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POSTPARTUM COMPLICATIONS

Category: Special Populations

Topic: Obstetrics

Level: Paramedic

Next Unit: Complications of Delivery

28 minute read

The postpartum period spans from birth until six to eight weeks after.

Postpartum complications during labor and delivery include

  • eclampsia (convulsions),
  • hemorrhage, and an
  • increased risk of embolism.

Further into the postpartum period, the embolism risk continues, but the bleeding risk begins to diminish over time. However,

  • dangers from infection present during the postpartum period.

If a woman has had a C-section, this adds additional hazards of which to be aware.

Before the modern age of antibiotics and hygiene, sexually active women of childbearing age fell into one of three groups:

  1. breastfeeding;
  2. pregnant; or
  3. dead.

Mortality in childbirth or in the puerperal period (after childbirth) was common, unsurprising, and just a fact of life (and death!). The 20th Century was a turning point during which most women who became pregnant could expect to not only have a baby, but survive. Today, we take for granted what a major societal change this has been. Nevertheless, in spite of improvements in efficiency in meeting the previous dangers with the modern tools of today, eclampsia, hemorrhage, infection, and embolism still contribute to a mortality rate, albeit reduced, and must be always kept in mind.

 

Eclampsia (See "Complications of Pregnancy")

Pre-eclampsia is a condition related to pregnancy, thought to be a complicated immunological reaction.

  • Hypertension,
  • proteinuria,
  • edema, and
  • hyperactive reflexes

are the clues to its diagnosis.

The cure for it is delivery, but it can linger into the postpartum period even to the point of ECLAMPSIA (convulsions). The convulsions of eclampsia can be associated with life-threatening stroke. Any woman with a history of recent childbirth who experiences a seizure may have eclampsia and not recent-onset epilepsy.

 

Postpartum Hemorrhage

Because the maternal-fetal "circulation" does not mix the two circulations, but is an adjacent arrangement of two very vascular tissues, any disruption can initiate a hemorrhagic emergency prior to, during, or after delivery, leaving open sinuses that were the diffusion points between the two separate circulations.

Even if this arrangement remains safely intact until delivery, the placenta and mother going their separate ways can still allow substantial blood loss from the exposed vascular areas in the uterus. The muscular portions of the uterus help squeeze these vascular areas shut, reducing bleeding, but this can fail with an overstretched uterus, such as in multiple gestations or a prolonged labor that exhausts the muscle.

"Uterine atony" (a-tonus, or without tone) is the inability of the uterus to firm up after delivery of the placenta and is associated with life-threatening bleeding. It can be addressed by

  1. direct stimulation (massaging the uterus briskly, called "fundal massage")--the first thing that should be tried, or hormonally, by
  2. having the mother breastfeed the newborn immediately (which is a good strategy even without the drama of bleeding).

    Both can be tried, but fundal massage should be first. An infant latching on stimulates the nipple (areola) area which stimulates the pituitary gland to release oxytocin, a hormone that causes uterine contractions (also, bonding).
     
  3. administering oxytocin (Pitocin) IV. 

Vaginal bleeding: Bleeding can be from the vagina due to traumatic tears from a precipitous delivery. Rapid delivery is characterized as vaginal expulsion that does damage on the way out. Precipitous is just another word for immediate or rapid. A normally-timed labor gives the vaginal tissues time to elasticize to accommodate the passage of the baby's head at delivery. In a precipitous labor/delivery, the tissues are stretched before they've had time to elasticize enough to prevent tears/lacerations. 

Precipitous delivery can be prevented in most cases by having the mother stop bearing down ("pushing") after delivery of the head, which also gives time to clean the face and suction, if indicated.

Simple non-internal inspection of the external genitalia may show a superficial area that is briskly bleeding. This is the only type of postpartum bleeding for which direct pressure is helpful. 

As with any bleeding emergency, oxygen administration and rapid transport to a hospital are strategies to manage postpartum hemorrhage. Pressure on the vaginal tissue is useful and recommended for vaginal tears, but this will do absolutely nothing for postpartum hemorrhage from anywhere deeper beyond the vagina.

Another type of hemorrhage is from a condition called DIC (see below), a coagulation disruption in which the policing clotting factors against hemorrhage are no longer available in the maternal circulation.

The Difference Between Vaginal Bleeding and Bleeding from Higher Up in the Pelvis

It is true that deliveries are messy and blood is no small part of that mess. Therefore, when there is a lot of blood pooling, how does one tell whether the bleeding is from the vaginal tissues or from higher up?

In the field, it doesn't matter. 

Certainly, if the woman is shocky from blood loss (tachycardia, hypotensive), it doesn't matter where the bleeding is coming from, since the standards of ABC, oxygen administration, large-bore IV access, and rapid transport are mandatory.

 

Pulmonary Embolism

Embolism risks are elevated in pregnancy and in postpartum women and can manifest as acute difficulty breathing or chest pain.

Risk is related to the higher amounts of estrogen during pregnancy, so women on birth control pills also have this risk due to the estrogen in them. The maternal circulation during pregnancy undergoes changes that lower the threshold of what is needed to initiate the clotting cascade. During pregnancy, there is an increase in coagulation factors and increased platelet reactivity. This is actually a protective mechanism to prevent excessive hemorrhage during placental separation. This tendency toward "over-coagulation" is offset by anticoagulant factors made in the maternal liver and the fetal tissue. If there is an imbalance, however, a tendency toward over-clotting can occur. Since this happens in the venous system, migrating clots will return to the right side of the heart and then be pumped to the lungs, obstructing blood flow suddenly. Respiration is therefore severely compromised.

Embolism happens quickly and the woman is usually aware immediately that something awful is happening. Therefore, any melodramatic complaints ("I can't breathe!) should be taken seriously.

Oxygen administration and rapid transport to a hospital are strategies to manage postpartum embolism.

 

DIC

Another phenomenon involving the clotting system is if there are many microemboli, enough to obstruct blood flow in many places and cause multiple organ failure. If that itself weren't bad enough, all of this clotting overwhelms the ability to clot overall, because all of the clotting factors are used up (consumed). Such a disaster is called DIC (Disseminated Intravascular Coagulopathy). This postpartum patient has a problem opposite of embolism, with uncontrolled bleeding from tissues normally well-behaved--such as the uterus after placenta separation. It is more likely after C-section surgery, the fresh uterine incision adding another site for bleeding.

As with an embolus, oxygen administration and rapid transport to a hospital are strategies to manage postpartum embolism. Fresh frozen plasma contains many of the clotting factors that have been depleted, but this requires a setting in intensive care.

 

Infection

The "puerperal fever" of yesteryear is what is now called postpartum endometritis.

ENDOMETRITIS: Endometritis is inflammation from infection of the endometrium--the lining of the uterus. Most cases of postpartum endometritis begin when bacteria via the vagina get a foothold into the uterus during pregnancy or during the birth process. Since infection is a cause of preterm labor and premature rupture of membranes, these incidents present as a higher risk for postpartum endometritis.

SIGNS & SYMPTOMS OF ENDOMETRITIS: Typical endometritis will involve fever, exquisite uterine tenderness, and left unchecked, sepsis.

C-section, which exposes the sterile inner abdominal/pelvic world to the bacteria-rich world outside, is commonly the cause, especially since it leaves behind the necrotic tissue of tied off blood vessels and sutured uterine incision that make a good breeding ground for bacteria.

Tears of the vagina and a repaired episiotomy (cut in the perineum to make more room for the baby to exit) are also fertile ground for infection.

UTI: Labor and delivery in a hospital or birthing facility can include catheterization of the bladder. The fetal head can cause urinary retention from compressing the urethra, so catheterization is common. Epidurals also prompt a need for catheterization, since they can cause urinary retention. The statistics are that 10% of all women who are catheterized develop a urinary tract infection, which can progress to a kidney infection (pyelonephritis). Such an infection is indicated by

  • fever,
  • back pain, and
  • bloody or painful urination.

The combination of recent delivery, fever, and painful pelvic area make infection obvious, but the challenge is not in making this diagnosis; the real challenge is getting the patient adequate care at an appropriate facility to treat or prevent actual sepsis, which is a life-threatening emergency.

 

Other Considerations

SPINAL HEADACHE: Some women who undergo conductive anesthesia (spinal or epidural anesthetics) suffer a complication wherein a hole remains persistently open in the dura of the spine (outer covering), allowing cerebrospinal fluid to leak out. This is always accompanied by a severe headache, and the headache is worse when sitting upright in which gravity makes the leak more brisk.

Laying flat on her back will improve or even temporarily eliminate her headache, and this maneuver is diagnostic.

If hydration and laying flat for a couple of days does not resolve it (via the hole resealing), a "blood patch" will have to be done (injecting a few cc's of the patient's own blood into the area of the leak to seal it). Sometimes more than one blood patch is necessary.

MASTITIS: The human body does not like standing fluid. From fluid behind the eardrum to urinary retention, standing fluid will become infected. The same applies to breast engorgement, which can become so sore that the woman stops breastfeeding, making the problem worse as unexpressed milk engorges the breasts. When infected, breast engorgement becomes mastitis and is easily treated with antibiotics and--especially--continuing to breastfeed to get the fluids moving again.

There should be no fear of giving the nursing baby the infection from the mastitis, since it is the infant who probably gave his or her mother the bacteria that infected he breast in the first place.