Puerperium PDF - 2023-2024

Puerperium  PRESENTED BY  Dr. Noha Ahmed Fouad  PREPARED BY  Dr. Noha Ahmed Fouad  Lecturer of physical theapy for gynecology and obstetrics  Badr University  2023-2024 OBJECTIVES By the end of the lecture the student should be able to: Recognize the difference between normal and abnormal pue...

Puerperium  PRESENTED BY  Dr. Noha Ahmed Fouad  PREPARED BY  Dr. Noha Ahmed Fouad  Lecturer of physical theapy for gynecology and obstetrics  Badr University  2023-2024 OBJECTIVES By the end of the lecture the student should be able to: Recognize the difference between normal and abnormal puerperium. Assess the problems of the woman postpartum. Plan a physical therapy program for each problem. NORMAL PUERPERIUM It is the period of adjustment after pregnancy and delivery at which the anatomical and physiological changes of pregnancy are reversed and the body returns to the non-pregnant state. CLASSIFICATION 1.Immediate puerperium ( First 24 hours) 2.Early puerperium ( Till 1st week post partum) 3.Remote puerperium ( Through 6 weeks post partum) time required for involution of genital organs 1- POSTPARTUM CHILLS Immediately after labor, the woman is in state of physical fatigue, slight shivering, muscular tremors and teeth chattering for 10-15 minutes and may last for 2 hours. This is normal response of the body because of the sudden drop in hormones, fluid loss and endorphins release. 2- TEMPERATURE Reactionary rise of body temperature not exceed 38.5 °C during first day post partum. If more than 38 °C and persist more than one day it is known as puerperal pyrexia. 50-100 gm in non-pregnant By 1st week PP ( size of 12 week pregnant uterus) Just palpable at symphysis pubis 1 kg immediately 3UTERINE INVOLUTION after labor (size 1000 gm full term of 20 week pregnant uterus) At level of umbilicus By end of 6th week PP (less than 100 gm) Normal Pattern of Uterine Involution  a) b) c) d)  Assessed by FUNDUS LEVEL TEST. After labor by 1 hour, fundus is palpated at the level of umbilicus. After 24 hours, fundus is palpated below umbilicus by about 2 cm. After 1 week, fundus is palpated midway between umbilicus and pubic bone. After 2 weeks become not palpable at the abdomen. By the end of 6th week, it becomes pelvic organ. Causes of sub-involution of the uterus  Retained placental fragment  Infection  Overdistension of the uterus  RVF  Non-suckling  Multiparity  Fibroids  Bad general condition and anemia 4- Decidua  It is shed off and discharge of lochia leaving basal layer from which regeneration of endometrium occurs 1st 3-4 days is red color (lochia rubra). After 4 days become pink then yellow (lochia serosa). After complete healing of placental site, it becomes white in color ( lochia alba). 5- AFTER PAINS It occurs during first 2-3 days post partum due to strong uterine contractions resulting from involution of the uterus. Most common in multiparas than primiparas. ▪ This pain is accentuated during suckling due to release of oxytocine hormone How to manage after pain? ▪ Analgesics. ▪ Hot packs. ▪ TENS (V shaped over the lower abdomen the same parameters in normal labor) ▪ Frequent urination every 2 hours. ▪ Daily time rest (Relaxation on face). (10-30 minutes twice daily for first 3 days ) Values of daily time rest:  It is a relaxed position  Relief  Help discharge of blood clots and lochia  Guard  Help after pains against RVF involution of the uterus 6- Cervix and vagina  Bruised and swollen with minor lacerations.  The os admit 1 to 2 fingers up to 48 hours postpartum. By the end of 1st week it should not pass 1 finger through the internal os. The vaginal wall regains its tone Minor laceration are common but heals rapidly 7- The muscular wall of the pelvic organs By the end of puerperium, abdominal and pelvic floor muscles regain their tone. Involution of abdominal muscles may require 6-7 weeks. 8- Breast and lactation Prolactin hormone initiates milk secretion.  1st three days postpartum, breast secretes colostrum (high protein and vitamins, less fat and carbohydrates). It is important to put the baby to the breast to promote bonding between the mother and baby. 9- Excretory function Constipation is common due to : Dehydration during Laxity labor of abdominal muscles Immobility Reflexly of women from perineal laceration Hormonal effect (Relaxine and progesterone) Cont: Excretory function Urinary retention is common due to : Immobility of Trauma to Reflexly women the sphincter from perineal trauma 10- Psychological changes  Post  Mild partum depression is called BABY BLUES. degree of depression and emotional liability are common and usually last for few days postpartum and need only reassurance. ABNORMAL PUERPERIUM AND POSTNATAL PROBLEMS 1. Perineal pain  Both episiotomy and perineal laceration are associated with presence of perineal pain postpartum immediately till 3 months after delivery.  Hidden perineal lacerations: Levator ani muscle may be injured without apparent tear in vaginal mucosa resulting in subsequent prolapse. Management of Perineal Pain A) Acute perineal pain: 1) Analgesics 2) Cryotherapy Ice pack for 4-5 min is effective in relieving pain. It relief edema and decrease NCV. 3) Ultrasound Pulsed, low intensity: 0.5-1 w/cm2 , duration: 5 minutes. Under water or water filled condom. 4) Pulsed electromagnetic energy (PEME)  collagen and fibrin deposition, swelling and inflammation. Non-direct contact, frequency: 27 MHz, pulse rate: 100 pulse per second, duration 10-15 minutes. 5) Low level laser therapy LLLT It promotes healing through: o Enhance immune system o Enhance protein synthesis o Accelerate the inflammatory phase of healing o Bactericidal effect It decreases pain through: o Increase serotonin metabolism o Increase beta endorphin o Decrease prostaglandins o Decrease nerve conduction velocity B) Chronic Perineal pain Perineal pain that lasts over weeks or months or dyspareunia is treated with: at frequency 3 Hz, Intensity 0.5-1 W/cm2 , Duration 5 minutes for 8 sessions. U.S. It increases the extensibility of collagen bands on the surface of the scar.  BOTH U.S & PEME ARE THE BEST CHOICE IN TREATING CHRONIC PERINEAL PAIN. 2. Symphysis pubis pain It is resulting from laxity of the ligaments and separation of the joint during pregnancy in addition to separtation between two recti Management: 1) Ice packs: over symphysis pubis for 10-15 minutes every 2 hours in 1st 24 hours postpartum. 2) U.S. 3) Static abdominal exercise before movement around bed. 4) Pillow placed between knees to make rolling. 5) Trochanteric belt. (IMPORTANT NOTE) The patient should be advised to rest for 20 minutes because U.S. effect may increase elasticity of collagenous tissue which is already soften from the effect of relaxin hormone. 3. Back pain  Causes of low back pain Postural Hormonal Ligamentous Referred from uterine contractions Management of back pain  Hot packs  Ultrasound: Continous, 1.5 w/cm2, 1 MHz, 10 minutes, 3 times/week.  Gentle massage.  TENS.  Manual therapy techniques: to correct alignment and alleviate pain by: ✓ Mobilization (high amplitude and low velocity motion of the spine). ✓ Manipulation (low amplitude and high velocity motion of the spine). Core stability exercises ✓ To train the muscles supporting the trunk include abdominal, back, pelvic floor and diaphragm. ✓ These muscles should work together in a balanced manner to avoid collapse of the spine. ✓ It involves activation of transverse abdominis and multifidus of the back.. Kinesio-taping: ✓ It supports muscles and joints ✓ Improves the function of the fascia and its position. ✓ Activation of blood and lymph by skin lifting. ✓ Deactivate pain by decrease the nociceptive stimuli. ✓ Is applied when lumber flexion reaches it’s maximum point using 50% stretch. Application of KT on lower back: 4. Diastasis recti (Divarication) It is the natural separation of rectus abdominis muscle during pregnancy resulting from the overstretch of abdominal muscles due to gravid uterus. It returns normal postnatal during puerperium. It is considered abnormal when the gap between the two recti exceeds 2.5 fingers, which indicates weakness of abdominal muscles. It is performed after 3 days postpartum in normal labor, and after 6 days postpartum in cesarean section delivery. Prevention of diastasis recti is achieved by keeping the core muscles strong antenatal and postnatal. Management of diastasis recti: Prevention of diastasis recti is achieved by keeping the core muscles strong antenatal and postnatal. a. Pelvic floor exercise. b. Abdominal exercises (Beginning with core stability). c. Electro therapy in the form of: ❖ Faradic stimulation  From supine lying, apply low frequency current 50-100 Hz, for 30 minutes, 3 times per week for 8 weeks.  By using 4 electrodes applied 2 cm paramedian, above and below the umbilicus. ❖ High voltage pulsed current Using six electrodes. Parameters: Frequency:100 Hz, Intensity: maximum tolerated, Duration: 30 minutes, three times per week for 8 weeks. Kinesio-tape for rectus diastasis: Using facilitation technique to increase muscle tone in the form of herringbone technique. 5. Breast disorders 1- Breast engorgement  Uncomfortable swelling of breast associated with increased milk secretion.  It is due to lymphatic and vascular congestion causing swelling and tenderness leading to milk stasis.  Resulting in difficulty of latching nipples.  From 2nd to 4th day postpartum. Management of breast engorgement 1. Emptying breast either manually or by pump. 2. Elevate the breasts by suitable supporting bra 3. Heat application before feed to increase blood flow and move fluids. 4. Cold application between feeds to decrease congestion and swelling. 5. Ultrasound: Continous mode  Heating effect which increases circulation and decrease pressure on milk ducts, improving milk flow.  The head firmly over the breast from the periphery toward areola for 2-3 sessions to break the cycle.  Parameters: F: 1 MHz, I: 0.5 W/cm2 for 10-15 minutes.  Feed the baby immediately within 20 minutes to gain the maximum benefits. 6. Cabbage leaves 7. Breast Massage 2. Mastitis  Infective mastitis  Resulting in swelling, pain, redness and fever and often associated with cracked nipples.  Mostly by staphylococcus aures bacteria.  After 1st week postpartum and before the end of 2nd week.  Another peak at 5-6 week postpartum. Management of Mastitis 1. Antibiotics 2. Stop breast feeding but express milk gently at feeding time. 3. Support the breast with uplifting breast binder. 4. Pulsed U.S. at F: 1 MHz, I: 1.5-21 W/cm2 for 1-2 minutes for 10 cm2 3. Blocked ducts  Non-infective mastitis.  Occurs at any time during breastfeeding.  Occurs as lump and tenderness with erythema.  Treatment: Continuous U.S., F: 1 MHz, I: 1.5-2 W/cm2 , for 1-2 minutes /10 cm2. 4. Scanty milk production  The amount of milk produced may be insufficient to breastfeed the baby.  Occurs at any time during breastfeeding.  Laser therapy.  Bilateral acupressure on acupoints of SI1, LI4, and GB21, three sessions per week with each session conducted 2-5 times. 6. Hemorrhoids  These are varicose veins in and around the anus and anal canal and often prolapse after labor.  MANAGEMENT: ▪ Ice packs for 10-20 minutes from prone lying. ▪ PEME when the hemorrhoids are thrombosed. 7. Epidural site pain  It produces small amount of hematoma in supraspinous ligament following injection.  Management: To decrease the local swelling and maintain mobility by: 1. Mobilization exercise of the back 2. Electrotherapy modalities 8. Spinal Headaches  The puncture of dura resulting in leakage of small amount of CSF into the epidural space that causes headache.  Management: - Decrease risk of circulatory and pulmonary complications by breathing and circulatory exercises. - Strengthening program while the mother lie in bed. 9. Paralytic ileus Early ambulation. b. Passive exercise of the lower limbs and trunk. c. Static abdominal exercise. d. Thermotherapy. e. Short wave diathermy for one hour twice a day return the bowel sounds in shorter time. a. 10- Carpal tunnel syndrome AS a result of fluid retention and edema: - Refrain from sleeping on the affected side if the condition unilateral and elevate the part. -Wear a night splint to maintain a neutral position of the wrist. - Exercise the wrist and hand after a period of rest to increase circulation and reduce edema. - Electrotherapy ( laser, Ultrasound, hot packs) 11- De Quervin tendonitis Pain over the styloid process of the radius - Resting of the wrist. - The use of the splint during the day to decrease movement and friction at styloid process that affected. - Electrotherapy as in carpel tunnel syndrome. - Local injection of hydrocortisone.