Role of P.

T in
Puerperium

lecture7
Prof. Dr. Ghada Elrefaye
 ILOS
1- Define Purperium and it’s types.
2- Identify common changes during purperium.
3- Management of common postnatal problems.
I- a) Definition of purperium:
Purperium is defined as 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.
 I- b) Types of purperium:
1- Immediate purperium:
The first 24 hours after delivery at which acute post anesthetic and post
delivery complications may occur.

2- Early purperium:

The first week postpartum

3- Remote purperium:
the period required for involution of genital organs (6 -8 weeks)
2- Common changes during purperium.
1- Temperature:
Immediately → shivering, muscular tremors for 10-15
m.

Temperature → slight rise (reactionary rise) not

exceed 38⁰.
If it rise more than 38⁰ or persist (puerperal pyrexia)
 2- Uterine involution:

It is the return of the uterus to it’s normal size, weight and

site within 6-8 weeks post-partum.

a- Size ( From 32 cm to 7 cm).

b- Weight (From 1000 g to 50 g).

c- Site or position ( From abdomen to pelvis).

 Normal pattern of uterine involution:

Uterine involution can be assessed by fundus level test.

a- Immediately after delivery the fundus palpated at the level of
the umbilicus.
b- After 1 week the fundus palpated midway between the
umbilicus and pubic bone.
c- After 2 weeks become not balbable at the abdomen (behind the
pubic bone).
d- By the end of 6-8 week become completely pelvic organ.
 Uterine sub-involution:

It is delay of the return of the uterus to it’s

normal size, weight and site after delivery.
 Causes of sub involution of the uterus
1- Retained placental fragment.
2- Retroversion flexion of the uterus.
3- Non-suckling (Absence of breast feeding).
4- Over distension of the uterus (Twins, hydrominos).
5- Multiparty.
7- Infection.
8- Fibroid.
 AFTER PAINS :

• After Pains occur during the first 2-3 days of the puerperium and are
more common in multiparas than primiparas. Such pains are
accentuated during suckling as a result of oxytocin release from the
posterior pituitary.
 3- The lochia:

There is discharge of blood, cervical mucus, non pathologic

bacteria and vaginal epithelium following delivery.
a- for the first 3-4 days is red in color → lochia rubra.
b- After 4 days become pink in color → lochia serosa.
4- Cervix and vagina:

The cervix and vagina recovered rapidly and both

return to the non pregnant state (closed) by the end of

purperium.
5- The muscular wall

By the end of purperium both pelvic floor and

abdominal muscles regain their tone.
6- The breast and lactation:

Under the effect of placental lactogen, the

prolactin level increase and the breast size increase

during pregnancy and purperium as preparation for

milk secretion.
 7- Execratory function:

constipation and urinary retention are common

condition during purperium due to
a- Immobility of the lady.
b- Hormonal effect (relaxin & progestron).
c- Reflexly from perenial trauma.
8- Psychological changes:

Mild degree of depression and emotional

disturbance are almost in the purperium, but
may present in some cases and require
psychiatric support.
9- Cardiovascular system:

- Cardiac output and plasma volume return within the

first week postnatal.
- During the first 10 days after delivery, there is an
increase in the clotting factors that is associated with a
higher risk of DVT, pulmonary embolism.
3- Management of common postnatal problems:

(Abnormal purperium and postnatal

problems)
 1- post partum hemorrhage(PPH):
a- primary: bleeding from genital tract of 600 ml or
more in first 24 hours following delivery.

b- Secondary: bleeding from genital tract after first 24

hours following delivery till the end of purperium.
N.B. (PPH is contraindicated for postpartum exercises
program).
 2- perenial pain:

It is due to trauma of perineum during

childbirth (Perennial laceration) or due to
episiotomy.
 Management of perennial pain:
1- Analgesic.
2- Ice application.
3- Pelvic floor exercises.
4- Use of appropriate cushion when sitting.
5- Teach the mother correct defecation by supporting
the wound.
6- Electrotherapy
 Ice application

Ice applied as ice pack for 4-5 minute or ice cube

massage for 2-3 minute. Ice relief edema and ↓ NCV.
Electrotherapy:
a- Ultrasound (US).
b- Low level laser therapy(LLLT).
c- Pulsed electromagnetic energy(PEME).
d- infrared(IR).
 a-Ultrasound (US):

Pulsed US ( 0.5-1 W/cm²) is applied for 3-5

minute either using to ↑ circulation & ↓ pain.
 b- Low level laser therapy:
The probe should be held vertical without direct contact
to the tissue at 1 cm intervals along the wound with the
following parameters.
a- Pain relief: 0.5-4 J/cm² & frequency > 1000 Hz.
b- Wound healing: 0.5-4 J/cm² & frequency ˂ 1000Hz.
c- Scar tissue : 4-6 J/cm² & frequency > 1000 Hz.
Mechanism of action LLLT to relief pain:

1- Increase serotonin metabolism.

2- Increase Beta endorphin.

3- Decrease Prostaglandin.

4- Decrease nerve conduction velocity.

5- Increase distal latency.

 Mechanism of action LLLT to promote wound healing.

1- Enhance immune system by ↑ IgG.

2- Accelerate the inflammatory phase of healing process.

3- Enhance protein synthesis (DNA & RNA).

4- Has bactericidal effect.

 c- PEME:

It is used without direct contact at frequency 27

MHz, pulse rate 100 p/s, pulse width 40-65 ms for 10-
15 minute.
Mechanism: a- ↓swelling & inflammation.
b- ↓ hematoma.
c- ↑ fibrin & collagen deposition.
N.B. Both US & PEME are clinically effective for treating
chronic perineal pain.
 d- Infrared(IR):
Exposure for 10-20 minutes twice a day
may help surface healing but not affect the
healing of deeper tissues.
N.B. IR is contraindicated if haemorrieds are
present.
 3- After pain:
It is abdominal cramp like pain following delivery
due to strong uterine contraction as attempt for
uterine involution.
This pain lasting for 2-3 days and ↑ by breast feeding
as suckling of the baby stimulate uterine contraction
due to release of oxytocin hormones from posterior
pituitary gland.
 Management of after pain:
1- Analgesic.
2- Heat application.
3- Daily time rest (relaxation on face).
4- TENS application.
 • Relaxation on face (Daily time rest).
• 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. 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.
Duration: for 10-30 minutes twice daily.
 TENS application to relief after pain:
TENS application in V shape at the lowr
abdomen with frequancy→ 80-120 Hz,
pulse width→ 150 ms & duration → 1
hour/day will relief after pain through gait
control theory & opiate mechanism (release
of endorphin and encephalin.
 4- Back pain:
Causes of low back pain:
1- Postural changes during pregnancy.
2- Spinal muscles spasm.
3- ligamentous strain.
4- Trauma during childbirth.
5- May be referred from post delivery uterine contraction.
 Management of back pain:
1- Gentle massage & mobilization of low back.

2- Strengthening exercises for the abdominal and back muscles.

3- Postural correction advices and exercises.
4- Hot back.
5- US (1-3 MHz & 0.5-1W/cm² for 5 minutes).
6-TENS ( 80-120 Hz &150 ms for 1 hour/day) paraspinal on (L2
–S4).
 5- Symphysis pubis pain:
It occurs during pregnancy and may be continuous after delivery due to
separation between both recti by growing baby.
Treatment
1-Stabilization of pelvic joint by trochanteric belt or full pelvic bender
2-Static abdominal exercises before movement around bed
3-Pillow placed between knees to make rolling
4-Ice for 10-15 m every 1-2 hours in the 1st 24 hours.
5-Pulsed US ( 3 or 1 MHz , 0.5 W/cm² for 3-4 minutes ).
N.B. Mother should rest 20 m because U.S increase elasticity of the tissue.
 6- Circulatory problems:
The common circulatory problems are:
1- Deep venous thrombosis.
2- Varicose veins.
3- Hemorrhoids (Varicose veins surrounding anus).
4- Edema of lower limb.
 Causes of circulatory problems:
The common causes of circulatory problems are:

1- hormonal effect ( relaxin & progesterone).

2- Anesthetic effect ( with CS).
3- Immobility of the lady.
 Management of circulatory problems:
1- Avoid prolonged sitting or prolonged standing.
2- Avoid sitting with acutely flexed knee..
3- Apply well-fitted below knee support stocking.
4- Bandaging.
5- Burger's exercises ( circulatory exercises).
6- Elevation of lower limb on a billow for 10-15 minutes for 3-4 times/day.
7- Intermittent compression (30 seconds with 60 mm Hz followed by 30
seconds with 20 mm Hz.
N.B. → DVT is contraindicated for physiotherapy program.
 7- Carpal tunnel syndrome:
It is tingling & numbness of the hand due to compression of the
median nerve at carpal tunnel.
Management:
1- Avoid sleeping on the affected hand.
2- Wear night splint to maintain neutral position of the hand.
3- Active free exercises of the affected hand to ↑ circulation and ↓
edema.
4- Ice pack over the wrist for 15 minutes to ↓ swelling & ↓ pain.
5- Contrast bath:
Place the affected hand on hot bath (40-45C°) for 3 minutes
then on cold bath (15C°) for 1 minute and repeat this cycle 3 times
this will ↑ deep circulation and cause sedative effect.

6- US:
Using US (0.5-2 W/cm² ) for 5-10 minutes will ↑circulation and
↓ pain also US has micro massage effect.

7- TENS:
Using TENS ( 80-120 Hz & 150 ms) by placing one electrode
proximal and the other one distal to write joint will↓ pain.
Any questions?