Postpartum Hemorrhage (PPH)

• Postpartum complications are health problems that occur after childbirth, affecting the mother's physical and psychological well-being.
• Early recognition and management of postpartum complications are essential to prevent serious morbidity or mortality.

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 route of delivery
• It is a leading cause of maternal morbidity and mortality worldwide.
• PPH can be categorized as early (primary) if it occurs within the first 24 hours after childbirth or late (secondary) if it occurs from 24 hours to 12 weeks postpartum.
• The most common causes of PPH are often referred to as the "4 Ts": Tone (uterine atony), Trauma (lacerations, hematomas, uterine inversion/rupture), Tissue (retained placental fragments), and Thrombin (coagulation disorders).
• Uterine atony, the failure of the uterus to contract adequately after delivery, is the most common cause of early PPH.
• Risk factors for uterine atony include overdistended uterus (large fetus, multiple gestation, polyhydramnios), high parity, prolonged or rapid labor, use of oxytocin during labor, history of uterine atony in previous pregnancies, magnesium sulfate administration, chorioamnionitis, and uterine fibroids.
• Trauma to the genital tract can cause significant bleeding. Lacerations can occur in the cervix, vagina, or perineum during delivery. Forceps or vacuum-assisted deliveries increase the risk of lacerations.
• Retained placental fragments can prevent the uterus from contracting properly.
• Coagulation disorders, such as disseminated intravascular coagulation (DIC), can lead to PPH.
• Assessment involves continuous monitoring of vital signs, assessing the amount of vaginal bleeding, evaluating uterine tone, and identifying any signs of shock (tachycardia, hypotension, pallor, clammy skin).
• Fundal massage is a critical intervention for uterine atony.
• Medications such as oxytocin, misoprostol, methylergonovine, and carboprost tromethamine are used to promote uterine contractions and reduce bleeding.
• Uterine tamponade with a balloon catheter can provide direct pressure to the uterine wall to control bleeding.
• Surgical interventions, such as uterine artery ligation, B-Lynch suture, or hysterectomy, may be necessary in severe cases of PPH.
• Blood products such as packed red blood cells, fresh frozen plasma, and platelets may be needed to replace blood loss and correct coagulation abnormalities.

Postpartum Infection

• Postpartum infections are infections that occur after childbirth, most commonly in the uterus (endometritis), wound (cesarean incision, episiotomy, laceration), urinary tract, or breast (mastitis).
• Endometritis is an infection of the uterine lining, often caused by bacteria that ascend from the vagina into the uterus after delivery.
• Risk factors for endometritis include cesarean birth, prolonged rupture of membranes, multiple vaginal examinations during labor, internal fetal monitoring, manual removal of the placenta, and poor hygiene.
• Wound infections can occur at the site of a cesarean incision, episiotomy, or laceration repair.
• Risk factors for wound infections include obesity, diabetes, poor nutrition, prolonged labor, and immunosuppression.
• UTIs are common postpartum infections caused by urinary catheterization, frequent vaginal examinations, and trauma to the urethra during delivery.
• Mastitis is an infection of the breast tissue, usually caused by bacteria entering through a cracked nipple.
• Fever, chills, abdominal pain, uterine tenderness, and foul-smelling lochia are signs and symptoms of endometritis.
• Wound infection symptoms include redness, swelling, warmth, pain, and purulent drainage at the incision site.
• Urinary frequency, urgency, dysuria, and hematuria (UTI symptoms).
• Breast pain, redness, swelling, warmth, and fever are signs of mastitis.
• Broad-spectrum antibiotics are typically used to treat endometritis until the woman is afebrile for 24 to 48 hours.
• Wound infections are treated with antibiotics and wound care, which may include opening and draining the wound.
• UTIs are treated with antibiotics.
• Mastitis is treated with antibiotics and continued breastfeeding or pumping to prevent milk stasis.
• Analgesics, such as acetaminophen or ibuprofen, can help relieve pain and fever.
• Encourage adequate hydration and nutrition to promote healing.
• Teach proper perineal hygiene to prevent the spread of infection.
• Educate on proper breastfeeding techniques and nipple care to prevent mastitis.

Thromboembolic Disease

• Thromboembolic disease refers to the formation of blood clots in the veins, which can lead to deep vein thrombosis (DVT) or pulmonary embolism (PE).
• Pregnancy is a hypercoagulable state, increasing the risk of thromboembolic events. This risk is further elevated in the postpartum period.
• Virchow's triad (hypercoagulability, venous stasis, and endothelial injury) contributes to the development of thromboembolic disease in pregnancy.
• Cesarean birth, obesity, immobility, history of thromboembolism, preeclampsia, and advanced maternal age are risk factors for thromboembolic disease.
• DVT involves the formation of a blood clot in a deep vein, usually in the leg.
• PE occurs when a blood clot travels to the lungs, blocking blood flow.
• Unilateral leg pain, swelling, redness, warmth, and tenderness are signs and symptoms of DVT.
• Sudden onset of dyspnea, chest pain, cough, hemoptysis, and anxiety are PE symptoms.
• Diagnostics include lower extremity ultrasound to detect DVT and CT angiography to diagnose PE.
• Anticoagulant therapy with heparin or low-molecular-weight heparin (LMWH) is the primary treatment for DVT and PE. Warfarin may be started after the initial heparin therapy.
• Thrombolytic therapy may be used in life-threatening cases of PE.
• Encourage early ambulation to prevent venous stasis.
• Apply compression stockings or sequential compression devices (SCDs) to promote venous return in high-risk women.
• Adequate hydration is important to prevent blood clots.
• Education on the signs and symptoms of DVT and PE, the importance of adherence to anticoagulant therapy, and the need for regular monitoring are important.

Postpartum Mood Disorders

• Postpartum mood disorders encompass a range of emotional and psychological disturbances that can occur after childbirth, including postpartum blues, postpartum depression (PPD), and postpartum psychosis.
• Postpartum blues, also known as "baby blues," are mild, transient mood changes that affect up to 80% of women in the first few weeks postpartum.
• PPD is a more severe and persistent mood disorder that affects approximately 10-15% of women after childbirth.
• Postpartum psychosis is a rare but serious psychiatric emergency that affects approximately 0.1-0.2% of women after childbirth.
• Hormonal changes, history of mood disorders, lack of social support, stressful life events, and complications during pregnancy or childbirth are risk factors for postpartum mood disorders.
• Symptoms of postpartum blues include mood swings, irritability, anxiety, tearfulness, and difficulty concentrating.
• Symptoms of PPD include persistent sadness, loss of interest in activities, changes in appetite and sleep, fatigue, feelings of worthlessness or guilt, difficulty bonding with the baby, and thoughts of harming oneself or the baby.
• Symptoms of postpartum psychosis include hallucinations, delusions, paranoia, confusion, rapid mood swings, and bizarre behavior.
• Screening for postpartum mood disorders using standardized tools such as the Edinburgh Postnatal Depression Scale (EPDS).
• Cognitive-behavioral therapy (CBT) and interpersonal psychotherapy (IPT) are effective treatments for PPD.
• Antidepressant medications, such as selective serotonin reuptake inhibitors (SSRIs), may be prescribed for PPD.
• Hospitalization and antipsychotic medications are usually required for postpartum psychosis.
• Provide emotional support and encouragement.
• Promote adequate rest, nutrition, and exercise.
• Encourage social interaction and support groups.
• Ensure patient safety and monitor for suicidal or homicidal ideation.
• Early identification, treatment, and support are essential for women experiencing postpartum mood disorders.