12.5 Other Puerperal Complications: Hematomas, Urinary Retention, Hemorrhoids, Postpartum Hypertension & Warning Signs
Key Takeaways
Severe perineal or rectal pain or pressure out of proportion to the repair, with normal lochia, suggests a vulvar or vaginal hematoma; large or expanding hematomas need incision, evacuation, and vessel ligation.
A postpartum patient who cannot void within about 6 hours of birth or catheter removal, or whose post-void residual exceeds about 150 mL, needs catheterization to prevent bladder injury and uterine atony.
Postpartum preeclampsia can appear up to 6 weeks after birth, so blood pressure is checked within 72 hours for severe hypertension and within 7–10 days for all hypertensive disorders.
Persistent postpartum blood pressure of 150/100 mmHg or higher is treated, severe-range values of 160/110 or higher need treatment within 30–60 minutes, and NSAIDs remain acceptable for most patients with hypertension.
Lactating patients need about 330–400 extra kcal per day, should continue a prenatal vitamin with iodine, and can safely lose about 1 lb per week without affecting milk supply.
Puerperal Hematomas
Hematomas form when vessels tear beneath intact skin or mucosa during birth or repair.
- Risk factors: Operative vaginal delivery, episiotomy or laceration repair, nulliparity, prolonged second stage, macrosomia, preeclampsia, and coagulopathy.
- Presentation: Severe perineal, vaginal, or rectal pain or pressure out of proportion to the expected recovery, a tense, tender, bluish swelling, difficulty voiding, and signs of hypovolemia with normal-appearing lochia (the blood is concealed).
| Type | Findings | Management |
|---|---|---|
| Vulvar | Visible tense, purple swelling of the labium | Small (<3–5 cm) and stable: ice, analgesia, serial measurement. Large or expanding: incision, evacuation, ligation of bleeders, and packing |
| Vaginal (paravaginal) | Rectal pressure; mass felt on vaginal or rectal exam | Usually surgical drainage under anesthesia; vaginal packing |
| Retroperitoneal | Flank or abdominal pain, unexplained tachycardia and hypotension, falling hemoglobin | CT imaging, resuscitation, and interventional radiology embolization or laparotomy |
Postpartum Urinary Retention and Bladder Distention
- Definition: Inability to void spontaneously within about 6 hours after vaginal birth (or 6 hours after catheter removal), or a post-void residual above about 150 mL (thresholds of 150–200 mL are used).
- Risk factors: Neuraxial anesthesia, operative vaginal delivery, prolonged second stage, perineal trauma or hematoma, and nulliparity.
- Why it matters: A distended bladder pushes the uterus up and to one side (usually the right) and can cause uterine atony and hemorrhage, while overdistention can permanently damage the detrusor.
- Management: Privacy, warm water over the perineum, analgesia, and early ambulation; then intermittent catheterization, or an indwelling catheter for 24 hours if retention recurs. Rule out a hematoma compressing the urethra.
Hemorrhoids
Pushing and pregnancy-related venous congestion make hemorrhoids common after birth. Treat with fiber, fluids, and a stool softener or osmotic laxative, sitz baths, witch hazel pads, and topical anesthetic or short-course hydrocortisone. A thrombosed external hemorrhoid seen within about 72 hours can be excised for faster relief; later, conservative care is preferred. Patients with third- or fourth-degree lacerations need bowel regimens and must avoid suppositories and enemas.
Postpartum Hypertension and Preeclampsia
- Blood pressure follow-up (ACOG): Check within 72 hours of discharge for patients with severe hypertension and within 7–10 days for all patients with a hypertensive disorder, using home monitoring or clinic visits.
- Postpartum preeclampsia can appear up to 6 weeks after birth, sometimes in patients with no prior hypertension. New severe headache, visual changes, shortness of breath, or epigastric pain need same-day evaluation.
- Treatment thresholds: Treat persistent blood pressure of 150/100 mmHg or higher. Severe-range blood pressure of 160/110 or higher needs IV labetalol, IV hydralazine, or immediate-release oral nifedipine within 30–60 minutes, plus magnesium sulfate when severe features are present.
- Breastfeeding-compatible options: Nifedipine ER, labetalol, and enalapril (an ACE inhibitor acceptable during lactation).
- NSAIDs: ACOG states NSAIDs can be used for postpartum pain in patients with hypertensive disorders of pregnancy, with caution in renal impairment.
- Long-term risk: Preeclampsia roughly doubles later cardiovascular disease risk, so the comprehensive postpartum visit should arrange lifelong blood pressure, lipid, and glucose follow-up.
Postpartum Headache Differential
| Cause | Clue |
|---|---|
| Post-dural puncture headache | Positional (worse upright, better lying down) after neuraxial anesthesia; epidural blood patch if severe |
| Preeclampsia/eclampsia | Hypertension, visual changes, hyperreflexia |
| Cerebral venous sinus thrombosis | Progressive headache, seizures, focal deficits; needs MR venography |
| Reversible cerebral vasoconstriction syndrome | Recurrent thunderclap headaches |
| Migraine or tension headache | Prior history, normal exam |
Fatigue, Sleep, Anemia, and Emotional Changes
- Postpartum anemia: Common after hemorrhage. Use oral iron (often every other day) for mild anemia; intravenous iron restores hemoglobin faster for moderate to severe anemia or oral intolerance.
- Persistent fatigue: Evaluate for anemia, postpartum thyroiditis (check TSH), depression, and sleep deprivation, and support safe infant sleep practices and shared night feeding.
- Postpartum blues affect most new parents during the first 2 weeks; symptoms beyond 2 weeks warrant depression screening (see the postpartum mood section).
Postpartum Nutrition and Recovery
- Lactation energy: About 330 extra kcal per day in the first 6 months and about 400 later (part of the need is met from pregnancy fat stores).
- Continue a prenatal vitamin with iodine (lactation iodine needs are about 290 mcg/day), DHA, vitamin D, and B12 for vegan diets; drink to thirst.
- Gradual weight loss of about 1 lb (0.5 kg) per week does not reduce milk supply.
- Resume exercise gradually once medically safe, working toward 150 minutes of moderate activity weekly, with pelvic floor exercises.
Teaching the POST-BIRTH Warning Signs (AWHONN)
Patients should call 911 for:
- Pain in the chest
- Obstructed breathing or shortness of breath
- Seizures
- Thoughts of hurting themselves or the baby
They should call their clinician for:
- Bleeding that soaks through one pad per hour, or clots the size of an egg or larger
- Incision that is not healing
- Red or swollen leg that is painful or warm
- Temperature of 100.4 °F (38 °C) or higher
- Headache that does not improve with medication, or bad headache with vision changes
Warning-sign education matters because more than half of pregnancy-related deaths in CDC review data occur in the year after birth, many after hospital discharge.
Three hours after a forceps-assisted vaginal birth with a second-degree repair, a patient reports severe, increasing rectal pressure and pain unrelieved by ibuprofen. Her heart rate has risen from 84 to 112 bpm, the uterus is firm at the umbilicus, and lochia is moderate. What is the most likely diagnosis?
Uterine atony
Normal postpartum perineal discomfort
Vaginal (paravaginal) hematoma
Postpartum urinary tract infection
Eight days after an uncomplicated birth, a 31-year-old with no history of hypertension calls with a severe headache and blurred vision. In clinic, her blood pressure is 166/112 mmHg on two readings 15 minutes apart. What is the most appropriate management?
Reassure her that hypertension after delivery resolves on its own and recheck her blood pressure in 1 week.
Treat with antihypertensives within 30–60 minutes and arrange urgent evaluation for postpartum preeclampsia.
Prescribe a triptan for presumed migraine and schedule a follow-up blood pressure check in 2 weeks.
Tell her to stop breastfeeding before starting any antihypertensive medication, then recheck in 3 days.
A patient who delivered vaginally under epidural anesthesia 7 hours ago has not voided. Her fundus is boggy and deviated to the right of midline, and bleeding has increased. What is the most appropriate next step?
Catheterize the bladder, then reassess fundal tone and bleeding.
Give methylergonovine 0.2 mg IM immediately without other intervention.
Encourage oral fluids and wait 6 more hours for spontaneous voiding.
Order a CT scan of the abdomen and pelvis.
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