In this research article, the author presents the results and analysis of his study aimed at conducting individual, differentiated rehabilitation treatment using a number of methods and means of a set of physical exercises, exercises on a fitball, using special exercises according to the Kegel method, using yellow light, and other exercises, and their individual combinations, with the purpose of rehabilitating patients who have undergone traumatic childbirth and, in particular, traumatic perineal ruptures of I-III degree. The author of the study provides an approximate rehabilitation complex for each group of patients, and also presents the features of the practical application of methods aimed at restoring the perineum with its traumatic ruptures of I-III degree.

Aim of the article

The purpose of this study and, writing, based on its results and their analysis, the positive aspects of the application, proposed by the author of the study, an approximate set of methods and means of restorative treatment and rehabilitation in patients who have suffered traumatic injuries to the perineum during childbirth, at the early and late stages of restorative treatment, after ruptures and injuries of the perineum, I-III degree.

The objectives of the study were 

1. Selection of an approximate set of methods and means of physical rehabilitation and rehabilitation treatment for this type of obstetric pathology. 

2. Determination of the degree of effectiveness of the selected rehabilitation complex at the outpatient stage of recovery of patients in the late postpartum period.

Research hypothesis

During the preparation for this study, the author had a working hypothesis, the essence of which is that the complex of restoration treatment and exercises of special physical culture proposed by him can accelerate and improve the process of rehabilitation of patients, with different options for crotch injuries, both in the early and late postoperative period.

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 generic paths of the future mother due to severe pressure on the muscles of the pelvic floor during childbirth. This is the most frequent type of birth injuries of the mother and complications of the birth act, more often found in primitive [2].

The frequency of generic trauma of the crotch tissues 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 gap, omission and loss of the pelvic organs, violation of their function and trophism (M.E. Selikhov, MV Kotovskaya, 2009; 2010). 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.

A study on the use and effectiveness of the proposed set 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 Komunal Institution “Central City Hospital” of the New Kakhovka, Kherson region, Ukraine. 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 was as follows: ruptures of the perineum of the 1st degree - 39 (53.43%) puerpens; ruptures of the perineum of the II degree - 31 (42.47%) puerpens; Gaps of perineum of the III degree - 3 (4.11%) puerpens. 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 ultrasonic examination (ultrasound) of the gap and a struck wound, with the determination of the state of the scar and the surrounding tissues of the perineum. All patients who took part in the study gave their voluntary, both oral and written, consent to participate in it.

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 medical exercises 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, with the aim of strengthening 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 using the exercises of the Kegel and the use of fitball, the exercise therapy and physiotherapeutic local treatment of the field of traumatic damage, using 10-15 sessions of magnetotherapy were actively used, the use of ultrasound and laser therapy [8], the use of the yellow spectrum of light using the apparatus of Zepter «Biopron» ® [9, 10]. 

In the 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, rupture of the anal sphincter) the criterion of the beginning and volume of the rehabilitation and recovery complex, was the healing of the tissue damaged during childbirth, as well as the presence of post-traumatic complications associated with such disorders as partial or complete or complete or complete The incontinence of gas and feces in case of damage to the anal sphincter, the presence of pain of varying degrees of intensity during intercourse (dyspareunia), both in the vagina and in 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 examination, 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 later, in the form of the insolvency syndrome of the pelvic floor, chronic pelvic pain syndrome, prolapse of the internal genital organs, rehabilitation measures aimed at strengthening the muscular-liner apparatus of the pelvic floor 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.

Initially, it was held in the medical exercises of the antenatalal consultation, and in the last 2-3 weeks at home. Patients performed a complex of special Kegel exercises, a fitball, therapeutic exercises, 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 Zepter “Bioptron” ® using an oxy spray, magneto-infrared irradiation of the perineum area [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 a 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 note 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. From the number of patients, with ruptures of the crotch 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%), the tissue injuries obtained as a result of the birth trauma occurred, the stable handle formed, the muscle-lump-linter-linen-linked liner gasket was strengthened The bottom, 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 examinations, survey and survey) 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 as patients positively and they willingly performed them, then any attempt to introduce therapeutic physical gimnastics, 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), aparat electroson (No. 10).

3-4 months after the start of the recovery treatment of 2 (66.67%) the patient from the stirred, the improvement of 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-painted defecation and gases (against the background of the corresponding diet), the possibility of sitting and performing sitting work. 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 conducted during these periods confirmed the stabilization of the restoration and refrapeling tissue processes, in the area of ​​the resulting gap, and the restoration of the perineum and anal sphincter in these patients

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 ligaments of the perineum, is an active prevention of the prolapse of the female internal genital organs. 

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

3. The results obtained rehabilitation, after the conducted course of the rehabilitation treatment and the complex of physical culture exercises, confirmed the correctness put forward by the author, the hypothesis conducted by him.