Puerperium Lecture Notes 2024 PDF

Puerperium Dr. Nancy Aboelnour Assist.Prof of physical therapy, Faculty of Physical Therapy, Aqaba University for Technology.  Puerperium It is the period of the adjustment after pregnancy and delivery when the anatomic and physiological changes of pregnancy are...

Puerperium Dr. Nancy Aboelnour Assist.Prof of physical therapy, Faculty of Physical Therapy, Aqaba University for Technology.  Puerperium It is the period of the adjustment after pregnancy and delivery when the anatomic and physiological changes of pregnancy are reversed and the body returns to the normal non- pregnant state. Stages of Puerperium 1.The immediate Puerperium: the first 24 hr after parturition, when post anesthetic or post delivery complication may occur. 2. The early Puerperium: which extend until the 1 st week post partum. 3.The remote Puerperium: include the period of time required for involution of the genital organs through the 6 th weeks post partum. Rehabilitation of post natal problem PT for women health 1. Spinal Headache: Spinal headaches are caused by leakage of cerebrospinal fluid into epidural space through a puncture hole in the dura mater that surrounds the spinal cord. This leakage decreases the pressure exerted by the spinal fluid on the brain and spinal cord, which leads to a headache. 2. Breast problem: A) Breast engorgement: -Uncomfortable swelling of the breasts associated with milk secretion, occurs from 2nd to 4th day postnatal. -Lymphatic &vascular congestion and interstitial edema→ swelling and tenderness. - milk tension in ducts →stasis of milk → inability of milk to flow. -It is difficult for the baby to attach to the nipple. Management: 1. Breasts are emptied manually or by breast pump. 2. Elevate breast by supporting brassieres. 3. Antibiotics. 4. Heat prior feeding → blood flow 5. Cold between feeding → congestion 6. U.S (continuous) → venous , lymphatic fluid and pressure on milk ducts U.S (pulsed) → cell membrane permeability, fluid movement B) Mastitis: inflammation and infection of the breast. pain, swelling, redness and fever, occur after 1st week, or at 5-6th week Management: 1. pulsed U.S (1MHz, 1.5-2 wcm2, 1-2 min) 2. IF to pain 3. Support breast with breast binder 4. stop breast feeding C) Blocked ducts: obstruction of milk flow in a portion of the breast, in the nipple or in the ductal system. A tender lump and erythema at any time of breast feeding due to finger compression or infrequent feeding. Management: 1. Cont. U.S (1MHz, 1.5-2 wcm2, 1-2 min). 2. Feeding from affected side. 3. Massage. D) Cracked nipple: Due to incorrect positioning at the breast At the first 2-4 days after birth, there is nipples tenderness by early baby suckling which stretch her nipple. Management: 1. I.R (10-15 min). 2. Clean, Moist the nipples regularly. E) Scanty of milk: Laser :- wave length 6328, power 25mw, 10 min, for 10 days Laser effect: ↑mitochondrial cells, epithelial tissue → stimulate ↑protein and lactose content. 3. Diastasis of recti abdominis ms: -It is a gap between the recti abdominis muscles in the mid line in the linea alba ˃ 25mm or 2.5 fingers. -It may occurs during pregnancy or in expulsive stage of labor. Assessment: Rectus diastasis test Management: 1. Static abdominal ex. 2. Graduated dynamic abdominal ex. a) Kinesiotaping during abdominal ex. b) using a sheet or towel. 3. Electrical stimulation: (frq. 80 pulse∕sec, pulse duration 0.1-0.5 ms for 1 ∕2 hr daily.) 4. After pains Intermittent contraction of the uterus as it shrinks back, down to return to its normal size, site and weight to the non pregnant state. Cramps like pains in lower abdomen, in the 1st 2-3 days of puerperium. In multiparous ˃ primiparus During 1st 12 hr post- partum uterine contraction are regular, strong and coordinated. After the 1st post- partum day, the intens., freq., regularity of contraction decreased, as involution proceed. Management: 1. Analgesics. 2. Maintain the bladder empty which enable uterus to work efficiently. 3. Heat application. 4. TENS: V-shape on lower abdomen, freq.→80-120 Hz, pulse width →150Ms 5. Relaxation on face: 10-30 min, twice daily. Description: Prone, pillow under feet, 2 pillows under pelvis prevent lumbar hyper lordosis or abdominal wall hyper extension. Values of relaxation on face: 1) Help involution of the uterus 2) Relaxed position 3) discharge of blood clots 4) Guard against retroversion flexion 5. Urinary retention: Due to sudden drop of intra abdominal pressure, bladder respond less to stretch reflex caused by filling Management: Early ambulation Relieve perineal pain 6. Perineal pain: Acute or chronic. Due to child birth trauma, episiotomy or both. A) Acute perineal pain: 1. Cold bath is more effective than warm bath. 2. Pelvic floor ex (contract-relax tec.) → ↑circulation, ↓edema 3. Teach mother correction defecation → using pad held against wound 4. Using cushion during sitting Electrotherapy: 1. Ice: Crushed ice in plastic glove, 4-5 min or ice cube in wet swab 2-3 min 2. pulsed U.S: inten. →0.5-1 w ∕cm2, duration→3-5 min 3. I.R: ↓freq., 10-20 min, twice daily. Surface vasodilatation, ↓pain 4. LLLT: ↓pain, ↑ healing, applied close to perineum 1 cm apart. Wound healing 600-750 nm, 0.5-4 j ∕cm2, ˂1000HZ Pain relief shorter wave length, 0.5-4 j ∕cm2, ˃1000HZ Scar ttt 750-905nm, 4-6 j ∕cm2, ˃1000HZ 5. PEME: ↑healing, ↓inflammation, ↑fibrin&collagen deposition Single head monopole close to perineum: freq 27 MHZ, pulse rate 100pulse∕sec, pulse width 40-65 ms, duration 10-15 min. B) Chronic perineal pain: Pain persist for weeks or months 1. U.S: 3 MHz, inten. →0.5-1 w ∕cm2, duration→5 min for 8 session Breakdown scar, ↑extensibility of scar, resorption of scar by depolmersation of mucopolysaccharides, mucoproteins, glycoproteins. 2. PEME 7. Symphysis Pubis Dysfunction - Defined as separation of the joint that allows excess lateral or anterior movement → 𝒔𝒚𝒎𝒑𝒉𝒚𝒔𝒊𝒔 𝒑𝒖𝒃𝒊𝒔 𝒅𝒚𝒔𝒇𝒖𝒏𝒄𝒕𝒊𝒐𝒏. - As the pelvic bones loosen during pregnancy by relaxin hormon, the pubic symphysis can temporarily separate. Management 1. Wear trochanteric belt or full pelvic bender 2. Static abdominal ex before move around bed 3. Pillows between knees to make rolling 4. Ice: 10-15 min every 1-2 hr in the first 24 hr 5. Pulsed U.S: 1 or 3MHz, int. 0.5 w ∕cm2, 3-4min for 2-3 session 8. Varicose veins: Are swollen and enlarged veins that usually occur on the legs and feet. Causes: 1. Progesterone effect on smooth muscle of venous wall hypotonia 2. intra-abdominal pressure 3. Pregnant uterus pressure on pelvic veins + edema in lower limb Management: 1. Avoid prolonged sitting and standing. 2. Avoid sitting with crossed legs during feeding. 3. Wearing below knee support stocking before ambulation. 4. Mother →supine, elevate legs on pillow, 10-15 min, 3-4 times ∕day. 5. Bandaging. 6. Burger ex. 7. Intermittent compression. Buerger's exercise are active free exercises depend on the effect of the gravity on the smooth muscles of the valves. aimed to improve leg and feet circulation. Description 1. the patient lies supine with legs elevated from 45 degrees until the skin turns pale, it will take approximately 2 minutes to occur and this time varies from one individual to another. 2. the patient sit at the edge of the plinth with feet hanging and doing the following exercises; dorsiflexion, plantar flexion, inversion, eversion, and flexion the extension of toes, this phase may also be maintained for 2 minutes. 3. the patient lies flat with his leg rested in a horizontal position and covered with a warm blanket for about 5 minutes.  30 sec inflation(60mmHg), then 20 sec deflation(20mmHg) for 20 min 9. DVT or SVT: Venous thrombosis occurs in superficial and deep veins of the lower extremities, Deep thrombi are most likely to develop in soleus muscle of calf muscle. symptoms of DVT include: tenderness throbbing pain – if the clot is in your leg, pain is usually in the calf or thigh when walking or standing up, and pain may be worse when you bend your foot upwards towards your knee a heavy ache in the affected area red or darkened skin around the painful area – depending on your skin tone this may be difficult to see warm skin around the painful area swollen veins that are hard or sore when you touch them Prophylactic ttt: 1. Early ambulation 2. Circulation, leg, breathing ex 3. Avoid pressure on thigh, calves. 10. Hemorrhoids: Varicose veins in and around anus. Occurs during pregnancy and childbirth. Causes: 1) Pressure of carrying a baby stress on the blood vessels in pelvic area. 2) During 2nd stage, Straining to push the baby out pressure on these blood vessels + prolapse of these veins 3) Constipation further ballooning. Management: 1. Ice packs for 10-20 min 2. PEME 3. Prevent constipation: water, fiber, ambulation. 11. Coccydynia: - Pain in the coccyx and sacral area. - Coccyx is articulated with sacrum by fibrocartilaginous disc supported by lateral ventral and dorsal sacrococcygeal ligaments. Causes: 1- passage of fetus through the birth canal →can cause trauma to this region. 2. The laxity→ coccyx move backward as parturition take place. 3. Using forceps (fracture, soft tissue damage) Problems: 1. Stretching or rupture of ligaments with or without displacement of coccyx 2. # of sacrococygeal joint with or without displacement of coccyx 3. Neuritis of coccygeal plexus Management: 12. Back pain: Is a common postnatal complaint. pain located in posterior pelvic and lumbar areas. Causes: 1. The physiological and biomechanical changes caused by pregnancy. 2. Trauma during labor and delivery. 3. Lack of postural control and stability during the early post- partum days. 4. Secondary to urinary tract infection or post delivery uterine contraction. Management: 1. Gentle mobilization, paraspinal massage. 2. Heat application. 3. Treatment of secondary causes. 4. Strength for abdominal and back muscles 5. Postural correction (advices and exercises). 6. TENS paraspinal. 13. LBP and sciatic pain: Sciatica refers to pain along the course of the sciatic nerve. The sciatic nerve travels from the lower back through the hips and buttocks and down to the leg. 1. U.S: Heating, micro massage effect → pain, muscls spasm, Circulation. Applied paravertebral. Pulsed & continues mode Freq (1 or 3 MHz), int. (0.5-1 w∕cm2), 3-5 min. 2. TENS. 14. The Carpal Tunnel syndrome -Carpal tunnel is a narrow passageway in the wrist. - Floor and sides are carpal bones. -Roof is transverse carpal ligament. -The flexor retinaculum serves to protect nine flexor tendons and median nerve as they pass through the carpal tunnel. Carpal tunnel syndrome - occurs when the tunnel becomes narrowed or when tissues surrounding the flexor tendons swell, putting pressure on the median nerve. This abnormal pressure on the nerve as a result of water retention and edema during pregnancy. Symptoms: - pain, numbness, tingling, and weakness in the hand. pain severity increase with carrying heavy objects , repetitive hand and wrist movements. Management: 1-Avoid sleeping on the affected side 2- Wear night splint to maintain neutral position on the wrist 3- Exercise (active ROM ) to ↑ circulation and ↓ edema 4-Electrotherapy: TENS : Electrodes placement above and below wrist, 80- 120Hz Ice: 15min Contrast bath: 40-50 C for 3min, 15 C for 1min, for 15min Ultrasound: 5-10 min 15. De Quervain syndrome: Is a painful condition that affects the tendons of the extensor pollicis brevis and abductor pollicis longus muscles in your wrist around the base of your thumb. The swelling or overuse or trauma causes the sheaths covering the tendons to become inflamed. This puts pressure on nearby nerves causing pain and numbness. Management: 1-Resting of the wrist. 2-Using splint to minimize movement. 3- TENS ,US, ICE application to relief pain decrease inflammation and edema. 16. Maternal fatigue Postpartum maternal fatigue can be conceptualized as a multidimensional concept with physical, emotional and cognitive aspects. Physical →feelings of tiredness or exhaustion. Emotional → feelings of anxiousness or depression cognitive → feeling unfocused or unmotivated Management: Relaxation training : to↓pain Social support Massage session 17. Postpartum depression: A type of depression that happens after having a baby. Women with postpartum depression experience emotional highs and lows, frequent crying, fatigue, guilt, anxiety and may have trouble caring for their baby. Causes: 1.Hormonal: After delivery, the drop of (estrogen and progesterone) leads to chemical changes in her brain trigger sever mood swings. 2. Lack of sleep. 3. Anxiety about woman ability to care for a newborn. 4. Self-image. woman may feel less attractive, struggle with her sense of identity. Management: Postpartum depression is treated differently, depending on the type of symptoms. 1. Anti-anxiety or antidepressant medications, psychotherapy. 2. Aerobic exercise → ↑concentration of brain nor epinephrine, serotonin. 3. Follow a suitable diet. 4. Avoid alcohol and caffeine. 5. Keep in touch with family and friends, don’t isolate yourself. 6. Relaxation techniques Thank you