FEATURES OF RECOVERY TREATMENT OF POST-PARTUM INJURIES OF THE PERINE

The article submitted research materials dedicated to restorative treatment and rehabilitation of patients who have undergone traumatic labor with rupture of the perineum I-III degree. Representing some set of methods and means of rehabilitation, and are described in detail proved particularly practical application of methods aimed at restoring and strengthening the perineum, especially the pelvic floor muscles. Practical recommendations on the use of physical therapy, special physical exercises as outpatient rehabilitation treatment, as well as at home.

The purpose of the article is to cover the practical aspects of the use of rehabilitation and restoration treatment in patients with the consequences of ruptures of the crotch of I-III degree arising in childbirth at different stages of postpartum rehabilitation.

A study on the use and effectiveness of the proposed approximate complex of methods and means of rehabilitation, during recovery treatment in patients with ruptures of the crotch of I-III degree obtained during childbirth, was carried out on the basis of the female consultation of the Komonalnal Institution "Central City Hospital" New Kakhovka, Kherson. regions, Ukraine, from January 2022 to July 2022. All patients who participated in the study gave their voluntary consent to participate in it. When conducting this study and writing an article, the author used methods such as questionnaires, followed by a critical analysis of the results, literary and critical analysis of available sources of information on the issue under study, the method of mathematical statistics of the research results.

The obstetric traumatism of the soft tissues of the perineum and its adverse consequences for the woman’s body have always been a problem of obstetrics [1]. The rupture of the perineum is damage that can occur due to a significant stretch of the birth canal of the future mother due to severe pressure on the muscles of the pelvic floor during childbirth. This is the most common type of birth injuries of the mother and complications of the birth act, which is more often found in primitive. [2]. The restoration of the anatomical and functional integrity of the perineum in women who have undergone ruptures in childbirth is one of the urgent problems of modern obstetrics. According to these available sources of information, the frequency of generic injuries of the crotch tissue does not tend to a decrease and, according to domestic and foreign authors, is 10.2–39% [3]. Gaps of perineum of the III degree range from 0.4 to 5% [4]. It has been proved that the inferior healing of the crotch wounds leads to a weakening of the vulvar ring, the muscles of the pelvic floor, subsequently leads to the occurrence of cicatricial deformation of the vulva, gaping of the sexual slit, omission and loss of the pelvic organs, violation of their function and trophism (M.E. Selikhov, M . Kotovskaya, 2009; S.G. Sultanova, 2010).

In total, 73 patients took part in the study. Their average age was 29.3 ± 1.04 years. In 48 (65.75%) these were the first birth, in 21 (28.77%) - the second birth, in 4 (5.48%) - third or more birth. All of them before childbirth went through a complex of preparatory classes in the conditions of a antenatal clinic. The distribution of degrees of crotch ruptures in patients of the studied group revealed the following: ruptures of the perineum of the 1st degree - 39 puerpens (53.43%); II degree - 31 puerpera (42,47); III degree - 3 puerpens - (3.11%). 

All patients, before the start of rehabilitation treatment, underwent a control examination of the gynecologist in the conditions of a female consultation, with a mandatory conduct of ultrasound examination (ultrasound) of the gap and a stuck wound, with the determination of the state of the scar and surrounding fabrics [5, 6]. In patients with ruptures of the 1st degree, recovery treatment [7] was used 5-7 days after discharge from the hospital, in the conditions of the therapeutic physical culture (ТFC) cabinet of the antenatal clinic. In most patients of this group, the wounds healed with primary tension, almost without any complications, most gaps did not require suturing, the fabrics were not infiltrated, mobile, elastic.

In this group, the complex of recovery treatment methods was limited to conducting Kegel and Fitball exercises within 2-3 weeks, in order to strengthen the muscles and ligamentous apparatus of the perineum and the pelvic floor after childbirth [6]. Taking into account the timing of tissue healing for cured ruptures of the 9th degree, taking into account the well -being of patients, their complaints, the condition of the wound, rehabilitation measures were carried out no earlier than 1 month after the injury in childbirth, in the conditions of a female consultation. The duration of the conducted complex of recovery treatment methods varied from 1.5 to 2 months, with joint control by a rehabilitologist and gynecologist. With this pathologists, simultaneously with the use of Kegel and the use of fitball, the therapeutic physical culture and physiotherapeutic local treatment of the field of traumatic damage was actively used, using 10-15 sessions of magnetotherapy, the use of ultrasound and laser therapy [8], the use of yellow spectra of light using the apparatus Zepter "Bioptron" ® [9, 10]. 

In a group of patients, with a rupture of the crotch of the III degree, where there were the most severe damage (vaginal tissues and muscles of the perineum, anal sphincter rupture) the criterion of the beginning and volume of the rehabilitation and restoration complex was the healing of the tissue damaged during childbirth, as well as the presence of post-traumatic complications, as well as the presence of post-traumatic complications associated with violations such as partial or complete incontinence of gases and feces in case of damage to the anal sphincter, the presence of pain of varying degrees of intensity during sexual intercourse (dyspareunia), both in the vagina and in the area of the scar and damaged perineum [1, 10]. 

All patients of this group, before starting rehabilitation treatment, were examined by specialists - a proctologist and gynecologist. The degree of healing of damaged tissues and the state of the scar directly depends on the volume of damage itself, and on the technique and the method of suturing damaged areas and the course of the postpartum period, the presence and severity of postpartum and postoperative complications [5, 10]. Healing of seams of any localization after childbirth is the process of complete restoration of the integrity of the soft tissues of the perineum [1, 3]. I received important data on the state of the scar and tissues at the place of damage, after examining and studying the place of damage, both during a special gynecological study, using bimanual vaginal and recto-vaginal examination, and according to the results of the ultrasound of the damage zone [1, 3, 10]. 

These important components were taken into account by us when planning and selecting methods of rehabilitation in this group of patients. Since in this group there is a high degree of risk of the formation of various pathologies in the future, in the form of the insolvency syndrome, chronic pelvic pain syndrome, prolapse of the internal genital organs, rehabilitation measures aimed at strengthening the muscle-ligamentous apparatus of the pelvic bottom, in our opinion, are, in our opinion, Very relevant and in demand. In this group, the duration of recovery therapy was the longest-from 2.5 to 3 months. 

At first, it was held in the LFK office of a antenatal clinic, and in the last 2-3 weeks at home. Patients performed a complex of special Kegel exercises, Fitball, exercise therapy using a set of exercises to strengthen the muscles of the perineum and the pelvic floor was actively used. Additionally, all patients received physiotherapeutic treatment in the form of the use of a yellow spectrum of light using the apparatus of the company “Zepter” “Bioptron” ® using an oxy spray, magneto-infrared irradiation of the perineum [9].

With the help of survey and an additional, expanded survey of patients, 1-3-6 months after the onset of recovery treatment (taking into account the examination data of a gynecologist, proctologist, ultrasound), subjective and objective control of the effectiveness of the ongoing rehabilitation measures was carried out. After 3-4 weeks, patients with ruptures of I degree (n = 39) noted the complete absence of discomfort and pain in the crotch area, could sit freely, spread their legs, perform certain physical activity and everyday work at the house, did not mark any unpleasant sensations and difficulties in defecation, gases and urination. After 3 months, in the presence of sexual activity, there were no problems in the group related to the birth injury.

Of the patients, with ruptures of the perineum of the II degree (n = 31), according to the data of the inspection, survey and survey, after 1-1.5 months of the rehabilitation treatment, 23 (74.19%) has complete healing of tissue damage obtained As a result of the birth injury, a stable scar formed, the muscular-ligamentous Aparage of the pelvic floor was strengthened, unpleasant sensations and discomfort during urination, gases and defecation were significantly fed. 2.5-3 months after the start of rehabilitation measures, 29 (93.55%) patients have noted a significant improvement in all parameters and the almost complete absence of dysparaunius phenomena and unpleasant omenses in the perineum with intimacy.

In the study of the effectiveness of recovery treatment, 6 months after the rehabilitation course, all 31 patients already noted the complete absence of any pathological disorders and discomfort when performing work, household chores and sexual relationships. In patients of the third group (n = 3), with the most severe injuries of the vagina, mouse and ligaments of the pelvic floor, anal sphincter and partially tissues of the rectum, recovery treatment was carried out for a long time-2.5-3 months. Almost the first changes in the direction of improving well-being and the beginning of positive changes (according to these medical examinations, ultrasound, survey and survey data) were noted no earlier than 1.5-2 months after the start of the use of a complex of recovery treatment methods.

The beginning of an improvement in the process of gases and defecation, the ability to sit, including And in the toilet during urination and/or performing a number of physical exercises, it appeared only 1.5-2.5 months after childbirth and a severe birth trauma, against the background of treatment and rehabilitation. If Kegel’s special exercises and fitballs, physiotherapeutic procedures were perceived positively and they willingly performed them, then any attempt to introduce exercise therapy caused fear, protest and obvious unwillingness to use physical loads due to fear of increasing discomfort, pain and possible complications. Therefore, in this group, we are faced with the problem of conducting additional psychological rehabilitation, and the use of methods such as aromatherapy with plant oils with sedative effect, combined with relaxing music (from 15 to 25 sessions), electrons (No. 10).

3-4 months after the start of the recovery treatment of 2 (66.67%) the patient from metered an improvement in the condition, in the form of a significant decrease in discomfort and pain at the site of the resulting birth, the possibility of painless or low-painful defecation and gases (against the background of the corresponding diet), Opportunities to sit and do sitting. After 6 months after the recovery treatment, all 3 patients noted a positive effect from the rehabilitation. After 6-9 months, all patients of this group gradually filed, and then the phenomena of dyspareunia and discomfort in the field of birth injury during sexual intercourse almost stopped. The data of gynecological and proctological examinations carried out during these periods confirmed the stabilization of the restoration and refrapeling tissue processes in the area of the resulting rupture and the restoration of the perineum and anal sphincter in these patients.

By analyzing the above materials of the study, the following conclusions can be made: 

1. A large number of ruptures of the crotch of I-III degree in modern obstetric practice requires not only their prevention, but also early and versatile rehabilitation and comprehensive restoration treatment of muscles and ligamentous Aparage of the perineum, is a means of active prevention of the production of female internal genital organs. 

2. The proposed approximate set of methods of restoration treatment of the consequences of the crotch ruptures can be proposed for active practical use, both at the outpatient and sanatorium-resort stage of the rehabilitation of this group of patients.