Postpartum Hemorrhage (PPH)

• Postpartum complications are any health problems that occur for the mother and/or the newborn(s) after childbirth, and they can range from minor to life-threatening.

Postpartum Hemorrhage (PPH)

• PPH is excessive bleeding after childbirth and is a leading cause of maternal mortality worldwide, historically defined as blood loss of >500 mL after vaginal birth or >1000 mL after cesarean birth.
• Current definition of PPH: cumulative blood loss of >1000 mL or bleeding associated with signs/symptoms of hypovolemia within 24 hours after the birth process.
• Early (primary) PPH occurs within the first 24 hours after childbirth, with uterine atony being the most common cause.
• Late (secondary) PPH occurs from 24 hours to 12 weeks postpartum, often due to retained placental fragments or infection.
• Risk factors for PPH include: overdistended uterus (e.g., multiple gestation, polyhydramnios, macrosomic fetus), high parity, prior PPH, operative vaginal delivery, induced or augmented labor, prolonged first or second stage of labor, use of magnesium sulfate, chorioamnionitis, uterine atony, lacerations, hematomas, retained placental fragments, uterine inversion, or coagulation disorders.
• Signs and symptoms include: excessive or bright red vaginal bleeding, a boggy uterus that doesn't respond to massage, abnormal clots, high temperature, pelvic discomfort or backache, persistent bleeding despite interventions, increased heart rate and decreased blood pressure (late signs), and swelling/pain in the perineal area if a hematoma is present.

Uterine Atony

• Uterine atony is the failure of the uterus to contract adequately after delivery.
• It is the most common cause of early postpartum hemorrhage.
• Management includes: fundal massage, ensuring bladder is empty, and medications (oxytocin, misoprostol, methylergonovine, carboprost tromethamine) to stimulate uterine contractions.

Lacerations and Hematomas

• Lacerations during childbirth can occur in the perineum, vagina, cervix, or around the urethra.
• Hematomas are collections of blood in the soft tissues of the vulva, vagina, or retroperitoneal area.
• Risk factors for lacerations include: operative vaginal delivery, precipitous birth, macrosomia, and previous perineal scarring.
• Risk factors for hematomas include: episiotomy, operative vaginal delivery, and prolonged second stage of labor.
• Treatment for lacerations involves repair with sutures, while small hematomas may resolve on their own; large hematomas may require incision and drainage.

Retained Placental Fragments

• Retained placental fragments can cause late PPH due to subinvolution of the uterus.
• Suspect in cases of profuse bleeding or a return to rubra bleeding after transitioning to serosa or alba.
• Diagnosis is often made by ultrasound.
• Treatment may involve manual exploration of the uterus, dilation and curettage (D&C), or medication (oxytocin, misoprostol).

Uterine Inversion

• Uterine inversion is a rare but life-threatening complication where the uterus turns inside out, typically during the third stage of labor.
• Risk factors include: fundal implantation of the placenta, short umbilical cord, uterine atony, and excessive traction on the umbilical cord.
• Treatment involves immediate manual replacement of the uterus, followed by uterotonic medications.

Thromboembolic Disorders

• Thromboembolic disorders, including deep vein thrombosis (DVT) and pulmonary embolism (PE), are major causes of maternal morbidity and mortality
• Increased risk during pregnancy and the postpartum period due to Virchow's triad: hypercoagulability, venous stasis, and endothelial injury.
• Risk factors include: cesarean birth, immobility, obesity, smoking, history of thromboembolism, varicose veins, advanced maternal age, and certain medical conditions (e.g., diabetes, hypertension).
• Signs and symptoms of DVT include: leg pain, swelling, redness, and warmth.
• Signs and symptoms of PE include: shortness of breath, chest pain, cough, and anxiety.
• Prevention includes: early ambulation, sequential compression devices (SCDs), and prophylactic anticoagulation in high-risk individuals.
• Treatment involves anticoagulation therapy (e.g., heparin, enoxaparin, warfarin).

Postpartum Infections

• Postpartum infections, also known as puerperal infections, can affect the uterus (endometritis), wound sites (cesarean incision, episiotomy), urinary tract (UTI), or breasts (mastitis).
• Risk factors include: cesarean birth, prolonged rupture of membranes, multiple vaginal examinations during labor, internal fetal monitoring, manual removal of the placenta, diabetes, compromised immune system.
• Endometritis is an infection of the uterine lining, most commonly caused by bacteria ascending from the vagina.
• Signs and symptoms of endometritis include: fever, uterine tenderness, foul-smelling lochia, and tachycardia.
• Wound infections typically present with redness, swelling, pain, and purulent drainage.
• UTIs are common in the postpartum period due to urinary catheterization and bladder trauma.
• Signs and symptoms of UTIs include: dysuria, frequency, urgency, and fever.
• Mastitis is an infection of the breast tissue, usually caused by bacteria entering through cracked nipples.
• Signs and symptoms of mastitis include: breast pain, redness, warmth, swelling, and fever.
• Treatment of postpartum infections involves antibiotics, wound care, and supportive measures.

Postpartum Mood Disorders

• Postpartum mood disorders include postpartum blues, postpartum depression (PPD), and postpartum psychosis.
• Postpartum blues are mild, transient emotional disturbances that affect the majority of women in the first few weeks after childbirth.
• Symptoms include: mood swings, tearfulness, anxiety, and irritability.
• PPD is a more severe and prolonged mood disorder that affects approximately 10-15% of women.
• Symptoms include: persistent sadness, loss of interest in activities, changes in appetite and sleep, fatigue, feelings of worthlessness, and thoughts of suicide.
• Postpartum psychosis is a rare but serious psychiatric emergency that can occur within the first few weeks after childbirth.
• Symptoms include: hallucinations, delusions, paranoia, and disorganized thinking.
• Risk factors for postpartum mood disorders include: history of depression, anxiety, or bipolar disorder, stressful life events, lack of social support, and complications during pregnancy or childbirth.
• Treatment involves therapy, medication (antidepressants, mood stabilizers), and hospitalization in severe cases.