Chapter 40 Complications in the postnatal period
Learning outcomes for this chapter are to:
1. Describe the range of physical health problems women may experience following childbirth
2. Discuss factors associated with postpartum physical morbidity
3. Explain the assessment and treatment of secondary postpartum haemorrhage and infection
4. Discuss the various emotional responses to childbirth, and psychosocial factors that place women at risk for emotional distress
5. Apply the best available evidence to the care of postpartum women.
This chapter discusses physical and psychological morbidity following childbirth. The postnatal period is conventionally defined as extending to six weeks following birth. After this time, women are presumed to have physically recovered from the birth and able to resume their roles. However, some women experience ongoing health problems related to the pregnancy and birth that persist during the first year postpartum. The considerable variety, duration and severity of morbidity are now being documented. In the past, health problems were narrowly defined as medical conditions requiring medical treatment, such as haemorrhage, thromboembolism and infection. More recently, researchers have broadened the scope of their work to incorporate women’s perspectives on their health, encompass both physical and emotional dimensions of wellbeing, and recognise the persistence of problems that are commonly experienced. This chapter commences with a review of physical complications and morbidity following childbirth. The second section relates to common emotional complications such as postnatal depression and anxiety disorders.
POSTPARTUM PHYSICAL MORBIDITY
The extent of postpartum physical health problems warrants close attention. There is relatively limited understanding of what constitutes postpartum health, the typical length of recovery from childbirth, and the impact of postpartum health on the lives of new mothers and their families. At three months postpartum, between 87% and 94% of women report at least one health problem (Borders 2006; Thompson et al 2002). Common concerns reported by postpartum women in a US study were fatigue (64%), breast discomfort (60%), headaches (50%), back or neck pain (43%), constipation (27%) and haemorrhoids (23%) (McGovern et al 2006).
A recent prospective survey of over 18,500 mothers across rural and metropolitan Victoria during the first postpartum year found that around 15% had probable depression, 94% experienced at least one major health problem (such as back pain, perineal pain, urinary incontinence), 26% reported sexual difficulties and 20% had relationship problems (Lumley et al 2006).
Generally, by six months postpartum most problems have resolved, but new health issues may appear, some of which have been masked by other problems, or are now construed as problematic because of their persistence. Long-term back pain, stress incontinence, sexual problems, haemorrhoids and depression persist in a significant number of women beyond 12 months (Borders 2006).
Associated factors
McGovern et al (2006) surveyed 817 primiparous US women and found those who experienced a caesarean section or operative vaginal birth reported significantly lower postpartum general health than women having a spontaneous vaginal birth. At five weeks postpartum, women who experienced a spontaneous vaginal birth reported better physical function, fewer role limitations and more vitality than women who had a caesarean delivery. The findings suggest that many mothers need ongoing rest and a longer period of recovery. Fatigue was the most common symptom, with around half of mothers reporting never or rarely feeling refreshed on waking in the morning.
In an Australian study by Thompson et al (2002), women who had a caesarean section reported more exhaustion, lack of sleep and bowel problems, and were more likely to be re-admitted to hospital within eight weeks of birth than women who had spontaneous vaginal births. Furthermore, women who had a forceps delivery or vacuum extraction reported more perineal pain and sexual problems than women who had a spontaneous vaginal birth, after adjusting for parity, perineal trauma and length of labour.
Seeking healthcare for postpartum problems
Although many women experience a considerable burden of morbidity in the year following birth, they often do not seek any professional assistance for their health concerns. In a recent review of 22 studies on general health status and prevalence of common physical health conditions of postpartum women, Cheng and Li (2008) concluded that the number of health problems experienced ranged from 1.8 to 6.2 per woman, depending on measures used and timeframe. Except for pain and infection, more than 80% of women in a US national survey did not seek help for their condition during the first two years postpartum (DeClercq et al 2006). In Australia, Brown and Lumley (2000) reported that one in seven women reporting a health problem had not talked to a healthcare professional about their own health. Of women reporting health problems, 49% would have liked more help or advice.
Women may seem reluctant to seek professional help for ongoing postpartum health problems for several reasons. Some women may believe that their health concerns are minor, self-limiting or an expected consequence of having a baby. They may feel embarrassed or inadequate about their ability to get ‘back to normal’ as quickly as anticipated (Percival & McCourt 2000). Women may perceive that healthcare professionals are unable to help or that there are limited options available to treat common postpartum problems such as extreme tiredness or musculoskeletal pain. Prescribing medication is a common response to women’s postpartum health problems, and some women may find this unacceptable because they are breastfeeding or for other reasons (Dennis & Chung-Lee 2006). When women do contact healthcare professionals for routine care or for specific concerns, the focus by those professionals seems to be the wellbeing of the baby, not that of the mother. Women may therefore perceive that healthcare professionals lack interest in their wellbeing (Dennis & Chung-Lee 2006).
Postpartum infection
Postpartum infection can be a precursor to other postpartum problems such as secondary postpartum haemorrhage and pelvic pain. This section describes endometritis; however, infections from caesarean section and perineal wounds or urinary tract infections can also hamper postpartum recovery and become a significant burden in women’s lives.
Endometritis
Endometritis is characterised by painful inflammation of the lining of the uterus, usually caused by infection. Caesarean section is the single most important risk factor for postpartum maternal infection (French & Smaill 2004). Preterm labour (often associated with genital tract infection) is strongly associated with the development of postpartum sepsis (Kankuri et al 2003). Any procedure or event that introduces infection into the uterus or adversely affects women’s ability to ward off infection predisposes them to endometritis. These include pre-labour rupture of membranes, blood loss, anaemia, operative vaginal birth, manual removal of placenta, repeated vaginal examinations and internal electronic fetal monitoring. Although endometritis is frequently linked with uterine infection, it is not always the case; sometimes the cause is unknown (Alexander et al 2002).
Women with endometritis may be febrile, with possibly only a low-grade temperature, and report abdominal/pelvic pain. On palpation, the uterus may be tender and sub involuted. The vaginal loss might be an unusual colour and frequently has an offensive smell. Bowel and bladder function may be disturbed and other possible infection or inflammation sites such as the breast (mastitis), or urinary tract or surgical incisions (wound infections), need to be excluded. Treatment with antibiotics is recommended (French & Smaill 2004). A consequence of endometritis is septic shock.
Postnatal vaginal bleeding
Many women experience problems with postpartum vaginal loss that does not follow the expected course. A UK survey found that 20% of women had problems with bleeding occurring between 28 days and three months postpartum. Only half of these women consulted a GP (Marchant et al 2002). Of those who did seek GP advice, the common presenting symptoms were excessive bleeding (66%) and prolonged bleeding (54%). The most common form of treatment was antibiotics alone (31%); however, 25% of women were neither treated nor referred. Referral was for hospital admission, outpatient appointment or direct referral for an ultrasound scan. Similarly, in an Australian study, 20% of women reported excessive or prolonged bleeding at eight weeks postpartum, and although this problem had resolved to a large extent by 24 weeks postpartum, 2% of women continued to experience prolonged or excessive bleeding (Thompson et al 2002).
Subsequently, Marchant et al (2006) reported that a history of secondary postpartum haemorrhage was most strongly predictive of excessive bleeding and/or prolonged vaginal bleeding. Other risk factors included vaginal bleeding prior to 24 weeks gestation, third-trimester hospital admission, maternal smoking, prolonged or incomplete third stage and primary postpartum haemorrhage for blood loss >500 mL.
Secondary postpartum haemorrhage
Secondary postpartum haemorrhage (PPH); see also ch 39 can be a life-threatening emergency, although in developed countries it is predominantly a problem of morbidity. Although secondary PPH is traditionally defined as excessive bleeding from the first 24 hours following birth until six weeks postpartum, many women bleed for longer. Marchant et al (2002) defined PPH as any abnormal or excessive bleeding from the birth canal between 24 hours and 12 weeks postpartum. This definition, however, does not refer to volume of blood loss or the woman’s condition and, because normal vaginal loss is poorly described, it is not very helpful in determining the incidence of secondary haemorrhage.
The incidence of secondary PPH determined by hospital admission is 2% (Marchant et al 2006). However, as postpartum vaginal loss is managed primarily in the community, calculating the incidence of secondary PPH from hospital admissions data may underreport the problem.
A history of primary PPH and manual removal of placenta are significant risk factors associated with secondary PPH (Marchant et al 2006). Other factors that may predispose women to secondary PPH include smoking, multiple pregnancies, threatened miscarriage, antepartum haemorrhage, hospital admission in the third trimester, precipitate labour of less than 2 hours, prolonged third stage, incomplete products of conception passed at birth, primary PPH, not breastfeeding and a history of secondary haemorrhage.
Treatment
Women requiring admission to hospital for secondary PPH are treated with drug therapy and/or surgery. From UK figures, 1% of women undergo surgical uterine evacuation of retained products of conception and a further 1% are admitted to hospital and managed with drugs but not surgery (Alexander et al 2002). A study of 132 women with secondary PPH identified that 84% required hospital admission, 63% experienced surgical evacuation of the uterus, 17% received a blood transfusion, three women suffered uterine perforation, and a hysterectomy was performed on one woman (Hoveyda & Mackenzie 2001).
The rationale for these treatments appears to be that the uterus has failed to contract sufficiently to prevent bleeding from the placental site and that the underlying cause is retained products of conception and/or intrauterine infection (Alexander et al 2008). Previously undiagnosed genital tract tears may also be a cause of secondary PPH, especially in the presence of infection. Drug therapy consists of oxytocics and/or antibiotics to control the bleeding and treat the possible infection. Hormones such as prostaglandins may also be given to help control bleeding. Some women require a blood transfusion. Surgery might involve evacuation of the products of conception, repair of cervical tear or uterine rupture and, rarely, hysterectomy (Balogun-Lynch & Whitelaw 2006).
In recent years, there has been an attempt to determine which women require surgical intervention to evacuate the uterus, given that many women undergo this procedure with no resulting evidence of retained products of conception. The surgery itself has risks such as haemorrhage from removal of the placental-site clot, introducing infection and uterine rupture. It was hoped that pelvic and/or abdominal ultrasound would assist in guiding treatment decisions about whether to intervene surgically. In a UK study, preoperative ultrasound examination did not provide better discrimination over clinical assessment about the likelihood of retained products of conception being removed during curettage (Hoveyda & Mackenzie 2001). It seems that retained products of conception can be overdiagnosed clinically and on ultrasound, as large clots produce a sub involuted uterus and show echogenic material similar to retained products of conception.
This proposition is supported by a study conducted in Israel, where histopathology reports confirmed the diagnosis of retained products of conception in only 17 (48.5%) of the 35 postpartum women who underwent evacuation of the uterus for suspected retained products of conception. Since the false-positive rate for sonographic diagnosis of retained products of conception in postpartum women is high, the authors suggest a more conservative approach to treatment (Sadan et al 2004). Similarly, Neill et al (2002) found that histology often failed to confirm retained placental tissue in women undergoing curettage for suspected retained products of conception.
A recent Cochrane Systematic Review attempted to evaluate the relative effectiveness and safety of the treatments for secondary PPH but concluded that none of the identified 36 studies could be included as they were not randomised or quasi-randomised comparisons of treatments (Alexander et al 2002). A well-designed randomised controlled trial (RCT) comparing the various therapies for women with secondary PPH against each other and against no treatment groups is needed.
Critical thinking exercise
1. Is there a role for alternative therapies such as reflexology, acupuncture and naturopathy in preventing secondary PPH?
2. What is the impact of secondary PPH on women’s wellbeing?
3. How might women prefer to have this problem managed?
4. Are women informed of the benefits, risks and unknowns of various treatment options? (Explain how you would ensure that the woman had all the information she needed to make a decision about treatment options for secondary PPH.)
5. What are the implications of this complication for breastfeeding?
Box 40.1 Summary: secondary PPH
• Secondary PPH is a significant cause of morbidity.
• Life-threatening secondary PPH in developed countries is rare.
• Secondary PPH is frequently associated with intrauterine infection.
• Treatment includes IV fluids, antibiotics, uterotonic medication and surgical evacuation of the uterus.
• Prostaglandins or other drugs to control bleeding and/or hysterectomy and/or blood transfusion may be needed in extreme cases.
• Surgical evacuation of the uterus in cases of suspected retained products of conception carries risks and is possibly performed more often than warranted.
Pelvic floor dysfunction
Urinary incontinence
The incidence of postpartum urinary incontinence (UI) is high. The most common type suffered by postpartum women is stress incontinence (between 0.3% and 44%) (Lemos et al 2008). Urge incontinence is also common, however, and many women experience a combination of different types of incontinence (Press et al 2007). Variable rates of UI are reported in the literature as a result of different data collection methods, definitions of incontinence, and time points when incontinence was assessed. Risk factors for UI are antenatal UI, lower levels of education, and higher body mass index (Burgio et al 2007).
A large population-based cohort study of women from the Australian Capital Territory (ACT) (n = 1193) found that 19% of women reported UI at eight weeks postpartum and 11% reported UI at 24 weeks (Thompson et al 2002). Similarly, Burgio et al (2003) found that 11% of women reported some degree of incontinence at 12 months postpartum. Although problems with UI often diminish in the weeks and months following birth, this is not always the case. Importantly, UI symptoms may worsen over the years (AIHW 2006).
Factors associated with urinary incontinence
Childbearing per se has long been implicated in UI. Women with higher parity are more likely to suffer symptoms of UI (e.g. Grodstein et al 2003), but the complete picture is far from clear. A longitudinal study involving 150 nuns (mean age 68 years, SD = 11.7) found that half had UI (Buchsbaum et al 2002). Stress incontinence was more common than urge incontinence. The authors concluded that the prevalence of UI in nulliparous, menopausal nuns was similar to rates reported in parous, postmenopausal women. While nuns differ from other women in a number of significant ways (due to their lifestyle), this study suggests that the effect of parity on UI may contribute to differential morbidity in the premenopausal years.
Other variables associated with pregnancy and childbearing also affect pelvic floor function. It seems that some or all of the following factors may have a role to play in postpartum pelvic floor function: becoming pregnant; antenatal pelvic floor exercises (Lemos et al 2008); antenatal perineal massage; gestation of pregnancy at birth; age of mother at first birth (Grodstein et al 2003); nature of the labour (e.g. duration) (Brown & Lumley 1998); events and procedures during labour (e.g. type of birth, perineal trauma, type of pushing); birthweight of infant (Brown & Lumley 1998); and length of breastfeeding (Burgio et al 2003).
There is conflicting evidence about several variables (e.g. type of birth, infant birthweight), and their relative contribution to UI requires further investigation. A recent review by the US National Institutes of Health concluded that weak-quality evidence supported elective caesarean delivery over planned vaginal birth, although the duration of effect was not clear (Weber 2007). Other factors, not specific to pregnancy and childbirth, have been found to be associated with postpartum UI . These include maternal obesity (Burgio et al 2007), smoking, pre-existing UI, race and lifestyle (Baessler & Schuessler 2003). The remainder of this section will examine the evidence relating to type of birth.
It seems that type of birth (elective caesarean section, emergency caesarean section, forceps, vacuum, spontaneous vaginal birth) is associated with differing rates of UI. In the short term, women having a caesarean section may have a lower incidence of UI (but not other urinary problems). Thompson et al (2002) found that compared with women having a spontaneous vaginal birth, women having a caesarean section were significantly less likely to report UI at eight weeks postpartum, but this difference was not statistically significant at 16 and 24 weeks postpartum. At 24 weeks postpartum, women who had delivered by caesarean section were more likely to report other urinary problems, such as passing urine frequently or being unable to pass urine, than were women who had a spontaneous vaginal birth.
An Israeli study, which excluded women with pre-existing stress incontinence, found the prevalence of stress incontinence one year after the first birth to be 10.3% for women experiencing a spontaneous birth, 12% for women experiencing a caesarean for prolonged labour, and 3.4% for women experiencing an elective caesarean (Groutz et al 2004). Similarly, an investigation of UI at six months postpartum found that 9% of women who delivered by caesarean section reported UI, in contrast with 25% of other women (Hvidman et al 2003).
In their review, Baessler and Schuessler (2003) concluded that elective caesarean section might prevent trauma to the anal sphincter but not necessarily the urethral sphincter. The development or presentation of defects in the endopelvic fascia leading to cystocele, rectocele, enterocele or loss of paravaginal support has not been investigated. Furthermore, prospective research is required on the impact of vaginal birth and intrapartum management on the endopelvic fascia.
Inconclusive results are also evident about the effects of operative vaginal birth. While one study found that women experiencing an operative vaginal birth were at higher risk of UI than women following a spontaneous vaginal birth (Burgio et al 2007), other studies have not demonstrated this association (Hvidman et al 2003; Thompson et al 2002). Press et al (2007) concluded that although short-term occurrence of stress incontinence is reduced by caesarean section, severe symptoms are equivalent by mode of birth.
Pelvic floor muscle training is commonly recommended during pregnancy and after birth for prevention and treatment of UI. This is a program of exercises that women can do several times a day to strengthen their pelvic floor muscles. The National Institute of Health and Clinical Excellence publication Urinary Incontinence: the Management of Urinary Incontinence in Women (NICE 2006) comments that: ‘Pelvic floor muscle training should be offered to women in their first pregnancy as a preventive strategy for urinary incontinence. There is evidence that pelvic floor muscle training used during a first pregnancy reduces the likelihood of postnatal urinary incontinence’.
Once UI is diagnosed, the midwife refers the woman for expert help. There are a number of therapies for UI: behavioural interventions, bladder retraining, muscle rehabilitation and electrical stimulation. The last has been demonstrated to improve continence in many patients. Trans-vaginal electrical stimulators are effective for over 50% of women with stress incontinence and detrusor instability. Electrical stimulation is used to inhibit detrusor overactivity or to improve pelvic floor musculature. Vaginal devices for treatment of stress incontinence are marketed in North America and Australia. Their effectiveness has not yet been determined (NICE 2006). Modified pessaries (vaginal cones) provide additional suburethral pressure (NICE 2006). The cones are pre-weighted devices of varying weights that are held by the vaginal musculature and are thought to help improve pelvic floor tone through active and sustained muscle contraction.
Where the previously discussed modalities have not improved incontinence, pharmacotherapy may be considered. The efficacy of a number of pharmacological therapies has been studied in the treatment of UI (Alhasso et al 2003). So far there are no ‘ideal’ medications for treatment of UI. The aims of pharmacotherapy are to decrease inappropriate bladder contractions, increase urethral resistance, or both. Anticholinergic drugs have been used in the treatment of urge incontinence to inhibit involuntary detrusor contractions. Adrenergic drugs (α-adrenoceptor agonists) have also been used in the treatment of stress incontinence; the drugs mediate the contractile response of the urethra and bladder. Other treatments (with little evidence of significant effects) have been trialled: calcium-channel blockers are a potential treatment for urge incontinence, but to date no trials have shown their benefit; serotonin and norepinephrine agonists also have putative continence-promoting properties through parasympathetic suppression and through enhancement of sympathetic and somatic activity (Alhasso et al 2003). As a last resort, surgical intervention may become necessary.
Critical thinking exercise
1. How have certain birthing practices affected pelvic floor function? (You may wish to consider the effects of Valsalva ‘coached’ pushing, birthing positions, and use of traction for controlled cord traction delivery of the placenta.)
2. How might teaching pelvic floor control in pregnancy, not just strengthening exercises (i.e. ability to relax pelvic floor for birth, not just lifting pelvic floor for strengthening), affect postpartum pelvic floor function and other birth outcomes?
3. What is the impact of delayed versus active pushing for women without an epidural?
Postpartum pain
Compared with the intensity of pain during labour, there has been little acknowledgement of postpartum pain except in the acute postoperative phase following caesarean section or perineal repair. After-birth pain and sore breasts/nipples need to be considered in the immediate aftermath of birth. Sources of ongoing postpartum pain include damage to the perineum shoulder, neck and back ache and haemorrhoids. Headaches are common (incidence ranging from 11%–80%) and may be associated with life changes such as sleep deprivation, irregular food intake and dehydration (Stella et al 2007). The experience of ongoing pain is also more common than realised. In a recent Chinese survey, 55.8% of participants reported chronic pain symptoms five years postpartum (Wang et al 2009).
