Postpartum Hemorrhage (PPH)

• Postpartum complications encompass a range of physical and psychological challenges that can arise after childbirth, impacting the mother's health and well-being.

Postpartum Hemorrhage (PPH)

• PPH is defined as a cumulative blood loss of ≥1,000 mL or bleeding associated with signs/symptoms of hypovolemia within 24 hours after birth, regardless of the route of delivery.
• It is a leading cause of maternal morbidity and mortality worldwide.

Causes of PPH: The 4 Ts

• Tone: Uterine atony, which is the failure of the uterus to contract adequately after delivery, is the most common cause.
• Trauma: Lacerations of the genital tract, hematomas, or uterine inversion or rupture.
• Tissue: Retained placental fragments.
• Thrombin: Coagulation disorders.

Uterine Atony

• Characterized by a soft, boggy uterus that does not contract effectively.
• Risk factors include:
  • Overdistended uterus (e.g., multiple gestation, polyhydramnios, macrosomic fetus).
  • Prolonged or precipitous labor.
  • High parity.
  • Use of magnesium sulfate.
  • Use of oxytocin during labor.
  • History of uterine atony in previous pregnancies.
• Management involves:
  • Uterine massage to stimulate contraction.
  • Administration of uterotonic medications (oxytocin, misoprostol, methylergonovine, carboprost).
  • Emptying the bladder.
  • Manual exploration of the uterus to rule out retained placental fragments.
  • If bleeding persists, balloon tamponade, uterine artery embolization, or surgery (e.g., hysterectomy) may be necessary.

Lacerations

• Can occur in the cervix, vagina, or perineum during delivery.
• Risk factors include:
  • Operative delivery (forceps or vacuum extraction).
  • Precipitous labor.
  • Macrosomic fetus.
  • Nulliparity.
• Management involves:
  • Visual inspection and repair of the laceration with sutures.
  • Ensuring adequate pain relief.

Retained Placental Fragments

• Occurs when a portion of the placenta remains in the uterus after delivery.
• Risk factors include:
  • Placenta accreta, increta, or percreta (abnormal placental attachment).
  • Manual removal of the placenta.
  • Preterm delivery.
• Management involves:
  • Manual exploration of the uterus and removal of the retained fragments.
  • Dilation and curettage (D&C) may be necessary if manual exploration is unsuccessful.
  • Uterotonic medications may be used to help the uterus contract and expel any remaining tissue.

Hematomas

• Collections of blood in the vulvar, vaginal, or retroperitoneal tissues.
• Risk factors include:
  • Operative delivery.
  • Episiotomy.
  • Prolonged second stage of labor.
• Management involves:
  • Small hematomas may resolve spontaneously with ice packs and analgesics.
  • Large hematomas may require incision and drainage, followed by pressure dressing.

Uterine Inversion

• Occurs when the uterus turns inside out, often during the third stage of labor.
• Risk factors include:
  • Excessive traction on the umbilical cord.
  • Uterine atony.
  • Fundal implantation of the placenta.
• Management involves:
  • Immediate replacement of the uterus into its correct position.
  • Administration of uterotonic medications after the uterus is replaced.
  • Possible use of tocolytic medications to relax the uterus during replacement.

Coagulation Disorders

• Can contribute to PPH if the mother has a pre-existing condition such as:
  • Von Willebrand disease.
  • Thrombocytopenia.
  • Disseminated intravascular coagulation (DIC).
• Management involves:
  • Addressing the underlying coagulation disorder.
  • Transfusion of blood products (e.g., platelets, fresh frozen plasma) as needed.

Assessment and Monitoring for PPH

• Frequent assessment of vital signs, uterine tone, and vaginal bleeding.
• Monitoring intake and output.
• Assessing for signs and symptoms of hypovolemia (e.g., tachycardia, hypotension, pallor, dizziness).
• Weighing perineal pads to estimate blood loss.
• Monitoring laboratory values (e.g., hemoglobin, hematocrit, coagulation studies).

Prevention of PPH

• Active management of the third stage of labor, including:
  • Administration of oxytocin after delivery of the anterior shoulder.
  • Controlled cord traction.
  • Uterine massage after placental delivery.
• Early identification and management of risk factors.

Thromboembolic Disorders

• Thromboembolic disorders, such as deep vein thrombosis (DVT) and pulmonary embolism (PE), are a significant cause of maternal morbidity and mortality in the postpartum period.
• Pregnancy is a hypercoagulable state, increasing the risk of blood clot formation.

Risk Factors for Thromboembolic Disorders

• Cesarean delivery.
• Obesity.
• History of thromboembolism.
• Varicose veins.
• Prolonged immobility.
• Advanced maternal age.
• High parity.
• Preeclampsia.

Deep Vein Thrombosis (DVT)

• Formation of a blood clot in a deep vein, usually in the leg.
• Symptoms include:
  • Pain, swelling, warmth, and redness in the affected leg.
  • Calf tenderness.
• Diagnosis is typically made with ultrasound.
• Management involves:
  • Anticoagulation therapy (e.g., heparin, low-molecular-weight heparin, warfarin).
  • Compression stockings.
  • Elevation of the affected leg.

Pulmonary Embolism (PE)

• Occurs when a blood clot travels to the lungs and blocks a pulmonary artery.
• Symptoms include:
  • Sudden onset of shortness of breath.
  • Chest pain.
  • Cough.
  • Hemoptysis (coughing up blood).
  • Tachycardia.
• Diagnosis is typically made with CT angiography or V/Q scan.
• Management involves:
  • Anticoagulation therapy.
  • Oxygen therapy.
  • In severe cases, thrombolytic therapy or surgical embolectomy may be necessary.

Prevention of Thromboembolic Disorders

• Encourage early ambulation after delivery.
• Use sequential compression devices (SCDs) during and after cesarean delivery.
• Encourage adequate hydration.
• Prophylactic anticoagulation may be considered in high-risk women.

Postpartum Infections

• Postpartum infections can occur in the uterus (endometritis), wound sites (e.g., episiotomy or cesarean incision), urinary tract, or breasts (mastitis).
• Risk factors include:
  • Cesarean delivery.
  • Prolonged labor.
  • Prolonged rupture of membranes.
  • Multiple vaginal examinations.
  • Use of internal fetal monitoring.
  • Compromised immune system.

Endometritis

• Infection of the uterine lining.
• Symptoms include:
  • Fever.
  • Uterine tenderness.
  • Foul-smelling lochia.
  • Tachycardia.
• Management involves:
  • Antibiotic therapy (usually broad-spectrum).

Wound Infections

• Infections of episiotomy or cesarean incision sites.
• Symptoms include:
  • Redness.
  • Swelling.
  • Pain.
  • Drainage.
  • Fever.
• Management involves:
  • Antibiotic therapy.
  • Wound care (e.g., opening and draining the wound, debridement).

Urinary Tract Infections (UTIs)

• Common postpartum infection, often associated with catheterization during labor.
• Symptoms include:
  • Dysuria (painful urination).
  • Frequency.
  • Urgency.
  • Suprapubic pain.
  • Fever.
• Management involves:
  • Antibiotic therapy.
  • Adequate hydration.

Mastitis

• Infection of the breast tissue, usually caused by Staphylococcus aureus.
• Symptoms include:
  • Breast pain.
  • Redness.
  • Swelling.
  • Fever.
  • Flu-like symptoms.
• Management involves:
  • Antibiotic therapy.
  • Frequent breastfeeding or pumping to empty the breast.
  • Warm compresses.
  • Analgesics.

Prevention of Postpartum Infections

• Strict adherence to aseptic technique during labor and delivery.
• Prophylactic antibiotics for cesarean delivery.
• Encourage good hygiene practices.
• Early recognition and treatment of infections.

Postpartum Mood Disorders

• Postpartum mood disorders encompass a range of emotional and psychological disturbances that can occur after childbirth, affecting the mother's well-being and ability to care for her infant.

Postpartum Blues

• Mild, transient mood disturbance that affects up to 80% of postpartum women.
• Characterized by:
  • Sadness.
  • Tearfulness.
  • Anxiety.
  • Irritability.
  • Fatigue.
• Typically resolves within a few days to 2 weeks postpartum.
• Usually, no treatment is required other than reassurance and support.

Postpartum Depression (PPD)

• More severe and persistent mood disorder that affects approximately 10-15% of postpartum women.
• Characterized by:
  • Depressed mood.
  • Loss of interest or pleasure in activities.
  • Changes in appetite or weight.
  • Sleep disturbances.
  • Fatigue.
  • Feelings of worthlessness or guilt.
  • Difficulty concentrating.
  • Suicidal ideation.
• Symptoms must be present for at least 2 weeks to meet the diagnostic criteria for PPD.
• Treatment involves:
  • Psychotherapy (e.g., cognitive behavioral therapy, interpersonal therapy).
  • Antidepressant medications.
  • Support groups.

Postpartum Psychosis

• Rare but severe psychiatric disorder that affects approximately 0.1-0.2% of postpartum women.
• Characterized by:
  • Hallucinations.
  • Delusions.
  • Disorganized thinking and behavior.
  • Rapid mood swings.
  • Risk of infanticide or suicide.
• Requires immediate medical attention and hospitalization.
• Treatment involves:
  • Antipsychotic medications.
  • Mood stabilizers.
  • Electroconvulsive therapy (ECT) may be considered in severe cases.

Risk Factors for Postpartum Mood Disorders

• History of depression or other mood disorders.
• Family history of mood disorders.
• Stressful life events.
• Lack of social support.
• Complicated pregnancy or delivery.

Screening for Postpartum Mood Disorders

• Routine screening for PPD is recommended at postpartum visits using standardized questionnaires, such as the Edinburgh Postnatal Depression Scale (EPDS).

Management of Postpartum Mood Disorders

• Early identification and treatment are crucial.
• Provide education and support to the mother and her family.
• Encourage the mother to seek professional help.
• Ensure the safety of the mother and her infant.