POST HHTM - kau



Abnormal Puerperium

and Post Natal Problems

1) Post partum haemorrhage (PPH):

Primary PPH is defined as bleeding from the genital tract of 600 ml or more in the first 24 hours following delivery. Such bleeding usually occurs very unexpectedly due to retained placental tissue or birth canal trauma.

Secondary PPH bleeding occurs after the first 24 hours of delivery until the end of the puerperium.

2) Puerperal sepsis:

It is a fibrile changes occurring during puerperium due to invasion of genital tract by pathogenic bacteria.

Sites of infection:

• Wound: mainly the placental site and wounds of the perineum, vulva, vagina or cervix.

• Dead tissue: usually blood clots, and retained placental fragment.

Predisposing factors:

• General: as anaemia, ante partum hemorrhage, post partum hemorrhage, malnutrition and toxaemia.

• Local: as lacerations, sloughing and premature rupture of the membrane.

Signs and Symptoms:

• Headache,

• Raised temperature,

• Vomiting,

• Dry tongue and lips.

Abdominal examination revealed a supra pubic tenderness and rigidity. The perineum, vulva, vagina or cervix are become infected and lochia is foul odour.

Treatment:

The primary goal of treatment is concerning the causes and its predisposing factors for the infection. At this time lactation and physiotherapy program should be stopped until fever disappear.

3) Retained Placenta:

This is described as a placenta still in uterus one hour after birth of the baby and is a common cause of PPH. Manual removal of the placenta is usually carried out under anesthesia.

4) Painful perineum:

This is a result of trauma during childbirth, due to an episiotomy, a spontaneous tear or a combination of both.

Classification of Laceration of the Perineum:

• 1sl degree: Involves the fourchette, the perineal skin and the posterior vaginal wall.

• 2nd degree: Involves the above structure as well as the muscle of the perineal body.

(1S| and 2nd degrees are called incomplete tears).

• 3rd degree: (Complete perineal tear): Involves the above structures as well as the external anal sphincter and it may include the anterior wall of the anal canal or rectum.

Submucous or hidden perineal tear:

The levator ani may be injured without apparent tear in the vaginal mucosa leading to subsequent prolapse.

The swelling and bruising which follow an episiotomy and repair or a tear produce a degree of pain. A haematoma may develop and cause very intense perineal pain. Other causes of perineal pain may include wound breakdown, excessively tight sutures and infection.

Management:

1. Cold baths are more effective than warm baths as warm baths tend to increase oedema and sensitivity to pain. Ice and local analgesics are the most helpful modalities.

2. Epifoam (1% hyclrocortisone and 1% local analgesia).

3. Electrotherapy.

4. Pelvic floor exercises; using a contract-relax technique as an efficient pump mechanism to increase circulation and decrease oedema.

5. Teach the mother the correct defecation technique by using of pressure pad held against the wound during evacuation.

6. Use of an appropriate cushion when sitting.

5) Circulatory problems:

a. Varicose veins:

The development of varicose veins during pregnancy appears to be related to the changes in the maternal blood circulation, the changes induced by the presence of progesterone on the smooth muscle of the venous walls, producing a degree of hypotonia, together with a raised intra-abdominal pressure.

Oedema which is present in lower limbs during pregnancy is aggravated by compression of pregnant uterus on pelvic veins which will predispose to varicose veins in lower limbs. Usually these veins are often painful, fade post-delivery, although they may reappear and increase with subsequent pregnancies.

Management:

1. Avoid prolonged standing and prolonged sitting.

2. Apply well-fitted below knee support stockings (20 - 40 mmHg) before ambulating in the morning.

3. Ask the mother to elevate her legs on pillows while taking supine lying position for 10 - 15 minutes for 3 - 4 times daily.

4. Intermittent compression: The sleeve of the compression machine fits to the affected leg just above the toes to the level of the knee joint. The compression session started with 30 second of inflation exerting pressure on the vein about 60 mm Hg, which is followed automatically by 20 second of rapid deflation at pressure of 20 mm. Hg. The total session time is about 20 minutes.

5. Bandaging.

6. Burger's Exercises.

During feeding, the mother may spend long periods in sitting so she is encouraged; not to sit with legs crossed or knees acutely flexed, to elevate legs when lying or sitting and vigorously exercise her calf muscles during this time.

b. Haemorrhoids:

Haemorrhoids may have been present in the antenatal period as a result of the vascular changes. During second stage of labour, the straining causes a ballooning and in some cases, a prolapse of these veins, resulting in excruciating pain in the perianal area. Surgical management may be necessary if the condition is severe.

Steroid analgesic creams may relief the pain. Cold therapy and pulsed electromagnetic energy relief the pain. Constipation is common in the early puerperium and straining to move the bowels can increase the risk of further ballooning. Also, oral analgesics containing codeine tend to increase constipation.

c. Deep venous thrombosis (DVT) or superficial venous thrombosis (SVT):

Venous thrombosis occurs most commonly in the superficial and deep veins of the lower extremities. Deep thrombi are most likely to develop in soleos muscle of calf muscle.

Prophylactic treatment against DVT or SVT through:

• Early ambulation.

• Avoidance of pressure on the thighs and calves, and sitting position with knees acutely flexed.

• Encouragement of circulatory, leg and deep breathing exercises.

6) After Pains:

After expulsion of foetus and placenta the uterus contracts to regain its normal size, weight and site, this is called involution of uterus.

Oxytocin is released from the posterior lobe of the pituitary gland in response to the sucking of the baby. The role of oxytocin is to facilitate uterine contractions and assists its involution. If contractions are strong the patient will complain of abdominal "cramp like" pains and/ or low back pain.

After pains occur during the first 2-3 days of the puerperium and are common in multiparous than primiparous. During the first 12 hours post partum, uterine contractions are regular, strong and coordinated. The intensity, frequency and regularity of contraction decrease after the first post partum day as involution proceed.

Management:

Analgesics.

TENS.

Frequently urinate every 2 hours to maintain an empty bladder which enables the uterus to work more efficiently with less pain.

Heat application.

Relaxation on face (Daily time rest).

Relaxation on face:

Encourage the woman to lie in prone lying position with two pillows under the pelvis, small pillow under feet, the upper limbs are extended beside the trunk and head turned to one side or the upper limbs are crossed with the forehead rested on crossed hands. The pillows under pelvis are to keep the back from hollowing and so stretching the abdomen (Figure 1).

Duration:

This position is taken for 10 - 30 minutes twice daily. Be sure that the bladder and rectum are empty before taking this position.

Values of relaxation on face:

• It is a relaxed position.

• Help involution of uterus.

• Help discharge of blood clots and lochia.

• Guard against retroversion flexion.

• Relief after pains.

Figure: Relaxation on face position.

7) Feeding Difficulties:

a. Brest Engorgement:

Engorgement is defined as an uncomfortable swelling of the breasts associated with increased milk secretion and usually occurs from the second to fourth day post natal. There may be lymphatic and vascular congestion and possible interstitial oedema, causing swelling and tenderness. This exacerbates the tension of milk in the ducts and may cause stasis of the milk, resulting in inability of the milk to flow. This swelling and hardness may make it difficult for the baby to attach to the nipple and problems can be further aggravated by nipple soreness.

Management of breast engorgement

The breasts are emptied by expressing them manually or by a breast pump.

Elevate the breasts by supporting brassieres.

Medical treatment as antibiotics and others to diminish milk secretion.

Electrotherapy.

b. Mastitis:

Mastitis occurs after the first week post partum and before end of 2nd week post partum and another peak at 5 - 6 weeks post partum. Mastitis is a clinical term which describes a range of inflammatory disorders of the breast.

Infective mastitis is most commonly caused by the bacteria staphylococcus aureus. It causes cellulitis of interlobular connective tissue resulting in pain, swelling, redness and fever. The axillary glands of the same side are usually enlarged and tender. It is often associated with cracked and fissured nipples allowing bacteria to enter the breast from the nipple. If an abscess is formed, it is incised.

Management:

Antibiotics.

Stop breast feeding but express milk gently at feeding time.

Support the breast with uplifting breast binder.

Electrotherapy.

c. Blocked ducts:

Obstruction of ducts can occur at any time in the breast-feeding period. Anything that disrupts normal breast drainage can be a risk factor, e.g. bruising, finger compression and hurried or infrequent feeds. It usually occurs as a tender lump and erythema and may called non-infective mastitis.

Management:

- Feeding from the affected breast first.

- Massaging the breast downward toward nipple before the feeding.

- Electrotherapy.

8) Diastasis of recti abdominis muscles (DRAM):

DRAM is a condition in which the rectus abdominis muscle separates in the mid-line at the linea alba. The diastasis is defined as a gap between the recti abdominis muscles of greater than 25 mm (2.5 fingers), palpated just superior to the umbilicus. The separation of linea alba may occur during pregnancy or in the expulsive stage of labour

Assessment by Ractus diastasis test

This test can be done by the mother herself or by the therapist.

Position of mother: crock lying position.

Position of therapist: Stride standing position at the level of the waist line with the four fingers are fitted vertically across the linea alba between xiphoid process and umbilicus.

Procedure: Ask the mother to raise her head and shoulders off from the plinth until the spines of the scapulae left the plinth, while, the therapist measures the diastasis by turning her fingers horizontally across the linea alba between xiphoid process and umbilicus to determine how many fingers fit into the space between the borders of the two rectal bellies.

The palpation should assess the following:

Width and length of any recti separation.

Region of greatest diastasis.

Bulge of the abdomen on recti contraction.

The woman's ability to activate abdominal musculature.

The endurance capacity of abdominal musculature.

Treatment:

Static abdominal exercises.

Graduated dynamic abdominal exercises,

9) Back pain:

Back pain is a very common postnatal complaint. The pain is most frequently located in the posterior pelvic and lumbar areas, also cervical and thoracic pain following delivery and in the immediate post delivery period.

Hormones released in pregnancy lead to ligamentous laxity which affects the biomechanics of the pelvic girdle and the vertebral column. The laxity of these ligaments may remain for some time after delivery despite the decrease in hormonal levels at birth. Relaxin levels return to its normal values three days post partum, but the effects of relaxin take up to three months to return to normal.

Causes of postnatal back pain:

Altered physiological and biomechanical state due to pregnancy.

Trauma during labour and delivery.

Lack of postural control and stability during the early post partum days.

Back pain can also be experienced due to post delivery uterine contractions during breast feeding.

Urinary tract infection will refer pain to the back.

Treatment:

Gentle mobilization if restricted joint movement.

Strengthening exercises for the abdominal and back muscles.

Postural correction advices and exercises.

Electrotherapy.

10) Epidural site pain:

Local pain can be present over epidural insertion sites, due to small amount of haematoma present in supra spinous ligament following the injection into body tissue.

Management:

Aims of treatment are to decrease local swelling and to maintain mobility by:

• Gentle controlled back mobilizing exercises (e.g. pelvic rocking and hip rotation).

• Electrotherapy as treatment of coccydynia.

11) Symphysis pubis pain:

It is a pain in the symphysis pubis which occurs during pregnancy and continuous after delivery. Also, it is resulted from birth.

Treatment:

* Stabilization of the pelvic joints by using trochanteric belt or a full pelvic bender.

* Static abdominal exercise is encouraged before movement around the bed.

* A pillow may be placed between knees to make rolling over more comfortable.

* Reduction of pain by electrotherapy.

12) Headaches:

Spinal Headaches:

The accidental puncture of the dura and the resultant leaking of the cerebrospinal fluid into the epidural space can give rise to severe headache. Symptoms aggravated by the upright position and relieved when the patient lies down. A mother who experiences a spinal headache is very distressed by this condition, as it has a spontaneous onset and she is unable to respond immediately to her baby's needs.

Physiotherapy Treatment:

1. Decrease the risk of deep venous thrombosis and pulmonary complications due to enforced bed rest, by circulatory, leg and breathing exercises.

2. Keep her physically comfortable by strengthening program while the mother lies in supine position.

13) Maternal Fatigue:

The demands on an inexperienced mother give rise to nervous tension and fatigue. Labour and delivery can also be an exhausting experience.

Management:

- Relaxation to alleviate the tension.

- Massage sessions.

14) Carpal tunnel syndrome:

Rarely post partum women develop carpal tunnel syndrome. Those complaining of the condition in the early days post delivery have usually been troubled by it during pregnancy as a result of fluid retention and oedema.

Management:

1. Refrain from sleeping on the affected side if the condition is unilateral and elevate the part if possible.

2. Wear a night splint to maintain a neutral position of the wrist.

3. Exercise the wrist and hand after a period of rest to increase the circulation and reduce oedema.

4. Electrotherapy.

15) De Quervain's tendonitis:

De Quervain's tendonitis is the painful wrist condition most frequently seen in the late postpartum period after the mother has been carrying her baby for some time.

It is characterized by pain over the styloid process of the raduis. Certain recurrent movements of the wrist, during carrying a baby, may cause excessive friction in this area and resultant pain.

By examination, local tenderness is felt over the site where the extensor and abductor tendons of the thumb cross the radial styloid process. Thickening of the fibrous sheaths occur, due to water retention during pregnancy which cause compression on the tendon, and a nodule may be palpated.

Treatment:

1. Resting of the wrist is advised.

2. Use of a splint during the day to minimize movement and friction at styloid process.

3. Electrotherapy as in carpal tunnel syndrome.

4. Local injection of hydrocortisone.

16) Coccydynla:

Coccydynia is the term used to describe a painful coccyx and neighbouring sacral area. The coccyx is loosely articulated with lower border of the sacrum via fibrocartilaginous disc supported by lateral, ventral and the dorsal sacrococcygeal ligaments. The mobility increases in this articulation during pregnancy. This laxity allows the coccyx to move backwards as parturition takes place.

Causes of coccydynia in postnatal period:

The passage of the foetus through the birth canal can cause acute trauma. This can be aggravated by forceps delivery.

Types of problems include:

- Stretching and/or rupture of the supporting ligaments with or without posterior displacement of the coccyx.

- Fracture of the ankylosed sacrococcygeal joint, with or without displacement of coccyx.

- Exacerbation of a previous coccygeal injury.

- Soft tissue damage, including neuritis of the coccygeal plexus.

Clinical findings

a. The patient complains of tail bone pain on:

• Sitting.

• Arising from chair after prolonged sitting for feeding both herself and her baby.

• Changing position, particularly getting in and out of bed.

• Standing, walking and forward flexion movements.

• Defaecation and coughing.

b. The patient sits down slowly and carefully, often shifting her weight from one buttock to the other. Usually the sitting posture is poor.

c. Pain is increased on palpation over the sacrococcygeal or coccygeal joint sites.

Treatment:

1- Demonstrate the proper techniques for getting in and out of bed.

2- Demonstrate comfortable positions for resting as:

• Side lying (this is also good position for feeding).

• Prone lying is also a good position to perform gluteal and pelvic floor exercise and for application of electrotherapy treatments.

3- Electrotherapy.

4- Pelvic floor exercise. Discontinue the exercise if symptoms increase.

5- Advice for normal bowel habits, particularly prevention of constipation.

6- Avoid forward flexion movements and lifting.

17) Urinary retention:

Is a common problem in the immediate puerperium and may result in overflow incontinence. The major cause of retention is pain from the perineum and partially due to the sudden decrease in intra abdominal pressure; the bladder has responds less readily to the stretch reflex caused by its filling.

Traditional methods of encouraging micturation include:

* Early ambulation.

* Hot baths.

* Relief of perineal pain by analgesic drugs and electrotherapy.

18) True incontinence:

Is a rare complication and is usually associated with a vesico-vaginal fistula resulting from pressure necrosis during obstructed labour or following direct injury to the bladder. After repair physiotherapy program is applied for such cases aiming to strength pelvic floor muscles as in cases of incontinence.

19) Faecal incontinence:

May occur following a third degree perineal tear where a recto-vaginal fistula is present. Some faecal incontinence may occur where the external anal sphincter is damaged.

Surgical closure is necessary which is followed by physiotherapy program to strength pelvic floor muscles.

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