Postpartum care and Complications

• Puerperium


  The first 6 weeks after delivery
• Postpartum care


  • Instruction about care of the neonate, breastfeeding, and patient's limitations
  • Emotional support during the period of adjustment
• Risk of postpartum complications can extend past the average patient's hospital stay
• Vaginal delivery


  Routine medical issues include pain control and perineal care
• Pain control after vaginal delivery

  1. Use nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen

  2. Use low-dose opioids for adequate patient comfort, particularly at the hour of sleep
• Perineal care after vaginal delivery

  1. Use ice packs around the clock for the first 24 hours

  2. Inspect the perineum to ensure perineal repair is intact and no hematomas have developed

  3. Manage hemorrhoids with over-the-counter medications, stool softeners, and ice packs
• Cesarean delivery


  Wound care and pain management are common components of postpartum care
• Wound care after cesarean delivery

  1. Observe for signs of wound infection or separation

  2. Manage pain with opioids, stool softeners, and NSAIDs
• Prophylactic antibiotics are given during cesarean section but additional dosages do not further decrease the risk of infection
• Breastfeeding


  Provides benefits to babies and mothers, but is challenging, particularly for first-time mothers
• Breastfeeding challenges


  • Interrupted skin-to-skin contact
  • Breastfeeding is not instinctive or intuitive to many women
  • Misalignment of expectations and reality
• Breast care for postpartum patients

  1. Use ice packs, tight bra, analgesics, and anti-inflammatory medications for patients not breastfeeding

  2. Assess breastfeeding positions and infant's latch for patients breastfeeding
• Routine postpartum immunization with Tdap is essential if women have not received the vaccine within 10 years prior to pregnancy
• Rh-negative women need to receive Rhogam within 72 hours postpartum
• Postpartum contraception


  Counseling on options like tubal ligation, hormonal methods, barrier methods, and IUDs
• Postpartum contraception counseling


  1. Discuss contraception options during prenatal period and continue in hospital postpartum

  2. Avoid combination OCPs until at least 3 weeks postpartum to reduce VTE risk

  3. IUD placement is usually done at the 6-week postpartum appointment
• Postpartum discharge instructions


  • Discuss perineal care, contraception, breast care, postpartum "blues", and activity restrictions
  • For cesarean delivery, also discuss wound care and when to resume driving
• Postpartum complications


  • Postpartum hemorrhage
  • Endomyometritis
  • Wound infections and separations
  • Mastitis
  • Postpartum depression
• Postpartum hemorrhage


  Blood loss exceeding 500 mL in vaginal delivery or 1000 mL in cesarean delivery
• Postpartum hemorrhage usually occurs during the first 24 hours, while the patient is still in the hospital. However, it can also occur in patients with retained products of conception (POCs) for up to several weeks postpartum. Endomyometritis and wound complications typically occur in the first week to 10 days postpartum, and mastitis typically occurs 1 to 2 weeks after delivery but may present anytime during breastfeeding. Postpartum depression can occur at any time during the puerperium and beyond and is probably grossly underdiagnosed.
• Postpartum hemorrhage


  Blood loss exceeding 500 mL in a vaginal delivery and greater than 1,000 mL in a cesarean section
• Early postpartum hemorrhage


  Occurs within the first 24 hours
• Late or delayed postpartum hemorrhage

  Occurs after 24 hours
• Common causes of postpartum bleeding

  • Uterine atony
  • Retained POCs
  • Placenta accreta
  • Cervical lacerations
  • Vaginal lacerations
• Management of postpartum hemorrhage


  1. Fluid resuscitation

  2. Preparations for blood transfusions

  3. Investigate cause of hemorrhage
• With blood loss greater than 2 to 3 L, patients may develop a consumptive coagulopathy and require coagulation factors and platelets
• In rare cases, if patients become hypovolemic and hypotensive, Sheehan syndrome, or pituitary infarction, may occur
• Sheehan syndrome


  Manifests with the absence of lactation secondary to the lack of prolactin or failure to restart menstruation secondary to the absence of gonadotropins
• Vaginal lacerations


  Should be repaired at the time of delivery
• Deep sulcal tears or vaginal lacerations behind the cervix may be quite difficult to visualize without careful retraction
• Vaginal hematoma


  Managed expectantly unless it is tense or expanding, in which case it should be opened, the bleeding vessel ligated, and the vaginal wall closed
• Rarely, a patient will develop a retroperitoneal hematoma that can lead to a large blood loss into this space
• Management of retroperitoneal hematoma

  1. Expectant management if patient is stable without a falling hematocrit

  2. Interventional radiology embolization if patient demonstrates continued bleeding with evidence of expansion of the hematoma or a further drop in hematocrit

  3. Surgical exploration and ligation of the disrupted vessels if patient becomes unstable
• Cervical lacerations


  Can cause a brisk postpartum hemorrhage, commonly a result of rapid dilation of the cervix during stage 1 of labor or maternal expulsive efforts prior to complete dilation
• Repair of cervical lacerations

  1. Adequate anesthesia

  2. Retract vaginal walls to visualize cervix

  3. Grasp anterior lip of cervix with ring forceps and "walk" around cervix to identify lacerations

  4. Repair lacerations with interrupted or running absorbable sutures
• Uterine atony


  The leading cause of postpartum hemorrhage, occurs when the uterus fails to contract adequately after delivery
• Risk factors for uterine atony

  • Chorioamnionitis
  • Exposure to magnesium sulfate
  • Multiple gestations
  • Macrosomic fetus
  • Polyhydramnios
  • Prolonged labor
  • History of atony with any prior pregnancies
  • Multiparity, particularly grand multiparity (more than five deliveries)
  • Uterine abnormalities or fibroids
• Diagnosis of uterine atony

  Palpation of a soft, enlarged, and boggy uterus
• Treatment of uterine atony

  1. IV oxytocin (Pitocin)

  2. Uterine massage

  3. Methylergonovine (Methergine)

  4. Hemabate (Prostin or PGF2)

  5. Misoprostol

  6. Dilation and curettage (D&C) to rule out retained POCs

  7. Uterine packing with inflatable tamponade (Bakri balloon)

  8. Uterine artery embolization

  9. Exploratory laparotomy with ligation of pelvic vessels and possible hysterectomy
• Careful inspection of the placenta should always be performed, but with vaginal delivery it can often be difficult to determine whether a small piece of the placenta has been left behind in the uterus