Manual Lymphatic Drainage For The Prevention And Reduction Of Discomfort And Lower Limb Edema In Pregnant And Postpartum Women

Abstract

Temos de prazer de lançar o primeiro livro internacional do ano de 2023, voltado a área de saúde, que tem como título Collection of International Topics in Health Science- V1 , essa obra é editada pela Seven Publicações Ltda, tendo a composição de diversos capítulos voltados ao desenvolvimento e disseminação do conhecimento na área da saúde.

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Manual Lymphatic Drainage For The Prevention And Reduction Of
Discomfort And Lower Limb Edema In Pregnant And Postpartum Women
https://doi.org/10.56238/colleinternhealthscienv1-015
ABSTRACT
Pregnancy is a special moment for women, but the
body changes typical of this phase can cause
discomfort and edema in the lower limbs. With the
objective of investigating the effects of manual
lymphatic drainage in the prevention and reduction of
discomfort and lower limb edema in pregnant and
postpartum women, a descriptive review study was
carried out. It can be concluded that manual lymphatic
drainage is a safe, practical and efficient method
recommended to reduce swelling, pain and discomfort
in pregnant and postpartum women.
Keywords: Manual Lymphatic Drainage, Postpartum
Perineal Pain, Gestational Edema.
1
INTRODUCTION
The growing uterus during pregnancy causes intermittent compression of the pelvic veins and the
inferior vena cava, and associated with the hormonal changes typical of pregnancy (increased progesterone
level) can increase water retention, especially in the lower limbs. Although swelling in the lower limbs is
considered normal during pregnancy, it can cause discomfort and a feeling of heaviness.
Manual lymphatic drainage is a therapeutic technique that allows lymphatic drainage into the
lymphatic vessels and ducts, through maneuvers that mimic physiological pumping, then, the following
question arose: Can manual lymphatic drainage prevent and reduce discomfort and edema of the lower
limbs in pregnant and postpartum women?
2
METHODOLOGY
The objective of this descriptive review study was to investigate the effects of manual lymphatic
drainage in the prevention and reduction of discomfort and edema of the lower limbs at in pregnant and
postpartum women. The data collection was obtained through the descriptors manual lymphatic drainage,
postpartum perineal pain, gestational edema obtained from PubMed, Scielo and Scholar Google. As
inclusion criteria, it was established the selection of articles in Portuguese and English between the years
2018 and 2022 with free access and related to the study objective. Abstracts, monographs, dissertations,
theses, and incomplete or paid articles were excluded from the study. During the selection, 52 articles were
obtained, of which only 7 met the criteria of this study and were selected for analysis.
Collection of international topics in health science:
Manual Lymphatic Drainage For The Prevention And Reduction Of Discomfort And Lower Limb
Edema In Pregnant And Postpartum Women 196
Capítulo 15

3
DEVELOPMENT
The lymphatic system is a system made up of organs and vessels that are responsible for transporting
lymph fluid (lymph) to regulate the water balance and filter toxins and pathogens from the body's tissues.
Therefore, it is a system that is part of both the circulatory system and the immune system. In case of
dysfunction of the lymphatic system, there will be fluid retention in the interstitial tissue resulting in edema
and it is in this case that manual lymphatic drainage is necessary.
Manual lymphatic drainage (DLM) is a tissue manipulation technique that mimics the physiological
pumping of the lymphatic system. It consists of rhythmic massage maneuvers on the skin that accelerate
mobilization and drain the lymphatic fluid into the lymph nodes and stimulate the return to circulation,
thereby maintaining the fluid balance of the interstitial spaces.
It can be stated that DLM is considered the gold standard method for the treatment of lymphedema
because it provides increased lymphatic circulation, removes waste products from cell metabolism, reduces
edema by increasing fluid dynamics, and decreased the activity of the sympathetic nervous system
(MARTIN, 2011 apud DE LA CUEVA-REGUERA et al, 2020).
Although the lymphatic system is highly competent, there are health conditions that can allow the
accumulation of lymphatic fluid, such as pregnancy. A woman's body undergoes physiological changes
during pregnancy to adapt to the development needs of the fetus, and one of the most common consequences
is the appearance of edema, especially in the lower limbs (LLLL). It is precisely in conditions of lymph
accumulation in some region of the body that the person can benefit most from DLM.
Table 1 presents a summary of the seven studies selected for the preparation of this material. The
research was organized in descending chronological order according to the year of publication.
Chart 1 - Comparison between studies
AUTHORS,
YEAR
OBJECTIVE
METHODOLOGY
CONCLUDING REMARKS
SOUZA et al.,
2022
To analyze the effects of
the MTD on the
symptoms of heaviness,
pain, edema and tingling
in the lower limbs of
pregnant women, as well
as on the reduction of
perimetry.
Non-randomized
clinical trial.
DLM reduced heaviness, pain,
swelling and tingling in the
lower limbs, as well as reduced
perimetry and maintained BP in
pregnant women.
ARNS;
SILVEIRA;
COSTA, 2021
To verify what the
scientific literature has
published about the
benefits of manual
lymphatic drainage for
pregnant women.
Integrative review.
DLM is a practical, natural,
non-invasive and effective
method to reduce edema during
pregnancy. It provides comfort
and decreases pain and
heaviness in the lower limbs.
DE LA CUEVA-
REGUERA et
al., 2020
To evaluate the efficacy
of DLM in second
pregnancy women with
gestational edema from
25 weeks gestation to the
end of the puerperium
period.
Prospective, single-
blind, randomized,
clinical trial.
DLM reduced pain intensity
compared to perineal massage
in women with gestational
edema until the end of the
puerperium.
Methodology focused on the area of interdisciplinarity:
Manual Lymphatic Drainage For The Prevention And Reduction Of Discomfort And Lower Limb
Edema In Pregnant And Postpartum Women
197

PEREIRA et al.,
2020
To evaluate and compare
pain relief in the lower
limbs of pregnant women
who performed DLM
with those who did not.
Analytical,
experimental, cross-
sectional,
prospective research
of the trial type
randomized clinical
trial.
Women who performed DLM
had pain relief in the lower
limbs compared to those who
did not perform DLM.
DELGADO et
al., 2019
To evaluate the effects of
lymphatic drainage in the
prevention and reduction
of edema of the lower
limbs in pregnant women
in the second and third
trimester of pregnancy.
Case series study.
The DLM was effective in
reducing edema, pain and
fatigue in the lower limbs in
pregnant women.
FERNANDES et
al., 2019
Introducing the benefits
of
DLM as an alternative
non-drug therapy to
relieve
effects of gestational
edema and improvements
in blood circulation that
may collaborate in the
control of BP in women
with preeclampsia.
Literature review.
The pregnant women benefited
from the effects of DLM, and
BP was maintained or even
decreased after the session.
However, DLM is not
recommended for pregnant
women diagnosed with pre-
eclampsia.
ROZA, 2018
To describe the effects of
the lymphatic drainage
technique on pregnant
women, by means of a
literature review.
Literature review.
DLM reduces swelling and
discomfort.
Source: Own authorship, 2023.
Fluid retention is quite common during pregnancy and generates edema in the body, especially in
the lower limbs. A natural, non-invasive, practical, and effective treatment is DLM. It can improve quality
of life during pregnancy, because it promotes the control of edema, reduces pain, fatigue, and the feeling
of heaviness in the lower limbs, provides relaxation and a sense of well-being (ARNS; SILVEIRA;
COSTA, 2021).
The pregnant woman can receive DLM as of the 3rd month of gestation, but it is also recommended
in the post-partum period. The application of the DLM technique requires special care regarding the
positioning of the pregnant woman, besides the fact that DLM is not applied to the breasts and abdomen,
regions that should only be moisturized. Another fundamental fact is the obstetrician's authorization for the
woman to undergo DLM and that the technique be applied by a professional who is competent in assisting
pregnant and postpartum women.
There are studies about the DLM and its benefits in pregnant women, among them there is an
integrative review study with the objective of verifying what the scientific literature has published about
the benefits of DLM for pregnant women. The research was carried out in the Virtual Health Library and
in the databases indexed: Nursing Database, LILACS and MEDLINE. Publications from 2010 to 2020,
available for free, in full and in Portuguese, were analyzed. The analysis of the studies allowed us to affirm
that DLM, besides reducing edema during pregnancy, can minimize other discomforts, such as pain, fatigue
Methodology focused on the area of interdisciplinarity:
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Edema In Pregnant And Postpartum Women
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and feeling of heaviness in the lower limbs. Therefore, it is a practical, natural and non-invasive method
recommended for pregnant women (ARNS; SILVEIRA; COSTA, 2021).
Another study that praises the DLM for pregnant women was carried out with 23 volunteers. The
non-randomized clinical trial study had the objective of analyzing the effects of the DLM on the symptoms
of weight, pain, edema, and tingling in the lower limbs of pregnant women. Pregnant women with
gestational age above 26 weeks, authorized by their obstetrician, participated in the study. The volunteers
should present sensation of heaviness, pain, edema and/or paresthesia in the lower limbs. People with blood
pressure higher than 140/100mmHg at the time of the DLM, with epidermal continuity lesion,
dermatological, lymphatic and cardiac diseases, infections and large and/or symptomatic varicose veins
were excluded (SOUZA et al., 2022).
The volunteers were submitted to anamnesis, perimetry, blood pressure evaluation, Borg's scale,
three satisfaction questionnaires: initial, final, and after two hours. The technique used was the Leduc
technique, with the pregnant woman in the supine position with the trunk slightly inclined, elevation of the
lower limbs with the help of positioning rollers below the knees and ankles during the entire session.
Measurement reduction was observed in most of the measurements performed by perimetry. There was a
significant statistical difference before, right after the session and after two sessions in relation to
improvement of pain (p=0.001*), paresthesia (p=0.01*), weight sensation (p=0.000*) and edema
(p=0.000*). Therefore, it is concluded that the DLM provided a decrease in pain, edema, weight sensation
and paresthesia in the lower limbs (SOUZA et al., 2022).
DLM is also recommended after childbirth. It is known that perineal trauma can occur during
childbirth, whose incidence is estimated between 30% and 85%, and pain can occur in more than 60% of
women. (DE LA CUEVA-REGUERA et al., 2020). DLM treatment has been used to reduce discomfort
and edema during pregnancy, as well as perineal pain after pregnancy. To determine the effectiveness of
DLM in these cases, studies have been developed.
An example of a postpartum study is a randomized, prospective, blinded clinical trial conducted
between January 2015 and January 2016. The study aimed to evaluate the effectiveness of DLM in women
in their second pregnancy with gestational edema from 25 weeks gestation until the end of the puerperal
period. Forty-nine women diagnosed with gestational edema participated in the research (DE LA CUEVA-
REGUERA et al., 2020).
The study participants were randomly divided into 2 groups. Group A with 30 women who received
conventional treatment plus perineal massage and group B with 19 women who received conventional
treatment plus DLM. The conventional treatment that both groups received consisted of pelvic floor muscle
training from the 25th week of gestation until delivery. The frequency of training was 5 days per week. All
wore compression stockings (Varicel, Spain) for 6 hours daily whose compression range was between 11
and 14 mmHg (DE LA CUEVA-REGUERA et al., 2020).
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Group A was trained to perform perineal massage. The women themselves, 1 day a week, massaged
themselves by inserting their index finger 5 cm into the vagina and sliding it down and side to side using a
lubricating jelly for 20 minutes. Group B received DLM from a therapist 1 day a week. DLM was performed
intracavity, on the labia majora, suprapubic and inguinal regions for 5 minutes. The study concluded that
DLM significantly reduced pain intensity compared to perineal massage (DE LA CUEVA-REGUERA et
al., 2020).
There are several studies on the benefits of the MTD for pregnant women. Among them, there is an
analytical, experimental, transversal, prospective, randomized clinical trial, which aimed to evaluate and
compare the pain relief in the lower limbs in pregnant women submitted and not submitted to the DLM. A
total of 28 pregnant women participated in the study, divided into 4 groups of 7 components: G1 in the 2nd
gestational trimester experimental group, G2 in the 3rd gestational trimester experimental group, G3 in the
2nd gestational trimester control group, and G4 in the 3rd gestational trimester control group. The groups
were evaluated using the visual analog pain scale and lower limb perimetry. The results of the studies were
analyzed by the method of analysis of variance, observing significant difference between G1 and G2 (p =
0.007) and G3 and G4 (0.0187), therefore, the group that received DLM benefited from the treatment with
reduction of edema and pain in the lower limbs (PEREIRA et al., 2020).
Another study on the effects of DLM in reducing lower limb edema in pregnant women was
conducted in 2018, in Pernambuco. The case series research aimed to evaluate the effects of lymphatic
drainage in the prevention and reduction of lower limb edema in pregnant women in the second and third
trimester of pregnancy. Ten singleton pregnant women, between 18 and 35 years old, primiparous and/or
multiparous, from the fourteenth week of pregnancy participated in the study. Pregnant women with
uncontrolled hypertension, renal failure, and deep vein thrombosis were excluded (DELGADO et al., 2019).
Each pregnant woman was stimulated in the cervical region for 15 minutes and drained for 20
minutes in each lower limb, twice a week. The volunteers were positioned in a supine position at 45° with
the help of a support triangle. The vital signs, lower limb perimetry, and visual analog scale were evaluated
in all volunteers before and after the sessions. A reduction of edema, pain, and fatigue in the lower limbs
could be observed. On average, after the first session (acute effect) the edema decreased by 2 cm, and after
the last session (delayed effect) it decreased by up to 5 cm. It is worth noting that all participants were
satisfied and would recommend DLM (DELGADO et al., 2019).
In order to present the benefits of DLM as a non-drug therapeutic alternative to mitigate the effects
of edema during pregnancy and improve blood circulation for blood pressure control in women with
preeclampsia, a literature review study was developed. The search was conducted in the Pubmed, Lilacs,
Scielo databases, books and journals whose inclusion criteria were: articles between 1990 and 2017, freely
available and online, in the Portuguese language. After the analysis of the material, it was possible to infer
that pregnant women without risk and with gestational edema benefit from DLM, because the treatment
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Edema In Pregnant And Postpartum Women
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stabilizes or decreases blood pressure. However, pregnant women diagnosed with preeclampsia are
considered high risk and DLM is not recommended (FERNANDES et al., 2019).
A literature review aimed to describe the effects of the DLM technique in pregnant women. For the
development of the study, information was collected in the Google Academic and Scielo databases in
scientific articles related to the use of lymphatic drainage and pregnant women. It can be concluded that all
the studies analyzed confirmed the benefits of DLM to reduce discomfort and edema in the lower limbs
(ROZA, 2018).
Therefore, DLM during pregnancy and postpartum can improve a woman's quality of life. In
pregnancy, DLM allows for the reduction of edema, and allows for detoxification, oxygenation, defense,
and nutrition of the tissues. In addition, it helps reduce pain, numbness, and heaviness in the lower limbs.
In the postpartum period, besides reducing the edema, it helps to control perineal pain.
To apply the DLM technique, the pregnant woman can be positioned in supine or lateral positions.
In the supine position, she should have her torso inclined at 45° and with a roller below the knees. The left
lateral position with the lower limbs resting on a wedge pillow is pleasant for expectant mothers because it
reduces compression of the inferior vena cava.
DLM is a combined technique with gentle, slow, progressive, harmonic, and rhythmic maneuvers
performed with the hands toward the superficial lymphatic system. It begins with the opening of the lymph
nodes in the lower limbs and then the lymph is directed with light compression movements from proximal
to distal and then from distal to proximal, in order to facilitate the displacement of the lymph.
It is emphasized that DLM must be applied from the 3rd month of pregnancy on, with the
obstetrician's authorization, for the prevention and/or treatment of gestational edema, pain, tiredness,
tingling, heaviness, or other typical pregnancy discomforts.
4
FINAL CONSIDERATIONS
DLM is a treatment technique that can be considered safe, well tolerated, and accepted, and has
proven benefits in reducing numbness, fatigue, and heaviness in the lower limbs. All the studies reviewed
attest to the efficiency of DLM in reducing the volume of edema in the lower limbs of pregnant women.
The technique is also recommended to reduce perineal pain and postpartum edema.
It is recommended that further studies be developed, especially regarding DLM in the puerperium,
as there was a dearth of research on the subject.
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REFERENCES
ARNS, P.; SILVEIRA, G.; COSTA, D. H. Drenagem linfática manual: benefícios para a gestante. Revista
Interdisciplinar de Ensino, Pesquisa e Extensão, v. 8, n. 1, p. 224-232, 26 fev. 2021. DOI:
10.33053/revint.v8i1.336
DE LA CUEVA-REGUERA et al. Effectiveness of manual lymphatic drainage vs. perineal massage in
secundigravida women with gestational oedema: A randomised clinical trial. International Wound
Journal, v.17, n.5, p.1453–1461, 2020. DOI: 10.1111/iwj.13427
DELGADO, A. et al. Efeitos da Drenagem linfática manual na diminuição do edema de membros inferiores
em gestantes. Revista Pleiade, v. 13, n. 28, p. 49-59, 2019. DOI: 10.32915/pleiade.v13i28.545
FERNANDES, A.C.F. et al. Efeitos da drenagem linfática em gestantes com doenças hipertensivas: revisão
da literatura. Revista Saúde em Foco. ed. 11, p. 158-183, 2019. Disponível em: chrome-
extension://efaidnbmnnnibpcajpcglclefindmkaj/https://portal.unisepe.com.br/unifia/wp-
content/uploads/sites/10001/2019/02/014_EFEITOS-DA-DRENAGEM-LINF%C3%81TICA-EM-
GESTANTES-COM-DOEN%C3%87AS-HIPERTENSIVAS.pdf Acesso em: 26 jul. 2022.
PEREIRA, A.J.A. et al. Drenagem linfática reduz dor durante a gestação? Brazilian Journal of
Development, v. 6, n. 10, p. 74486-74498, out. 2020. DOI: 10.34117/bjdv6n10-031
ROZA, T.A. A Drenagem linfática manual aplicada em gestantes. Revista Estética em Movimento, v. 1,
2018. Disponível em: http://revista.fumec.br/index.php/esteticaemmovimento/article/view/6504 Acesso
em: 26 jul. 2022.
SOUZA, S.M. et al. Impacto da drenagem linfática manual nos sintomas relacionados ao edema de
membros inferiores de gestantes. Fisioterapia e Pesquisa, v.28, n.4, p. 376-383, out-dez. 2022. DOI:
10.1590/1809-2950/19030327042020.
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