what really works.

A note of perspective: in women with stress incontinence, the 2018 Cochrane review of 31 studies and 1,817 women found about eight times the likelihood of recovery with training compared with doing nothing (56% against 6%; 4 studies, 165 women, high quality). Training does cure, and the authors of the 2020 Cochrane review say so too: the uncertainty about training as a treatment in pregnancy and the postpartum period contrasts with the more established effectiveness in middle-aged women.

How to really contract (and how to tell you are getting it wrong)

Here is the finding that should open every discussion about Kegels. In a study published in the American Journal of Obstetrics and Gynecology, 47 women performed a pelvic floor contraction after a standard verbal explanation, the way almost everyone learns, while a device measured urethral pressure.

Only 23 out of 47, 49%, produced a correct contraction. And 12, 25%, used a technique that could promote incontinence instead of correcting it: they pushed downwards, convinced they were squeezing. And it was not predictable by eye: age, number of births and weight did not say who would manage it.

Be careful not to read it worse than it is: it does not mean "almost everyone gets it wrong for good". In the Norwegian study of the 300 pregnant women, after careful instruction only 4% could not contract correctly. The variable is not you: it is how well you were explained it.

How you can tell for yourself in the meantime:

  • belly, buttocks and thighs should not visibly tighten. If your bottom lifts off the bed, you are using something else;
  • you should not hold your breath. If the contraction only comes while holding your breath, you are pushing, not closing;
  • the direction is inwards and upwards, as if you wanted to hold back gas from the bowel, not downwards;
  • in a mirror the perineum draws in, rather than bulging outwards;
  • then comes the release. A contraction without a complete release is only half of the movement.

Two things not to do. Interrupting the flow of urine can be useful once to understand which muscles are involved, but it is not an exercise and should not be repeated during urination. And do not take your subjective feeling as proof you are doing it right: NICE guideline NG123 calls for an assessment of the contraction before starting a supervised programme, because it is the only check that does not depend on how it feels to you.

The detail on how to perform them, with the most common mistakes, is in Kegel exercises: how to do them properly (and when not to).

How many times, from when, for how long

The guidelines are less vague than you might expect. NICE NG210 of 2021 recommends encouraging all pregnant women or women who have just given birth to do pelvic floor exercises, and considering a supervised 3-month programme from the twentieth week for those with a first-degree relative with pelvic floor disorders; postpartum, for those who had an operative birth or an anal sphincter injury.

Why not for everyone? Not because it does not work: the committee writes that, given the cost of offering it to such a large group and the limits of the economic analysis, it prefers to leave it as an option rather than recommend it routinely. It is a health system decision, not a judgement on effectiveness.

On dosage, the numerical reference is NICE NG123: at least 8 contractions, 3 times a day, in a supervised course of at least 3 months. To be complete: that recommendation concerns the treatment of stress or mixed incontinence in women in general, not prevention in pregnancy. And on the optimal dose, the 2024 Cochrane review (which precisely excludes pregnant women and women in the early postpartum period) is clear that studies are lacking: the only data on weekly frequency comes from a single study of 68 women.

On when to start, the 2020 Cochrane review refers to early and structured training begun at the start of pregnancy; in the Norwegian trial it ran from the twentieth to the thirty-sixth week. Earlier is better, and three months is the minimum duration that recurs everywhere.

One last point on the type of exercise. The same 2024 Cochrane review compared direct training, with repeated and isolated contractions, against indirect training, meaning exercises that do not contract the pelvic floor (breathing, deep abdominals, postures): for quality of life related to incontinence, the direct approach did slightly better (SMD 0.70; 4 studies, 170 women, low certainty). This applies to women already incontinent and outside pregnancy, so it should be taken as guidance rather than proof: but a course where you "work on the pelvic floor" without ever consciously contracting it is not the same thing.

"But will labour be harder then?"

It is the fear that stops more women than any other: if I strengthen it, it will not open up afterwards.

The study that answers most directly is the analysis of birth outcomes from a randomised trial of 268 first-time mothers, assigned around the twentieth week to a supervised programme or a control group: no difference either in the length of the second stage of labour or in the use of operative delivery. The authors' conclusion can be quoted in full: training does not seem to either facilitate or hinder labour.

On the other side, the Norwegian trial of 301 nulliparous women found fewer prolonged active pushes beyond 60 minutes in the training group (24% against 38%), but the average length of the second stage was not significantly shorter (40 minutes against 45; p = 0.06). Meta-analyses sit in between: the 2020 one (16 studies, 2,829 women) estimates an average shortening of about 21 minutes and a reduction in severe perineal lacerations (RR 0.57; 95% CI 0.38–0.84); the 2024 one (30 studies, 6,691 women) confirms the reduction in third- and fourth-degree tears (RR 0.50; 95% CI 0.31–0.80) but finds no effect on episiotomy (RR 0.95; 95% CI 0.85–1.07).

The limitation needs stating: the authors of the 2020 meta-analysis warn that most studies have a moderate to high risk of bias. The cautious reading: no sign that a trained pelvic floor hinders birth, and a signal, not definitive, that it may protect the perineum. If your goal is specifically to reduce the risk of tearing, the approach with the most specific evidence is a different one: perineal massage in the last month.

What has NOT been shown

The part that is usually missing, and it is worth as much as the rest.

  • It is not a cure if the leakage is already there, neither in pregnancy nor postpartum.
  • It does not prevent faecal incontinence. In women with or without symptoms, training in pregnancy has shown no differences in the prevalence of faecal incontinence in late pregnancy (RR 0.64; 95% CI 0.36–1.14; 3 studies, 910 women).
  • It does not reduce caesarean sections, operative births or episiotomies. On these outcomes the meta-analyses find no differences.
  • Beyond 12 months after birth, it is unknown: the 2020 Cochrane review says the evidence is sparse.
  • Starting only after birth, offered indiscriminately to everyone, is not likely to reduce incontinence (RR 0.88; 95% CI 0.71–1.09; 3 studies, 826 women).
  • On sexual life in pregnancy there are no studies. A 2019 systematic review of 10 studies and 3,607 participants found encouraging results postpartum, but no study on the effect during pregnancy.

Red flags: when to stop and call

The exercises are safe: the 2019 Canadian guideline on physical activity in pregnancy, which assessed maternal, foetal and neonatal morbidity, identified no harm from antenatal physical activity. Some situations, however, have nothing to do with exercises and have a precise threshold.

Today, without waiting for the next check:

  • loss of clear fluid, continuous or in a gush: loss of amniotic fluid is not urine leakage and is not managed with exercises;
  • vaginal bleeding;
  • regular, painful contractions before the thirty-seventh week;
  • the baby is moving less than usual.

In none of these cases are exercises the answer: you stop and call today whoever is following your pregnancy. With bleeding, fluid loss or reduced movements you go to obstetric A&E, you do not wait for the next appointment.

The same day, to the doctor or midwife:

  • burning when you urinate, constant urgency or fever: a possible urinary infection, which in pregnancy must be treated and not waited out;
  • you cannot empty your bladder: a reason to be seen straight away, not to push on with the exercises;
  • pelvic floor pain during or after the exercises that does not go away: that programme, as it stands, is not right for you.

And a general rule: if while contracting you feel that it gets worse, with more heaviness or more urgency, the answer is not to contract harder. Sometimes the problem is not a weak muscle but one that cannot relax, and there strengthening is the wrong move.

What a physiotherapist can do, and what they cannot

The most useful thing that can be done for you is simple to say and hard to find: watch how you contract and tell you whether you are doing it right. That is what separates the 49% in the study with verbal explanation from the 4% in the one with careful instruction, and NICE notes that in all the included studies the training was supervised by a trained professional.

It does not, however, have to be in person at every session: a 2023 review of supervised and unsupervised programmes in women already incontinent concludes that both can work, provided there are instruction sessions and regular reassessments. The included studies, however, had a high risk of bias, so it is a pointer, not a certainty. The do-it-yourself approach that certainly does not work is the one with neither.

In a video call, this is what happens: you establish what kind of leakage you have (or whether you have none, which is the best position to start from), you are taught the contraction with checks you can verify yourself, the dosage is set, and it is reviewed every few weeks. With Ri-Hub you start with a free twenty-minute introductory consultation with a physiotherapist; subsequent sessions cost 29,90 €. The full pathway for pregnancy and the postpartum period is on Ri-Hub Mamma.

What physiotherapy does not do: it does not replace whoever is following your pregnancy, it does not decide for them whether there is an obstetric contraindication, and it does not promise to resolve leakage already present with a standard programme. If the right place is not us, we will tell you straight away.

In three lines

If you have no leakage, training the pelvic floor in pregnancy is one of the few things in physiotherapy with solid evidence behind it: 62% less risk by late pregnancy and 29% less three to six months after birth; in the Norwegian trial this meant one woman in six who does not develop incontinence in pregnancy. If the leakage is already there, the same studies show no effect: what you need is an assessment, not a generic programme. And labour does not become harder: no data show that a trained pelvic floor hinders labour.

For the wider picture, with the numbers on pregnancy and postpartum: moving during and after pregnancy.

Sources

Last source check: September 2026.

Domande frequenti

Is pelvic floor training in pregnancy really worth it?

Yes, and here the evidence is among the strongest in all of physiotherapy, but its value lies mainly in prevention. The 2020 Cochrane review, which pooled 46 studies with 10,832 women from 21 countries, found that among continent women who train their pelvic floor during pregnancy, the risk of reporting urine leakage in late pregnancy is 62% lower (RR 0.38; 95% CI 0.20–0.72; 6 studies, 624 women, moderate quality), and between three and six months after birth it is 29% lower (RR 0.71; 95% CI 0.54–0.95; 5 studies, 673 women, high quality). A 29% effect with evidence judged to be of high quality is rare: it means new studies are unlikely to overturn it.

And if I already leak? Does training make it stop?

Here the answer changes, and this is the part almost nobody tells you. In the same Cochrane review, among women who were already incontinent when they entered the studies, there is no evidence that training the pelvic floor during pregnancy reduces leakage: neither in late pregnancy (very low quality evidence) nor between three and six months after birth (RR 0.94; 95% CI 0.70–1.24; 1 study, 187 women). And in women with persistent leakage after birth, the result at 6 to 12 months was RR 0.55 with a confidence interval from 0.29 to 1.07: it looks like 45% less, but the interval crosses 1, so statistically it is not an effect. The 2018 British Journal of Sports Medicine review, covering 24 studies and 15,982 women, reaches the same conclusion in more direct words: exercise prevented the onset of incontinence in continent women, but was not therapeutic in those who were already incontinent. This does not mean there is nothing to be done: it means a generic programme is not enough and an individual assessment is needed.

From which week do I start, and for how long?

The conclusions of the 2020 Cochrane review refer to early, structured training begun at the start of pregnancy. The British NICE guideline NG210 of 2021 is more practical: it recommends encouraging all pregnant women to do pelvic floor exercises, and considering a supervised 3-month programme from the twentieth week for women who have a first-degree relative with pelvic floor disorders. In the reference Norwegian trial the programme lasted 12 weeks, from the twentieth to the thirty-sixth week, supervised by physiotherapists. Three months is the minimum duration that recurs everywhere.

How many contractions should I do a day?

The most precise reference comes from NICE guideline NG123: pelvic floor training programmes should include at least 8 contractions performed 3 times a day, and the supervised course should last at least 3 months. To be complete: that recommendation concerns treating stress or mixed incontinence in women in general, not prevention during pregnancy, and on the optimal dose the 2024 Cochrane review, which deliberately excludes pregnant women and women in the early postpartum period, concludes that better studies are needed: the only data on frequency comes from a single study of 68 women. Eight contractions three times a day remain a reasonable starting point, not a magic formula.

How do I know whether I am contracting the right muscles?

You cannot guess it, and you cannot assess it yourself. In a study published in the American Journal of Obstetrics and Gynecology, 47 women performed a pelvic floor contraction after a standard verbal explanation, while a urethral pressure profile measured what was actually happening: only 23 (49%) produced a correct contraction, and 12 (25%) used a technique that could promote incontinence rather than correct it, because they pushed downwards believing they were squeezing. Age, number of births, weight and previous surgery did not predict who would manage it. The good news comes from a Norwegian study of 300 nulliparous women between the eighteenth and twenty-second weeks: after careful instruction, only 4% could not contract correctly. The difference is not the woman: it is the quality of the explanation.

Does training the pelvic floor make labour harder?

It is the most widespread fear, and the data do not confirm it. The analysis of birth outcomes from a randomised study of 268 first-time mothers found no differences either in the length of the second stage of labour or in the use of operative delivery; the authors conclude that training does not seem to either facilitate or hinder labour. The Norwegian trial of 301 nulliparous women found fewer cases of prolonged active pushing beyond 60 minutes in the training group (24% versus 38%), but the average length of the second stage was not significantly shorter (40 minutes versus 45, p = 0.06). Meta-analyses sit in between: the 2020 one (16 studies, 2,829 women) estimates an average shortening of about 21 minutes of the second stage and a reduction in severe perineal lacerations (RR 0.57), while warning that most studies have a moderate to high risk of bias. The 2024 meta-analysis (30 studies, 6,691 women) confirms the reduction in third- and fourth-degree tears (RR 0.50; 95% CI 0.31–0.80) but finds no effect on episiotomy (RR 0.95; 95% CI 0.85–1.07).

When should I call the midwife straight away or go to A&E?

Today, without waiting for your next check, if you lose clear fluid continuously or in a gush (loss of amniotic fluid is not urine leakage and is not managed with exercises), if you have vaginal bleeding, if you have regular, painful contractions before the thirty-seventh week, or if you feel the baby is moving less than usual. The same day, instead, if it burns when you urinate or you have a fever (a possible urinary infection, which in pregnancy must be treated, not waited out), and immediately if you cannot empty your bladder. Exercises are paused and resumed later, when whoever is following your pregnancy tells you it is safe.

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