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C"rrent #$%G&N > Chapter 31. Postpartum Hemorrhage & the Abnormal Puerperium >

'#(T'A)T*M H+M#))HAG+
,e-inition
Postpartum hemorrhage denotes ecessi!e bleeding "> #$$ mL in !aginal deli!ery% &ollowing
deli!ery. Hemorrhage may occur be&ore' during' or a&ter deli!ery o& the placenta. Actual measured
blood loss during uncomplicated !aginal deli!eries a!erages ($$ mL' and blood loss o&ten may be
underestimated. )e!ertheless' the criterion o& a #$$*mL loss is acceptable on historical grounds.
+lood lost during the &irst ,- hours a&ter deli!ery is early postpartum hemorrhage; blood lost
between ,- hours and . wee/s a&ter deli!ery is late postpartum hemorrhage.
.nci!ence
0he incidence o& ecessi!e blood loss &ollowing !aginal deli!ery is #123. Postpartum hemorrhage is
the most common cause o& ecessi!e blood loss in pregnancy' and most trans&usions in pregnant
women are per&ormed to replace blood lost a&ter deli!ery. Hemorrhage is the third leading cause o&
maternal mortality in the 4nited 5tates and is directly responsible &or approimately one*sith o&
maternal deaths. 6n less*de!eloped countries' hemorrhage is among the leading obstetric causes o&
maternal death.
Mor/i!ity 0 Mortality
Although any woman may su&&er ecessi!e blood loss during deli!ery' women already compromised
by anemia or intercurrent illness are more li/ely to demonstrate serious deterioration o& condition'
and anemia and ecessi!e blood loss may predispose to subse7uent puerperal in&ection. 8a9or
morbidity associated with trans&usion therapy "eg' !iral in&ection' trans&usion reactions% is
in&re7uent but is not insigni&icant. 8oreo!er' other types o& treatment &or anemia may in!ol!e some
ris/.
Postpartum hypotension may lead to partial or total necrosis o& the anterior pituitary gland and
cause postpartum panhypopituitarism' or 5heehan:s syndrome' which is characteri;ed by &ailure to
lactate' amenorrhea' decreased breast si;e' loss o& pubic and aillary hair' hypothyroidism' and
adrenal insu&&iciency. 0he condition is rare "< 1 in 1$'$$$ deli!eries%. A woman who has been
hypotensi!e postpartum and who is acti!ely lactating probably does not ha!e 5heehan:s syndrome.
Hypotension also can lead to acute renal &ailure and other organ system in9ury. 6n etreme
hemorrhage' sterility will result &rom hysterectomy per&ormed to control intractable postpartum
hemorrhage.
+tiology
Causes o& postpartum hemorrhage include uterine atony' obstetric lacerations' retained placental
tissue' and coagulation de&ects.
*T+).N+ AT#N&
Postpartum bleeding is physiologically controlled by constriction o& interlacing myometrial &ibers that
surround the blood !essels supplying the placental implantation site. 4terine atony eists when the
myometrium cannot contract.
Atony is the most common cause o& postpartum hemorrhage "#$3 o& cases%. Predisposing causes
include ecessi!e manipulation o& the uterus' general anesthesia "particularly with halogenated
compounds%' uterine o!erdistention "twins or polyhydramnios%' prolonged labor' grand multiparity'
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uterine leiomyomas' operati!e deli!ery and intrauterine manipulation' oytocin induction or
augmentation o& labor' pre!ious hemorrhage in the third stage' uterine in&ection' etra!asation o&
blood into the myometrium "Cou!elaire uterus%' and intrinsic myometrial dys&unction.
#$(T+T).C 1AC+)AT.#N(
=cessi!e bleeding &rom an episiotomy' lacerations' or both causes approimately ,$3 o&
postpartum hemorrhages. Lacerations can in!ol!e the uterus' cer!i' !agina' or !ul!a. 0hey usually
result &rom precipitous or uncontrolled deli!ery or operati!e deli!ery o& a large in&ant> howe!er' they
may occur a&ter any deli!ery. Laceration o& blood !essels underneath the !aginal or !ul!ar
epithelium results in hematomas. +leeding is concealed and can be particularly dangerous because
it may go unrecogni;ed &or se!eral hours and become apparent only when shoc/ occurs.
=pisiotomies may cause ecessi!e bleeding i& they in!ol!e arteries or large !aricosities' i& the
episiotomy is large' or i& a delay occurred between episiotomy and deli!ery or between deli!ery and
repair o& the episiotomy.
Persistent bleeding "especially bright red% and a well*contracted' &irm uterus suggests bleeding &rom
a laceration or &rom the episiotomy. When cer!ical or !aginal lacerations are identi&ied as the source
o& postpartum hemorrhage' repair is best per&ormed with ade7uate anesthesia.
5pontaneous rupture o& the uterus is rare. ?is/ &actors &or this complication include grand
multiparity' malpresentation' pre!ious uterine surgery' and oytocin induction o& labor. ?upture o& a
pre!ious cesarean section scar a&ter !aginal deli!ery may be an increasingly important cause o&
postpartum hemorrhage.
)+TA.N+, '1AC+NTA1 T.((*+
?etained placental tissue and membranes cause #11$3 o& postpartum hemorrhages. ?etention o&
placental tissue in the uterine ca!ity occurs in placenta accreta' in manual remo!al o& the placenta'
in mismanagement o& the third stage o& labor' and in unrecogni;ed succenturiate placenta.
4ltrasonographic &indings o& an echogenic uterine mass strongly support a diagnosis o& retained
placental products. 0he techni7ue probably is better used in cases o& hemorrhage occurring a &ew
hours a&ter deli!ery or in late postpartum hemorrhage. 0rans!aginal duple @oppler imaging also is
e&&ecti!e in e!aluating these patients. 5ome e!idence indicates that sonohysterography may aid in
the diagnosis o& residual trophoblastic tissue. 6& the endometrial ca!ity appears empty' unnecessary
dilatation and curettage may be a!oided.
C#AG*1AT.#N ,+2+CT(
Coagulopathies in pregnancy may be ac7uired coagulation de&ects seen in association with se!eral
obstetric disorders' including abruptio placentae' ecess thromboplastin &rom a retained dead &etus'
amniotic &luid embolism' se!ere preeclampsia' eclampsia' and sepsis. 0hese coagulopathies may
present as hypo&ibrinogenemia' thrombocytopenia' and disseminated intra!ascular coagulation.
0rans&usion o& more than 2 4 o& blood in itsel& may induce a dilutional coagulopathy.
Aon Willebrand:s disease' autoimmune thrombocytopenia' and leu/emia may occur in pregnant
women.
)is3 2actors
Pre!ention o& hemorrhage is pre&erable to e!en the best treatment. All patients in labor should be
e!aluated &or ris/ o& postpartum hemorrhage. ?is/ &actors include coagulopathy' hemorrhage' or
blood trans&usion during a pre!ious pregnancy> anemia during labor> grand multiparity> multiple
gestation> large in&ant> polyhydramnios> dys&unctional labor> oytocin induction or augmentation o&
labor> rapid or tumultuous labor> se!ere preeclampsia or eclampsia> !aginal deli!ery a&ter pre!ious
cesarean birth> general anesthesia &or deli!ery> and &orceps deli!ery.
Management
')+,+1.4+)& ')+'A)AT.#N
All obstetric patients should ha!e blood typed and screened on admission. Patients identi&ied as
being at ris/ &or postpartum hemorrhage should ha!e their blood typed and cross*matched
immediately. 0he blood should be reser!ed in the blood ban/ &or ,- hours a&ter deli!ery. A large*
bore intra!enous catheter should be securely taped into place a&ter insertion. @eli!ery room
personnel should be alerted to the ris/ o& hemorrhage. 5e!erely anemic patients should be
trans&used as soon as cross*matched blood is ready.
With concerns associated with blood trans&usion' autologous blood donation in obstetric patients at
ris/ &or postpartum hemorrhage has been ad!ocated. @espite care&ul e!aluation &or ris/ &actors'
with the eception o& cases o& placenta pre!ia' our ability to predict which patients will ha!e
hemorrhage and re7uire blood trans&usion remains poor> there&ore' the cost o& such an approach
may not be 9usti&ied.
,+1.4+)&
Bollowing deli!ery o& the in&ant' the uterus is massaged in a circular or bac/*and*&orth motion until
the myometrium becomes &irm and well contracted. =cessi!e and !igorous massage o& the uterus
be&ore' during' or a&ter deli!ery o& the placenta may inter&ere with normal contraction o& the
myometrium and instead o& hastening contraction may lead to ecessi!e postpartum blood loss.
TH.), (TAG+ #2 N#)MA1 1A$#)5 '1AC+NTA1 (+'A)AT.#N
0he placenta typically separates &rom the uterus and is deli!ered within # minutes o& deli!ery o& the
in&ant. Attempts to speed separation are o& no bene&it and may cause harm. 5pontaneous placental
separation is impending i& the uterus becomes round and &irm' a sudden gush o& blood comes &rom
the !agina' the uterus seems to rise in the abdomen' and the umbilical cord mo!es down out o& the
!agina.
0he placenta then can be remo!ed &rom the !agina by gentle traction on the umbilical cord. Prior to
placental separation' gentle steady traction on the cord combined with upward pressure on the
lower uterine segment "+randt*Andrews maneu!er% ensures that the placenta can be remo!ed as
soon as separation occurs and pro!ides a means o& monitoring the consistency o& the uterus.
Adherent membranes can be remo!ed by gentle traction with ring &orceps. 0he placenta is inspected
&or completeness immediately a&ter deli!ery.
Man"al )emoal o- the 'lacenta
Cpinion is di!ided about the timing o& manual remo!al o& the placenta. 6n the presence o&
hemorrhage' it is unreasonable to wait &or spontaneous separation' and manual remo!al o& the
placenta should be underta/en without delay. 6n the absence o& bleeding' many ad!ocate remo!al
o& the placenta 3$ minutes a&ter deli!ery o& the in&ant.
=&&orts to promote routine manual remo!al o& the placenta were o&ten made in the past. 0he
rationale includes shortening the third stage o& labor' decreasing blood loss' de!eloping eperience
in manual remo!al as practice &or dealing with placenta accreta' and pro!iding a way to
simultaneously eplore the uterus. =!idence now indicates that manual remo!al o& the placenta may
be a ris/ &actor &or postpartum endometritis. 0hese real or potential bene&its must be weighed
against the discom&ort caused to the patient' the ris/ o& in&ection' and the ris/ o& causing more
bleeding by inter&ering with normal mechanisms o& placental separation.
Techni6"e: 0he uterus is stabili;ed by grasping the &undus with a hand placed o!er the abdomen.
0he other hand traces the course o& the umbilical cord through the !agina and cer!i into the uterus
to palpate the edge o& the placenta. 0he membranes at the placental margin are per&orated' and the
hand is inserted between the placenta and the uterine wall' palmar side toward the placenta. 0he
hand is then gently swept &rom side to side and up and down to peel the placenta &rom its
attachments to the uterus. When the placenta has been completely separated &rom the uterus' it is
grasped and pulled &rom the uterus.
0he &etal and maternal sides o& the placenta should be inspected to ensure that it has been remo!ed
in its entirety. Cn the &etal sur&ace' incomplete placental remo!al is mani&ested as interruption o&
the !essels on the chorionic plate' usually shown by hemorrhage. Cn the maternal sur&ace' it is
possible to see where cotyledons ha!e been detached. 6& e!idence o& incomplete remo!al is
obser!ed' the uterus must be re*eplored and any small pieces o& adherent placenta remo!ed. 0he
uterus should be massaged until a &irm myometrial tone is achie!ed. @epending on the patient:s
other ris/ &actors &or postpartum endometritis' prophylactic antibiotics can be gi!en at the time o&
manual remo!al o& the placenta.
.mme!iate 'ostpart"m 'erio!
4terotonic agents can be administered as soon as the in&ant:s anterior shoulder is deli!ered. ?ecent
studies show a signi&icantly lowered incidence o& postpartum hemorrhage in patients recei!ing
oytocin "either low*dose 6A or 68% at the time o& deli!ery o& the anterior shoulder and controlled
cord traction compared to patients recei!ing 6A oytocin &ollowing placental deli!ery. 0here was no
greater incidence o& placental retention. Howe!er' populations without ultrasound screening &or
twins ha!e a potential ris/ &or entrapment o& an undiagnosed second twin' and oytocin should only
be gi!en a&ter placental deli!ery. ?outine administration o& oytocics during the third stage reduces
the blood loss o& deli!ery and decreases the chances o& postpartum hemorrhage by -$3. Cytocin'
1$1,$ 4DL o& isotonic saline' or other intra!enous solution by slow intra!enous in&usion or 1$ 4
intramuscularly can be used. +olus administration should not be used because large doses "> # 4%
can cause hypotension. =rgot al/aloids "eg' methylergono!ine maleate $., mg intramuscularly% also
can be routinely used' but they are not more e&&ecti!e than oytocin and pose more ris/ because
they rarely cause mar/ed hypertension. 0his occurs most commonly with intra!enous administration
or when regional anesthesia is used. =rgot al/aloids should not be used in hypertensi!e women or in
women with cardiac disease.
)epair o- 1acerations
6& bleeding is ecessi!e be&ore placental separation' manual remo!al o& the placenta is indicated.
Ctherwise' ecessi!e manipulation o& the uterus should be a!oided.
0he !agina and cer!i should be care&ully inspected immediately a&ter deli!ery o& the placenta' with
ade7uate lighting and assistants a!ailable. 0he episiotomy is 7uic/ly repaired a&ter massage has
produced a &irm' tightly contracted uterus. A pac/ placed in the !agina abo!e the episiotomy helps
to /eep the &ield dry> attaching the &ree end o& the pac/ to the ad9acent drapes reminds the
operator to remo!e it a&ter the repair is completed.
0he tendency o& bleeding !essels to retract &rom the laceration site is the reason &or 1 o& the
cardinal principles o& repair. +egin the repair abo!e the highest etent o& the laceration. 0he highest
suture is also used to pro!ide gentle traction to bring the laceration site closer to the introitus.
Hemostatic ligatures are then placed in the usual manner' and the entire birth canal is care&ully
inspected to ensure that no additional bleeding sites are present. =tensi!e inspection also pro!ides
time to con&irm that prior hemostatic e&&orts ha!e been e&&ecti!e.
A cer!ical or !aginal laceration etending into the broad ligament should not be repaired !aginally.
Laparotomy with e!acuation o& the resultant hematoma and hemostatic repair or hysterectomy is
re7uired.
Large or epanding hematomas o& the !aginal walls re7uire operati!e management &or proper
control. 0he !aginal wall is &irst eposed by an assistant. 6& a laceration accompanies the
hematoma' the laceration is etended so that the hematoma can be completely e!acuated and
eplored. When the bleeding site is identi&ied' a large hemostatic ligature can be placed well abo!e
the site. 0his ensures hemostasis in the !essel' which is li/ely to retract when lacerated. 0he
hematoma ca!ity should be le&t open to allow drainage o& blood and ensure that bleeding will not be
concealed i& hemostasis cannot be achie!ed.
6& no laceration is present on the !aginal side wall when a hematoma is identi&ied' then an incision
must be made o!er the hematoma to allow treatment to proceed as outlined.
Bollowing deli!ery' reco!ery room attendants should &re7uently massage the uterus and chec/ &or
!aginal bleeding.
+al"ation o- 'ersistent $lee!ing
6& !aginal bleeding persists a&ter deli!ery o& the placenta' aggressi!e treatment should be initiated.
6t is not su&&icient to per&orm per&unctory uterine massage' &or instance' without searching &or the
cause o& the bleeding and initiating de&initi!e treatment. 0he &ollowing steps should be underta/en
without delayE
7. 8anually compress the uterus.
2. Cbtain assistance.
8. 6& not already done' obtain blood &or typing and cross*matching.
9. Cbser!e blood &or clotting to rule out coagulopathy.
:. +egin &luid or blood replacement.
6. Care&ully eplore the uterine ca!ity.
;. Completely inspect the cer!i and !agina.
<. 6nsert a second intra!enous catheter &or administration o& blood or &luids.
M+A(*)+( T# C#NT)#1 $1++,.NG
Man"al +=ploration o- the *ter"s
0he uterus should be eplored immediately in women with postpartum hemorrhage. 8anual
eploration also should be considered a&ter deli!ery o& the placenta in the &ollowing circumstancesE
"1% when !aginal deli!ery &ollows pre!ious cesarean section> ",% when intrauterine manipulation'
such as !ersion and etraction' has been per&ormed> "3% when malpresentation has occurred during
labor and deli!ery> "-% when a premature in&ant has been deli!ered> "#% when an abnormal uterine
contour has been noted prior to deli!ery> and ".% when there is a possibility o& undiagnosed multiple
pregnancyFto rule out twins.
=nsure that all placental parts ha!e been deli!ered and that the uterus is intact. 0his should be done
e!en in the case o& a well*contracted uterus. =ploration per&ormed &or reasons other than
e!aluation o& hemorrhage also should con&irm that the uterine wall is intact and should attempt to
identi&y any possible intrauterine structural abnormalities. 8anual eploration o& the uterus does not
increase &ebrile morbidity or blood loss.
Techni6"e: Place a &resh glo!e o!er the glo!e on the eploring hand. Borm the hand into a cone
and gently introduce it by &irm pressure through the cer!i while stabili;ing the &undus with the
other hand. 5weep the bac/s o& the &irst and second &ingers across the entire sur&ace o& the uterus'
beginning at the &undus. 6n the lower uterine segment' palpate the walls with the palmar sur&ace o&
1 &inger. 4terine lacerations will be &elt as an ob!ious anatomic de&ect. All eploration should be
gentle because the postpartum uterus is easily per&orated.
4terine rupture detected by manual eploration in the presence o& postpartum hemorrhage re7uires
immediate laparotomy. A decision to repair the de&ect or proceed with hysterectomy is made on the
basis o& the etent o& the rupture' the patient:s desire &or &uture childbearing' and the degree o& the
patient:s clinical deterioration.
$iman"al Compression an! Massage
0he most important step in controlling atonic postpartum hemorrhage is immediate bimanual
uterine compression' which may ha!e to be continued &or ,$13$ minutes or more. Bluid
replacement should begin as soon as a secure intra!enous line is in place. 0yped and cross*matched
blood is gi!en when it is a!ailable. 8anual compression o& the uterus will control most cases o&
hemorrhage due to uterine atony' retained products o& conception "once the products are remo!ed%'
and coagulopathies.
Techni6"e: Place a hand on the patient:s abdomen and grasp the uterine &undus> bring it down
o!er the symphysis pubis. 6nsert the other hand into the !agina and place the &irst and second
&ingers on either side o& the cer!i and push it cephalad and anteriorly. 0he pulsating uterine
arteries should be &elt by the &ingertips. 8assage the uterus with both hands while maintaining
compression. Prolonged compression ",$13$ minutes% may be re7uired but almost always is
success&ul in controlling bleeding.
6nsert a Boley catheter into the bladder during compression and massage because !igorous &luid and
blood replacement will cause diuresis. A distended bladder will inter&ere with compression and
massage' will contribute to the patient:s discom&ort' and may itsel& be a ma9or contributor to uterine
atony.
C"rettage
Curettage o& a large' so&t postpartum uterus can be a &ormidable underta/ing because the ris/ o&
per&oration is high and the procedure commonly results in increased rather than decreased
bleeding. 0he suction curette' e!en with a large cannula' co!ers only a small area o& the postpartum
uterus' and its si;e and shape increase the li/elihood o& per&oration. A large blunt curette' the
Gban9oG curette' probably is the sa&est instrument &or curettage o& the postpartum uterus. 6t can be
used when manual eploration &ails to remo!e &ragments o& adherent placenta.
Curettage should be delayed unless bleeding cannot be controlled by compression and massage
alone. C!erly !igorous puerperal curettage can result in &ocal complete remo!al o& the
endometrium' particularly i& the uterus is in&ected' with subse7uent healing characteri;ed by
&ormation o& adhesions and Asherman>s syn!rome "amenorrhea and secondary sterility due to
intrauterine adhesions and uterine synechiae%. 6& circumstances permit' ultrasonic e!aluation o& the
postpartum uterus may distinguish those patients who will bene&it &rom curettage &rom those who
should be managed without it.
*terine 'ac3ing
Although once widely used &or control o& obstetric hemorrhage' uterine pac/ing is no longer &a!ored.
0he uterus may epand to considerable si;e a&ter deli!ery o& the placenta' thus accommodating
both a large !olume o& pac/ing material and a large !olume o& blood. 0he techni7ue also demands
considerable technical epertise because the uterus must be pac/ed uni&ormly with # yards o& -*
inch gau;e' sometimes with the aid o& special instrumentation "0orpin pac/er%. Howe!er' this
method has been used success&ully' a!oiding con!ersion to laparotomy in H reported cases. As a
last resort' uterine pac/ing may be particularly appropriate in centers where an inter!entional
radiologist is not immediately a!ailable.
*terotonic Agents
Cytocin ,$1-$ 4DL o& crystalloid should be in&used' i& not already running' at a rate o& 1$11#
mLDmin. 8ethylergono!ine $., mg can be gi!en intramuscularly but is contraindicated i& the patient
is hypertensi!e. 6ntramyometrial in9ection o& prostaglandin B
,
"PIB
,
% to control bleeding was
initially described in 1H(.. 6ntra!aginal or rectal prostaglandin suppositories' intrauterine irrigation
with prostaglandins' and intramyometrial in9ection o& prostaglandins also ha!e been reported to
control hemorrhage &rom uterine atony. 6ntramuscular administration o& 1#*methylprostaglandin
analogue was success&ul in treating 2#3 o& patients with postpartum hemorrhage due to atony.
Bailures in these series occurred in women who had uterine in&ections or unrecogni;ed placenta
accreta. 5ide e&&ects usually are minimal but may include transient oygen desaturation'
bronchospasm' and' rarely' signi&icant hypertension. 0ransient &e!er and diarrhea may occur. A
recent randomi;ed controlled trial showed ecellent e&&icacy o& 2$$ g o& rectal misoprostol' a
prostaglandin =
1
analogue' in the treatment o& primary postpartum hemorrhage secondary to atony.
)a!iographic +m/oli?ation o- 'elic 4essels
=mboli;ation o& pel!ic and uterine !essels by angiographic techni7ues is increasingly common and
has success rates &rom 2#1H#3 in eperienced hands. 6n institutions with trained inter!entional
radiologists' the techni7ue is worth considering in women o& low parity as an alternati!e to
hysterectomy. With the patient under local anesthesia' a catheter is placed in the aorta and
&luoroscopy is used to identi&y the bleeding !essel. Pieces o& absorbable gelatin sponge "Iel&oam%
are in9ected into the damaged !essel or into the internal iliac !essels i& no speci&ic site o& bleeding
can be identi&ied. 6& bleeding continues' &urther emboli;ation can be per&ormed. 0his techni7ue has
the ad!antage o& being e&&ecti!e e!en when the cause o& hemorrhage is etrauterine and in the
presence or absence o& uterine atony. 8any authors recommend emboli;ation be&ore internal iliac
ligation' because ligation obstructs the access route &or angiography. Ade7uate recanali;ation can
occur to maintain &ertility' although &ertility rates &ollowing emboli;ation are not /nown.
#peratie Management
0he patient:s wishes regarding &urther childbearing should be made clear as soon as laparotomy is
contemplated &or the management o& postpartum hemorrhage. 6& the patient:s wishes cannot be
ascertained' the operator should assume that the childbearing &unction is to be retained. Whene!er
possible' the spouse or &amily members should also be consulted prior to laparotomy.
')+((*)+ #CC1*(.#N #2 TH+ A#)TA
6mmediate temporary control o& pel!ic bleeding may be obtained at laparotomy by pressure
occlusion o& the aorta' which will pro!ide !aluable time to treat hypotension' obtain eperienced
assistants' identi&y the source o& bleeding' and plan the operati!e procedure. 6n the young and
otherwise healthy patient' pressure occlusion can be maintained &or se!eral minutes without
permanent se7uelae.
*T+).N+ A)T+)& 1.GAT.#N
@uring pregnancy' H$3 o& the blood &low to the uterus is supplied by the uterine arteries. @irect
ligation o& these easily accessible !essels can success&ully control hemorrhage in (#1H$3 o& cases'
particularly when the bleeding is uterine in origin. ?ecanali;ation can occur' and subse7uent
pregnancies ha!e been reported.
Techni6"e: 0he uterus is li&ted upward and away &rom the side to be ligated. Absorbable suture on
a large needle is placed around the ascending uterine artery and !ein on 1 side o& the uterus'
passing through the myometrium ,1- cm medial to the !essels and through the a!ascular area o&
the broad ligament. 0he suture includes the myometrium to &i the suture and to a!oid tearing the
!essels. 0he same procedure is then per&ormed on the opposite side. 6& the ligation is per&ormed
during cesarean section' the sutures can be placed 9ust below the uterine incision under the bladder
&lap. 6t is not necessary to mobili;e the bladder otherwise. +ilateral uteroo!arian artery ligation can
also be per&ormed in an attempt to reduce blood &low to the uterus. 0his techni7ue should be
per&ormed with absorbable suture near the point o& anastomoses between the o!arian artery and
the ascending uterine artery at the uteroo!arian ligament.
.NT+)NA1 .1.AC A)T+)& 1.GAT.#N
+ilateral internal iliac "hypogastric% artery ligation is the surgical method most o&ten used to control
se!ere postpartum bleeding "Big 3111%. =posure can be di&&icult' particularly in the presence o& a
large boggy uterus or hematoma. Bailure rates o& this techni7ue can be as high as #(3 but may be
related to the s/ill o& the operator' the cause o& the hemorrhage' and the patient:s condition be&ore
ligation is attempted.
Techni6"e: 0he peritoneum lateral to the in&undibulopel!ic ligament is incised parallel with the
ligament' or the round ligament is transected. 6n either case' the peritoneum to which the ureter
will adhere is dissected medially' which remo!es the ureter &rom the operati!e &ield. 0he pararectal
space is then enlarged by blunt dissection. 0he internal iliac artery on the lateral side o& the space is
isolated and doubly ligated "but not cut% with sil/ ligatures at its origin &rom the common iliac
artery. 0he operator must be care&ul not to tear the ad9acent thin !eins. +lood &low distally to the
uterus' cer!i' and upper !agina is not occluded' but the pulse pressure is su&&iciently diminished to
allow hemostasis to occur by in situ thrombosis. Bertility is preser!ed' and subse7uent pregnancies
are not compromised.
$-1&NCH $)AC+ (*T*)+
An alternati!e to the !essel ligation techni7ues is placement o& a brace suture to compress the
uterus in cases o& di&&use bleeding &rom atony or percreta "Big 311,%. A small case series shows
success and a!oidance o& hysterectomy using this no!el approach.
2ig"re 87@7.

Location o& ligatures &or right internal iliac "hypogastric% artery ligation.
2ig"re 87@2.

Techni6"e: Laparotomy is made in the standard way &or cesarean section' and a low*trans!erse
uterine incision is made a&ter the bladder is ta/en down. 0he uterus is eteriori;ed. 0o test the
e&&ecti!eness o& the method' the uterus is compressed manually and another operator chec/s the
!agina &or decreased bleeding. 4sing no. , catgut' the uterus is punctured 3 cm &rom the right lower
incision and 3 cm &rom the right lateral border. 0he suture is threaded to emerge 3 cm abo!e the
upper incision margin and - cm &rom the lateral border. 0he catgut is now !isible anteriorly as it is
passed o!er to compress the uterine &undus approimately 3- cm &rom the right cornual border. 0he
suture is &ed posteriorly and !ertically to enter the posterior wall o& the uterine ca!ity at the same
le!el as the pre!ious entry point. A&ter manual compression' the suture is tightened and then
passed posteriorly on the le&t side and passed around the uterine &undus again' this time on the le&t.
0he suture is brought anteriorly to puncture the uterus at the upper part o& the le&t uterine incision
and then reemerge below the lower incision in a symmetric &ashion. With 1 operator pro!iding
compression' the other throws the /not. 0he hysterotomy is closed in the standard &ashion &or a
cesarean section.
H&(T+)+CT#M&
Hysterectomy is the de&initi!e method o& controlling postpartum hemorrhage. 5imple hemostatic
repair o& a ruptured uterus with or without tubal ligation in a woman o& high parity or in poor
condition &or more etensi!e surgery may be pre&erred unless she has intercurrent uterine disease.
0he procedure is undoubtedly li&esa!ing.
+*Lynch brace suture "see tet &or details%.
$loo! )eplacement
+lood and &luid replacement are re7uired &or success&ul management o& postpartum hemorrhage.
8assi!e trans&usions may be necessary in patients with se!ere hemorrhage. Component therapy is
ad!ocated' with trans&usion o& pac/ed cells' platelets' &resh*&ro;en plasma' and cryoprecipitate
when indicated. +lood products should be obtained and gi!en without delay when needed' because
postponing trans&usion may only contribute to the de!elopment o& disseminated intra!ascular
coagulation.
MANAG+M+NT #2 ,+1A&+, '#(T'A)T*M H+M#))HAG+
@elayed postpartum hemorrhage "bleeding , wee/s a&ter deli!ery% is almost always due to
subin!olution o& the placental bed or retained placental &ragments. 6n!olution o& the placental site is
normally delayed when compared with that o& the rest o& the endometrium. Howe!er' &or un/nown
reasons' in subin!olution the ad9acent endometrium and the decidua basalis ha!e not regenerated
to co!er the placental implantation site. 0he in!olutional processes o& thrombosis and hyalini;ation
ha!e &ailed to occur in the underlying blood !essels' so bleeding may occur with only minimal
trauma or other "un/nown% stimuli. Although the cause o& subin!olution is un/nown' &aulty placental
implantation' implantation in the poorly !asculari;ed lower uterine segment' and persistent in&ection
at the implantation site ha!e been suggested as possible &actors. 4terine compression and bimanual
massage' as pre!iously described' control this type o& bleeding' but it may be necessary to continue
compression and massage &or 3$1-# minutes or longer. As pre!iously mentioned' trans!aginal
ultrasound may aid in diagnosis o& retained placental products. 6& imaging studies suggest
intraca!itary tissue' curettage is warranted.
+road*spectrum antibiotics should be started when resuscitation allows. Cytocin 1$ 4
intramuscularly e!ery - hours or 1$1,$ 4DL intra!enous solution by slow continuous in&usion' 1#*
methyl PIB
,
"Prostin 1#8% $.,# mg intramuscularly e!ery , hours' or ergot al/aloids' such as
methylergono!ine maleate $., mg orally e!ery . hours' should be administered &or at least -2
hours.
'1AC+NTA ACC)+TA
A layer o& decidua normally separates the placental !illi and the myometrium at the site o& placental
implantation. A placenta that directly adheres to the myometrium without an inter!ening decidual
layer is termed placenta accreta.
Classi-ication
$& ,+G)++ #2 A,H+)+NC+
'lacenta Accreta 4era
Ailli adhere to the super&icial myometrium.
'lacenta .ncreta
Ailli in!ade the myometrium.
'lacenta 'ercreta
Ailli penetrate the &ull thic/ness o& the myometrium.
$& AM#*NT #2 '1AC+NTA1 .N4#14+M+NT
2ocal A!herence
A single cotyledon is in!ol!ed.
'artial A!herence
Cne or se!eral cotyledons are in!ol!ed.
Total A!herence
0he entire placenta is in!ol!ed.
.nci!ence
=stimates o& the incidence o& placenta accreta "all &orms% !ary &rom 1 in ,$$$ to 1 in ($$$
deli!eries. Placenta accreta !era accounts &or approimately 2$3 o& abnormally adherent placentas'
placenta increta accounts &or 1#3' and placenta percreta accounts &or #3. 0he rate has risen
slightly o!er the last , decades' paralleling the cesarean section rate.
0he immediate morbidity associated with an abnormally adherent placenta is that associated with
any type o& postpartum hemorrhage. 8assi!e blood loss and hypotension can occur. 6ntrauterine
manipulation necessary to diagnose and treat placenta accreta may result in uterine per&oration and
in&ection. 5terility may occur as a result o& hysterectomy per&ormed to control bleeding.
?ecurrence may be common with lesser degrees o& adherence.
+tiology
+oth ecessi!e penetrability o& the trophoblast and de&ecti!e or missing decidua basalis ha!e been
suggested as causes o& placenta accreta. Histologic eamination o& the placental implantation site
usually demonstrates the absence o& the decidua and )itabuch:s layer. Cases o& placenta accreta
ha!e been seen in the &irst trimester' suggesting that the process may occur at the time o&
implantation and not later in gestation.
Although the eact cause is un/nown' se!eral clinical situations are associated with placenta
accreta' such as pre!ious cesarean section' placenta pre!ia' grand multiparity' pre!ious uterine
curettage' and pre!iously treated Asherman:s syndrome.
0hese conditions share a common possible de&ect in &ormation o& the decidua basalis. 0he incidence
o& placenta accreta in the presence o& placenta pre!ia a&ter 1 prior uterine incision is between 1-3
and ,-3' a&ter , is ,31-23' and a&ter 3 is 3#1#$3. 0he incidence o& placenta accreta a&ter
success&ul treatment o& Asherman:s syndrome may be as high as 1#3.
,iagnosis
Ad!erse e&&ects &rom placenta accreta in pregnancy or during the course o& labor and deli!ery are
uncommon. ?arely' intra*abdominal hemorrhage or placental in!asion o& ad9acent organs prior to
labor has occurred' with the diagnosis made at laparotomy.
0he diagnosis o& placenta increta prior to deli!ery based on the lac/ o& the sonolucent area normally
seen beneath the implantation site during ultrasonographic eamination is a &inding con&irmed in
se!eral reports. 5onographic antenatal diagnosis o& the less in!asi!e placental accreta also has been
reported. Color @oppler imaging appears to be particularly help&ul in diagnosis. 8agnetic resonance
imaging has also aided in the diagnosis o& placenta accreta. 0he diagnosis is more o&ten established
when no plane o& clea!age is &ound between the placenta or parts o& the placenta and the
myometrium in the presence o& postpartum hemorrhage. ?etained placental parts pre!ent the
myometrium &rom contracting and thereby achie!ing hemostasis. +leeding can be bris/. 6nspection
o& the already separated placenta shows that portions are missing' and manual eploration may
produce additional placental &ragments.
@elayed spontaneous separation o& the placenta is also an indication o& an unusually adherent
placenta. Bocal or partial in!ol!ement may be mani&ested as di&&iculty in establishing a clea!age
plane during manual remo!al o& the placenta. ?emo!al o& a totally adherent placenta is di&&icult.
Persistent e&&orts to manually remo!e a totally adherent placenta are &utile and waste time' and
they result in e!en more blood loss. Preparation &or hysterectomy should begin as soon as the
diagnosis is suspected.
Management
Bluid and blood replacement should begin as soon as ecessi!e blood loss is diagnosed. 6nsertion o&
a second large*bore intra!enous catheter may be necessary. =!aluation o& puerperal hemorrhage
should be per&ormed as outlined in =!aluation o& Persistent +leeding.
Conser!ati!e treatment o& placenta accreta in women o& low parity has occasionally succeeded. 0he
placenta "or portions o& it% is le&t in situ i& bleeding is minimal and will later slough o&&. 5uccess&ul
subse7uent pregnancies ha!e been reported' although the ris/ o& recurrence o& placenta accreta
may be high. 6n up to (,3 o& cases o& placenta accreta' particularly those associated with placenta
pre!ia' hysterectomy is re7uired.
5uccess&ul conser!ati!e treatment o& placenta percreta is rare' but the conser!ati!e approach may
be a reasonable option i& only &ocal de&ects are present' blood loss is not ecessi!e' and the patient
wishes to preser!e &ertility. 6n anticipated cases o& se!ere placenta accreta' preoperati!e balloon
occlusion and emboli;ation o& the internal iliac arteries may minimi;e intraoperati!e blood losses.
5uccess&ul emboli;ation in unpredicted cases o& placenta accreta has been reported. Howe!er'
additional resection o& ad9acent organs' such as partial cystectomy' may be necessary in placenta
percreta.
*T+).N+ .N4+)(.#N
,e-inition
4terine in!ersion is prolapse o& the &undus to or through the cer!i so that the uterus is in e&&ect
turned inside out. Almost all cases o& uterine in!ersion occur a&ter deli!ery and may be worsened by
ecess traction on the cord be&ore placental separation. )onpuerperal uterine in!ersion is rare and
usually is associated with tumors "eg' polypoid leiomyomas%.
Classi-ication
6& the uterus is in!erted but does not protrude through the cer!i' the in!ersion is incomplete. 6n
complete in!ersion' the &undus has prolapsed through the cer!i. Cccasionally' the entire uterus
may prolapse out o& the !agina.
Puerperal in!ersion has also been classi&ied on the basis o& its duration. Acute in!ersion occurs
immediately a&ter deli!ery and be&ore the cer!i constricts. Cnce the cer!i constricts' the in!ersion
is termed subacute. Chronic in!ersion is noted more than - wee/s a&ter deli!ery. 0oday' nearly all
cases o& uterine in!ersion are o& the acute !ariety and are recogni;ed and treated immediately a&ter
deli!ery.
.nci!ence
6n series reported within the past 3$ years' the incidence o& uterine in!ersion has !aried &rom 1 in
-$$$ to 1 in 1$$'$$$ deli!eries> an incidence o& 1 in ,$'$$$ is &re7uently cited. Cne wor/er
reported no in!ersions in more than 1$'$$$ personally conducted deli!eries. 8ore recent re!iews
indicate a greater incidence o& uterine in!ersion' approimately 1 in ,$$$ to 1 in ,#$$ deli!eries.
0he morbidity and mortality associated with uterine in!ersion correlate with the degree o&
hemorrhage' the rapidity o& diagnosis' and the e&&ecti!eness o& treatment.
0he immediate morbidity is that associated with any postpartum hemorrhage> howe!er'
endomyometritis &re7uently &ollows uterine in!ersion. 0he intestines and uterine appendages may
be in9ured i& they are entrapped by the prolapsed uterine &undus. @eath has occurred &rom uterine
in!ersion' although with prompt recognition' de&initi!e treatment' and !igorous resuscitation' the
mortality rate in this condition should be 7uite low.
+tiology
0he eact cause o& uterine in!ersion is un/nown' and the condition is not always pre!entable. 0he
cer!i must be dilated and the uterine &undus must be relaed &or in!ersion to occur. ?apid uterine
emptying may contribute to uterine relaation.
Conditions that may predispose women to uterine in!ersion include &undal implantation o& the
placenta' abnormal adherence o& the placenta "partial placenta accreta%' congenital or ac7uired
wea/ness o& the myometrium' uterine anomalies' protracted labor' pre!ious uterine in!ersion'
intrapartum therapy with magnesium sul&ate' strong traction eerted on the umbilical cord' and
&undal pressure.
8any cases o& uterine in!ersion result &rom mismanagement o& the third stage o& labor in women
who already are at ris/ &or de!eloping uterine in!ersion. 0he &ollowing maneu!ers are to be
a!oidedE ecessi!e traction on the umbilical cord' ecessi!e &undal pressure' ecessi!e intra*
abdominal pressure' and ecessi!ely !igorous manual remo!al o& the placenta.
,iagnosis
0he diagnosis o& uterine in!ersion usually is ob!ious. 5hoc/ and hemorrhage are prominent' as is
considerable pain. A dar/ red1blue bleeding mass is palpable and o&ten !isible at the cer!i' in the
!agina' or outside the !agina. A depression in the uterine &undus or e!en an absent &undus is noted
on abdominal eamination. Partial in!ersion in which the &undus stays within the !agina can escape
immediate notice i& the attendant is not aware o& this complication.
Treatment
5uccess&ul management o& patients with uterine in!ersion depends on prompt recognition and
treatment. 6& initial measures &ail to relie!e the condition' it may progress to the point at which
operati!e treatment or e!en hysterectomy is necessary. 5hoc/ associated with uterine in!ersion
typically is pro&ound. Hemorrhage can be massi!e' and hypo!olemia should be !igorously treated
with &luid and blood replacement.
MAN*A1 )+'#(.T.#N.NG #2 TH+ *T+)*(
0reatment should begin as soon as the diagnosis o& uterine in!ersion is made. Assistance is !ital. An
initial attempt should be made to reposition the &undus. 0he in!erted &undus' along with the
placenta i& it is still attached' is slowly and steadily pushed upward in the ais o& the uterus "Big 311
3%. 6& the placenta has not separated' do not remo!e it until an ade7uate intra!enous in&usion has
been established.
2ig"re 87@8.

6& the initial attempt &ails' induce general anesthesia' pre&erably with a halogenated agent "eg'
halothane% to pro!ide uterine relaation. Alternati!ely' #$ g o& 6A nitroglycerin can be gi!en as a
bolus to rela the uterus and a!oid intubation. 0he dose can be repeated at least once. While
awaiting anesthesiology assistance' easily a!ailable tocolytics may be used e&&ecti!ely. =ither
intra!enous magnesium sul&ate or terbutaline $.,# mg gi!en as a bolus dose intra!enously has been
used success&ully to achie!e uterine relaation in subacute in!ersion' and neither has been
associated with bleeding.
Techni6"e: 0he operator:s &ist is placed on the uterine &undus' and the &undus is gradually pushed
bac/ into the pel!is through the dilated cer!i. 0he general anesthetic or uterine relaant is
discontinued. 6n&usion o& oytocin or ergot al/aloids is started and &luid and blood replacement
continued. Alternati!ely' prostaglandins can be used to e&&ect uterine contraction a&ter repositioning.
+imanual uterine compression and massage are maintained until the uterus is well contracted and
hemorrhage has ceased. 0he placenta can then be remo!ed.
Antibiotics should be started as soon as is practical. Cytocics or ergot al/aloids are continued &or at
least ,- hours. Bre7uent determinations o& the hematocrit le!el should be made to ascertain the
need &or &urther blood replacement. 6ron supplements should begin with resumption o& oral inta/e.
(*)G.CA1 )+'#(.T.#N.NG #2 TH+ *T+)*(
?eplacement o& an in!erted uterus.
5urgical repositioning o& the uterus is rarely necessary in contemporary medical practice in the
4nited 5tates. Howe!er' when all other e&&orts ha!e &ailed to reposition the e!erted uterus'
operati!e inter!ention may be li&esa!ing. 0his is generally accomplished by a !ertical incision
through the lower uterine segment directly posterior. 0he uterus is repositioned by either pulling
&rom abo!e or' !ery rarely' pushing &rom below "using a sterile glo!e%. 0he incision is then repaired
as would be any uterine incision. +lood replacement' antibiotics' and care&ul monitoring are
necessary &or success&ul perioperati!e management.
A$N#)MA1.T.+( #2 TH+ '*+)'+).*M: .NT)#,*CT.#N
When compared with the dramatic and climactic e!ents o& deli!ery' the puerperium may seem
une!ent&ul. )e!ertheless' signi&icant physiologic changes occur during this inter!al' and they
undoubtedly in&luence many o& the problems that o&ten arise rapidly and without warning.
Hypotension and shoc/ demand urgent treatment and care&ul &ollow*up. Cardiac monitoring and
insertion o& 5wan*Ian; or central !enous pressure catheters may be prudent to permit rapid
e!aluation o& hemodynamic status. Appropriate medical and surgical consultation are also
recommended.
'#(T'A)T*M 0 '*+)'+)A1 .N2+CT.#N(
6n&ections are among the most prominent puerperal complications. An impro!ed understanding o&
the natural history o& &emale genital in&ections and the a!ailability o& power&ul antibiotics may ha!e
produced a complacent attitude toward puerperal in&ections that is unrealistic. Postpartum in&ections
still are costly to both patients and society' and they are associated with an admittedly small but
not negligible threat o& serious disability and death.
Puerperal morbidity due to in&ection has occurred i& the patient:s temperature is higher than 32 JC
"1$$.- JB% on , separate occasions at least ,- hours apart &ollowing the &irst ,- hours a&ter
deli!ery. C!ert in&ections can and do occur in the absence o& these criteria' but &e!er o& some
degree remains the hallmar/ o& puerperal in&ection' and the patient with &e!er can be assumed to
ha!e a genital in&ection until pro!ed otherwise.
.nci!ence
Puerperal in&ectious morbidity a&&ects ,123 o& pregnant women and is more common in those o&
low socioeconomic status' who ha!e undergone operati!e deli!ery' with premature rupture o& the
membranes' with long labors' or who ha!e multiple pel!ic eaminations.
Postpartum in&ections are responsible &or much o& the morbidity associated with childbirth' and they
either are directly responsible &or or contribute to the death o& approimately 23 o& all pregnant
women who die each year. 0he costs are considerable' not only in additional days o& hospitali;ation
and medications but also in time lost &rom wor/.
5terility may result &rom the se7uelae o& postpartum in&ections' such as periadneal adhesions.
Hysterectomy occasionally is re7uired in patients with serious postpartum or postoperati!e in&ection.
'athogenesis
0he &lora o& the birth canal o& pregnant women is essentially the same as that o& nonpregnant
women' although !ariations in culture techni7ues and in the study populations ha!e produced
mar/edly di&&erent results. 0he !aginal &lora typically includes aerobic and anaerobic organisms that
are commonly considered pathogenic "0able 3111%. 5e!eral mechanisms appear to pre!ent o!ert
in&ection in the genital tract' such as the acidity o& the normal !agina> thic/' tenacious cer!ical
mucus> and maternal antibodies to most !aginal &lora.
Ta/le 87@7. 'ercentage o- #rganisms .solate! -rom the 4agina or Ceri= in
@uring labor and particularly a&ter rupture o& the membranes' some o& the protecti!e mechanisms
are no longer present. =aminations and in!asi!e monitoring apparatus probably &acilitate the
introduction o& !aginal bacteria into the uterine ca!ity. +acteria can be cultured &rom the amniotic
&luid o& most women undergoing intrauterine pressure monitoring' but o!ert postpartum in&ection is
seen in &ewer than 1$3 o& these cases. Contractions during labor may spread bacteria present in
the amniotic ca!ity to the ad9acent uterine lymphatics and e!en into the bloodstream.
0he postpartum uterus initially is de!oid o& mechanisms that /eep it sterile' and bacteria may be
reco!ered &rom the uterus in nearly all women in the postpartum period. Whether or not disease is
clinically epressed depends on the presence o& predisposing &actors' the duration o& uterine
contamination' and the type and amount o& microorganisms in!ol!ed. 0he necrosis o& decidua and
other intrauterine contents "lochia% promotes an increase in the number o& anaerobic bacteria'
hereto&ore limited by lac/ o& suitable nutrients and other &actors necessary &or growth.
5terility o& the endometrial ca!ity returns by the third or &ourth postpartum wee/. Iranulocytes that
penetrate the endometrial ca!ity and the open drainage o& lochia are e&&ecti!e in pre!enting
Normal 'regnant an! Nonpregnant Aomen.
#rganism 'ercentage .solate!
Aero/ic /acteria
Lactobacillus 1(1H(
@iphtheroids 1-123
Staphylococcus epidermidis (1.(
Staphylococcus aureus $11,
*Hemolytic streptococci ,1#3
*Hemolytic streptococci $1H3
)onhemolytic streptococci -13(
Iroup @ streptococci -1--
Escherichia coli $1,2
Gardnerella vaginalis -$1-3
Neisseria gonorrhoeae 11(
Mycoplasma 1#1(,
Ureaplasma -$1H#
Anaero/ic /acteria
Lactobacillis 111(,
Bacteroides fragilis $1,$
Bacteroides species $1#$
usobacterium species $112
!eptococcus species $1(1
!eptostreptococcus species 1,1-$
"eillonella species $1,(
#lostridium species $11(
Bifidobacterium species $13,
Eubacterium species $13.

in&ection in most patients.
+tiology
Almost all postpartum in&ections are caused by bacteria normally present in the genitalia o&
pregnant women. 0he lochia is an ecellent culture medium &or organisms ascending &rom the
!agina. 6n women who ha!e undergone cesarean section' more de!itali;ed tissue and &oreign bodies
"sutures% are present' pro!iding additional &ertile ground &or possible contamination and subse7uent
in&ection. Approimately ($3 o& puerperal so&t*tissue in&ections are mied in&ections consisting o&
both aerobic and anaerobic organisms> in&ections occurring in women undergoing cesarean section
are more li/ely to be serious.
General +al"ation
0he source o& in&ection should be identi&ied' the li/ely cause determined' and the se!erity assessed.
8ost women with &e!er in the postpartum period ha!e endometritis. 4rinary tract in&ection is the
net most common in&ection. )eglected or !irulent endomyometritis may progress to more serious
in&ection. Ienerali;ed sepsis' septic pel!ic thrombophlebitis' or pel!ic abscess may be the end result
o& an initial in&ection o& the endometrial ca!ity.
+n!ometritis
+tiology
All o& the &ollowing circumstances ha!e led to higher than normal postpartum in&ection ratesE
prolonged rupture o& the membranes "> ,- hours%' chorioamnionitis' an ecessi!e number o& digital
!aginal eaminations' prolonged labor "> 1, hours%' toemia' intrauterine pressure catheters "> 2
hours%' &etal scalp electrode monitoring' preeisting !aginitis or cer!icitis' operati!e !aginal
deli!eries' cesarean section' intrapartum and postpartum anemia' poor nutrition' obesity' low
socioeconomic status' and coitus near term.
Cesarean section and low socioeconomic class are consistently associated with higher rates o&
postpartum in&ection' and cesarean section is easily the most common identi&iable ris/ &actor &or
de!elopment o& puerperal in&ection. 5ome series report an in&ection rate o& -$12$3 &ollowing
cesarean section deli!ery. Postpartum in&ection is more li/ely to be serious a&ter cesarean section
than a&ter !aginal deli!ery. A history o& bacterial !aginosis con&ers a higher ris/ o& postcesarean
endometritis.
Clinical 2in!ings
(&M'T#M( AN, (.GN(
Be!er and a so&t' tender uterus are the most prominent signs o& endometritis. 0he lochia may or
may not ha!e a &oul odor. Leu/ocytosis "white blood cell count > 1$'$$$D L% is seen. 6n more
se!ere disease' high &e!er' malaise' abdominal tenderness' ileus' hypotension' and generali;ed
sepsis may be seen. 8o!ement o& the uterus causes increased pain.
2eer
Although the puerperium is a period o& high metabolic acti!ity' this &actor should not raise the
temperature abo!e 3(., JC "HH JB% and then only brie&ly in the &irst ,- hours postpartum. 8odest
temperature ele!ations may occur with dehydration. Any woman with a &e!er o!er 32 JC "1$$.- JB%
at any time in the puerperium should be e!aluated.
=ndometritis results in temperatures ranging &rom 32 JC to o!er -$ JC "1$$.- JB to > 1$- JB%'
depending on the patient' the causati!e microorganism' and the etent o& in&ection. 0he lower range
o& temperatures is more common. =ndometritis usually de!elops on the second or third postpartum
day. =arly &e!er "within hours o& deli!ery% and hypotension are almost pathognomonic &or in&ection
with *hemolytic streptococci.
*terine Ten!erness
0he uterus is so&t and e7uisitely tender. 8otion o& the cer!i and uterus may cause increased pain.
Abdominal tenderness is generally limited to the lower abdomen and does not laterali;e. A care&ully
per&ormed baseline eamination should include an adneal e!aluation. Adneal masses palpable on
abdominal or pel!ic eamination are not seen in uncomplicated endometritis' but tubo*o!arian
abscess may be a later complication o& an in&ection originally con&ined to the uterus. +owel sounds
may be decreased and the abdomen distended and tympanitic.
Pel!ic eamination con&irms the &indings disclosed by abdominal eamination.
1A$#)AT#)& 2.N,.NG(
Hematologic 2in!ings
Leu/ocytosis is a normal &inding during labor and the immediate puerperal period. White blood cell
counts may be as high as ,$'$$$D L in the absence o& in&ection' so higher counts can be anticipated
in in&ection. +acteremia is present in #11$3 o& women with uncomplicated endometritis.
Mycoplasma is &re7uently reco!ered &rom the blood o& patients with postpartum &e!er. 6n&ections
with Bacteroides as the predominant organism are &re7uently associated with positi!e blood
cultures.
*rinalysis
4rinalysis should be routinely per&ormed in patients thought to ha!e endometritis because urinary
tract in&ections are o&ten associated with a clinical picture similar to that o& mild endometritis. 6&
pyuria and bacteria are noted in a properly collected specimen' appropriate antibiotic therapy &or
urinary tract in&ections should be started and a portion o& the specimen sent &or culture.
1ochia C"lt"res
+acteria coloni;ing the cer!ical canal and ectocer!i almost always can be reco!ered &rom lochia
cultures' but they may not be the same organisms causing endometritis. Accurate cultures can be
achie!ed only i& specimens obtained transcer!ically are &ree &rom !aginal contamination. 8aterial
should be obtained using a speculum to allow direct !isuali;ation o& the cer!i and a glo!ed culture
de!ice "a swab that is co!ered while it is passed through a contaminated area' then unco!ered to
obtain a culture &rom the desired area%. 0ransabdominal aspiration o& uterine contents does secure
an uncontaminated specimen' but routine use o& this techni7ue probably is not 9usti&ied' and
con&irmation o& placement within the uterine ca!ity may be di&&icult. 4nless special means are ta/en
to pre!ent cer!ical contamination and to ensure the reco!ery o& anaerobic species' results o& lochia
cultures must be interpreted with great care.
$acteriologic 2in!ings
Although the organisms responsible &or puerperal in&ections !ary considerably among hospitals'
most puerperal in&ections are due to anaerobic streptococci' gram*negati!e coli&orms' Bacteroides
spp.' and aerobic streptococci. #hlamydia and Mycoplasma are also implicated in many postpartum
in&ections' but clinical isolates are rare because o& the di&&iculty in culturing these organisms.
Ionococci are reco!ered in !arying degrees. 0he percentage o& representati!e microorganisms
reco!ered &rom women with endometritis is gi!en in 0able 311,.
Ta/le 87@2. 'ercentage o- #rganisms )ecoere! -rom Aomen with
'ostpart"m +n!omyometritis.
#rganism 'ercentage .solate!
Aero/ic /acteria
Iroup A streptococci ,1.
Iroup + streptococci .1,1
Iroup @ streptococci 311-
Patterns o& bacterial isolates in puerperal in&ections in the patient:s hospital are more important in
guiding selection o& appropriate antibiotics than are studies &rom the literature.
A+)#$.C $ACT+).A
Iroup A streptococci are no longer a ma9or cause o& postpartum in&ection' but in&ection with these
organisms still occurs occasionally. 6& more than an isolated instance o& in&ection due to these
streptococci occurs' immediate measures should be ta/en to halt a potential epidemic. Penicillin is
highly e&&ecti!e.
6n as many as 3$3 o& women with clinically recogni;ed endometritis' group + streptococci are
partly or wholly responsible &or the in&ection. Classic presenting signs are high &e!er and
hypotension shortly a&ter deli!ery. Howe!er' group + streptococci are commonly reco!ered &rom the
!aginas o& pregnant women whether or not they ha!e endometritis. Why some women with positi!e
cultures de!elop serious illness whereas others do not undoubtedly depends on the presence o&
predisposing &actors as well as other' as yet un/nown' elements. 6t is interesting that positi!e
cultures in women do not correlate well with the incidence o& streptococcal in&ection in their
newborns. Penicillin is the treatment o& choice &or patients with endometritis.
Iroup @ streptococci' which include Streptococcus faecalis$ are common isolates in endometritis.
Ampicillin in high doses is the treatment o& choice. Aminoglycosides are also e&&ecti!e against this
group.
Staphylococcus aureus is not commonly seen in cultures &rom women with postpartum in&ections o&
the uterus. Staphylococcus epidermidis is &re7uently reco!ered &rom women with postpartum
in&ections. 0hese organisms are typically not seen in pure culture. When established staphylococcal
in&ections re7uire treatment' na&cillin' cloacillin' or cephalosporins should be used.
Among the gram*negati!e aerobic organisms li/ely to be reco!ered in postpartum uterine in&ections'
Escherichia coli is the most common. 6n postpartum uterine in&ections' E coli is more li/ely to be
isolated &rom seriously ill patients' whereas in urinary tract in&ections' it is the most commonly
isolated organism but is not necessarily &ound in the sic/est patients. Hospital*ac7uired E coli is
most susceptible to aminoglycosides and cephalosporins.
0he incidence o& Neisseria gonorrhoeae is ,123 in pregnant women antepartum. 4nless repeat
screening eaminations and treatment o& patients with positi!e cultures are underta/en in women
Enterococcus 1,1,1
Cther streptococci 3,
Staphylococcus epidermidis ,2
Staphylococcus aureus 1$
Escherichia coli 1313.
Ionococci 11-$
Gardnerella vaginalis 1.
Anaero/ic /acteria
Bacteriodes fragilis 1H1(#
Bacteroides species 1(11$$
!eptococcus -1-$
!eptostreptococcus 1#1#-
"eillonella species 1$
#lostridium species -13,

near term' the incidence o& asymptomatic endocer!ical gonorrhea at deli!ery probably is only
slightly less' and it is reasonable to belie!e that some cases o& puerperal endometritis are
gonococcal in origin.
Gardnerella vaginalis$ a cause o& !aginitis' is seen in isolates &rom women with postpartum
in&ections' usually in those with a polymicrobial cause' although pure isolates ha!e been reported.
Cther gram*negati!e bacilli that are commonly encountered on medical and surgical wards "eg'
%lebsiella pneumoniae$ Enterobacter$ !roteus$ and !seudomonas spp.% are uncommon causes o&
endometritis.
ANA+)#$.C $ACT+).A
Anaerobic bacteria are in!ol!ed in puerperal in&ections o& the uterus in at least #$3 and perhaps as
many as H#3 o& cases. 0hey are much less commonly seen in urinary tract in&ections. Anaerobic
Peptostreptococci and Peptococci are commonly reco!ered in specimens &rom women with
postpartum in&ection' particularly with other anaerobic species. Clindamycin' chloramphenicol' and
the newer cephalosporins are acti!e against these organisms.
Bacteroides spp.' particularly Bacteroides fragilis$ are commonly &ound in mied puerperal
in&ections. 0hese are li/ely to be the more serious in&ections "eg' puerperal pel!ic abscess' cesarean
section wound in&ections' and septic pel!ic thrombophlebitis%. When in&ection with this organism is
suspected or con&irmed' clindamycin' chloramphenicol' or third*generation cephalosporins should be
used.
Iram*positi!e anaerobic organisms are represented only by #lostridium perfringens$ which is not
in&re7uently isolated &rom an in&ected uterus but which is a rare cause o& puerperal in&ection.
#TH+) #)GAN.(M(
Mycoplasma and Ureaplasma spp. are common genital pathogens that ha!e been isolated &rom the
genital tract and blood o& postpartum women both with and without o!ert in&ection. 0hese
pathogens are &re7uently &ound in the presence o& other bacteria. 0he role o& these organisms in
puerperal in&ections is un/nown.
#hlamydia trachomatis is now thought to be the leading cause o& pel!ic in&lammatory disease in
some populations. +ecause the population most at ris/ &or pel!ic in&lammatory disease is the same
as that most li/ely to become pregnant' it is not surprising that #hlamydia is in some way in!ol!ed
in puerperal in&ections' but it is in&re7uently isolated as a cause o& early postpartum endometritis.
#hlamydia is more &re7uently associated with mild late*onset endometritis' so cultures &or this
organism should be obtained &rom patients with endometritis diagnosed se!eral days a&ter deli!ery.
#hlamydia is di&&icult to culture' and it is possible that as more e&&ecti!e culture techni7ues become
a!ailable' the place o& this organism in the morbidity associated with postpartum in&ections will be
clari&ied.
,i--erential ,iagnosis
6n the immediate postpartum period' in!oluntary chills are common and are not necessarily an
indication o& o!ert in&ection. Lower abdominal pain is common as the uterus undergoes in!olution
with continuing contractions.
=tragenital in&ections are much less common than endometritis and urinary tract in&ections. 8ost
o& these in&ections can be e&&ecti!ely ruled out by history and eamination alone. Patients should be
as/ed' at a minimum' about coughing' chest pain' pain at the insertion site o& intra!enous
catheters' breast tenderness' and leg pain. =amination o& the breasts' chest' intra!enous catheter
insertion site' and leg !eins should determine whether these areas might be the source o& the
postpartum &e!er. Chest *ray &ilms are rarely o& bene&it unless signs and symptoms point to a
possible pulmonary cause o& the &e!er.
Treatment
0he choice o& antibiotics &or treatment o& endometritis depends on the suspected causati!e
organisms and the se!erity o& the disease. 6& the illness is serious enough to re7uire antibiotics'
initial therapy should consist o& intra!enous antibiotics in high doses. Bactors rein&orcing the need
&or this approach include the large !olume o& the uterus' the epanded maternal blood !olume' the
bris/ diuresis associated with the puerperium' and the di&&iculty in achie!ing ade7uate tissue
concentrations o& the antibiotic distal to the thrombosed myometrial blood !essels. Clindamycin plus
an aminoglycoside is a standard &irst*line regimen. Iood e!idence now indicates that once*a*day
dosing o& gentamicin is as e&&ecti!e as the traditional thrice*daily regimen. 5ingle*agent therapy
with second* or third*generation cephalosporins is an acceptable alternati!e.
0he response to therapy should be care&ully monitored &or ,-1-2 hours. @eterioration or &ailure to
respond determined both clinically and by laboratory test results re7uires a complete re*e!aluation.
Ampicillin is added when the patient has a less than ade7uate response to the usual regimen'
particularly i& Enterococcus spp. are suspected.
6ntra!enous antibiotics are continued until the patient has been a&ebrile &or ,-1-2 hours.
?andomi;ed and prospecti!e trials ha!e shown that additional treatment with oral antibiotics a&ter
intra!enous therapy is unnecessary. Patients with documented concurrent bacteremia can be
treated similarly' unless they ha!e persistently positi!e blood cultures or a staphylococcal species
cultured. 6& the patient remains &ebrile despite the standard antibiotic regimens' &urther e!aluation
should be initiated to loo/ &or abscess &ormation' hematomas' wound in&ection' and septic pel!ic
thrombophlebitis.
Bor patients /nown to be in&ected or at etremely high ris/ &or in&ection at the time o& deli!ery'
initial therapy with ,* or 3*drug regimens in which 1 o& the agents is clindamycin is prudent. 5ingle*
agent intra!enous in&usion o& broad*spectrum agents such as piperacillin or ce&oitin appears to be
e7ually e&&ecti!e.
*rinary Tract .n-ection
Approimately ,1-3 o& women de!elop a urinary tract in&ection postpartum. Bollowing deli!ery' the
bladder and lower urinary tract remain somewhat hypotonic' and residual urine and re&lu result.
0his altered physiologic state' in con9unction with catheteri;ation' birth trauma' conduction
anesthesia' &re7uent pel!ic eaminations' and nearly continuous contamination o& the perineum' is
su&&icient to eplain the high incidence o& lower urinary tract in&ections postpartum. 6n many
women' preeisting asymptomatic bacteria' chronic urinary tract in&ections' and anatomic disorders
o& the bladder' urethra' and /idneys contribute to urinary tract in&ection postpartum.
Clinical 2in!ings
(&M'T#M( AN, (.GN(
4rinary tract in&ection usually presents with dysuria' &re7uency' urgency' and low*grade &e!er>
howe!er' an ele!ated temperature is occasionally the only symptom. White blood cells and bacteria
are seen in a centri&uged sample o& catheteri;ed urine. A urine culture should be obtained. 0he
history should be re!iewed &or e!idence o& chronic antepartum in&ections. 6& a woman had an
antepartum urinary tract in&ection' then her postpartum in&ection li/ely is caused by the same
organism. ?epeated urinary tract in&ections call &or care&ul postpartum e!aluation. 4rethral
di!erticulum' /idney stones' and upper urinary tract anomalies should be ruled out.
4rinary retention postpartum in the absence o& regional anesthesia or well a&ter its e&&ects ha!e
worn o&& almost always indicates urinary tract in&ection.
Pyelonephritis may be accompanied by &e!er' chills' malaise' and nausea and !omiting.
Characteristic signs o& /idney in!ol!ement associated with pyelonephritis include costo!ertebral
angle tenderness' dysuria' pyuria' and' in the case o& hemorrhagic cystitis' hematuria.
1A$#)AT#)& 2.N,.NG(
E coli is easily the most common organism isolated &rom in&ected urine in postpartum women
"approimately (#3 o& cases%. Cther gram*negati!e bacilli are much less li/ely to be reco!ered. E
coli is less li/ely to be the causati!e organism in women who had repeated urinary tract in&ections in
the recent past.
Treatment
Antibiotics with speci&ic acti!ity against the causati!e organism are the cornerstone o& therapy in
uncomplicated cystitis. 0hese drugs include sul&onamides' nitro&urantoin' trimethoprim*
sul&amethoa;ole' oral cephalosporins "cephalein' cephradine%' and ampicillin. 5ome hospitals
report a high incidence o& microbial resistance to ampicillin. 0he oral combination o& amoicillin*
cla!ulanic acid pro!ides a better spectrum o& bacterial sensiti!ity. 5ul&a antibiotics can be used
sa&ely in women who are breast&eeding i& the in&ants are term without hyperbilirubinemia or
suspected glucose*.*phosphate dehydrogenase de&iciency. High &luid inta/e should be encouraged.
Pyelonephritis re7uires initial therapy with high doses o& intra!enous antibiotics' such as ampicillin
211, gDd or &irst*generation cephalosporins "ce&a;olin 31. gDd' cephalothin -12 gDd%. An
aminoglycoside can be added when resistant organisms are suspected or when the patient has
clinical signs o& sepsis. A long*acting third*generation cephalosporin' such as ce&triaone 11 , g
e!ery 1, hours' also can be used. 0he response to therapy may be rapid' but some women respond
with gradual de&er!escence o!er -2 hours or longer. 4rine cultures should be obtained to guide any
necessary modi&ications in drug therapy i& the patient:s response is not prompt. =!en with prompt
resolution o& &e!er' antibiotic therapy should be continued intra!enously or orally &or a total o& 1$
days. 4rine &or culture should be obtained at a postpartum !isit a&ter therapy has been completed.
'ne"monia
Women with obstructi!e lung disease' smo/ers' and those undergoing general anesthesia ha!e an
increased ris/ &or de!eloping pneumonia postpartum.
Clinical 2in!ings
(&M'T#M( AN, (.GN(
5ymptoms and signs are the same as those o& pneumonia in nonpregnant patientsE producti!e
cough' chest pain' &e!er' chills' rales' and in&iltrates on chest *ray &ilm. 6n some cases' care&ul
di&&erentiation &rom pulmonary embolus is re7uired.
B-)A& AN, 1A$#)AT#)& 2.N,.NG(
Chest *ray &ilm con&irms the diagnosis o& pneumonia. Iram*stained smears o& sputum and material
&or culture should be obtained.
Streptococcus pneumoniae and Mycoplasma pneumoniae are the , most li/ely causati!e organisms.
S pneumoniae can easily be identi&ied on gram*stained smears. 6n&ection with M pneumoniae can be
suspected on clinical grounds.
Treatment
Appropriate antibiotics' oygen "i& the patient is hypoic%' intra!enous hydration' and pulmonary
toilet are the mainstays o& therapy.
Cesarean (ection Ao"n! .n-ection
.nci!ence
Wound in&ection occurs in -11,3 o& patients &ollowing cesarean section.
+tiology
0he &ollowing ris/ &actors predispose to subse7uent wound in&ection in women undergoing cesarean
sectionE obesity' diabetes' prolonged hospitali;ation be&ore cesarean section' prolonged rupture o&
the membranes' chorioamnionitis' endomyometritis' prolonged labor' emergency rather than
electi!e indications &or cesarean section' and anemia.
Clinical 2in!ings
(&M'T#M( AN, (.GN(
Be!er with no apparent cause that persists to the &ourth or &i&th postoperati!e day strongly suggests
a wound in&ection. Wound erythema and tenderness may not be e!ident until se!eral days a&ter
surgery. Cccasionally' wound in&ections are mani&ested by spontaneous drainage' o&ten
accompanied by resolution o& &e!er and relie& o& local tenderness. ?arely' a deep*seated wound
in&ection becomes apparent when the s/in o!ertly separates' usually a&ter some strenuous acti!ity
by the patient.
1A$#)AT#)& 2.N,.NG(
Iram*stained smears and culture o& material &rom the wound may be help&ul in guiding selection o&
the initial antibiotic. +lood cultures may be positi!e in the patient with systemic sepsis due to wound
in&ection. 0he organisms responsible &or most wound in&ections originate on the patient:s s/in. S
aureus is the organism most commonly isolated. Streptococcus species' E coli$ and other gram*
negati!e organisms that may originally ha!e coloni;ed the amniotic ca!ity are also seen.
Cccasionally' Bacteroides$ which comes only &rom the genital tract' is isolated &rom material ta/en
&rom serious wound in&ections.
?arely' necroti;ing &asciitis and the closely related synergistic bacterial gangrene can in!ol!e
cesarean section incisions. 0hey are recogni;ed by their intense tissue destruction' lac/ o& sensation
in the in!ol!ed tissues' and rapid etension. ?adical debridement o& necrotic and in&ected tissue is
the cornerstone o& treatment.
Treatment
.N.T.A1 +4A1*AT.#N
0he incision should be opened along its entire length and the deeper portion o& the wound gently
eplored to determine whether &ascial separation has occurred. 6& the &ascia is not intact' the wound
is dissected to the &ascial le!el' debrided' and repaired. Wound dehiscence has a high mortality rate
and should be treated aggressi!ely. @ehiscence is uncommon in healthy patients and with
P&annenstiel incisions. 0he s/in can be le&t open to undergo delayed closure or to heal by primary
intention.
6& the &ascia is intact' the wound in&ection can be treated by local measures.
,+2.N.T.4+ M+A(*)+(
8echanical cleansing o& the wound is the mainstay o& therapy &or cesarean wound in&ection. Cpening
the wound encourages drainage o& in&ected material. 0he wound can be pac/ed with saline*soa/ed
gau;e ,13 times per day' which will remo!e necrotic debris each time the wound is unpac/ed. 0he
wound can be le&t open to heal' or it can be closed secondarily when granulation tissue has begun to
&orm.
Anti/iotic 'rophyla=is -or Cesarean (ection
0he high rate o& in&ection "a!eraging 3#1-$3% &ollowing cesarean section is su&&icient reason to
consider prophylactic perioperati!e antibiotic administration in high*ris/ patients. 6& possible' a
single drug should be used because o& the con!enience. 0he drug should ha!e a wide spectrum o&
acti!ity' including reasonably good acti!ity against pathogens li/ely to be present at the incision
site. 0he dosage regimen should be designed to ensure ade7uate tissue le!els at the time the
operation begins or shortly therea&ter. 0he drug should not be one that is used to treat serious'
established in&ections. 0he duration o& therapy should be short. "Antibiotics administered &or > -2
hours can hardly be called prophylactic.% 0he drug should be &ree o& ma9or side e&&ects and should
be relati!ely inepensi!e.
Cne drug commonly used is ce&a;olin 1 g intra!enously when the umbilical cord is clamped' &ollowed
by , similar doses at .*hour inter!als. A single dose has been shown to be as e&&ecti!e as a 3*dose
regimen. Almost all studies on the use o& prophylactic antibiotics in patients with cesarean section
deli!eries ha!e shown signi&icant reductions in the incidence o& in&ection' regardless o& the drugs'
doses' and schedules used. Howe!er' no regimen has pro!ided total protection against the incidence
o& &e!er and associated morbidity' nor has one completely pre!ented serious postoperati!e
in&ections. Low*ris/ women' that is' those undergoing electi!e cesarean section who are not in
acti!e labor' do not bene&it to the same degree &rom prophylactic antibiotics.
+pisiotomy .n-ection
6t is surprising that in&ected episiotomies do not occur more o&ten than they do' because
contamination at the time o& deli!ery is uni!ersal. 5ubse7uent contamination during the healing
phase also should be common' yet in&ection and disruption o& the wound are in&re7uent "$.#133%.
0he ecellent local blood supply is suggested as an eplanation &or this phenomenon.
+tiology
6n general' the more etensi!e the laceration or episiotomy' the greater the chances &or in&ection
and brea/down o& the wound. 8ore tissue is de!itali;ed in a large episiotomy' thereby pro!iding
greater opportunity &or contamination. Women with in&ections elsewhere in the genital area
probably are at greater ris/ &or in&ection o& the episiotomy.
Clinical 2in!ings
(&M'T#M( AN, (.GN(
Pain at the episiotomy site is the most common symptom. 5pontaneous drainage is &re7uent' so a
mass rarely &orms. 6ncontinence o& &latus and stool may be the presenting symptom o& an
episiotomy that brea/s down and heals spontaneously.
6nspection o& the episiotomy site shows disruption o& the wound and gaping o& the incision. A
necrotic membrane may co!er the wound and should be debrided i& possible. A care&ul recto!aginal
eamination should be per&ormed to determine whether a recto!aginal &istula has &ormed. 0he
integrity o& the anal sphincter should be e!aluated.
1A$#)AT#)& 2.N,.NG(
6n&ection with mied aerobic and anaerobic organisms is common. Staphylococcus may be
reco!ered &rom cultures o& material &rom these in&ections. Culture results &re7uently are misleading
because the area o& the episiotomy typically is contaminated with a wide !ariety o& pathogenic
bacteria.
Treatment
6nitial treatment should be directed toward opening and cleaning the wound and promoting the
&ormation o& granulation tissue. Warm sit; baths or Hubbard tan/ treatments help the debridement
process. Attempts to close an in&ected' disrupted episiotomy are li/ely to &ail and may ma/e
ultimate closure more di&&icult. 5urgical closure by perineorrhaphy should be underta/en only a&ter
granulation tissue has thoroughly co!ered the wound site. 0here is an increasing trend towards
early repair o& episiotomy wound dehiscence' in contrast to con!entional wisdom' which suggests a
3* to -*month delay. 5e!eral large case series show ecellent results once initial in&ection is treated.
Mastitis
Congesti!e mastitis' or breast engorgement' is more common in primigra!idas than in multiparas.
6n&ectious mastitis and breast abscesses also are more common in women pregnant &or the &irst
time and are seen almost eclusi!ely in nursing mothers.
+tiology
6n&ectious mastitis and breast abscesses are uncommon complications o& breast&eeding. 0hey almost
certainly occur as a result o& trauma to the nipple and the subse7uent introduction o& organisms
&rom the in&ant:s nostrils to the mother:s breast. S aureus contracted by the in&ant while in the
hospital nursery is the usual causati!e agent.
Clinical 2in!ings
(&M'T#M( AN, (.GN(
+reast engorgement usually occurs on the second or third postpartum day. 0he breasts are swollen'
tender' tense' and warm. 0he patient:s temperature may be mildly ele!ated. Aillary adenopathy
can be seen.
8astitis presents 1 wee/ or more a&ter deli!ery. 4sually only 1 breast is a&&ected and o&ten only 1
7uadrant or lobule. 6t is tender' reddened' swollen' and hot. 0here may be purulent drainage' and
aspiration may produce pus. 0he patient is &ebrile and appears ill.
1A$#)AT#)& 2.N,.NG(
0he organism responsible &or in&ectious mastitis and breast abscess almost always is S aureus.
Streptococcus spp. and E coli are occasionally isolated. Leu/ocytosis is e!ident.
Treatment
C#NG+(T.4+ MA(T.T.(
0he &orm o& treatment depends on whether or not the patient plans to breast&eed. 6& she does not'
tight breast binding' ice pac/s' restriction o& breast stimulation' and analgesics help to relie!e pain
and suppress lactation. 8edical suppression o& lactation probably does not hasten in!olution o&
congested breasts unless the drug is ta/en !ery early a&ter deli!ery. +romocriptine ,.# mg twice
daily orally &or 1$ days is an e&&ecti!e regimen' although concerns about its side*e&&ect pro&ile ha!e
curtailed its use. Bor the woman who is breast&eeding' manually emptying the breasts &ollowing
in&ant &eeding is all that is necessary to relie!e discom&ort.
.N2+CT.#*( MA(T.T.(
6n&ectious mastitis is treated in the same way as congesti!e mastitis. Local heat and support o& the
breasts help to reduce pain. Cloacillin' dicloacillin' na&cillin' or a cephalosporinFantibiotic with
acti!ity against the commonly encountered causati!e organismsFshould be administered. 6n&ants
tolerate the small amount o& antibiotics in breast mil/ without di&&iculty. 6t may be prudent to chec/
the in&ant &or possible coloni;ation with the same bacteria present in the mother:s breast.
6& an abscess is present' incision and drainage are necessary. 0he ca!ity should be pac/ed open
with gau;e' which is then ad!anced toward the sur&ace in stages daily. 8ost authorities recommend
cessation o& breast&eeding when an abscess de!elops. Antistaphylococcal antibiotics should be
prescribed. 6nhibition o& lactation is also recommended.
,.(#),+)( #2 1ACTAT.#N
.nhi/ition 0 ("ppression o- 1actation
Anatomic alteration o& the breasts during pregnancy prepares them &or sustained mil/ production
shortly a&ter deli!ery. 0he rapid decrease o& serum estrogen and progesterone le!els postpartum
does not occur in prolactin le!els' which decrease much more slowly. 0he breast is no longer sub9ect
to the inhibitory e&&ects o& the steroid hormones and now comes under the in&luence o& high
prolactin le!els to begin sustained mil/ production.
Colostrum is secreted in late pregnancy and &or the &irst ,13 days postpartum. 6t is higher in protein
"much o& which may be antibodies% and minerals and lower in carbohydrates and &at than is later
breast mil/. Prior to &ull mil/ production' &rom the second to the &ourth postpartum days' the
breasts become enlarged' engorged' and tender. 0he breast lobules enlarge' and al!eoli and blood
!essels proli&erate. 8il/ production truly begins around the third or &ourth postpartum day.
Bortuitously' in&ants may &re7uently ta/e this long to &eel a sensation o& hunger and to de!elop the
neuromuscular control necessary to success&ully empty the breast.
6n spite o& the mani&old bene&its o& breast&eeding &or both in&ants and mothers' at least one*third o&
all women who gi!e birth today do not wish to nurse' and perhaps an additional 1$1,$3
discontinue attempts within a &ew wee/s o& deli!ery. Bor these women' inhibition o& lactation &or
relie& o& breast congestion and tenderness may be necessary.
'H&(.CA1 M+TH#,( #2 (*'')+((.#N #2 1ACTAT.#N
6nhibition o& physical stimuli that encourage mil/ secretion can pre!ent lactation. 0ight breast
binding' a!oidance o& any tactile breast stimulation' ice pac/s' and mild analgesics "eg' aspirin or
ibupro&en% are e&&ecti!e in inhibiting lactation and relie!ing the symptoms o& breast engorgement in
#$3 o& women. Physical methods success&ully inhibit lactation and pre!ent breast engorgement
either be&ore the onset o& lactation or a&ter it has been established &or some time.
H#)M#NA1 (*'')+((.#N #2 1ACTAT.#N
Large doses o& estrogen alone ha!e been used to suppress lactation> they do inhibit mil/
production' probably by acting directly on the breast. =strogens are somewhat more success&ul than
physical methods alone. 5ide e&&ects are tolerable in young women who ha!e had !aginal deli!eries'
but increased rates o& thrombophlebitis and pulmonary embolism are seen in women older than 3#
years' in those who ha!e undergone cesarean section' and in women with di&&icult deli!eries. Bor
these reasons' pure estrogens are no longer used &or suppression o& lactation as they once were.
Burthermore' drug*induced suppression o& lactation is not !ery e&&ecti!e a&ter lactation has been
established.
0he ergot deri!ati!e bromocriptine has strong prolactin*inhibiting and thus lactation*inhibiting
properties. 6n the dosage ranges used to suppress lactation' the drug is relati!ely &ree o& serious
side e&&ects. 8inor side e&&ects include nausea and nasal congestion. 8ore serious associations with
hypertension' cerebro!ascular accidents' and myocardial in&arction ha!e been reported. 0he ris/s
seem to be reported &re7uently when bromocriptine is used in patients with pregnancy*induced
hypertension. @rawbac/s o& bromocriptine therapy include the necessity &or prolonged treatment
"1$11- days% and a more rapid resumption o& o!ulation. A signi&icant number o& women ha!e
rebound lactation "121-$3%. 0he Bood and @rug Administration "B@A% remo!ed pain&ul breast
engorgement as an indication &or bromocriptine use in 1H2H. 0he B@A noted that although there is
no clear proo& o& ad!erse e&&ects o& these medications' there is no pro!ed health bene&it' so e!en
minor sa&ety concerns become signi&icant because o& their potential un&a!orable e&&ects on the
bene&itDris/ ratio. +romocriptine may be a reasonable treatment option in women with se!ere
congesti!e mastitis.
.nappropriate 1actation
Lactation is physiologic in late pregnancy and &or a considerable period a&ter deli!ery. 6n the woman
who has not lactated &or 1 year or more or who has ne!er been pregnant' lactation may indicate a
signi&icant endocrinopathy.
'#(T'A)T*M M#N.T#).NG
5erious and acute obstetric and postanesthetic complications o&ten occur during the &irst &ew hours
immediately &ollowing deli!ery. 0here&ore the patient should be trans&erred to a reco!ery room
where she can be constantly attended to and where obser!ation o& bleeding' blood pressure' pulse'
and respiratory change can be made e!ery 1# minutes &or at least 11, hours a&ter deli!ery or until
the e&&ects o& general or ma9or regional anesthesia ha!e disappeared. Cn return to the patient:s
room or ward' the patient:s blood pressure should be ta/en and the measurement repeated e!ery
1, hours &or the &irst ,- hours and daily therea&ter &or se!eral days. Preeclampsia1eclampsia'
in&ection' or other medical or surgical complications o& pregnancy may re7uire more prolonged and
intensi!e postpartum care.
'#(T'A)T*M C#M'1.CAT.#N(
Complications o- Anesthesia
0he most common respiratory complications that &ollow general anesthesia and deli!ery are airway
obstruction or laryngospasm and !omiting with aspiration o& !omitus. +ronchoscopy' tracheostomy'
and other related procedures must be per&ormed promptly as indicated. Hypo!entilation and
hypotension may &ollow an abnormally high subarachnoid bloc/. +ecause serum cholinesterase
acti!ity is lower during labor and the postpartum period' hypo!entilation during the early
puerperium may &ollow the use o& large amounts o& succinylcholine during anesthesia &or cesarean
section. +rie& postpartum shi!ering is commonly seen a&ter completion o& the third stage o& labor
and is no cause &or alarm. 0he cause o& the shi!ering is un/nown' but it may be related to loss o&
heat' or it may be a sympathetic response. 5ubcutaneous emphysema may appear postpartum a&ter
!igorous bearing*down e&&orts. 8ost cases resol!e spontaneously.
6& preeclampsia has been ruled out' hypertension in the immediate puerperium may be due to
ecessi!e use o& !asopressor or oytocic drugs. 6t must be treated promptly with a !asodilator.
Hydrala;ine # mg administrated slowly intra!enously usually reduces the blood pressure.
Postanesthetic complications that mani&est themsel!es later in the puerperium include
postsubarachnoid puncture headache' atelectasis' renal or hepatic dys&unction' and neurologic
se7uelae.
Postpuncture headache usually is located in the &orehead' deep behind the eyes> occasionally' the
pain radiates to both temples and to the occipital region. 6t usually begins on the &irst or second
postpartum day and lasts 113 days. +ecause new mothers &re7uently de!elop !arious types o&
headache' the correct diagnosis is essential. An important characteristic o& postspinal puncture
headache is increased pain in the sitting or standing position and signi&icant impro!ement when the
patient is supine. 0he mild &orm is relie!ed by aspirin or other analgesics. Headache is due to
lea/age o& cerebrospinal &luid through the site o& dural puncture into the etradural space. 6t is
ad!isable to supplement the daily oral inta/e o& &luids with at least 1 L o& #3 glucose in saline
intra!enously. Administration o& (11$ mL o& the patient:s own blood into the thecal space at the
point o& pre!ious needle insertion will GpatchG the lea/ing point and relie!e the headache in most
patients. 5ubdural hematoma is a rare complication o& chronic lea/age o& cerebrospinal &luid and
resultant loss o& support to intracranial structures.
A small percentage o& women who de!elop headaches during this time also show symptoms o&
meningeal irritation. Headache due to aseptic chemical meningitis is not relie!ed by lying down.
Lumbar puncture re!eals a slightly ele!ated pressure and an increase in spinal &luid protein and
white blood cells but no bacteria. 5ymptoms usually disappear 113 days later' and the spinal &luid
returns to normal within - days with no se7uelae. 0reatment is conser!ati!e and includes supporti!e
measures' analgesics' and &luids.
)eurologic problems in the puerperium sometimes &ollow traumatic childbirth' such as in9ury to the
&emoral ner!e caused by &orceps when the patient was in the lithotomy position. 5uch complications
are rarely bilateral' which aids in the di&&erential diagnosis o& a spinal cord lesion. =!idence o& more
serious neurologic se7uelae &ollowing regional or general anesthesia &or deli!ery re7uires
consultation with the anesthesiologist or a neurologist.
'ostpart"m Car!iac 'ro/lems
0he puerperium is relati!ely complicated &or the patient with congenital or ac7uired heart disease.
Bollowing deli!ery' the cardio!ascular system responds with sharply increased cardiac output as a
result o& unimpeded !enous return &rom the lower etremities and pel!is. 0his produces a relati!e
bradycardia that may persist &or se!eral days. Bor the initial &ew days a&ter deli!ery' the intracellular
water and sodium retained during pregnancy are mobili;ed and contribute to increasing cardiac
output. A concomitant postpartum diuresis gradually mitigates the bradycardia and increases
cardiac output "see Chapter (%.
4al"lar Heart ,isease
0he management principles underlying treatment o& !al!ular heart disease in the postpartum period
are those instituted in the intrapartum periodE antibiotic prophylais o& bacterial endocarditis'
care&ul &luid and electrolyte administration' accurate "o&ten continuous in!asi!e% monitoring' and
&re7uent physical eaminations to detect changes in cardio!ascular status. ?eturn to an ambulatory
state soon a&ter deli!ery reduces the possibility o& thrombophlebitis. 0he postpartum period is also a
time &or the patient to care&ully consider &urther childbearing options in light o& the &etal outcome
and the possible progression o& heart disease during the antecedent pregnancy.
Women whose !al!ular heart disease re7uired systemic anticoagulation be&ore deli!ery should
continue the treatment postpartum> howe!er' oral anticoagulants can be used instead o& heparin.
0here are no reports o& problems in term breast&ed in&ants o& women ta/ing war&arin or dicumarol.
Cther oral anticoagulants are contraindicated i& the patient is breast&eeding.
'ostpart"m Car!iomyopathy
A cardiomyopathy uni7ue to the latter hal& o& pregnancy and the puerperium has been described by
numerous in!estigators. 0he incidence is estimated to be 1 in -$$$ deli!eries. Congesti!e heart
&ailure' cardiomegaly' and cardiac arrhythmias de!elop in otherwise healthy young women. 0his
problem is addressed in Chapter ,,A on cardiac disease in pregnancy.
'ostpart"m '"lmonary 'ro/lems
?eturn to nonpregnant pulmonary physiology occurs by . wee/s a&ter deli!ery. =cept &or women
undergoing general anesthesia' the puerperium is not a time o& special concern. 0he &actors placing
pregnant women at ris/ &or highly destructi!e chemical aspiration pneumonitis "gastric pH < ,.#
and &asting gastric contents > ,# mL% persist &or at least -2 hours a&ter deli!ery. 0hus' women
undergoing general anesthesia in the puerperium "eg' &or tubal ligation% are at high ris/ &or
aspiration. A nonparticulate antacid should be used preoperati!ely &or women undergoing general
anesthesia in the puerperal period as well as other anesthetic techni7ues "rapid se7uence induction
o& anesthesia' endotracheal intubation' and preanesthetic &asting% designed to pre!ent aspiration o&
gastric contents.
Pulmonary hypertension' either primary or secondary to congenital heart disease' is an o!ert threat
to the mother:s li&e in the intrapartum and postpartum periods. 0he most important management
principle is to use in!asi!e monitoring to a!oid hypo!olemia "see Chapter ,,A%.
'ostpart"m Thyroi!itis
0hyroid abnormalities' particularly o& immunologic origin' are common in the postpartum period.
Although racial di&&erences eist' between 33 and 1(3 o& women will de!elop postpartum
thyroiditis' and o!er hal& o& these women will ha!e positi!e microsomal antibody titers. Patients with
/nown Ira!es: disease are at particular ris/> e!en i& they are euthyroid at time o& deli!ery'
approimately 1$3 will eperience postpartum hyperthyroidism. Postpartum thyroiditis usually
presents with mild transient hyperthyroidism 312 months postpartum' &ollowed by mild and
transient hypothyroidism' although simple hypothyroidism or hyperthyroidism may be seen.
5uppression o& hyperthyroid symptoms or temporary thyroid hormone supplementation may be
necessary' but most women reco!er completely and are euthyroid within .1H months a&ter deli!ery.
0he recurrence ris/ &or postpartum thyroiditis in a subse7uent pregnancy is 1$1,#3.
'ostpart"m Throm/ophle/itis 0 Throm/oem/olism
Historically' the puerperium has been /nown as the time &or occurrence o& se!ere thrombophlebitic
conditions and pulmonary embolism' probably as a result o& the once*pre!alent recommendation o&
prolonged bed rest &ollowing parturition. =!en though contemporary postpartum management
encourages early ambulation' puerperal thrombophlebitis and thromboembolism remain a serious
problem.
0hrombophlebitis re7uires care&ul and prolonged medical management. 0he ris/ o& recurrence in a
subse7uent pregnancy is substantial' and a history o& thrombophlebitis may prohibit the &uture use
o& oral contracepti!es and replacement estrogens.
0he incidence o& thrombophlebitic conditions is di&&icult to estimate because the clinical diagnosis o&
these disorders is highly unreliable. Cne study o& !enographically con&irmed deep !enous
thrombosis reported 1.3 antepartum cases per 1$'$$$ deli!eries and ..1 postpartum cases per
1$'$$$ deli!eries. 8ost studies con&irm that the incidence o& super&icial thrombophlebitis' deep !ein
thrombosis' and pulmonary embolism is ,1. times higher in the postpartum period than in the
antepartum period' although these data may be in&luenced by the e&&ects o& the prolonged
postpartum bed rest once ad!ocated. "8ethods o& diagnosis and treatment o& thromboembolic
conditions are discussed in Chapter ,..%
'ostpart"m Ne"ropsychiatric Complications
'eripheral Nere 'alsy
)er!e palsies in!ol!ing pel!ic ner!es or parts o& the lumbosacral pleus result &rom pressure by the
presenting part or trauma by obstetric &orceps. 0ypically' the palsy occurs a&ter prolonged labor in a
nullipara and presents as unilateral &ootdrop noted when ambulation resumes a&ter deli!ery. 8ost
cases resol!e spontaneously in a matter o& days or wee/s. A &ew may ha!e a more protracted
course. =lectromyography may help in predicting the course o& the disorder.
(ei?"res
Postpartum sei;ures immediately raise the possibility o& eclampsia' but i& the inter!al since deli!ery
is more than -2 hours' other etiologies should be considered. 6n the absence o& a history o& epilepsy
or signs o& pregnancy*induced hypertension' a thorough e!aluation to determine the cause o& the
sei;ures must be per&ormed.
'ostpart"m ,epression
Considering the ecitement' anticipation' and tension associated with imminent deli!ery' the
mar/ed hormonal alterations &ollowing deli!ery' and the substantial new burdens and
responsibilities that result &rom childbirth' it is not surprising that some women eperience
depression a&ter deli!ery. 0he incidence o& postpartum depression is di&&icult to estimate' but the
disorder is common. 0he disorder in its usual &orm is sel&*limited and benign. Howe!er'
hypothyroidism is emerging as a cause o& some cases o& postpartum depression' and screening &or
this disorder should be considered i& suggested by clinical presentation.
6n women who su&&ered &rom depression be&ore they became pregnant and in those without
e&&ecti!e support mechanisms' the se!erity o& depression may be more pro&ound and the
conse7uences &ar more serious. An openly psychotic state may de!elop within a &ew days a&ter
deli!ery and render the woman incapable o& caring &or hersel& or her newborn. 6n some cases she
may harm her in&ant and hersel&.
Psychiatric consultation should be obtained &or the postpartum woman who shows symptoms o&
se!ere depression or o!ert psychosis. )ursery personnel are o&ten the &irst to notice that the new
mother does not de!ote the usual amount o& attention to her newborn "see Chapter .,%.
)+2+)+NC+(
+*Lynch C et alE 0he +*Lynch surgical techni7ue &or the control o& massi!e postpartum hemorrhageE
an alternati!e to hysterectomyK Bi!e cases reported. +r L Cbstet Iynaecol 1HH(>1$-E3(,. MP86@E
H$H1$1HN

+rown C5' +ertolet +@E Peripartum cardiomyopathyE A comprehensi!e re!iew. Cbstet Iynecol
1HH2>1(2E-$2.

Capella*Allouc 5 et alE Hysteroscopic treatment o& se!ere Asherman:s syndrome and subse7uent
&ertility. Hum ?eprod 1HHH>1-E1,3$. MP86@E 1$3,#,.2N

@ubois L et alE Placenta percretaE +alloon occlusion and emboli;ation o& the internal iliac arteries to
reduce intraoperati!e blood losses. Am L Cbstet Iynecol 1HH(>1(.E(,3. MP86@E H$((.-1N

Ohan IP et alE Controlled cord traction !ersus minimal inter!ention techni7ues in deli!ery o& the
placentaE A randomi;ed control study. Am L Cbstet Iynecol 1HH(>1((E(($. MP86@E H3.H21(N

Lo/umamage A4 et alE A randomi;ed study comparing rectally administered misoprostol !ersus
5yntometrine combined with an oytocin in&usion &or the cessation o& primary post partum
hemorrhage. Acta Cbstet Iynecol 5cand ,$$1>2$E23#.

8iller @A et alE Clinical ris/ &actors &or placenta pre!ia*placenta accreta. Am L Cbstet Iynecol
1HH(>1((E,1$. MP86@E H,-$.$2N

Pelage L et alE Li&e*threatening primary postpartum hemorrhageE 0reatment with emergency
selecti!e arterial emboli;ation. ?adiology 1HH2>,$2E3#H. MP86@E H.2$##HN

?ogers L et alE Acti!e !ersus epectant management o& the third stage o& labourE 0he
Hinchingbroo/e randomised controlled trial. Lancet 1HH2>3#1E.H3. MP86@E H#$-#13N

0erry AL' Hague W8E Postpartum thyroiditis. 5emin Perinatol 1HH2>,,E-H(. MP86@E H22$11HN

Copyright Q,$$. 0he 8cIraw*Hill Companies. All rights reser!ed.
Pri!acy )otice. Any use is sub9ect to the 0erms o& 4se and )otice. Additional Credits and Copyright 6n&ormation.


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