Subject: Complications of the Postpartum Period/Postpartum Emergencies

POLICY: Postpartum complications and emergencies may occur at any point within the six week postpartum period of care, or beyond.  A number of disorders such a postpartum hemorrhage, endometritis, and eclampsia are unique to the postpartum client.  Other disorders, such as cardiomyopathy, deep vein thrombosis, and pulmonary embolus, may be seen with increased frequency in women after delivery.

GUIDELINES: 1. Women will be seen in office at 48 hours following delivery with their baby, then a visit at two weeks, and six weeks post birth.   If they have had hospital delivery, they will be seen in office following discharge, and continue the normal schedule of visits.  Each visit will encompass the following key elements of postpartum care:

·         breast care

·         fever

·         s/s infection

·         lochia/ blood loss

·         pain

·         blood pressure/ s/s postpartum hypertension and headache

·         mood changes

·         s/s danger, warning signs

2.  The practice has 24-hour on-call coverage to respond to any postpartum emergent need.  Some emergencies may be handled in office, or the client may be referred out to ED care or referral to OB care or Primary Physician as indicated.

PROCEDURE: 1.  Hemorrhage

·         Early postpartum hemorrhage= >500cc within 24 hours (blood loss often underestimated)

·         Late or delayed = >500cc after the first 24 hours

·         Predisposing factors include: multiparity, uterine overdistension, trauma, abnormal labor pattern, prolonged labor, retained placental fragments,  hx of PPH or maternal anemia (see PPH protocol for more detailed information)

·         Prevention: risk assessment, inspect placenta for completeness, exploration of uterus as indicated, avoid overmanipulation of uterus, consider/start IV fluids

·         Signs of Impending PPH: excessive bleeding (>2 pads/30mins-1 hr) lightheadedness, nausea, visual disturbances, anxiety, pale/ashen color, clammy skin, increasing pulse and respirations, BP the same or decreasing

·         Actions to Take:

1.   Summon help, call EMS as indicated for hospital transport

2.   Check uterine tone, fundal/uterine massage, consider/perform bimanual compression, internal bimanual as indicated

3.   Administer PPH meds/oxytocics (see PPH protocol)

4.   Position mother in shock position (elevate legs, lower head)

5.   Increase or begin free flow oxygen 8-10L

6.   Increase or begin IV fluids (LR 1000cc with 20 IU Pitocin)

·         Early PPH: caused by uterine atony, lacerations, retained placental fragments, coagulation problems

o   Uterine atony: slow, steady or massive PPH, sometimes underestimated or “hidden” behind clots; VS may not change immediately

o   Retained placenta or fragments: partial separation of placenta caused by: pulling on the cord, uterine massage prior to separation, rough handling of uterus, placenta accreta .  Treatment: massage, manual removal of all or part of placenta/exploration of uterus, oxytocics, D&E in hospital

·         Late PPH:  PPH after 24 hrs, between 24hrs and 6wks pp, caused by sub-involution of uterus, abnormal involutiuon at placental site, retained fragments, infection, development of hematomas on vulva, vaginal, or peritoneal.

o   Symptoms: excessive or bright red bleeding, boggy uterus, passing large clots, backache, change in VS/ s/s shock ( increase T/R/P, decrease BP)

o   Sub-Involution: uterus remains large, does not involute; no change/progression of lochia, lochia returns to rubra, leukorrhea with backache and infection, pain, flank pain, difficulty voiding, mass felt on vaginal exam, abdominal distension, shock

o   Treatment: massage, methergine 0.2 oral course for 24hrs,  IV oxytocin, D&E in hospital/ hospital care/transfer, antibiotics for infection

2. Puerperal Infection

·         Symptoms: Temp > 100.4 (with exception of the first 24 hours)on any 2 of the first 10 days postpartum, increased pain, uterine tenderness, malodorous discharge from vagina, chills/ flushing, body aches, change in VS, tachycardia, tachypnea

·         Types of infections:

o   Endometritis

o   Peritonitis

o   Cystitis/ UTI/Pyelonephritis

o   Thrombophebitis

o   Mastitic infection/ breast abcess

·         Predisposing factors to infection:

o   Poor nutrition

o   Low socio-economic staus

o   Hx of infections

o   Anemia

o   Immunodeficiency

o   Intrapartum factors: prolonged labor, PROM, poor aseptic technique, birth trauma, multiple exams, episiotomy,lacerations, C-section

o   Postpartum factors: manual removal of placenta, PPH, retained placental fragments

o   Causative organisms : 30% aerobic(staph, E. coli, Klebsiella, Pseudomonas), 70% anerobes (bacteriodes)

·         Endometritis: Infection of the endometrium (placental site, decidua, cervix) with: discharge, foul smelling, bloody,uterine tenderness, irregular temp elevations, tachycardia, chills, subinvolutiuon

·         Peritonitis: Infection of the peritoneum, can be life threatening! ( high temp, chills, malaise, pain,local or referred,  subinvolution, rebound tenderness, nausea)

3.  Cystitis/ Bladder infection

·         urgency, increased frequency

·         burning, dysuria

·         suprapubic pain

·         hematuria

·         flank pain, CVAT, back pain

4. Pylelonephritis

·         kidney infection ascending from bladder, usually right kidney

·         spiking temp, shaking chills, flank pain, back pain, CVAT

·         hx of asymptomatic bacteruria

·         urgency, frequency, dysuria

5.  Perineal Infections

·         swelling, localized tenderness, redness, discharge from would site, pus

·         infected laceration sites should be debrided, irrigated with sterile water or normal saline

·         instruct client to do sitz bath TID, maintain good hygiene and irrigate with peri bottle to cleanse

·         allow to close spontaneously

·         consider/give antibiotics:

o   Augmentin 250mg TID x 7d

o   Cephalexin (Keflex) 250mg QID x 7d

o   Clindamycin (if PCN allergic) 300mg QID x 7d

o   Bactrim DS BID x 7d

7.   Deep Vein Thrombosis (DVT):

·         Women who have just delivered have a 5 times the normal risk for DVT. 3/1000 pregnancies get DVT.

·         Risks:

o   Hx of DVT, major surgery(C-section), operative vaginal delivery, immobilization, trauma, infection, coagulopathies, obesity, high parity, African-American, age > 35

o   Reduction in venous flow and tissue injury increase risk

·         Diagnosis:

o   high index of suspicion with: swelling (>2cm difference) of calf, pain, warm, red, palpable cord, Homan’s sign, pain with dorsiflexion of foot

·         Treatment: Referral to MD care for further evaluation