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Usually the amount of lochia is similar to a normal menstrual period. If the discharge is heavier, consider retained placenta and/or endometritis. In case of suspected retained placenta: amoxicillin/clavulanic acid PO (dose expressed in amoxicillin): amoxicillin PO: 1 g 3 times daily + metronidazole PO: 500 mg 3 times daily 11.4.2 Infectious complicationsLook for an infection in patients with fever higher than 38 °C for more than 48 hours. Postpartum endometritis and salpingitisClinical features– Fever, usually high – Abdominal and/or pelvic pain, foul-smelling or purulent vaginal discharge – Uterus enlarged, soft, painful when mobilized; open cervix; swelling in the posterior fornix Management– Admit to inpatient department; administer antibiotherapy: ampicillin IV: 2 g every 8 hours + metronidazole IV: 500 mg every 8 hours + gentamicin IM: 5 mg/kg once daily Continue this treatment 48 hours after resolution of fever and other clinical signs . For early, minor forms (no fever, minor pain), outpatient treatment is possible with: Ratio 7:1: 2625 mg daily (1 tablet of 875/125 mg 3 times daily) – Look for retained placenta and perform uterine evacuation after 24 to 48 hours of antibiotherapy. If the patient is haemodynamically unstable due to haemorrhage or infection, perform uterine evacuation immediately. Pelvic abscess or peritonitisA complication of untreated puerperal endometritis/salpingitis. Clinical features– Abdominal guarding or spasm, ileus, pelvic mass Management– Laparotomy or, in case the abscess is confined to the Pouch of Douglas, colpotomy to drain the abscess. Other infectious complications– Abscess after caesarean section. Note: in case of fever, systematically test for malaria in endemic areas. Cracked nipplesClinical features– Nipple erosion and intense pain when starting to nurse. Management– Clean with soap and clean water before and after each feeding; dry carefully. Breast engorgementClinical features– Bilateral pain 2 to 3 days after childbirth; firm, painful breasts. Management– Cold or warm compresses (before nursing); more frequent nursing. LymphangitisClinical features– Unilateral pain, 5 to 10 days after childbirth. Local inflammation, red, hot painful with no fluctuation. – High fever (39-40 °C); enlarged axillary lymph node. – No pus in the milk collected on a compress. Management– Empty the breast by nursing the neonate frequently on the involved side. If the mother finds nursing too painful, temporarily stop nursing on the painful side (but empty the breast manually) and continue breastfeeding with the other breast. Breast infections (mastitis, abscess)Clinical features– Mastitis: • Firm, red, painful, swollen area of one breast associated with fever. • Axillary lymph node may be enlarged. • Purulent discharge from the nipple. – Breast abscess: fluctuant, tender, palpable mass. Management– Temporarily stop nursing on the affected side. Carefully express all milk from the infected breast (manually). 11.4.4 Urine leakageClinical features– Look for a possible vesicovaginal fistula, especially after a prolonged labour. Management– If there is a fistula: see Chapter 7, Section 7.2.5. Stress incontinence is more common among grand multiparas, after a forceps or vacuum extraction, and in cases of foetal macrosomia. It usually disappears within 3 months with pelvic floor exercises. 11.4.5 Psychological disorders“The baby blues”This syndrome has its onset within days after the delivery and lasts usually 2 weeks. It is characterised by mood swings, crying, irritability, anxious worrying centred on the neonate, and doubts about the ability to be a “good mother”, combined with insomnia, loss of appetite and concentration problems. These problems generally diminish within a few days. Reassurance, family support and follow-up to ensure that the patient does not develop depression are usually sufficient. Postpartum depressionPostpartum depression develops in the first weeks after childbirth; it can be severe and is often underestimated. The characteristic symptoms of depression are sadness, frequent crying, loss of self-confidence, constant concerns about the child (or, on the contrary, a feeling of indifference), feeling incompetent as a mother, and feelings of guilt (or even aggressive thoughts toward the child) combined with insomnia and loss of appetite. These symptoms last more than 2 weeks and gradually worsen, leading to a state of exhaustion. The interview should look for possible suicidal thoughts and assess the mother’s ability and desire to take care of the child (depression can have repercussions for the child’s development). An understanding and reassuring attitude and help with daily activities by family and friends are essential. Antidepressant medication may be necessary (choose an antidepressant compatible with breastfeeding, which should be continued whenever possible). Refer to the Clinical guidelines, MSF. Note: postpartum depression is more frequent after a stillbirth or intrauterine foetal death. Postpartum psychosisThis occurs less frequently and is characterised by the onset of psychotic symptoms after childbirth. Symptoms include irritability, major mood swings, delusions, hallucinations, and disorganised, bizarre and sometimes violent behaviour. The patient should be sent to a doctor immediately. Antipsychotic treatment, and usually hospitalisation, is necessary. Refer to the Clinical guidelines, MSF. |