Postpartum Complications

Postpartum Complications:
Principles
The most frequent cause of
postpartum hemorrhage is
uterine atony.

Anything that overdistends the
uterus, causes it to contract
poorly or overworks the uterus
is a set-up for uterine atony.

Postpartum Hemorrhage
- Continues to be a leading cause of
maternal morbidity and death in the US
- Can occur with little
warning

- Definitions (PP lecture)
* also include 10% drop
in Hct between
admission and
postpartum
- 50% underestimation of blood loss

Postpartum Complications
Postpartum Complications
- Most common cause (90%) is uterine
atony (marked hypotonia)
- Less common causes are retained
placenta, placenta accreta,
cervical/vaginal lacerations, uterine
rupture
- Predisposing causes of uterine atony
* Multiparity * Hydramnios
* Macrosomic fetus * Traumatic birth
* Rapid or prolonged labor

Postpartum Complications
* Use of magnesium sulfate
* Use of oxytocin
* Multiple pregnancy
- Management of uterine
atony
* Manual massage of the uterus
* Expression of clots
* Eliminate bladder distention



* IV of lactated Ringers or normal saline
with 10-40 units of oxytocin added

* Ergonovine or methyl-ergonovine (IM)
if not hypertensive

Postpartum Complications
- Non-adherent Retained Placenta
* May result from partial separation of the
placenta or entrapment of the partially
or fully separated placenta
* Treated by manual removal of the
placenta
* If no epidural, nitrous oxide and oxygen
inhalation

Postpartum Complications
- Adherent Retained Placenta
* Unknown etiology
* Probably implantation in a defective area
of endometrium
* Manual removal is unsuccessful and
laceration or perforation of uterine wall
may result from attempts
* Degrees of adherence
- Placenta accreta = slight penetration of
myometrium

Postpartum Complications
- Placenta increta = deep penetration of
myometrium
- Placenta percreta = penetration to the
point of perforation of the myometrium
* Treatment may indicate
hysterectomy and
blood replacement
- Inversion of the uterus
* Potentially life-threatening complication
* 1 in 2000-2500 births
Postpartum Complications
* Partial or complete
* Contributing factors
- Fundal implantation of placenta
- Vigorous fundal pressure
- Excessive traction to cord
- Uterine atony, fibroids or abnormally
adherent placenta
- Most often in multiparas with placenta
accreta/increta

-
Postpartum Complications
- Coagulopathies
* When bleeding continues with no
identifiable source, a coagulopathy must
be considered
* Coagulation status must be assessed
quickly and continuously
* Abnormal results depend
on the cause and may include:
- Increased prothrombin time
- Increased partial prothrombin time


Postpartum Complications
- Decreased platelets
- Decreased fibrinogen level
- Increased fibrin degradation products
- Prolonged bleeding time
* Idiopathic throbocytopenia
* Von Willebrand Disease

Postpartum Complications
* Disseminated intravascular coagulation
(DIC)
- Diffuse and consumes large amounts
of clotting factors
- Widespread external and internal
bleeding
- Predisposing factors: abruptio placentae,
amniotic fluid embolism, dead fetus
syndrome (6 weeks), severe pre-eclampsia,
septicemia, cardiopulmonary arrest,
hemorrhage

Postpartum Complications
* Diagnosis
- Spontaneous bleeding from gums and
nose
- Petechiae around blood pressure cuff
- Thromboembolic Disease

* Types
- Superficial venous thrombosis saphenous)

- Deep venous thrombosis (foot to
iliofemoral region


Postpartum Complications
- Pulmonary embolism (complication of
DVT)
* Incidence has decreased because of
early ambulation after birth
* Major causes
- Venous stasis
- Hypercoagulation
* Medical management
- Superficial analgesic (NSAID), rest
with elevation of the leg, elastic stockings

Postpartum Complications
- Local application of heat may also be
used
- Deep vein thrombosis IV heparin (5-7
days), bedrest with affected leg elevated,
analgesia followed by elastic stockings
and oral anticoagulant therapy (warfarin)
for 3 months
* Woman should be encouraged
not to massage area and,
when on bedrest, not to
flex knees sharply
* Anticoagulant therapy for 6 months
Postpartum Complications
Postpartum Complications
-Pulmonary embolism
* Signs/symptoms
- Shortness of breath
- Diaphoresis
- Chest pain
- Tachycardia
* Treated with continuous IV heparin
followed by intermittent subcutaneous
or oral
Postpartum Infections

- Puerperal Infection (Childbed Fever)
- Any infection of the genital canal that
begins within 28 days after abortion,
miscarriage or childbirth
- Definition is a fever of 38
o
C (100.4
o
F)
on 2 successive days of the first 10 days
postpartum (not counting
1
st
24 hours after birth

Postpartum Complications
- Common infections
* Endometritis
* Wound infections
* Mastitis
* UTIs
* URIs
- More common in women with concurrent
medical or immunosuppressive conditions

Postpartum Complications
- Also increased risk with
* A Cesarean or other operative birth
* Prolonged labor
* Prolonged rupture of membranes
* Internal fetal or uterine monitoring
- Signs/symptoms
* Endometritis
- Pelvic pain
- Uterine tenderness
- Foul-smelling, profuse lochia

Postpartum Complications
* Wound infection
- Erythema, edema, warmth,
tenderness, sero-purulent drainage
wound separation
* Mastitis
- Almost always
unilateral
- Develops well after
milk flow established
- Usually hemolytic S. aureus

Postpartum Complications
- Infected nipple fissure usually the
initial lesion
- Accompanied by inflammatory edema
and engorgement that obstruct milk
flow in the region and generalized
mastitis follows
- Chills, fever, malaise, pain
- Treated by antibiotics and emptying
breasts q 2-4 hours by feeding,
manual expression or pump

Postpartum Complications
Postpartum Psychological Complications
- Grieving
* Normal response to loss of a child or
loss of the ideal child
* The woman grieves the death of the
idealized child

* May interfere
with the ability to
bond with the child

Postpartum Complications
Postpartum Complications
* Death of a baby
- Questions about what happened
- Bewilderment, resentfulness,
bitterness
- Most women interested in seeing the
baby and this is therapeutic
- Staff and patients, friends and
relatives tend to avoid a woman whose
baby has died

- Woman needs the opportunity to talk
about it
Perinatal depression
* Prevalence of major and minor
depression begins to rise after delivery
and peaks in the 3
rd
month
* Postpartum Blues
- 50% of women have symptoms
- Peak on 5
th
postpartum day
- considered a normal part of early
motherhood
- Go away within 10 days







- Depression
* Blues vs. Depression vs. Psychosis
(handout)

* Blues
- Emotional lability
- Feelings of sadness
- Related to hormone shifts, fatigue,
sleep deprivation
* Depression
- Feelings continue beyond the
immediate
postpartal period and longer than 1
year

Postpartum Complications
* Postpartum Depression
- May occur in 10% - 23% of women
- A true, major depression
- Can last into the 2
nd
year after delivery
- Risk factors
* Past history of depression (often bipolar)
* Depression during pregnancy
* Previous history of postpartum depression
* Life stress
* Poor social support
Postpartum Complications
* History baby blues
* History of severe PMS
* Poor marital relationship
* Family history of postpartum
depression
- Symptoms
* Feeling of sadness, extreme fatigue,
inability to stop crying, anxiety about
her own or the babys health,
insecurity and psychosomatic symptoms
Postpartum Complications
* Cheryl Beck (PPSS)

- Teetering on the edge
- Brain is full of cobwebs
- I have lost my self
* Basic psychosocial problem with control
- Postpartum Psychosis
* Response to the crisis of childbearing

* Majority of these women have had
symptoms of mental illness that precede
the pregnancy

Postpartum Complications
Postpartum Complications
* Other major life crises can precipitate
the same illness
* Exceptional sadness, out of touch with
reality, thoughts of infanticide or that
the child is possessed

* This is a psychiatric emergency and
requires hospital admission
* Do not leave the woman alone and do
not leave her alone with her infant
* Risks of suicide and infanticide are
significant