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. 1st 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:

• Avoid prolonged standing and prolonged sitting.• Apply well-fitted below knee support stockings (20 - 40 mmHg) before

ambulating in the morning.• Ask the mother to elevate her legs on pillows while taking supine lying

position for 10 - 15 minutes for 3 - 4 times daily.• 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.

• Bandaging.• 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.

• 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.

Feeding difficulty: Breast Engorgement

Engorgement is defined as an uncomfortable swelling of thebreasts associated with increased milk secretion and usuallyoccurs from the second to fourth day post natal. There may belymphatic and vascular congestion and possible interstitial edema,causing swelling and tenderness. This exacerbates the tension ofmilk in the ducts and may cause stasis of the milk, resulting ininability of the milk to flow. This swelling and hardness may make itdifficult for the baby to attach to thenipple and problems can befurther aggravated by nipple soreness.

Management of breast engorgement:

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

2. Elevate the breasts by supporting brassieres.

3. Medical treatment as antibiotics and others to diminish milk

secretion.

4. Electrotherapy.

8) Diastases 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.

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 ofcoccydynia.

11) Symphysis pubis pain:

It is a pain in the symphysis pubis which occurs duringpregnancy and continuous after delivery. Also, it is resultedfrom 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:• Decrease the risk of deep venous thrombosis and pulmonary

complications due to enforced bed rest, by circulatory, leg and breathing exercises.

• 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

13) 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.

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.

14) 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.