الفهرس 
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Abstract
The postpartum, postnatal or puerperium is one of the most important events that constitutes a powerful and unique experience in women’s lives and lives of their families. All postpartum - related experiences are etched into women’s memories and shape their maternal identities. It is defined as the period following labor during which the maternal body in general, and the genital organs, in particular, return back to the pr-pregnant status with minimum alteration left and it lasts from 4-8 weeks. During this period the women experience many physiological and psychological changes. Physiological changes include: The reproductive system changes which involve the uterus, cervix, vagina, perineum, supportive structures, breasts as well as return of ovarian functions. As a result of return of body systems to its normal positions (systems adaptation), the postpartum women experiencing some of minor discomforts. Afterpains is influenced by many factors which are as follows: multiparty due to weakness of uterine muscle overdistended uterus due to a large size baby, multiple pregnancy, polyhydramnios, The severity of afterpain increases due to the decreased strength of uterine muscle in case of multiparity, and increased sensitivity of the central nervous system. However, in nulliparous women, afterpains is less common and is usually not experienced due to the high strength of the uterine muscles, since smooth muscles of the uterine are well contracted after delivery. The afterpain is a major burden requiring powerful pain relief treatments as pharmacological analgesia and non-pharmacological therapy. Pharmacological treatment includes the use of prescribed medication as Non- steroidal anti-inflammatory drugs (NSAIDs) and paracetamol. Despite pharmacological pain relief may be effective consideration needs to be given in breast- feeding women. Therefore, it is essential to provide an effective and safe pain management options and alternatives to mainstream medical treatments to women during the postpartum period. Progressive muscle relaxation (PMR), was developed by Edmund Jacobson and is known in the literature’s science 1938. The aim of this technique or intervention is to help the person to get mindful insight about the differences between the tension sensation and relaxation sensation in the same muscle group. This will help the woman to reach the state of deep muscle relaxation in all muscles and understands the benefits of relaxation state. (PMR) is a therapeutic method of pain management that can diminish the emotional components of pain, strengthen coping abilities, give patients a sense of control, contribute to pain relief, decrease fatigue, as well as improve sleep quality that is widely used to induce nerve-muscle relaxation.
Last but not least postpartum nurses play an important role in the post-partum period. They use a wide range of skills and work in a variety of medical environments to provide care to mothers, babies and their families. Also, one of crucial roles of them in postpartum period is to maintain woman’s pain rating scale between 0 and 2 points at all times. Pain is considered the fifth vital sign, so it should be assessed along with the other four parameters and utilization of non-pharmacological interventions like relaxation technique is important in order to increase women’s feeling of pain control as well as decreases their feeling of weakness besides, improves their activity level and functional capacity.
Aims of the Study Determine the effect of progressive muscle relaxation technique on postpartum afterpains intensity among multiparous women. Design: A quasi experimental research design was utilized in this study.
Settings: The study was conducted at the postnatal unit of El-Shatby Maternity University Hospital affiliated to Alexandria University.
Subjects: A convenient sample of 100 postnatal women from the previously mentioned setting was recruited according to the following inclusion criteria: Multipara With normal course of pregnancy, labor and postpartum Free from any chronic medical and obstetrical problems, didn’t receive any pharmacological pain relief measures. The sample size was calculated using power analysis (Epi-info7) program based on the following parameters: Population size is 1350/3 months expected frequency50% acceptable error 10%Confidence coefficient 95% minimal sample size 98 women. final sample size 100 women.
Tools of the study : three tools were used:
Tool one: “Women’s socio–demographic and clinical data structured interview schedule:
This tool was developed by the researcher and entailed three Parts.
Part (I): Women’s socio-demographic data such as age, level of education, occupation, current residence and family type.
Part (II): Reproductive history such as gravidity, parity, type of previous deliveries, complications of previous pregnancies and deliveries as well as number of abortions, stillbirths and living children.
Part (III): Clinical assessment sheet, which included baseline data such as vital signs, uterine consistency, and level of funds.
Tool two: Short-form McGill Pain Questionnaire (SF-MPQ):
This tool was originally developed by Melzack (1987), and revised by Terkawi et al (2017) to ensure compatibility with Arabian culture. It was adapted and translated into Arabic language by the researcher to assess the sensory and affective behavior associated with pain.
This tool included subscales:
Pain Rating Index (PRI), which comprises 15 items that reflects both the sensory (11 items) and affective (5 items) dimensions of pain. These items were responded by a 5-points Likert like scale as follows:0= None,1= Mild 2=Moderate 3=Severe4= Unbearable. The total score was ranged between 0 to 60 and classified as follows:- No pain=0,Mild pain (from 1 to 15),Moderate pain (from 16 to 30),Severe pain (from 31 to 45),Unbearable pain (from 46 to 60).
Visual Analogue Scale (VAS):
It is a self-report device that consists of a horizontal line in centimeters from 0 to 10, corresponding to the degree of pain, where 0 indicates no pain, 1-3 indicates mild pain, 4-6 indicates moderate pain, 7-9 indicates severe pain and 10 indicate unbearable pain. It is a 10-points numerical scale.
Tool three: A modified version of Chamber Price Pain Rating Scale (CPPRS)
It was originally developed by Chambers and Price (Basyouni et al., 2018). and then revised for its reliability& validity (Haefeli & Elfering, 2006). It includes four dimensions: posture, gross motor activity, facial expression and verbalization. For each dimension, one of a three alternatives (0, 1, 2) is to be elicited by the researcher. For posture, the choice is between very relaxed, guarded and tense posture. For gross motor activity, the choice is between very restless, slightly restless and quiet. For facial expression, the choice is between no frowning, some frowning and constant frowning or grimacing. Finally, women’s verbalization varies between normal no sound, groans/moans and cries/sobs.The total score of the four dimensions ranges from 0-8 and classified as follows: No pain (0) Mild pain (1-2) Moderate pain (3-4) Severe pain (5-6) Unbearable pain (7-8)
- The study tools were tested for content validity by 7 experts in the field of the study. The necessary modifications were done accordingly.
- A pilot study was carried out on 10 post-partum women of the study sample in order to test the clarity and applicability of the research tools.
- Tools were checked for their reliability by using Cronbach’s alpha test and the result was reliable for tool two (PRI=0.96 & VAS= 0.93) and tool three (CPPRS = 0.91).
- Collection of data covered a period of 4 months starting from the middle of February till the middle of June 2022, 2 days/week; 4-5 postpartum women /day.
- Finally, after collecting the necessary data, data was revised, categorized, coded, computerized, tabulated and properly analyzed.
The main findings of the present study were
Socio - demographic data.
- The mean age was 30.12 ± 5.982 years for the study group and 29.70 ± 4.514 years for control group.
- Level of education also revealed that almost three-fifths & more (56% & 64%) of the latter and the former groups respectively were illiterate or read and write.
- Occupation manifested that a sizeable proportion of the study and the control groups (70% & 60%) respectively were housewives.
- The vast majority of the working former and latter groups (93.3% & 95%) respectively were workers, merchants and farmers.
Reproductive history.
- Around two-thirds (66% & 68%) of the study and the control groups respectively had 4-7 pregnancies.
- About three-fifths (56% & 58%) of them respectively had no abortion. Approximately one-half and more (48% & 54%) had 1-3 deliveries.
- All (100%) of the two groups had normal deliveries.
- The majority of the study and the control groups (86% & 90%) respectively had no stillbirth, and almost three-fifths (56% & 60%) of the latter and the former groups respectively had 1-3 living children.
Sensory and affective dimensions of pain after interventions, using PRI.
- After the 1st & the 2nd sessions, highly statistically significant differences were found between the two groups (P=<0.0001), where a sizeable proportion of the control group (64%) had unbearable pain, compared to only (18% & 0%) respectively of the study group.
- On the 3rd PP day, a highly statistically significant difference was also detected between the two groups (P=<0.0001), where a large proportion of the control group (68%) had severe pain, compared to none of the study group.
Pain intensity after interventions, using VAS.
- After the 1st & the 2nd sessions, the relationship between the two groups was highly statistically significant (P=<0.0001), where 64% of the control group had unbearable pain, compared to 18% & 0% respectively of the study group.
- On the 3rd PP day, it was also found between the two groups (P=<0.0001), where 68% of the control group had severe pain, compared to none of the study group.
Behavioral responses to pain after interventions, using CPPRS.
- After the 1st & the 2nd sessions, highly statistically significant differences were realized between the two groups was (P=<0.0001), where a greater proportion of the control group (64%) had unbearable pain, compared to only (18% & 0%) respectively of the study group.
- On the 3rd PP day, a highly statistically significant difference was also disclosed between them (P=<0.0001), where almost two-thirds (68%) of the control group had severe pain, compared to none of the study group.
Conclusion
Based on the findings of the present study, it can be concluded that progressive muscle relaxation technique significantly reduced intensity of afterpains of postpartum mothers with the intervention. So, the study aim and hypothesis were achieved within the framework of the present study.
Recommendations
Based on the findings of the present study, the following recommendations are suggested:
The progressive muscle relaxation technique should be offered as a part of standard postpartum care in hospitals.
In-service training programs should be carried out for postpartum health care providers to increase their awareness about the positive effects of a progressive muscle relaxation technique in the management of postpartum afterpain. The progressive muscle relaxation technique can be recommended as an effective modality for postpartum afterpain management, respecting postpartum mother’s preferences.
For further researches
- Replication of the same study in different Egyptian health setting in order to assess the effect of progressive muscle relaxation technique on cesarean pain.