Postpartum complications

The period of adjustment after pregnancy and delivery is known as postpartum or puerperium, which lasts six to eight weeks. During this time, your body goes through physical changes as it adjusts to not being pregnant. Two major concerns during the postpartum period are excessive bleeding and infection.


Postpartum hemorrhage
Definition
Postpartum hemorrhage is a serious condition in which there is heavy bleeding that's difficult to stop. Postpartum hemorrhage occurs most often during the first 24 hours after delivery, but it can develop up to six weeks later.

Causes/associated factors
Postpartum hemorrhage may develop if your uterus does not contract enough to compress the open blood vessels in the uterine walls. This may be due to a variety of factors, including:

a long, fatiguing labor or difficult delivery
stretching of the uterus caused by a large baby or too much amniotic fluid (the fluid that protects the baby in the womb)
uterine fibroids (growths) that hinder uterine contractions
Postpartum hemorrhage may also be related to tears in your cervix or vagina, a ruptured or inverted (turned inside out) uterus, fragments of the placenta retained in your uterus, a blood-clotting problem or an infection. The risk is greater if you've had several pregnancies or you've had a previous postpartum hemorrhage.

Fortunately, delayed postpartum hemorrhage is uncommon. If you do begin to hemorrhage after you've been discharged from the hospital, seek medical attention promptly.

Symptoms
Symptoms of postpartum hemorrhage may include increased vaginal bleeding (especially if it saturates a sanitary pad in an hour or less), bright red vaginal bleeding after the fourth postpartum day, discharge that contains blood clots, and dizziness or lightheadedness upon standing.

Diagnosis
Diagnosis is based on the amount of bleeding. Blood tests can help the doctor evaluate the extent of blood loss. You'll probably need a pelvic exam and maybe an ultrasound (using sound waves to create images of internal body parts) for your doctor to identify the cause of the hemorrhage.

Treatment
You'll be given fluids intravenously. If there was significant blood loss, you may also need a blood transfusion. Further treatment depends on the cause of the hemorrhage. If your uterus isn't contracting enough, for example, your doctor may try uterine massage to encourage it to contract.

Medications such as oxytocin, methergine and prostaglandins may also be used to stimulate contractions. Any lacerations will be repaired, and any placenta fragments or blood clots found in your uterus will be removed. If your blood is not clotting properly, you'll be given medication to encourage the process. You may need antibiotics if an infection is present or suspected.

Complications
If blood loss is severe, you may go into cardiovascular shock. Without immediate medical attention, this is a life-threatening complication. In rare cases, a hysterectomy (surgical removal of the uterus) may be necessary if the bleeding can't be stopped.


General postpartum infection
Definition
Postpartum infections can develop in the genital or urinary tract, incisions related to delivery, the lungs or the breasts.

Causes/associated factors
Postpartum infections are caused by bacteria, which can enter your body during or after a vaginal delivery, cesarean section (C-section, surgical delivery of a baby through the abdomen) or while breastfeeding. Women who have C-sections face a much higher risk of postpartum infection than those who deliver vaginally, especially if they were in labor a long time.

Bacteria in the genital tract can infect your uterus (a condition known as endometritis), the pelvic structures (pelvic cellulitis), the fallopian tubes (salpingitis) and the abdominal cavity (peritonitis). Bacteria can also enter the urinary tract and cause a bladder infection (cystitis) or a kidney infection (pyelonephritis).

Bacteria that enter the body through a C-section incision or an episiotomy incision (an incision between the vagina and anus to create more room for a baby to be delivered and help prevent the vaginal tissues from tearing) or vaginal tear can also lead to infection. Bacteria that enter your breast while nursing can lead to mastitis (a breast infection). Pneumonia (a lung infection) can develop after a C-section, especially if general anesthesia is used.

Signs/symptoms
Depending on the location of the infection, you may notice:

fever of 100 degrees F or higher
abdominal discomfort or side pain
foul-smelling vaginal discharge or urine
pain, tenderness and possibly drainage from an incision or tear
difficult or painful urination
cough or difficulty breathing
general feeling of illness
chills
headache
appetite loss
Diagnosis
If you run a fever during the first six weeks after delivery, consult your doctor. To determine if an infection has developed, your doctor will do a physical exam, including a pelvic exam. The doctor will look for any additional symptoms that could indicate the infection's source. You may need a series of blood tests, an electrolyte measurement and a urinalysis. In some cases, an ultrasound may also be recommended.

Treatment
If you're diagnosed with a postpartum infection or it's strongly suspected, you'll receive oral antibiotics (taken by mouth). If you have a serious infection, you may need intravenous antibiotics and hospitalization.

Complications
An untreated infection can lead to a more serious, generalized infection.

Prevention
To help prevent infection, wipe from front to back after you urinate or have a bowel movement. Then, clean the perineal area (the area between the vagina and anus) with warm water from a squirt bottle and dry gently with clean gauze pads or wipes. Remember to wash your hands with soap and water before cleaning this area and after using the toilet. Follow any specific instructions your doctor may have given you, such as how to take care of any incisions. Promptly report any symptoms to your doctor to help keep an infection from becoming serious.


Uterine infection (endometritis)
Definition
Endometritis is an infection of the uterine lining. It's the most common cause of postpartum infection.

Causes/associated factors
Many factors may put you at risk for developing endometritis, including:

having a C-section after a long labor
water breaking more then 24 hours before delivery
labor lasting more than eight hours
genital tract infection before delivery
traumatic delivery
multiple vaginal exams during labor after membranes have ruptured
anemia (a condition marked by a decreased number of red blood cells or hemoglobin, a protein in red blood cells that contains iron)
preeclampsia (a serious condition that develops during the third trimester)
retaining tissue of the placenta in the uterus after delivery
Signs/symptoms
Symptoms of endometritis include:

a fever of 100 degrees F or higher
abdominal or uterine pain or tenderness
foul-smelling vaginal discharge
a general feeling of illness
appetite loss
Diagnosis
To diagnose endometritis, the doctor will do a physical exam, including a pelvic exam. You may need a series of blood tests, a urinalysis and a urine culture. In some cases, an ultrasound may also be recommended.

Treatment
Endometritis is treated with high doses of intravenous antibiotics. Once the fever is gone, you will probably be given additional oral antibiotics.

Complications
Severe endometritis can lead to salpingitis (an infection of the fallopian tubes) or septicemia (a generalized infection of the blood). It's important to treat salpingitis aggressively in order to preserve fertility.

Prevention
To help prevent a uterine infection, practice good perineal care. Again, wipe from front to back after you urinate or have a bowel movement. Then, clean the perineal area (the area between the vagina and anus) with warm water from a squirt bottle and dry gently with clean gauze pads or wipes. Remember to wash your hands with soap and water before cleaning this area and after using the toilet. Promptly report any symptoms to your doctor to help keep an infection from becoming serious.


Breast infection
Definition
Mastitis is a bacterial infection that can develop in one or both breasts. It's most common in women who have recently given birth, especially those who are breastfeeding.

Causes/associated factors
Mastitis develops when bacteria enter your breast, often from the nose or throat of a nursing baby. Mastitis is more common when your breasts are not emptied well or often enough, or are irritated or cracked. Risk factors include:

missed or delayed feedings
supplemental feedings of water or formula
a sleepy baby who does not empty your breast well
improper positioning of the baby at your breast
a baby who sucks incorrectly
limited feeding time (sometimes mistakenly suggested to prevent sore breasts)
use of a nipple shield
use of a breast pump
being overly tired or stressed
Signs/symptoms
Symptoms of mastitis may include:

pain, swelling, redness, warmth and hardness in the affected breast
fever (frequently higher than 101 degrees F)
chills
general feeling of illness
appetite loss
achiness
headache
Diagnosis
Diagnosis is typically based on your symptoms and a breast exam. Your doctor may also do blood tests, an evaluation of the breast drainage and possibly a breast ultrasound (using sound waves to create images of internal body parts).

Treatment
Prompt antibiotic treatment is often prescribed. Most antibiotics used to treat mastitis are fine for the baby, but be sure to speak with your doctor about any warning signs that might indicate an allergic reaction in the baby. While you're on antibiotics, rest as much as possible. This is especially important while you still have a fever and pain. In addition:

Nurse at least every two hours, including during the night, until your symptoms are relieved.

Before nursing, wash your hands well with soap and water to prevent the spread of infection. Apply warm (not hot) compresses to your breasts for 10 to 20 minutes before nursing, take a warm shower or lie on your side in a warm bathtub for 10 to 20 minutes to help stimulate the milk flow (let down). Then begin nursing on the unaffected side, which allows let-down to occur before beginning on the affected side.

Gently express enough breast milk by hand to soften the areola before nursing if your areola is swollen and the baby cannot latch on. This may be easiest after your warm water treatment or while you stand in the shower.

Massage your breasts before and during feedings.

Make sure your baby is positioned well on the breast. The baby should take as much of the nipple and areola into the mouth as possible. Change the baby's position while still on the breast to ensure complete emptying.

After nursing and between feedings, apply a warm compress to the area for comfort.

If your doctor approves, take a mild pain medication such as acetaminophen to relieve discomfort after you nurse.

Wear a nursing bra that fits well 24 hours a day. Avoid tight bras and those with underwires.

Drink plenty of fluids -- at least enough to increase the amount you urinate.

If your baby can't nurse effectively or you must miss a feeding, express the milk manually or with a breast pump.
Complications
Left untreated, mastitis can quickly develop into a breast abscess (collection of pus). If this happens, you'll need to have the abscess surgically drained or aspirated (when the pus is drawn out with a needle). Breastfeeding can continue in either situation. However, if the abscess is surgically drained, the incision must be far enough away from the nipple so your baby).

Avoid giving your baby supplemental feedings of water, sugar water or formula unless it's medically necessary.
Position your baby correctly at your breast and make sure the baby is sucking correctly.
If your baby can't breastfeed effectively or you must miss a feeding, express the milk manually or with a breast pump.
Avoiding pacifiers may help prevent nipple confusion for some babies.

It also helps to take good care of your nipples. Shower every day, using only water on your breasts. Avoid getting any soap or shampoo on your breasts. Don't wash your breasts before or after nursing. It's best to express a little milk after each feeding, spread it over each nipple and areola and then air-dry your breasts. If your breasts leak milk, you may want to use nursing pads. To avoid breast irritation, avoid the plastic-lined variety and change them whenever they get wet.