Postpartum complications

Prepared by: Tea.AMAL

Introduction
• Definition
• *Puerperium: is period from the expulsion of the placenta to the time
the reproductive organs return to pregravida state lasts 6 weeks.
• * POSTPARTUM: A postpartum period or postnatal period is the period
beginning immediately after the birth of a child and extending for about
six weeks.
• Less frequently used are the terms puerperium or puerperal period.
• * Involution of the uterus: is the process by which the uterus is
transformed from pregnant to non-pregnant state. It is a physiological
process occurring after parturition; the hypertrophy of the uterus has to
be undone since it does not need to house the fetus anymore
• |The uterus returns to its normal site, tone & position of non pregnant
state Mechanism
POSTPARTUM SPECIFIC COMPLICATIONS AND MANAGEMENT

• POSTPARTUM HEMORRHAGE (PPH)

• Definition
• PPH: Loss of more than 500 ml of blood from the
genital tract in the first 24 hours after vaginal delivery
and more than 1000 ml after cesarean section.
• - Excessive vaginal bleeding resulting in signs of
hypovolemia (Hypotension, Tachycardia, oliguria, light
headedness)
• - A 10% decline in post partum hemoglobin
concentration from antepartum levels
• Types
• Primary: Occurs within first 24 hrs
• Secondary: After 24hrs to the end of puerperium
(42days after delivery)
• Causes
• - Atonic uterus (70%)
• - Genital tract trauma (20%)
• - Retained placenta or placenta fragment (10%)
• - Coagulopathy (1%) 
• Causes of primary PPH (4 Ts)
• Tone: uterine atony
• Tissue: retained tissue
• Trauma: laceration, rupture, inversion
• Thrombin: Coagulopathy
• Causes of secondary PPH
• Retained of POC
• Sub-involution of placenta site
• Infection
• Inherited coagulation defects
• Signs and Symptoms
• 1. Continuous vaginal bleeding
• 2. Hypovolemic shock (low BP, rapid pulse, cold and clammy skin)
• 3. Anemia (Palor, tachycardia, swelling)
• Risk factors
• Overdistension of the uterus (Polyhydramnios, Multiple pregnancies,
Macrosomia…)
• Grandmultiparity
• Previous history of PPH
• Ante-partum hemorrhage
• Myomatous uterus
• Hypertensive disorders
• Drug use (Mgso4, Salbutamol…)
• Investigations
• - FBC
• - Blood group crossmatch
• - Blotting profile

• Management
• - Principles
• • Resuscitation of the mother
• • Identification of the specific cause of PPH
• • Call for help (Obstetrician, Anesthetist, midwife…)
• • Management is done following the figure below
• Treatment approaches for PPH
• Called for help
• Uterine massage
• Empty the bladder
• Bi-manual compression
• Inspect for obvious laceration

• Resuscitative measure of PPH

• Airway, breathing, circulation
• Lay flat
• Give oxygen, check vitals
• Too large bore IV, R/L or N?
• Argent blood group and cross match, clotting
• Oxytocin drugs
• Management
• Atony is the most common cause of bleeding
• Uterine massage, bi-manual uterine compression
• Expel clothes
• Manual exam of the uterus ( put your whole hand and arm inside)
• Empty the bladder
• Examine for laceration , repair quickly
• Ask about history of clotting disorder
 
• Medical management
• Utero tonic medication (power replacement of uterus)
• Oxytocin is an effective first line treatment for PPH (10iu) should be injected I.M or 20 iu in one liter of N/S
may be infused at a rate of 250ml/hrs as much 500ml can be infused over 10 min without complication
• Methylergometrine 0.2mg for I.M repeat 2-4 hour, avoid in hypertension mother
• Uterine tamponate
• Backing with gauze
• Can sock with thrombin
• Intra-uterine folly catheter
• Surgical management
• Consider surgical when uterine agents and tamponate don’t work
• Uterine curettage
• Exploratory laprotomy: hypogastric artery ligation, by lateral uterine artery ligation
• Hysterectomy
• Complications
• Hypovolemic shock
• Sheehan syndrome
• Renal failure
• Anemia
• Death
• Prevention of PPH
• AMTSL: reduces incidence of PPH
• 10 iu oxytocin I.M or 0.5mg Ergometrine immediately after birth
• Controlling cord traction for delivery of placenta
• Uterine massage at delivery of placenta until uterus is well contracted
• Empty bladder
• Baby starts breastfeeding as soon as possible
• Avoid routine episiotomy
SUB-INVOLUTION

DEFINITION: Sub involution is incomplete return

of the uterus to its pre pregnant size and shape.
• Sub-involution of the uterus is impaired and
deficient involution of the uterus following
delivery.
• With sub involution, at a 4 or 6 week post
portal risk, the uterus is still enlarged and soft
and the woman still has a lochia discharge.
Causes of subinvolution

• Predisposing factors
• Grand multiparity
• Over distension of uterus as in twins and hydramnios
• Maternal ill health
• Cesarean section
• Prolapse of the uterus
• Uterine fibroid (leiomyomas)
• No sucking of the baby
• Aggravating factors
• Retained products of conception
• Uterine sepsis
• Retention of lochia (lochiametra)
• Clinical features
• Excessive or prolonged discharge of lochia
• Irregular or excessive uterine bleeding
• Irregular cramp like pain
• Uterine height more than normal for the particular day of postpartum
Cont..
• Prevention of sub-involution
• Make sure the placenta and membranes are complete expelled
• Give ergo or oxytocin after birth
• Keep uterus well contracted after birth
• Put the baby on breast
• Advice the mother on hygiene

• Treatment
• 1. Oral administration of methyl Ergometrine 0.2mg Q 10 hours to improve uterine time
and complete involution.
• 2. An oral antibiotic if the uterus is tender on palpation and analgesics
• 3. Exploration of the uterus for retained products
• 4. Pessary in prolapse or retroversion
• N.B. Be certain that women know at discharge from a health care facility the normal
process of involution and lochial discharge
Puerperal infection
• Puerperal pyrexia
• An elevation of temperature to 38c°(100.4F°) or more occurring on two separate occasions at 24hrs
apart( excluding the first 24hrs) within the first 10days following delivery is called puerperal pyrexia
• Causes
• Puerperal sepsis
• Urinary tract infection: cystitis, pyelonephritis
• Breast infection
• Infection of laparotomy wound (cesarean section)
• Intercurrent infection: acute bronchitis, pneumonia, influenza, acute appendicitis and enteric fever
• Thrombophlebitis
• Deep vein thrombosis
• Flaring up of tuberculosis
• Puerperal Sepsis
• Infection of the genital tract that occurs at any time between the rupture of membranes in labour
and 42 day following delivery or abortion
• Cause
• a. Endogenous bacteria
• b. Exogenous bacteria
• Symptoms
• - Pelvic pain
• - Fever 38.50C or more
• - Abnormal smell, foul dour of vaginal discharge
• - Delay in the rate of reduction of the size of the
uterus. (Sub-involution)
Risk factors for puerperal sepsis

•Poor hygiene
•Poor aseptic technique
•Manipulations in birth canal
•Presence of dead tissue in the birth canal due to IUFD
•Retained fragments of placenta or membranes shedding of dead tissue from vaginal wall
following obstructed labour.
•Insertion of unsterile hand, instrument or packing / traditional practices should also be
examined/
•Pre existing anemia and malnutrition
• Prolonged of obstructed labour
•Prolonged rupture of membrane
• Frequent vaginal examinations
•Caesarean section and other operative deliveries
• Unrepaired vaginal or cervical lacerations
• Preexisting sexually transmitted disease
•Post partum hemorrhage
•Not being immunized against tetanus
•diabetes
• Site of infection
• 1. Placental site
• 2. Perineum
• 3. Vagina
• 4. Cervix
• 5. Uterus
• Women are vulnerable to infection in the proportion
because the placental site is large, warm, dark moist,
rich to grow very quickly.
• During delivery traumatized tissue of tear in the vagina
or perineal area is susceptible to infection.
•Managing Puerperal sepsis
•1. Isolation and Barrier nursing of the woman Nurse the woman in a separate room,
use gloves only when attending her keep one set of equipment, dishes and other
utensils for the use of this woman, wash hands carefully before & after attending this
woman.
•2. Administration of high doses of antibiotics / Broad spectrum/
•3. Give plenty of fluids:- the aim of this is to correct or prevent dehydration and help
to lower the fever.
• In severe cases it is necessary to give IV fluids at first.
•4. Ruling out Retained placental fragments:- suspect this if the uterus is soft and bulky,
if lochia are excessive and contain blood clots, it can be a sign of puerperal sepsis.
•The woman should be referred to a facility that has the equipment and health care
personnel trained to perform curettage.
•5. Providing skilled nursing care:- Careful attention to the comfort of the woman.
•It is important for the woman to rest, monitor uterine size, measure intake and
output, keep accurate recurs; prevent spread of infection and cross infection.
•Accurate observation, recording and reporting
• Prevention
• improvement of general hygiene
• Take aseptic precaution while dressing Perineal wound
• Restriction of visitors in the postpartum ward
• Vulva and perineum to be washed/cleaned with mild
antiseptic solution following urination and defecation
• Abstinence from sexual intercourse in the last two
months
• Avoid unnecessary vaginal examination and douches in
the later month
• Breast complications
• The common breast complications in puerperium are breast engorgement, cracked and retracted nipple,
mastitis, breast abscess and failing lactation
•  
• Breast engorgement
• Breast engorgement may occur due to excessive production of milk, obstruction to outflow of milk or poor
removal of milk by the baby.
• It usually manifests after the milk secretion starts (3rd or 4th postpartum day)
• Symptoms
• Both breasts feel tender, tense and firm
• Nipples become edematous and flushed
• The veins over the breasts become engorged and prominent
• Generalized malaise and rise of temperature
• Painful breastfeeding
• Preventive measures
• To initiate breastfeeding early and feeding at frequent intervals
• Exclusive breastfeeding on demand
• Feeding in correct position
• Management
• Support the breasts with a binder or brassier
• Manual expression of any milk after each
feeding and keeping the intervals short
between feeds
• Analgesics for pain
• The cause of poor sucking by the newborn
should be corrected
• Cracked and retracted nipples
• The nipples may become painful due to loss of surface epithelium with the formation of raw
area of the nipple or due to a fissure situated at the tip or the base of the nipple
• These two conditions often co-exist, which are referred to as the cracked nipple
• Cracked nipple is sore nipples are any persistent pain in the nipples that lasts throughout the
entire breastfeeding or hurts between feeding
• Causes
• Inadequate hygiene resulting in the formation of a crust over the nipple
• Retracted nipple
• Vigorous sucking and an inadequate milk flow
• The women experiences soreness and pain at the site of the fissure, the fissure may become
infected, when infected, the infection may spread to the deeper tissue producing mastitis and
hence, it should be treated
• Prevention
• Local cleanliness during pregnancy, and in the puerperium before and after each
breastfeeding t prevent crust formation over the nipple
• Treatment
• Application of tincture on benzoic after the night feeding and the fissure is likely to be healed in
8 to 12 hours
• The nipple is to be kept dry and exposed to air
• Breast milk should be removed by manual expression or pump
• If infected, an antiseptic cream is applied locally
• If it fails to heal, breastfeeding from the affected breast is stopped for 24 hours
• Retracted nipple (inverted nipple)
• An inverted nipple is a condition in which the nipple is pulled inward into the breast instead of
pointing outward.
• This condition can also called nipple inversion, nipple retracted or invaginated nipple and its
common in Primigravida.
• Manually pulling out the retracted nipple during the last two months of pregnancy is useful to
rectify the defect
• After delivery, the nipple is pulled out by the suction action of the disposable syringes
• The procedure may have to be repeated for few days
• Acute Puerperal Mastitis
• Is inflammation of the breast and externally painful and may lead to abscess formation.
• The most common infectious organism is staphylococcus aureus.
• The most likely source of the infection is the baby and out breaks of skin and eye infections
among babies are frequently due to staphylococcus aureus.
• Organisms are transmitted by cross infection and can easily affect a whole part.
•  
•  
• Sign and symptoms
• - Occurs after the 8th postnatal day
• - The onset is rapid with a sharp rise in temperature which can reach as high as 40C.
• - Rapid pulse
• - Throbbing pain and tenderness in the affected breast.
• - A wedge shaped, indurate and reddened area of the breast is seen on examination
• Investigation
• - A sample of breast milk is sent for bacteriological examination
• Treatment
• Prophylactic:
• Antenatal care to nipple, prevention of engorgement and isolation of the
infected baby
• Curative
• Isolation of the mother and baby
• Suspension of breastfeeding on the affected side until the infection is
controlled
• Manual expression of milk to relieve engorgement
• Suppression of lactation by bromocriptine (parlodel) 2.5mg orally for 14 days
• Antibiotic therapy for at least 10days
• Analgesics and sedatives as required
• Breast Abscess
• Acute puerperal mastitis may lead to abscess formation. If this occurs the
affected breast is extremely painful, edema is usually present and the breast
becomes tense and red.
• The axially glands become tender and enlarged.
• The abscess must be incised and drained to prevent spread into other areas of
breast which would cause damage.

• Prevention
• The best method of treatment lies in prevention.
• Attention to hand washing and hygiene will both lower the incidence of
infection among babies and reduce risk of breast infection in mothers.
• Nurses, midwives and doctors must maintain cleanliness and wash their hands
before attending to a mother or a baby
Failing lactation

• Causes
• Debilitating state of the mother
• Elderly Primigravida
• Failure to suckle the baby regularly
• Depression or anxiety state in the puerperium
• Premature baby, who is too weak to suck
• Ill development of breasts
• Painful breast lesion
• Treatment
• Antenatal
• Education regarding the advantages of breastfeeding
• Correction of abnormalities like retracted nipple
• Maintenance of adequate breast hygiene especially in the last two months of pregnancy
• Improvement the general health status of the mother
• Postnatal
• Encourage adequate fluid intake
• Treat painful lesions promptly
• Express residual milk after each feeding
• Drugs like prolactin is useful
Perineal wound

• The perineum is the area of skin and muscle

between the vaginal opening and the anus
• Perineal wounds usually occur following trauma,
ablation of malignancy of the genitalia, low pelvic
tumors, or following thermal or electrical injuries.
• These wounds remain a significant problem and
can commonly present as wound infection,
abscess, dehiscence, delayed healing, or
persistent Perineal sinuses
• Factors Affecting Wound Healing
1. Hygiene
• Personal hygiene of both the patient and anyone else who is in contact with the wound could have an
effect on the healing process.
• Any time that the wound dressing is changed, the person doing so should wash his or her hands with
soap and water first.
• Additionally, this best practice should be done in a sterile environment using clean wound care
products to help prevent infection.
• Overall and oral health can also play a role in the time it takes area to heal.
2. Nutrition
• What patients eat can help speed up the progress of healing wounds.
• For instance, foods that are high in protein, iron, a variety of minerals (zinc and copper) and vitamins
(A, B and C) will all help move things along.
• On top of that, carbohydrates and fats are necessary for providing the body with energy, and fatty
acids promote wound healing as well. And what patients eat is equally important as what they drink.
• It is especially vital for those in need of burn wound care to keep hydrated as the skin works to
recover from the injury.
3. Age
• As with many things related to health, age plays a factor in the time it takes
a wound to heal properly.
• Seniors are likely to experience lengthier recovery times, as their skin
suffers from reduced elasticity.
• The older we get, the more likely we are to need wound infection
treatment, as our immune systems weaken with age.
4. Blood supply : Good blood supply
• Physiology of wound healing
• Hemostasis (blood clotting): Within the first few minutes of injury, platelets
 in the blood begin to stick to the injured site.
• Inflammation: distraction of the tissue
• Proliferation (growth of new tissue)
• Maturation (remodeling): During maturation (developing)
Complications of wound healing

• The major complications are many:

• Deficient scar formation: Results in wound dehiscence or
rupture of the wound due to inadequate formation of
granulation tissue.
• Excessive scar formation: Hypertrophic scar
• Exuberant granulation (proud flesh).
• Deficient contraction (in skin grafts) or excessive
contraction (in burns).
• Others: Dystrophic calcification, pigmentary changes,
painful scars, incisional hernia etc.
Deep vein thrombosis and pulmonary embolus (DVT&PE)

• Definition:
• DVT is the formation of blood clots within the deep veins, most commonly in the lower extremities or pelvis.
• PE is thrombosis or showers of emboli in the pulmonary vessels

• Pregnancy associated causes

• - Vessel damage during pregnancy
• - Mechanical impedance of venous return
• - Changes in local clotting factors

• Risk factors
• - Advanced maternal age
• - Increased parity
• - Multiple gestations
• - Surgery (C/S, episiotomy, and lacerations)
• - Prolonged immobility, as with bed rest
• - Dehydration
• - Prior DVT or PE
• - Lupus anticoagulant
• - Pre-eclampsia
Signs and symptoms

• - Pain or tenderness, fever

• - With PE tachycardia, dyspnea and chest pain.
• - Asymmetric limb swelling, > 2 cm larger than opposite side
• - Warmth or erythema of skin over area of thrombosis
• - Homans sign (calf pain with dorsiflexion of the foot)
• Complications
• - Septic pelvic thrombophlebitis
• - Death
• Investigations
• - Fool blood count, coagulation test (PTT, PT/ INR) Liver function, renal function
• - Ultrasound
• - CT scan
• - Chest x-ray
• - Angiography
• Prevention
• Leg movement and exercises
• Elastic stockings
• Active breathing exercises
• Avoid sitting with legs dangling down
• Intermittent calf muscle compression
• Prophylactic anticoagulant therapy
• Avoiding the use of estrogen for suppression of lactation
• Management
• Bed rest with the foot end raised above the heart level
• Analgesics to relieve pain in the affected area and sedatives to ensure
sleep
• Antibiotics
• Heparin therapy 15,000 units IV followed by 10,000units 4 to 6 hourly,
heparin is continued for 7 to 10 days or even longer.
• Warfarin orally is commonly used in addition to heparin and may
continued for 3 to 6 month’s maintenance therapy
• Gentle movement in bed to be started when the pain subsides, in about a
week
• Caval filter may be inserted if there is free-floating thrombus detected by
scan or phlebogram
• Psychological disturbances in the puerperium
• The events of pregnancy, labour and delivery together with the peak experience of giving birth, all contribute to
mixture of emotional reactions in the mother during the first week of puerperium
• There are three distinctive types of psychological disturbances seen in the puerperium: postpartum blue (baby blue),
postpartum depression and puerperal psychosis
• Postpartum blue (baby blue)
• The postpartum blues, maternity blues, or baby blues is a transient condition that 75-80% of mothers could
experience shortly after childbirth with a wide variety of symptoms which generally involve mood lability, tearfulness,
and some mild anxiety and depressive symptoms
• Causes of postpartum blue
• After the placenta is delivered, the placental "hormone factory" shuts down causing radical changes in hormone
levels, and the woman can suffer symptoms due to withdrawal from the high pregnancy levels of oestrogen, 
progesterone and endorphins.
• Combined with this shift in hormone levels is the physical, mental and emotional exhaustion - as well as 
sleep deprivation typical of parenting a newborn.
• All of these factors contribute to the condition.
• It can also be normal for the ovaries (having been virtually inactive for the last six months of the pregnancy) to take a
number of weeks to return to producing normal pre-pregnancy hormone levels.
• This condition may also be associated with thyroid dysfunction.
• An association with serotonin has been suggested
• Symptoms of postpartum blue
• Weepiness and bursting into tears.
• Sudden mood swings.
• Anxiousness and hypersensitivity to criticism.
• Low spirits and irritability.
• Poor concentration and indecisiveness.
• Feeling 'unbonded' with the baby.
• Restless insomnia.
• Management
• Baby blues generally disappear without medical intervention within two weeks.
• If symptoms persist longer another diagnosis may be identified
• Social interventions such as relative baby-sitting for few hours, so that the mother can get
some sleep or assistance with household or providing instruction on newborn care can
often help significantly.
• Women who have this condition are likely to have it recur with subsequent pregnancies
• Postpartum Depression:
• A period of unhappiness or low morale which lasts longer than several weeks and may
include ideation of self-inflicted injury or suicide
• State of mind production serious, long-term lowering of enjoyment of life or inability to
visualize a happy future
• Postpartum depression (PPD), also called postnatal depression, is a type of
clinical depression which can affect both sexes after childbirth
• Causes
• The cause of PPD is not well understood. Hormonal changes, genetics, and major life events
have been hypothesized as potential causes.
• Certain contributory factors identified are:
• Experiencing stress-inducing life events around the time of childbirth such as bereavement or
relationship disharmony
• Low self esteem, lack of support and stress associated with postnatal care
• Severe maternal blues later developing to depression
• Demands of motherhood and loss of personal freedom
• Diagnosis
• Symptoms of postpartum depression are similar to those of depression occurring at any
other time
• Characteristics symptoms include bouts of crying, sadness and emotional liability, guilt,
loss of appetite or anorexia, profound sleep disturbances, poor concentration and
memory, irritability and feelings of inadequacy to care for the newborn or other children
• In postpartum depression, there is the tendency to experience difficulty falling asleep, the
woman will sleep for long periods.
• They often feel well in the morning but deteriorate as the day goes on.
• In most other depression, early waking is the pattern with symptoms more acute in the
morning.
• The woman may feel constantly tired in spite of adequate periods of rest and may appear
over anxious about her baby in spite of evidence that the baby is well and thriving.
• Some women may not communicate or admit their feelings; they conceal their depression
so well that the condition may not be diagnosed for months
• Risk factors
• While the causes of PPD are not understood, a number of factors have been suggested to increase the risk:
• Prenatal depression or anxiety
• A personal or family history of depression
• Moderate to severe premenstrual symptoms
• Maternity blues
• Birth-related psychological trauma
• Birth-related physical trauma
• Previous stillbirth or miscarriage
• Formula-feeding rather than breast-feeding
• Cigarette smoking
• Low self-esteem
• Childcare or life stress
• Low social support
• Poor marital relationship or single marital status
• Low socioeconomic status
• Infant temperament problems/colic
• Unplanned/unwanted pregnancy
• Elevated prolactin levels
• Oxytocin depletion
• Management
• Midwife suspects a woman is depressed, this should be reported to the
physician
• In less severe cases, treatment with mild sedation or anti-depressants
may be prescribed.
• Counseling is known to be helpful, particularly if initiated at an early
stage.
• Involvement of the spouse and other family members may also be
advantageous.
• When the depression is more advanced, admission to hospital will be
necessary.
• Untreated or undiagnosed depression can evolve into a psychotic illness
Puerperal Psychosis

• Introduction
• This severe form of mental illness affects approximately one or two mothers in every 1000.
• The onset is rapid and usually occurs within the first few days after delivery.
• The symptoms are those of depressive psychosis, manic illness or in some cases schizophrenia.
This illness most often affects primipara.
• Definition:
• Puerperal psychosis: is a depressive disorder occurring within 6 months after delivery
Causes/Risks factors
• Previous depression
• Family history of depression
• History premenstrual syndrome
• Current history of abuse
• Unwanted pregnancy
• Alcohol or substance abuse
• Vulnerability to hormonal change
• Environmental stressors
• Signs and symptoms
• Five signs of the following, most of the day, every day, for two weeks
• Depressed or irritable mood
• Inability to enjoy (anhedonia) –
• Changes in sleep: (cannot sleep when the baby is sleep)
• Changes in appetite
• Guilt
• Thought of death
• Investigations
• Thyroid test to rule out hypothyroidism
• CT scan to rule out cerebral tumor
•  
• Management
• The illness must be treated promptly by admission to a psychiatry unit under
the care of a consultant.
• Medication and psychotherapy
• In most cases the baby will be able to accompany his mother into hospital and
this should be encouraged if at all possible prompt psychiatric case is vital and
skilled psychiatric nursing care is required including medical treatments.
• With prompt treatment the prognosis is good but, unfortunately, it is likely that
further episodes of the illness will occur throughout the woman’s life around
there is a high risk of recurrence in subsequent pregnancies.
• Complications
• Suicide
• Infanticide
• Recommendations
• If any signs/symptoms of depression alert health facility
• Encourage breastfeeding
• Role of the midwife
• The community midwife should continue to visit both mother and baby to
undertake the nonpsychiatric aspects of postnatal care.
• Family support also needs consideration
• Midwife needs to offer advice and support to women during subsequent
pregnancies and to alert the physician regarding psychiatric care when
appropriate, in order to initiate prompt referral, should it become necessary.
• The community midwife should be able to help the mother reestablish the
mother-baby relationship and rebuild self-esteem by encouraging care of the
baby within a safe environment