Postpartum Care and Puerperal Complications
Domain 4 - Postpartum Care and Puerperal Complications
This domain tests postpartum haemorrhage, puerperal sepsis, breastfeeding problems and normal involution. The exam favours “what is the first drug” and “how much blood loss counts” questions.
Core rules
- PPH: ≥500 mL after vaginal birth, ≥1000 mL after caesarean, or any loss causing haemodynamic compromise. Causes are the four T's: tone, trauma, tissue, thrombin.
- Stepwise PPH care: uterine massage and emptying the bladder → oxytocin 10 IU IM/IV → misoprostol 800 µg sublingual → carboprost 250 µg IM every 15 minutes (maximum 2 mg; contraindicated in asthma) → tranexamic acid 1 g IV within 3 hours → balloon tamponade, B-Lynch, hysterectomy.
- Ergometrine is contraindicated in hypertension and preeclampsia.
- Secondary PPH (24 hours to 12 weeks) is usually retained products - ultrasound then evacuation plus antibiotics.
- Endometritis: fever ≥38 °C on two of the first 10 days with uterine tenderness and foul lochia - clindamycin plus gentamicin.
- Mastitis: usually Staphylococcus aureus; continue breastfeeding and give dicloxacillin or cefalexin.
- Involution: fundus at the umbilicus on day 1, descends about 1 cm daily, impalpable by 2 weeks. Lochia rubra → serosa → alba.
- Breastfeeding: initiate within one hour, exclusive for six months.
Worked example
Ten minutes after a spontaneous delivery the placenta is complete but the uterus is soft and blood loss has reached 700 mL with tachycardia. Diagnosis: atonic PPH. Actions: bimanual massage, empty bladder, oxytocin 10 IU IM, IV access with crystalloid, tranexamic acid 1 g, then misoprostol; catheterise and monitor urine output; escalate to balloon if bleeding persists.
Traps
Under-estimating visual blood loss; giving tranexamic acid after 3 hours; carboprost in an asthmatic; ergometrine in preeclampsia; assuming fever is always mastitis.