Chapter 28: The Woman With a Postpartum Complication

Postpartum hemorrhage represents the most common life-threatening condition and is categorized by timing and etiology: early hemorrhage typically results from uterine atony or laceration-related trauma, while late hemorrhage frequently involves subinvolution of the uterus or incomplete expulsion of placental tissue. Assessment skills focus on identifying a boggy, enlarged fundus and implementing immediate interventions including fundal massage, urinary catheterization to empty the bladder, and administration of uterotonic medications such as oxytocin, methylergonovine, and carboprost. The chapter distinguishes between overt vaginal bleeding and concealed hemorrhage occurring within vulvar or retroperitoneal hematomas, both of which can lead to hypovolemic shock as the body's compensatory mechanisms of vasoconstriction and increased heart rate become overwhelmed. Management priorities center on fluid resuscitation and addressing the underlying cause. Thromboembolic complications arise from the combination of venous stasis, vessel wall injury, and hypercoagulability during pregnancy and postpartum, manifesting as superficial thrombophlebitis, deep vein thrombosis, or the potentially fatal pulmonary embolism. The chapter details prophylactic and therapeutic anticoagulation strategies. Puerperal infections encompassing endometritis, surgical site infections, urinary tract infections, and lactational mastitis are presented with attention to risk factors elevated by cesarean delivery and the critical importance of prompt antibiotic therapy. The chapter concludes by addressing maternal mental health complications, distinguishing transient postpartum blues from pathological conditions including peripartum major depression, postpartum psychosis with its psychiatric and medical urgency, and postpartum anxiety disorders, underscoring the necessity for systematic screening and comprehensive psychosocial support.