Postpartum complications
• Following NVD the average hospital stay is 1.4
days (1.7 for first-time mothers; 1.2 for previous
mothers)
• 2 days for an assisted vaginal delivery & 3.4
days following a caesarean.
• Haemorrhage
• Infection
• PE
• 6/52 postnatal check
A 25 year old female presents to her GP with
thick, smelly and bloody discharge two weeks
after the delivery of her first child. She was
otherwise well and was recovering at home
from the uncomplicated birth of her child. On
examination, the lady was pyrexial and was
tender over the suprapubic region.
1)What sort of PPH is this?
2)What is the likely pathology?
3)What was the GP's course of management?
PPH
• Minor PPH (500 mls- 1L) / Major > 1L
• Primary PPH = >500mls within 24 hours
• Secondary PPH = abnormal bleeding
24hours & 6 weeks.
Primary PPH
• Common cause: 70% uterine atony
Secondary PPH
• Infection : Endometritis
• RPOC
PPH = 4 T’s
• Tone (uterine tone) 70%
• Tissue (retained tissue - placenta) 20 %
• Trauma ( Lacerations and uterine rupture)
10%
• Thrombin ( coagulation disorders) 1%
Management
Primary PPH
• If haemodynamically unstable  ABC, O2
and IV access. Bimanual compression and
uterine massage.
nd
2
Management of
PPH in
primary care
Investigations:
• FBC
• Midstream Urine
• High vaginal swab
• Ultrasound
Start broad spectrum abx Co-amoxiclav +
metronidazole
Infection -Endometritis
• Infection of endometrium
• Ascending infection from lower genital
tract
• most important factor the mode of delivery
• 1-3 % after NVD, 15-40% after C-section
Hx:
Fever, abd pain, offensive d/c, dispareunia
O/E:
Pyrexia, tachycardia, lower abd tenderness,
offensive d/c, uterine and adnexal
tenderness
Ivx:
• Blds: FBC,CRP
• Microbiology: HVS,
endpocervical/chlamydia swab
Management:
Broad spectrum antibiotic, surgery for
RPOC
• 90 % resolve after 48-72 hours IV abx
• 35 years old lady, 17 day postnatal. Breast
feeding, sore and warm right breast for the
past 48 hours.
1)Diagnosis
2)Management
3)Advice
Mastitis
• Inflammation or infection of the breast
• 1 in 3 mothers will have mastitis
Symptoms:
• Mastalgia, swelling and erythema (start
usually in section near nipple),
temperature, flue like symptoms.
• Common organism: S.aureus
Management
Mild mastitis no treatment. Encourage
breast feeding
Infective mastitis : start antibiotics
- Flucloxacillin 500mg qdsfor 14 days
If penicillin allergic:
- Erythromycin 500 mg qds for 10-14days
Advice
- Continue to feed from the affected breast
- After each feed express any remaining
milk from affected breast
- Analgesia (paracetamol & Ibuprofen)
- Avoid wearing a bra
Complications:
Breast abscess 1 in 100
Infections (other)
C-section wound infection
• Episiotomy site
- Ensure early detection and management
Pulmonary Embolism
• More likely to occur 6/52 post delivery.
• The risk is 1/500
Increase risk of thrombosis if :
- Prolonged labour >24 hours
- C section
- Received a blood transfusion
Symptoms:
Dyspnoea/ pleuritic chest pain /coughhaemoptysis/ R HF in severe cases
Signs:
Tachypnoea/ tachycardia/Hypoxia
IF PE suspected, start treatment dose
LMWH and admit to hospital
Postnatal prophylaxis
6 weeks postnatal check
Postnatal check
• Should cover:
- Physical
- Psychological
- Social
Physical
•
•
•
•
•
•
Mode of delivery
Concerns about own health
Perineum/ C- section scar healing well?
Discharge/ periods
Bowel and bladder
If breast feeding, soreness or
engorgement
Examination
• Abdominal examination
?endometritis/RPOC
• Consider checking BP and Hb
• Contraception
• Pelvic floor exercises
Psychological
• Any issues around the birth that need
discussing
• Mood. Can use a postnatal depression
screening tool
• Any concerns about the baby (should be
covered in baby 6 weeks check)
Social
• Support at home
• Sleep
• Smoking
Summary
• PPH 4 T’s
• Endometritis
• MastitisS.aureusFlucloxacillin or
erythromicin for 2/52
• PE ensure high risk women are on LMWH
post delivery.
• Holistic approach to postnatal check
References
•
Postpartum Haemorrhage, Prevention and Management (Green-top 52)
•
West Midlands Key Health Data 2006/07
•
GP notebook – Mastitis
•
http://www.fastbleep.com/medical-notes/o-g-and-paeds/16/36/503 (cases)
•
http://www.patient.co.uk/doctor/Mother's-6-Week-Postnatal-Check.htm
•
http://www.planapregnancy.co.uk/PP2010/static/GT37ReducingRiskThrombo.pdf
•
Oxford handbook of obstetrics and gynaecology. 2nd edition
?
Cases
A 24-year-old woman presents 8 days after giving birth. She complains
of a persistent pink vaginal discharge which is 'smelly'. On examination
her pulse is 90 / min, temperature 38.2ºC and she has diffuse
suprapubic tenderness. On vaginal examination the uterus feels
generally tender. Examination of her breasts is unremarkable. Urine
dipstick shows blood ++. What is the most appropriate management?
A.
Arrange urgent ultrasound to exclude retained products + send
MSSU + take high vaginal swab
B.
Send MSSU + take high vaginal swab + start oral co-amoxiclav
+ metronidazole
C.
Arrange urgent ultrasound to exclude retained products + send
MSSU + start oral co-amoxiclav
D.
Admit to hospital
E.
Send MSSU + take high vaginal swab + start oral co-amoxiclav
• This woman by definition has puerperal
pyrexia, likely secondary to endometritis.
She needs to be admitted for intravenous
antibiotics.
Case 2
• Which one of the following statements regarding
the lactational amenorrhoea method (LAM) of
contraception post-partum is correct?
A.
1-2 top up feeds per day are allowed as long
as this is in addition to breastfeeding
B.
Is recommended for mothers with HIV
C.
Should only be used if women decline longacting reversible contraceptives
D.
Is 100% effective if the woman is amenorrhoeic
E.
The effectiveness decreases after 6 months
• Lactational amenorrhoea method (LAM)
• is 98% effective providing the woman is
fully breast-feeding (no supplementary
feeds), amenorrhoeic and < 6 months
post-partum
Case 3
• A 29-year-old woman who is 2 weeks postpartum
consults you regarding contraception. She is interested
in having an intrauterine device (IUD) inserted and asks
when it could be fitted. She had a emergency caesarean
section for failure to progress. What is the most
appropriate advice to give?
A.
B.
C.
D.
E.
An IUD can be inserted 4 weeks postpartum
An IUD can be inserted 12 months postpartum
An IUD can be inserted today
An IUD can be inserted 12 weeks postpartum
An IUD is contraindicated in the long-term
• Answer A
between 48 hours and 4 weeks postpartum
(increased risk of perforation)
Case 4
•
woman rings for advice 18 days post-partum.
She is keen to start her progestogen-only pill
again. There have been no problems since
giving birth and breast feeding is going well.
What is the most appropriate advice?
A.
Contraindicated if breast-feeding
B.
Start immediately, effective immediately
C.
Start on day 28, effective after 7 days
D.
Start on day 28, effective after 2 days
E.
Can be started after 3 months, effective after
2 days
• Answer B
• Progestogen only pill (POP)
• the FSRH advise 'postpartum women (breastfeeding and nonbreastfeeding) can start the POP at any time postpartum.'
• after day 21 additional contraception should be used for the first 2
days
• a small amount of progestogen enters breast milk but this is not
harmful to the infant