Postpartum Complications and Hemorrhage (PPH)

• Postpartum complications encompass a range of physical and psychological conditions that can affect women after childbirth
• Early recognition and management are essential to minimize long-term health consequences

Postpartum Hemorrhage (PPH)

• PPH is defined as blood loss of more than 500 mL after vaginal birth or more than 1000 mL after cesarean birth
• PPH can also be diagnosed by a 10% change in hematocrit from admission
• Primary PPH occurs within the first 24 hours after childbirth and is most commonly caused by uterine atony
• Secondary PPH occurs from 24 hours to 12 weeks postpartum, often due to retained placental fragments or infection
• Uterine atony is the failure of the uterus to contract adequately after delivery
• Risk factors for uterine atony include multiparity, multiple gestation, polyhydramnios, macrosomic infant, prolonged or precipitous labor, use of oxytocin during labor, history of uterine atony, and certain medical conditions
• Assessment includes frequent monitoring of vital signs, assessment of uterine tone, and estimation of blood loss which should be performed every 15 minutes
• Management of uterine atony involves fundal massage and administration of uterotonic medications such as oxytocin, misoprostol, methylergonovine, and carboprost
• If medications are ineffective, other interventions such as uterine tamponade with a balloon catheter or surgical procedures may be necessary
• Lacerations of the genital tract can cause PPH, especially if they are deep or involve blood vessels
• Retained placental fragments can interfere with uterine contraction and lead to late PPH
• Hematomas, collections of blood in the soft tissues, can also cause PPH and severe pain
• Accurate assessment of blood loss is crucial; weighing perineal pads can provide a more accurate estimate
• A patient may not show signs or symptoms of hypovolemia until significant blood loss has occurred due to the increased blood volume during pregnancy
• Monitor for signs and symptoms of shock, such as tachycardia, hypotension, pallor, and decreased urine output
• Provide emotional support and education to the patient and family about PPH and its management

Postpartum Infections

• Postpartum infections are infections that occur in the genital tract within 28 days after childbirth or abortion
• Common postpartum infections include endometritis, wound infections, urinary tract infections (UTIs), and mastitis
• Endometritis is an infection of the uterine lining, often caused by bacteria that ascend from the vagina into the uterus
• Risk factors for endometritis include cesarean birth, prolonged labor, prolonged rupture of membranes, multiple vaginal examinations during labor, and manual removal of the placenta
• Assessment findings include fever, uterine tenderness, foul-smelling lochia, and tachycardia
• Wound infections can occur at the site of episiotomy, laceration repair, or cesarean incision
• Risk factors include obesity, diabetes, prolonged labor, and poor hygiene
• Assessment findings include redness, swelling, warmth, pain, and drainage at the wound site
• UTIs are common in the postpartum period due to bladder trauma, urinary catheterization, and urinary retention
• Assessment findings include urinary frequency, urgency, dysuria, and suprapubic pain
• Mastitis is an infection of the breast tissue, usually caused by bacteria that enter through cracked nipples
• Assessment findings include breast pain, redness, swelling, warmth, and fever
• Encourage breastfeeding or manual milk expression to prevent milk stasis
• Antibiotics are typically prescribed to treat postpartum infections
• Provide education on proper perineal hygiene, wound care, and breastfeeding techniques
• Encourage adequate hydration and nutrition to promote healing

Thromboembolic Disorders

• Thromboembolic disorders, such as deep vein thrombosis (DVT) and pulmonary embolism (PE), are a significant cause of maternal morbidity and mortality
• Pregnancy increases the risk of thromboembolism due to hypercoagulability, venous stasis, and blood vessel damage during childbirth
• Risk factors include cesarean birth, obesity, immobility, history of thromboembolism, and certain medical conditions
• DVT typically occurs in the lower extremities and is characterized by pain, swelling, redness, and warmth in the affected leg
• A positive Homans' sign (pain on dorsiflexion of the foot) may be present but is not a reliable indicator of DVT
• PE occurs when a blood clot travels to the lungs, causing respiratory distress and chest pain
• Signs and symptoms of PE include sudden onset of dyspnea, chest pain, cough, hemoptysis, and tachycardia
• Prevention of thromboembolism includes early ambulation, leg exercises, and the use of sequential compression devices (SCDs)
• Anticoagulant medications, such as heparin or low-molecular-weight heparin, are used to treat DVT and PE
• Monitor for signs and symptoms of bleeding while the patient is on anticoagulants

Postpartum Psychiatric Disorders

• Postpartum psychiatric disorders include postpartum blues, postpartum depression (PPD), postpartum anxiety, postpartum obsessive-compulsive disorder (OCD), and postpartum psychosis
• Postpartum blues are a transient period of sadness and tearfulness that affects up to 85% of women in the first few weeks after childbirth
• Symptoms of postpartum blues typically resolve within 2 weeks without intervention
• Postpartum depression (PPD) is a more severe and persistent mood disorder that affects approximately 10-15% of women
• Symptoms of PPD include persistent sadness, loss of interest in activities, changes in appetite and sleep, fatigue, feelings of worthlessness, and difficulty concentrating
• Postpartum anxiety is characterized by excessive worry, fear, and panic attacks
• Postpartum OCD involves intrusive, unwanted thoughts and compulsive behaviors
• Postpartum psychosis is a rare but serious psychiatric emergency characterized by hallucinations, delusions, and disorganized thinking
• Risk factors for postpartum psychiatric disorders include a history of mental illness, previous PPD, stressful life events, lack of social support, and complications during pregnancy or childbirth
• Assessment includes screening for mood disorders using standardized tools such as the Edinburgh Postnatal Depression Scale (EPDS)
• Treatment for postpartum psychiatric disorders may include psychotherapy, medication, and support groups
• Provide emotional support and education to the patient and family about postpartum psychiatric disorders and their management
• Encourage early intervention and referral to mental health professionals

Other Postpartum Complications

• Urinary retention can occur due to bladder trauma, swelling, and decreased bladder tone
• Monitor urine output and assess for bladder distention
• Encourage frequent voiding and catheterize if necessary
• Diastasis recti is the separation of the abdominal muscles, which can occur during pregnancy
• Encourage gentle abdominal exercises to help strengthen the muscles
• Postpartum thyroiditis is an inflammation of the thyroid gland that can occur in the first year after childbirth
• Symptoms may include fatigue, weight changes, and mood disturbances
• Treatment may involve thyroid hormone replacement