Postpartum Complications

Postpartum Hemorrhage

• Any blood loss causing hemodynamic instability (eg. >0.5L vaginal, >1L in C-section)

• Primary (immediate <24h of delivery) usually due to uterine atony

• Secondary (late >24h) usually due to retained products of conception or infection

• Etiology four T’s:

  • Tone - uterine atony, distended bladder, infection

  • Trauma - uterine, cervical, vaginal

  • Tissue - retained placenta/clots

    • Manual removal or D&C

  • Thrombin - coagulopathy (pre-existing or acquired)

• Active management of 3rd stage of labour

  • Oxytocin after delivery of anterior shoulder, eg. 10 units IM

  • Controlled cord traction (decrease duration)

  • Wait for signs of placental separation before delivery of placenta (vaginal bleeding, laxity)

  • Delivery of placenta

  • Assess uterine fundus

  • Inspect placenta for completeness

  • Inspect for uterine inversion (uterus into vagina)

  • Inspect for trauma (genital tract, vaginal)

  • Inspect for hematoma

  • Inspect for IV sites (ongoing bleeding may suggest DIC)

• Management

  • Bimanual fundal massage

  • Oxytocin 10 units IM, then 20-40 units/1L NS infusion 200-500mL/h titrated to uterine tone and hemorrhage control

  • Call for help (Obstetrics/Surgery)

  • Vitals q5 mins, IV x2, Fluid resuscitation, O2 as needed

    • Consider Crossmatch, CBC, Coags (INR, fibrinogen, D-dimer)

  • Keep patient warm

  • Foley catheter (empty bladder)

  • Tranexamic acid 1g IV over 10 mins, repeat after 30 mins if needed

  • Consider other uterotonics

    • Carboprost (Hemabate) 0.25mg IM q15mins (max 2mg)

      • Avoid in asthma

    • Misoprostol 800mcg sublingual or rectal

    • Methylergonovine 0.2mg IM q2-4h

      • Avoid if hypertensive, Raynaud syndrome, scleroderma

  • Consider intrauterine tamponade (packing, condom + foley, Bakri balloon), emergency embolization, emergency laparotomy, emergency hysterectomy

Postpartum Pyrexia

• Fever >38C on any 2 of first 10d postpartum (except first day)

• DDx

  • Endometritis

    • • Rising fever, uterine tenderness (usually postpartum day 2-3)

      • Treat with antibiotics with anaerobic coverage (eg. clinda/genta IV until improved x 24-48h)

  • Wound infection

  • Mastitis/engorgement

• • • Treatment

      • Empty breast (breastfeeding, pumping, expression)

      • Antibiotic coverage, eg. Cephalexin or cover MRSA if risk (TMP SMX, Clindamycin)

    • Ultrasound r/o abscess if does not respond in 72h

    • If non-lactational and mass does not resolve → FNA r/o inflammatory CA

• • UTI

  • Pneumonia

  • DVT

Postpartum “blues" vs. depression 

• Postpartum Blues

  • Onset day 3-10, increased anxiety, irritability, decreased concentration, sleep disturbance

  • Mild and self-limited, <2w

• Postpartum Depression (within 1y of delivery)

  • Suspect if >2w or severe (r/o psychosis)

  • Screen with Edinburgh Postnatal Depression Scale or PHQ-9

    • Risk: Previous depression, poor social/financial support, stressful life events during pregnancy or after delivery (domestic violence, abuse)

  • Diagnose as with depression (≥5 of MSIGECAPS)

  • Treat SSRI (eg. sertraline) and psychotherapy