ATI/ OB | PRIMER Postpartum Complications
STAT Stitch Deep Dive Podcast Beyond The Bedside · Regular Guy
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Show Notes
Postpartum Hemorrhage (PPH) is a leading cause of maternal death, defined as blood loss ≥1000 mL or hypovolemic symptoms within 24 hrs of birth. The primary cause is uterine atony, a failure of the myometrium to contract, resulting in a boggy uterus.
The 4 Ts of PPH:
- Tone (Atony): Restore tone via immediate bimanual fundal massage and uterotonics.
- Trauma: Lacerations or hematomas. Suspect trauma if bright red bleeding persists despite a firm uterus. Genital tears range from 1st to 4th degree (involving rectal mucosa).
- Tissue: Retained placenta (not expelled within 30 mins). Placenta Accreta Spectrum increases hemorrhage risk.
- Thrombin: Coagulopathies like Idiopathic Thrombocytopenic Purpura (ITP) and Von Willebrand Disease prevent clotting.
Priority PPH Actions: Massage the fundus, quantify blood loss exactly (1g weight = 1mL blood), empty the bladder via catheter (distention displaces the uterus, worsening atony), and administer uterotonics.
High-Yield Medications:
- Oxytocin: First-line uterotonic. Monitor for water intoxication.
- Methylergonovine: Uterotonic. Contraindicated in hypertension.
- Carboprost: Uterotonic. Contraindicated in asthma and cardiac disease.
- Misoprostol: Prostaglandin given to contract the uterus.
- Magnesium Sulfate: Prevents seizures. High-alert drug. Monitor deep tendon reflexes and vitals. Antidote: Calcium Gluconate. Avoid concurrent calcium channel blockers.
- Terbutaline: Tocolytic to relax the uterus during emergencies.
Emergencies & Shock: Hypovolemic shock manifests as BP <85/45, HR >110, oliguria, and pallor. The Shock Index (HR/systolic BP) guides triage; values ≥1.0 indicate moderate/severe risk. Uterine Inversion is a life-threatening prolapse usually caused by excessive cord traction. Priority: Give tocolytics to relax the uterus, manually replace it, then administer oxytocin to maintain tone. Subinvolution, the failure of the uterus to return to normal size, causes late PPH (24 hrs to 6 weeks postpartum) characterized by a boggy uterus.
Thromboembolism: Pregnancy causes hypercoagulability. Deep Vein Thrombosis (DVT) typically presents as unilateral pitting edema and redness, mostly in the left leg. Treat with low molecular weight heparin, elevate legs, and use compression devices.
Postpartum Infections:
- Endometritis: Highest risk after cesarean. Manifests as fever, severe uterine tenderness, and foul-smelling lochia.
- Mastitis: Breast infection causing flu-like symptoms and localized redness. Teaching: Keep breastfeeding/pumping on the affected side and use cool compresses.
- Sepsis: High mortality. Treat rapidly with IV broad-spectrum antibiotics, crystalloid fluids, and blood cultures.
- Wound Assessment: Evaluate perineal tears using the REEDA mnemonic (Redness, Edema, Ecchymosis, Drainage, Approximation).