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 retained placenta and/or endometritis.

In case of suspected retained placenta:
– Digital curettage or manual vacuum aspiration or extremely cautious instrumental curettage, with antibiotic coverage (Chapter 9).
– Antibiotherapy for 5 days:
amoxicillin/clavulanic acid PO (dose expressed in amoxicillin):
Ratio 8:1: 3000 mg daily (2 tablets of 500/62.5 mg 3 times daily)
Ratio 7:1: 2625 mg daily (1 tablet of 875/125 mg 3 times daily)
or

amoxicillin PO: 1 g 3 times daily + metronidazole PO: 500 mg 3 times daily

11.4.2 Infectious complications

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

Postpartum endometritis and salpingitis

Clinical features

– Fever, usually high
– Abdominal and/or pelvic pain, foul-smelling or purulent vaginal discharge
– Uterus enlarged, soft, painful when mobilized; open cervix; swelling in the posterior fornix

Management

– Admit to inpatient department; administer antibiotherapy:
amoxicillin/clavulanic acid IV (dose expressed in amoxicillin): 1 g every 8 hours + gentamicin IM: 5 mg/kg once daily
or
ampicillin IV: 2 g every 8 hours + metronidazole IV: 500 mg every 8 hours + gentamicin IM: 5 mg/kg once daily
Continue this treatment 48 hours after resolution of fever and other clinical signs
2.

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

– Look for retained placenta and perform uterine evacuation after 24 to 48 hours of antibiotherapy. 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.

Clinical features

– Abdominal guarding or spasm, ileus, pelvic mass

Management

– Laparotomy or, in case the abscess is confined to the Pouch of Douglas, colpotomy to drain the abscess.
– Same antibiotherapy 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 4.2.3).

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

11.4.3 Breast-related complications

Cracked nipples

Clinical features

– Nipple erosion and intense pain when starting to nurse.
– No fever (except when associated with lymphangitis).

Management

– Clean with soap and clean water before and after each feeding; dry carefully.
– Observe the neonate while nursing, and correct the position if necessary. Cracked nipples are often caused by incorrect latching onto the breast.

Breast engorgement

Clinical features

– Bilateral pain 2 to 3 days after childbirth; firm, painful breasts.

Management

– Cold or warm compresses (before nursing); more frequent nursing.
– Gentle manual expression (Appendix 3) before nursing, if the neonate cannot latch onto the overly distended breast or after nursing to finish emptying the breast.
Engorgement subsides in 24 to 48 hours.

Lymphangitis

Clinical features

– Unilateral pain, 5 to 10 days after childbirth. Local inflammation, red, hot painful with no fluctuation.
– High fever (39-40 °C); enlarged axillary lymph node.
– No pus in the milk collected on a compress.

Management

– Empty the breast by nursing the neonate 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, Appendix 7).

Breast infections (mastitis, abscess)

Clinical features

– Mastitis:
• Firm, red, painful, swollen area of one breast associated with fever.
• Axillary lymph node may be enlarged.
• Purulent discharge from the nipple.

– Breast abscess: fluctuant, tender, palpable mass.

Management

– Temporarily stop nursing on the affected side. Carefully express all milk from the infected breast (manually).
– Routine analgesia (paracetamol PO, Appendix 7); cold or warm compresses.
– Antibiotherapy with activity against staphylococci may prevent progression to breast abscess (cloxacillin PO: 1 g 3 times daily for 7 days).
– Breast abscess: urgent drainage as the abscess can quickly spread, and antibiotherapy as above.

11.4.4 Urine leakage

Clinical features

– Look for a possible vesicovaginal fistula, especially after a prolonged labour.

Management

– 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 foetal 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 2 weeks.
It is characterised by mood swings, crying, irritability, anxious worrying centred on the neonate, 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

Postpartum depression develops in the first 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 child (or, on the contrary, a feeling of indifference), feeling incompetent as a mother, and feelings of guilt (or even aggressive thoughts toward the child) 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 child (depression can have repercussions for the child’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). Refer to the Clinical guidelines, MSF.

Note: postpartum depression is more frequent after a stillbirth or intrauterine foetal death. 

Postpartum psychosis

This occurs less frequently and is characterised by the onset of psychotic symptoms after childbirth.
Symptoms include irritability, major 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. Refer to the Clinical guidelines, MSF.