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

Dysfunctional breastfeeding

Inadequate Milk Intake

  • Mothers should breastfeed when infant shows signs of hunger or q4 hours (8-12 feeds in first 24h, which decreases slowly to seven feeds per day by 1-2 months)

  • Infant should urinate one void per number of days of life until 6-8 times daily by day 5

  • Suspect inadeqaute milk intake if >7% weight loss or if the infant does not regain their weight by 2w

  • Causes

    • Inadequate milk production

      • Breast development (previous surgery, radiation, endocrine -prolactinoma)

      • Delay in lactogenesis within first 5d

        • Usually due to obesity, hypertension, PCOS

      • Medications (oxytocin, SSRI, estrogen)

      • Offering only one side per feeding

    • Poor milk extraction

      • Infrequent feeding

      • Inadequate latch-on

      • Maternal-infant separation

      • Use of supplemental formula

Nipple and Breast Pain

  • DDx

    • Trauma

    • Vasoconstriction

    • Engorgement/Excessive milk supply

    • Plugged ducts

    • Infection

    • Dermatitis/psoriasis

General treatment

  • Proper positioning and latch

    • Support breast with hand in shape of "C" (fingers under breast, thumb on top)

    • Place baby's chin below areola

      • Top and bottom lips wide open

      • Lower lip turned outward against breast

      • Chin touching breast, nose close to breast

      • Full cheeks

      • Re-try latch if discomfort, noisy sucking, does not swallow rhythmically

    • If unable to get proper latch, consider pumping with expressed breastmilk until problem is addressed

    • Lactation consultant

  • No data for galactogogues (domperidone, metoclopramide, fenugreek) over breastfeeding technique interventions

  • Antibiotic ointment (bacitracin or mupirocin) on cracked nipples to prevent infection and form a barrier

    • All Purpose Nipple Ointment (APNO)

      • Mupirocin ointment 2%: 15 grams

      • Betamethasone ointment 0.1%: 15 grams

      • Miconazole powder added to a concentration of 2% miconazole

      • Total ~30g, Apply sparingly after each feeding. Do not wash or wipe off.

  • Cool or warm compresses, breastmilk to nipple

pph.pdf