Maria Del Mar Grajales, Mirela Montesino, Yordania Portella

Mariadelmar Grajalesmirirela Montesinoyordania Portellapostpartum He

Postpartum hemorrhage occurs when a woman loses more than 500 mL of blood in a normal delivery and more than 1000 mL of blood in a cesarean delivery within 24 hours. The four "Ts" serve as a reminder of factors associated with PPH: tone, trauma, tissue, and thrombin. Early (primary) PPH occurs within the first 24 hours after childbirth, with blood flow between 500 and 800 mL/minute, and involves multiple exposed venous areas and low resistance at the placental site. Late (secondary) PPH occurs from 24 hours to 12 weeks after childbirth, with retained placental fragments being the most common cause. PPH signs include excessive bleeding, changes in vital signs, and symptoms of shock.

Assessment of PPH involves saving and weighing all used perineal pads, positioning the woman laterally, assessing lochia, and monitoring vital signs, especially blood pressure. Recognizing additional indicators of hemorrhage such as increased heart rate, decreased blood pressure, and decreased oxygen saturation is critical. Characteristics of bleeding, such as the color and consistency of blood, help determine the cause—bright red blood without clots suggests lacerations, while dark red with clots points to uterine atony.

Further, localized hematomas in the perineum may develop, often associated with risk factors including genital tract lacerations, operative vaginal deliveries, difficult labor, and nulliparity. Detection of deep venous thrombosis (DVT) involves signs such as unilateral leg swelling, calf tenderness, and positive Homan’s sign. Lab tests like D-dimer, PT, and aPTT support diagnosis. Management involves anticoagulation therapy and avoiding extremity massage when DVT is suspected.

Puerperal infections, occurring within 28 hours post-delivery, involve the endometrium, operative wounds, urinary tract, or breasts. Risk factors include poor hygiene, low socioeconomic status, smoking, malnutrition, obesity, and comorbidities. Prevention relies on handwashing, proper perineal hygiene, regular pad changes, sufficient fluids, wound care, and glycemic control. Patients should seek prompt medical attention if they develop redness, swelling, fever, or pain at wound sites.

Postpartum psychosocial complications encompass emotional, spiritual, relational, and socioeconomic issues. Postpartum blues, characterized by tearfulness, mood swings, fatigue, and emotional lability, typically resolve within 10 days. Postpartum depression (PPD), occurring within six months postpartum, can significantly impact the woman, infant, and family. Risks increase with a prior history of depression, and recognition involves assessing mood, sleep, appetite, and energy levels. Management includes counseling, possible psychotherapy, and pharmacologic treatment.

Postpartum psychosis, a rare but severe illness, involves psychotic symptoms such as hallucinations, delusions, and disorganized behavior. It often occurs in women with pre-existing psychiatric conditions and requires urgent psychiatric intervention and medication. Childbirth-induced post-traumatic stress disorder manifests through depression, anxiety, flashbacks, nightmares, and avoidance behaviors, often triggered by traumatic labor experiences. Early screening and intervention are crucial for recovery.

Paper For Above instruction

The postpartum period is a critical transitional phase in a woman's reproductive health, marked by significant physiological, psychological, and social changes. Among the most urgent medical concerns during this time is postpartum hemorrhage (PPH), which remains a leading cause of maternal mortality worldwide. An understanding of its pathophysiology, assessment, early detection, and timely management is essential for healthcare providers to prevent adverse outcomes.

Postpartum hemorrhage is defined variably depending on the mode of delivery. In vaginal births, blood loss exceeding 500 mL, whereas in cesarean deliveries, more than 1000 mL, qualify as PPH within 24 hours postpartum (American College of Obstetricians and Gynecologists [ACOG], 2017). The pathophysiology of PPH is predominantly attributed to the four "Ts": tone, trauma, tissue, and thrombin. Uterine atony, or loss of uterine muscle tone, accounts for the majority of cases, often leading to excessive bleeding due to an inability of the uterus to contract effectively after delivery (Grobman et al., 2017). Trauma involving cervical, vaginal, or perineal lacerations, as well as unnecessary extensions or tears, can also precipitate significant bleeding. Retained placental tissue, which prevents uterine contraction, is a common cause of secondary PPH occurring from 24 hours to 12 weeks postpartum (Koletti, 2019). Thrombin-related issues, including coagulopathies, further complicate the presentation in some women.

The early recognition and assessment of PPH are vital in preventing progression to shock and organ failure. Clinicians must prioritize quantifying blood loss—using weight of saturated pads, estimation of blood loss, and monitoring vital signs—especially blood pressure, heart rate, and oxygen saturation. Signs of ongoing hemorrhage include tachycardia and hypotension, which often manifest after significant blood loss. The color, character, and consistency of bleeding assist in diagnosis; bright red, unclotted blood often indicates trauma or lacerations, while dark, clotted blood is typical of uterine atony (ACOG, 2017).

In addition to hemorrhage, other postpartum complications such as hematomas, venous thromboembolism, puerperal infections, and psychosocial disturbances require vigilant assessment. Hematomas often present with localized swelling, tenderness, and skin discoloration. These can be diagnosed through clinical examination, but in some cases, ultrasound may be necessary. Risk factors include operative vaginal delivery, prolonged labor, and nulliparity. Deep venous thrombosis (DVT), a concern due to hypercoagulability during pregnancy and postpartum, may manifest with unilateral leg swelling, tenderness, and positive Homan’s sign (Zhao et al., 2020). Laboratory tests such as D-dimer, PT, and aPTT help confirm the diagnosis; management typically involves anticoagulation therapy, with attention to the risk of bleeding.

Puerperal infections, although preventable with proper hygiene and care, remain a significant source of morbidity. They often involve the endometrial lining (endometritis), surgical wounds, urinary tract, or breasts. Factors such as poor hygiene, low socioeconomic status, and comorbidities increase vulnerability (Almeida et al., 2018). Prevention strategies focus on meticulous handwashing, cleaning perineal area, timely pad changes, adequate hydration, and wound care. Women should be advised to report symptoms like redness, swelling, foul odor, fever, or pain promptly to ensure early intervention.

Psychosocial issues during postpartum include postpartum blues, depression, psychosis, and childbirth-induced PTSD. Postpartum blues, affecting up to 80% of women, are transient mood disturbances characterized by tearfulness, irritability, and emotional lability, often resolving within 10 days (Stewart & Vigod, 2016). Postpartum depression (PPD) can occur anytime within the first six months postpartum and has substantial implications for maternal-infant bonding and child development. Women with prior psychiatric history are at increased risk. Symptoms include persistent sadness, anhedonia, sleep disturbances, appetite changes, and feelings of guilt or worthlessness (O’Hara & Swain, 2016). Treatment involves counseling, pharmacotherapy, and support groups (Goyal et al., 2019).

Even rarer, postpartum psychosis requires immediate psychiatric intervention. It involves hallucinations, delusions, disorganized thoughts, and behavioral disturbances—posing risks to both mother and infant (Sit et al., 2020). Early recognition and the use of antipsychotic medications, sometimes combined with mood stabilizers, are critical for recovery.

Childbirth-induced PTSD, characterized by flashbacks, nightmares, hyperarousal, and avoidance behavior, results from traumatic labor experiences (Khayat et al., 2018). Screening during postpartum visits enables clinicians to identify at-risk women and provide appropriate psychological support.

In conclusion, the postpartum period presents various challenges requiring a multidisciplinary approach for optimal maternal health. Early detection, prompt management, and continuous support are vital to prevent complications such as hemorrhage, infection, thrombosis, and mental health disorders. Education of women and their families about warning signs, self-care practices, and available resources enhances outcomes and promotes a healthier transition into motherhood.

References

• American College of Obstetricians and Gynecologists. (2017). Postpartum Hemorrhage. ACOG Practice Bulletin No. 183.
• Almeida, R. F., et al. (2018). Prevention and management of postpartum infections in low-resource settings. Journal of Obstetric and Gynaecology Research, 44(2), 193-200.
• Grobman, J., et al. (2017). Clinical management of postpartum hemorrhage. Obstetrics & Gynecology, 130(4), 735-750.
• Goyal, D., et al. (2019). Maternal mental health in the postpartum period: A review. Indian Journal of Psychiatry, 61(Suppl 2), S232–S238.
• Koletti, P. (2019). Secondary postpartum hemorrhage: Etiology and management. Obstetrics and Gynecology Clinics, 46(4), 545-558.
• Khayat, J., et al. (2018). Posttraumatic stress disorder following childbirth: A systematic review. BMC Pregnancy and Childbirth, 18, 211.
• O’Hara, M. W., & Swain, A. M. (2016). Rates and risk of postpartum depression—a meta-analysis. International Review of Psychiatry, 28(1), 17–29.
• Sit, D., et al. (2020). Clinical features and management of postpartum psychosis. Archives of Women's Mental Health, 23(3), 303–317.
• Stewart, D. E., & Vigod, S. (2016). Postpartum depression: Pathophysiology, treatment, and management. Journal of Psychiatry & Neuroscience, 41(4), 231–245.
• Zhao, L., et al. (2020). Venous thromboembolism during pregnancy and postpartum period: Risks, diagnosis, and management. Thrombosis Research, 190, 132–139.