11.4 Postpartum complications

11.4.1 Excessive uterine bleeding

Usually the amount of lochia is similar to a normal menstrual period. If the discharge is heavier, consider the possibility of retained products and/or endometritis.

If suspicion of retained placenta:
– Digital curettage or manual vacuum aspiration or extremely cautious instrumental curettage, with antibiotic coverage (Chapter 9).

– Antibiotic therapy for 5 days:
amoxicillin/clavulanic acid PO (dose expressed in amoxicillin)
Using the 8:1 ratio: 3000 mg daily, i.e. 2 tablets of 500/62.5 mg 3 times daily
Using the 7:1 ratio: 2625 mg daily, i.e. 1 tablet of 875/125 mg 3 times daily
or
amoxicillin PO: 3 g/day in 3 divided doses + metronidazole PO: 1.5 g/day in 3 divided doses

11.4.2 Infectious complications

Look for an infectious complication in patients with fever higher than 38°C for more than 48 hours.

Postpartum endometritis and salpingitis

– Fever, usually high.

– Abdominal and/or pelvic pain, foul-smelling or purulent lochia.

– Physical exam: uterus enlarged, soft, painful when mobilized; open cervix; swelling in the posterior fornix.

– Admit to inpatient department and start antibiotic therapy:
amoxicillin/clavulanic acid IV (dose expressed in amoxicillin): 3 g/day in 3 divided doses
+ gentamicin IM: 3 to 5 mg/kg once daily
or
ampicillin IV: 6 g/day in 3 divided doses
+ metronidazole IV: 1.5 g/day in 3 divided doses
+ gentamicin IM: 3 to 5 mg/kg once daily
Continue this treatment for 48 hours after resolution of fever. Do not switch to oral treatment2.

– For minor, very early forms (no fever, minor pain), outpatient treatment is possible with:
amoxicillin/clavulanic acid PO (dose expressed in amoxicillin) for 5 to 7 days
Using the 8:1 ratio: 3000 mg daily, i.e. 2 tablets of 500/62.5 mg 3 times daily
Using the 7:1 ratio: 2625 mg daily, i.e. 1 tablet of 875/125 mg 3 times daily

– Look for retained placenta, and evacuate after 24 to 48 hours of antibiotic therapy. If the patient is haemodynamically unstable due to haemorrhage or infection, perform uterine evacuation immediately.

Pelvic abscess or peritonitis

A complication of untreated puerperal endometritis/salpingitis.
– Abdominal guarding or spasm, ileus, pelvic mass.
– Surgical treatment: laparotomy or, in case the abscess is confined to the Pouch of Douglas, colpotomy to drain the abscess.
– Same antibiotic regimen as for postpartum endometritis and salpingitis.

Other infectious complications

– Abscess after caesarean section.
– Lymphangitis and breast abscess (Section 11.4.3).
– Pyelonephritis (Chapter 4, Section 4.2.7).

Note: in case of fever, systematically test for malaria in endemic areas.

11.4.3 Breast-related complications

Cracked nipples

– Nipple erosion and intense pain when starting to nurse. No fever (except when associated with lymphangitis).
– Clean with soap and clean water before and after each feeding; dry carefully.
– Cracked nipples are often caused by incorrect latching onto the breast: watch the infant nurse, and correct the position if necessary.

Breast engorgement

– Bilateral pain 2 to 3 days after childbirth; hard, painful breasts.
– Warm compresses (before nursing); gentle manual expression (before nursing, if the infant cannot latch onto the overly distended breast or after nursing to finish emptying the breast); more frequent nursing.
For manual expression, see Appendix 3, Section 3.2.
– Engorgement is a benign problem that subsides in 24 to 48 hours.

Lymphangitis

Inflammation of a milk duct

– Unilateral pain, 5 to 10 days after childbirth. Local inflammation, red, hot painful with no fluctuation, high fever; axillary lymphadenopathy possible. Milk collected on a compress shows no pus.
– Empty the breast by nursing the infant frequently on the involved side. If the mother finds nursing too painful, temporarily stop nursing on the painful side (but empty the breast manually) and continue breastfeeding with the other breast.
– Routine analgesia (paracetamol PO: 3 g/day in 3 divided doses).

Mastitis

Breast infection

– Unilateral infection, with satellite lymph node; breast swollen, hot, red, painful, purulent discharge from the nipple, at times associated with fever.
– Temporarily stop nursing on the infected side. Carefully express all milk from the infected breast (manually) and administer an antibiotic with anti-staphylococcal activity:
cloxacillin PO: 3 g/day in 3 divided doses for at least 7 days.
– Routine analgesia (paracetamol PO: 3 to 4 g/day in 3 to 4 divided doses).
– Antibiotic treatment helps prevent progression to breast abscess that requires surgical drainage. Surgical drainage of a “ripe” abscess is urgent, because an abscess can quickly spread.

11.4.4 Urine leakage

– Look for a possible vesicovaginal fistula, especially after a difficult home birth or prolonged labour.
– If there is a fistula: see Chapter 7, Section 7.2.5.
– If there is no fistula, stress incontinence is likely: propose exercises to strengthen the pelvic floor.

Stress incontinence is more common among grand multiparas, after a forceps or vacuum extraction, and in cases of macrosomia. It usually disappears within 3 months with pelvic floor exercises.

11.4.5 Psychological disorders

“The baby blues”

This syndrome has its onset within days after the delivery and lasts usually two weeks.
It is characterised by mood swings, crying, irritability, anxious worrying centred on the infant, and doubts about the ability to be a “good mother”, combined with insomnia, loss of appetite and concentration problems.
These problems generally diminish within a few days. Reassurance, family support and follow-up to ensure that the patient does not develop depression are usually sufficient.

Postpartum depression

Post-partum depression develops in the first several weeks after childbirth; it can be severe and is often underestimated.
The characteristic symptoms of depression are sadness, frequent crying, loss of self-confidence, constant concerns about the infant (or, on the contrary, a feeling of indifference), feeling incompetent as a mother, and feelings of guilt (or even aggressive thoughts toward the infant) combined with insomnia and loss of appetite. These symptoms last more than 2 weeks and gradually worsen, leading to a state of exhaustion.
The interview should look for possible suicidal thoughts and assess the mother’s ability and desire to take care of the infant (depression can have repercussions for the infant’s development).
An understanding and reassuring attitude and help with daily activities by family and friends are essential.
Antidepressant medication may be necessary (choose an antidepressant compatible with breastfeeding, which should be continued whenever possible). See the MSF handbook, Clinical guidelines.

Note: perinatal death is associated with increased rates of postpartum depression.

Postpartum psychosis

This occurs less frequently and is characterised by the onset of psychotic symptoms after childbirth.
Symptoms include irritability, important mood swings, delusions, hallucinations, and disorganised, bizarre and sometimes violent behaviour.
The patient should be sent to a doctor immediately. Antipsychotic treatment, and usually hospitalisation, is necessary. See the MSF handbook, Clinical guidelines.