Gynecological, Sexual, and Reproductive Health EOR: Postpartum Care

What is Amniotic Fluid Embolism?

A rare, life-threatening obstetric emergency in which amniotic fluid, fetal cells, or debris enter the maternal circulation, triggering cardiorespiratory collapse and disseminated intravascular coagulation (DIC).

What is the classic clinical triad of amniotic fluid embolism?

Sudden hypoxia (respiratory distress), hypotension/cardiovascular collapse, and coagulopathy (DIC), typically occurring during labor, delivery, or immediately postpartum.

When does amniotic fluid embolism most commonly occur?

During labor, at delivery, or within 30 minutes postpartum; it is unpredictable and not preventable.

What are the major risk factors for amniotic fluid embolism?

Advanced maternal age, placenta previa/abruption, preeclampsia, multiparity, cesarean or operative delivery, induction of labor, and uterine rupture.

How is amniotic fluid embolism diagnosed?

It is a clinical diagnosis of exclusion based on abrupt cardiorespiratory collapse and DIC; no confirmatory lab test exists, though it may be confirmed at autopsy by fetal squamous cells in pulmonary vessels.

What is the management of amniotic fluid embolism?

Immediate supportive care—high-flow oxygen/intubation, aggressive hemodynamic support with fluids and vasopressors, transfusion of blood products for DIC, and prompt delivery of the fetus if undelivered; CPR if arrest occurs.

What is APGAR Score?

A standardized 0-to-10 scoring system used to assess a newborn's clinical status at 1 and 5 minutes after birth.

What are the five components of the APGAR score (mnemonic: APGAR)?

Appearance (color), Pulse (heart rate), Grimace (reflex irritability), Activity (muscle tone), and Respiration (respiratory effort); each scored 0, 1, or 2.

At what time intervals is the APGAR score assessed?

At 1 minute and 5 minutes after birth; if the 5-minute score is

How is APGAR score interpreted?

7-10 is reassuring/normal, 4-6 is moderately abnormal, and 0-3 is low and requires immediate resuscitation.

Does the APGAR score predict long-term neurologic outcome?

No; it reflects the need for resuscitation and immediate physiologic status, but is not designed to predict long-term outcomes or diagnose asphyxia.

What is the heart rate scoring for APGAR?

Absent = 0,

What is Endometritis?

A polymicrobial infection of the uterine endometrium and myometrium, most commonly occurring postpartum.

What is the single greatest risk factor for postpartum endometritis?

Cesarean delivery, especially after prolonged labor or rupture of membranes.

How does postpartum endometritis typically present?

Fever (>38°C) within the first 10 days postpartum, uterine/fundal tenderness, foul-smelling lochia, and possible tachycardia or lower abdominal pain.

What organisms typically cause postpartum endometritis?

Polymicrobial—a mix of aerobic and anaerobic organisms including group B strep, Gardnerella, Bacteroides, Enterococcus, and Escherichia coli ascending from the lower genital tract.

What is the first-line treatment for postpartum endometritis?

IV clindamycin plus gentamicin until the patient is afebrile and asymptomatic for 24-48 hours; ampicillin is added for suspected enterococcus.

What additional risk factors predispose to endometritis?

Prolonged rupture of membranes, prolonged labor, multiple vaginal exams, retained products of conception, and chorioamnionitis.

What is Lactation?

The physiologic process of milk production and secretion by the mammary glands to nourish the newborn.

Which hormones drive milk production and milk ejection (letdown)?

Prolactin stimulates milk production; oxytocin stimulates milk ejection (letdown reflex) via myoepithelial cell contraction.

What triggers the postpartum onset of lactation?

The abrupt drop in estrogen and progesterone after delivery of the placenta, which removes inhibition of prolactin's effect on the breast.

What is colostrum and why is it important?

The thick, yellowish first milk rich in protein, immunoglobulins (especially IgA), and antibodies; it provides passive immunity before transitioning to mature milk around days 3-5.

What is the management of lactational mastitis?

Continue breastfeeding/emptying the breast, supportive care (warm compresses, analgesics), and antibiotics (dicloxacillin or cephalexin) covering Staphylococcus aureus for 10-14 days.

How does breastfeeding affect maternal fertility?

Exclusive breastfeeding can suppress ovulation via prolactin-induced inhibition of GnRH (lactational amenorrhea), but it is not a reliable contraceptive method.

What is Perineal Laceration / Episiotomy Care?

Management of perineal tissue trauma sustained during vaginal delivery, whether spontaneous (laceration) or surgically created (episiotomy).

How are perineal lacerations classified by degree?

1st degree = vaginal/perineal skin only; 2nd = into perineal muscles; 3rd = involves the anal sphincter; 4th = extends through the rectal mucosa.

Why is routine episiotomy no longer recommended?

Routine episiotomy increases the risk of extension to 3rd/4th-degree lacerations and is associated with more pain and complications; it is now reserved for select indications.

What is the recommended care for perineal lacerations?

Sitz baths, ice packs in the first 24 hours, analgesics (acetaminophen/NSAIDs), stool softeners to prevent straining, and perineal hygiene to promote healing.

What are the main complications of perineal lacerations?

Infection, wound dehiscence, hematoma formation, rectovaginal fistula (with 4th-degree), and fecal/urinary incontinence.

What distinguishes a midline from a mediolateral episiotomy?

Midline is easier to repair and less painful but carries higher risk of extension to the anal sphincter; mediolateral has lower extension risk but more pain and blood loss.

What is Postpartum Hemorrhage?

Excessive bleeding after delivery, defined as cumulative blood loss ≥1000 mL or blood loss with signs of hypovolemia within 24 hours of birth (regardless of route).

What is the most common cause of postpartum hemorrhage?

Uterine atony, accounting for approximately 70-80% of cases.

What are the four main causes of postpartum hemorrhage (mnemonic: 4 T's)?

Tone (uterine atony), Trauma (lacerations/rupture), Tissue (retained placenta), and Thrombin (coagulopathy).

How is primary distinguished from secondary postpartum hemorrhage?

Primary occurs within the first 24 hours after delivery; secondary occurs from 24 hours to 12 weeks postpartum (often due to retained products or subinvolution).

What is the first-line management of postpartum hemorrhage from uterine atony?

Bimanual uterine massage and uterotonic medications—oxytocin first-line, followed by methylergonovine, carboprost (Hemabate), or misoprostol.

Which uterotonic is contraindicated in hypertension, and which in asthma?

Methylergonovine is contraindicated in hypertension/preeclampsia; carboprost (prostaglandin F2-alpha) is contraindicated in asthma.

What are the key risk factors for postpartum hemorrhage?

Uterine overdistension (multiple gestation, polyhydramnios, macrosomia), prolonged or precipitous labor, grand multiparity, retained placenta, chorioamnionitis, and operative delivery.

What are escalating interventions if uterotonics fail to control PPH?

Uterine tamponade (Bakri balloon), uterine artery embolization, B-Lynch compression suture, and, as a last resort, hysterectomy.

What is Postpartum Physiology?

The series of normal physiologic changes during the puerperium as the maternal body returns to its pre-pregnancy state over approximately 6 weeks.

What is uterine involution and how is it monitored?

The progressive shrinking of the uterus back to pre-pregnancy size; the fundus descends roughly 1 cm (one fingerbreadth) per day and is no longer palpable abdominally by about 2 weeks.

What is lochia and what are its normal stages?

Postpartum vaginal discharge progressing through lochia rubra (red, days 1-3), lochia serosa (pinkish-brown, days 4-10), and lochia alba (yellow-white, up to 4-6 weeks).

When does menstruation typically resume postpartum?

Around 6-8 weeks in non-breastfeeding women; it may be delayed for months in those exclusively breastfeeding due to lactational amenorrhea.

What normal cardiovascular and hematologic changes occur postpartum?

An immediate increase in cardiac output and autotransfusion from uterine involution, diuresis of excess fluid in the first week, and a physiologic leukocytosis that can reach 20,000-25,000/µL.

What are postpartum "afterpains" and who experiences them most?

Cramping from uterine contractions during involution, often intensified by breastfeeding (oxytocin release) and more pronounced in multiparous women.

What constitutes normal versus abnormal postpartum mood changes?

"Postpartum blues" are mild, self-limited mood swings resolving within 2 weeks; persistent symptoms beyond 2 weeks or functional impairment suggest postpartum depression requiring evaluation.