Postpartum Complications - Cheat Sheet
Your final 30-minute revision companion for postpartum hemorrhage, infection, mastitis, thrombophlebitis, and mood disorders. Every item here is exam-critical.
POSTPARTUM HEMORRHAGE (PPH)
Formulas
PPH Diagnosis: >500 mL (vaginal) OR >1,000 mL (cesarean) OR hemodynamic instability
Meaning
Threshold blood loss OR signs of shock (tachycardia, restlessness, hypotension late)
Watch out
Do NOT wait for hypotension — tachycardia and restlessness are earlier signs of shock. Hypotension is LATE.
When to use
Any postpartum bleeding assessment — these are the cutoff numbers for PPH diagnosis
Common values
Value
>500 mL
Symbol
—
Quantity
PPH threshold, vaginal delivery
Value
>1,000 mL
Symbol
—
Quantity
PPH threshold, cesarean delivery
Value
~1 cm (1 fingerbreadth) per day
Symbol
—
Quantity
Fundal descent rate
Value
day 10 postpartum
Symbol
—
Quantity
Fundus non-palpable by
Important facts
- The 4 Ts of PPH: TONE (atony—#1 cause), TRAUMA (lacerations/hematoma), TISSUE (retained placenta), THROMBIN (coagulation disorder).
- Bright-red, steady bleeding with a FIRM fundus = TRAUMA, not atony. Look for cervical/vaginal tears or hematoma.
- Fundus DEVIATED OFF MIDLINE (usually right) = FULL BLADDER. Empty the bladder immediately — it prevents uterine contraction.
- FIRST action for boggy uterus = FUNDAL MASSAGE. Do this before drugs.
- Risk factors for atony: overdistension (macrosomia, multiple gestation, polyhydramnios), prolonged/precipitous labor, high parity, oxytocin use, retained placenta.
- Count and WEIGH pads to quantify blood loss accurately. Saturating 1 pad/hour = significant bleeding.
- Ensure LARGE-BORE IV access (18-gauge or larger), establish 2 lines if heavy bleeding; send blood for type/cross, CBC, coagulation studies.
- Keep woman WARM, FLAT, legs slightly elevated if shocky; give supplemental O₂; anticipate massive transfusion protocol.
Key definitions
Early (Primary) PPH
Example
Woman delivers vaginally; 2 hours later, fundus is boggy and lochia is heavy — assess for early PPH.
Blood loss >500 mL vaginal or >1,000 mL cesarean within the FIRST 24 HOURS postpartum.
Late (Secondary) PPH
Example
Mother goes home after vaginal delivery; at 2 weeks postpartum, bright-red bleeding returns — suspect retained placenta or subinvolution.
Bleeding from 24 hours to 6–12 weeks postpartum, usually from retained placental fragments or subinvolution.
Uterine Atony
Example
Fundus is soft and displaced; with massage, it firms — atony managed with massage and oxytocin.
Loss of uterine contractility; the uterus feels boggy and soft. THE NUMBER-ONE CAUSE of early PPH.
Subinvolution
Example
At day 14 postpartum, fundus is still 2 cm above umbilicus — suspect subinvolution from retained placenta.
Slowed or incomplete return of the uterus to non-pregnant size; fundus remains high or boggy after day 10.
Diagrams to know
- Normal fundal descent: firm, at/below umbilicus postpartum, descends ~1 cm/day, non-palpable by day 10.
- Lochia progression: RUBRA (dark red, days 1–3) → SEROSA (pinkish-brown, days 4–10) → ALBA (yellowish-white, up to 6 weeks).
- Shock progression: tachycardia and restlessness (early) → tachypnea → pale, cold skin → hypotension (LATE—danger sign).
UTEROTONIC DRUGS FOR PPH
Formulas
OXYTOCIN: 10–40 units/L IV infusion OR 10 units IM (single dose)
Meaning
Oxytocin dose; IV infusion is standard for atony; IM for immediate effect.
Watch out
Monitor for water intoxication with large IV volumes (hyponatremia). Do NOT push as IV bolus — always dilute.
When to use
FIRST-LINE for uterine atony. Safe in hypertension and preeclampsia.
METHYLERGONOVINE: 0.2 mg IM (may repeat)
Meaning
Ergot alkaloid causing sustained uterine contraction.
Watch out
CONTRAINDICATED IN HYPERTENSION/PREECLAMPSIA — raises BP dangerously. ALWAYS check BP before each dose.
When to use
For atony AFTER delivery of placenta (not before, risk of placental entrapment).
CARBOPROST (15-methyl PGF2α): 250 mcg IM every 15–90 minutes (max 8 doses)
Meaning
Prostaglandin causing uterine contraction.
Watch out
CONTRAINDICATED IN ASTHMA — causes bronchospasm. Common side effects: diarrhea, fever, flushing, shivering.
When to use
If oxytocin/ergot fail; useful in resource-limited settings.
MISOPROSTOL: 600–1,000 mcg rectally or orally
Meaning
Prostaglandin E1; no refrigeration needed.
Watch out
Side effect: fever/shivering. Not as potent as IV oxytocin; use as adjunct.
When to use
Resource-limited settings (does not require cold chain).
Important facts
- OXYTOCIN = safest, first-line. No contraindications in hypertension.
- METHYLERGONOVINE = contraindicated in hypertension/preeclampsia (risks hypertensive crisis). CHECK BP BEFORE EACH DOSE.
- CARBOPROST = contraindicated in asthma (bronchospasm). Side effects common: diarrhea, fever, flushing.
- Order of escalation: massage → oxytocin → methylergonovine or carboprost → bimanual compression → balloon tamponade → surgery (curettage, hysterectomy).
- All uterotonics cause sustained ('tetanic') uterine contraction — monitor for abdominal pain.
- Ergot alkaloids cause vasoconstriction — avoid in cardiac disease.
Key definitions
Bimanual Compression
Example
Excessive bleeding persists despite oxytocin — perform bimanual compression while summoning help.
Manual technique: one hand in vagina massages fundus, other hand on abdomen stabilizes; used if drugs fail.
Uterine Balloon Tamponade
Example
Atony uncontrolled by oxytocin/ergot — insert balloon (Bakri, Foley) and inflate to compress bleeding vessels.
Balloon catheter inserted into uterus and filled with fluid to apply pressure; stops bleeding mechanically.
Diagrams to know
- Uterotonic selection flowchart: Is BP elevated? NO → oxytocin or methylergonovine. YES → oxytocin only. Does patient have asthma? YES → avoid carboprost.
PUERPERAL (POSTPARTUM) INFECTION
Formulas
Puerperal Infection Diagnosis: Temperature ≥38°C (100.4°F) on ANY 2 of the FIRST 10 postpartum days (EXCLUDING day 1)
Meaning
Fever ≥38°C on days 2–10; two separate febrile episodes confirm diagnosis.
Watch out
Day 1 fever is usually from anesthesia or dehydration, not infection — do NOT count it. Start counting from day 2.
When to use
Any postpartum fever workup.
Common values
Value
≥38°C (100.4°F)
Symbol
—
Quantity
Fever threshold for puerperal infection
Value
Any 2 days within first 10 postpartum days (excluding day 1)
Symbol
—
Quantity
Fever timing for diagnosis
Important facts
- RISK FACTORS: Cesarean birth (biggest risk), prolonged rupture of membranes (PROM), prolonged labor, multiple vaginal exams, retained placental fragments, hemorrhage.
- SIGNS: Fever, chills, uterine tenderness (REBOUND pain), foul-smelling or profuse lochia, tachycardia, malaise, subinvolution.
- ORGANISM most common: polymicrobial (normal vaginal flora ascending). Gram-negatives, anaerobes, Group B Strep common.
- MANAGEMENT: Obtain cultures BEFORE antibiotics. Give BROAD-SPECTRUM IV antibiotics (common: clindamycin + gentamicin). Daily labs for WBC trend.
- NURSING: Position in SEMI-FOWLER (facilitates lochia drainage toward vagina by gravity). Teach perineal hygiene (FRONT-TO-BACK wiping), frequent pad changes, handwashing.
- MONITOR: Lochia character (foul smell is red flag), fundal tenderness, fever curve, WBC count, vital signs for sepsis progression (hypotension, altered mental status).
- Continue antibiotics FULL COURSE as prescribed, even if symptoms improve.
Key definitions
Endometritis
Example
Day 3 postpartum: fever 38.5°C, fundus tender, lochia foul-smelling — endometritis suspected; culture and broad-spectrum antibiotics.
Infection of uterine lining (most common form of puerperal infection); causes fever, uterine tenderness, foul/profuse lochia.
Subinvolution
Example
Day 7 postpartum, fundus still 2 cm above umbilicus; if combined with fever and foul lochia, suggests infected retained placenta.
Slowed involution; fundus remains enlarged and boggy. Can be complication of infection or retained tissue.
Diagrams to know
- Endometritis sign progression: fever → chills → fundal tenderness (REBOUND) → foul lochia → if untreated → sepsis (hypotension, confusion).
- Lochia normal vs. abnormal: Normal = progresses rubra→serosa→alba, no odor. Abnormal = foul smell, excessive amount, return to rubra.
MASTITIS
Common values
Value
2–4 weeks postpartum
Symbol
—
Quantity
Typical postpartum onset of mastitis
Important facts
- TIMING: Usually 2–4 weeks postpartum (lactation phase).
- ORGANISM: Staphylococcus aureus (#1 cause), entered through cracked/fissured nipple; MRSA possible (use vancomycin/clindamycin if resistant).
- RISK FACTORS: Poor latch, engorgement, missed feedings, tight bras, inadequate nipple care (no cleansing, moisturizing).
- SIGNS: UNILATERAL redness, warmth, hardness, tenderness in WEDGE-SHAPED area of breast. Flu-like symptoms: fever, chills, body aches, malaise.
- MANAGEMENT: CONTINUE BREASTFEEDING or PUMPING — emptying the breast is therapeutic. Milk from affected side is SAFE for infant (bacteria killed by gastric acid).
- ANTIBIOTICS: Dicloxacillin or cephalexin (first-line anti-staph). Clindamycin or vancomycin for MRSA. Full 10–14 day course.
- COMFORT: Warm compresses before feeding (aids milk flow), cold compresses after feeding (reduces inflammation). Analgesics (ibuprofen, acetaminophen safe in lactation). Rest, hydration.
- PREVENTION: Proper latch and positioning (rotate starting breast), frequent emptying, avoid tight bras, nipple care (gentle cleansing, lanolin or hydrogel pads to prevent cracking).
Key definitions
Mastitis
Example
Day 14 postpartum: left breast red, warm, hard, tender, wedge-shaped area; fever 38.8°C, body aches; mastitis diagnosed.
Inflammation/infection of breast tissue in a lactating mother; usually UNILATERAL, from Staphylococcus aureus via cracked/fissured nipple.
Milk Stasis
Example
Mother skips feedings due to pain or fatigue; milk backs up → breast becomes engorged, warm, tender → portal for S. aureus.
Accumulation of milk due to missed feedings, poor latch, or engorgement; predisposes to mastitis (milk is ideal medium for bacteria).
Diagrams to know
- Mastitis pathway: Cracked nipple → S. aureus entry → milk stasis (poor emptying) → inflammation/abscess → fever + wedge area of redness/warmth/tenderness.
THROMBOEMBOLIC DISORDERS (DVT & PE)
Common values
Value
1.5–2.5× control (or per protocol)
Symbol
—
Quantity
aPTT target for heparin therapy
Value
2–3
Symbol
—
Quantity
INR target for warfarin therapy
Important facts
- RISK FACTORS: Cesarean birth, obesity, immobility, varicosities, advanced maternal age (>35), prior thrombosis, thrombophilia, prolonged labor, infection.
- VIRCHOW'S TRIAD (all present in postpartum): Hypercoagulability (elevated clotting factors), venous stasis (immobility, uterine compression), endothelial injury (delivery trauma).
- DVT SIGNS: Unilateral leg pain, warmth, redness, EDEMA, leg tense. HOMANS SIGN (calf pain on dorsiflexion) — UNRELIABLE, no longer emphasized.
- PE SIGNS: SUDDEN dyspnea, pleuritic chest pain (worse on breathing), tachypnea (RR >20), tachycardia, apprehension, syncope, hemoptysis (if infarction).
- MANAGEMENT DVT: BED REST with leg ELEVATED. WARM MOIST COMPRESSES for comfort. DO NOT MASSAGE THE LEG (risk of clot dislodgement and embolism).
- ANTICOAGULATION: Heparin (IV, SC) or LOW-MOLECULAR-WEIGHT HEPARIN (LMWH, e.g., enoxaparin SC) are FIRST-LINE (do not cross placenta, safe in lactation). Warfarin is teratogenic (AVOID antepartum), acceptable postpartum/lactation.
- MONITORING: aPTT for heparin (target 1.5–2.5× control). INR for warfarin (target 2–3). Platelet count for heparin-induced thrombocytopenia (HIT).
- ANTIDOTES: Protamine sulfate (heparin antidote), Vitamin K (warfarin antidote).
- PREVENTION: Early ambulation, leg exercises (ankle pumps, quadriceps sets), adequate hydration, compression devices (TED hose, sequential compression devices) for high-risk women.
Key definitions
Deep Vein Thrombosis (DVT)
Example
Day 3 postpartum after cesarean: left leg swollen, warm, red, painful — DVT suspected; no calf massage; elevate, anticoagulate.
Blood clot in deep leg vein; presents with unilateral leg pain, warmth, redness, swelling (edema), tense leg.
Pulmonary Embolism (PE)
Example
Day 5 postpartum, woman suddenly gasps, complains of chest pain, HR 130, RR 28, O₂ sat drops — PE suspected; oxygen, anticoagulation, ICU.
Clot lodge in pulmonary artery; MEDICAL EMERGENCY. Sudden dyspnea, pleuritic chest pain, tachypnea, tachycardia, apprehension, possibly hemoptysis.
Hypercoagulability
Example
Pregnancy increases Factor V, VIII, X, XII; stasis from uterine compression; vessel injury from delivery → thrombus risk.
Pregnancy/postpartum state of elevated clotting factors, venous stasis, and vessel injury (Virchow's triad) — thrombosis risk.
Diagrams to know
- PE vs. DVT: DVT localized (leg pain, swelling, redness). PE systemic (dyspnea, chest pain, shock) — more dangerous.
- Virchow's triad in postpartum: (1) Hypercoagulability = ↑ clotting factors, ↓ fibrinolysis. (2) Venous stasis = immobility, uterine compression of iliac veins. (3) Endothelial injury = delivery trauma.
POSTPARTUM MOOD DISORDERS
Common values
Value
Within days, resolves by ~2 weeks
Symbol
—
Quantity
Baby blues onset and duration
Value
Within first year postpartum (usually weeks–months)
Symbol
—
Quantity
PPD onset window
Value
Within 1–2 weeks; ~0.1–0.2% of births
Symbol
—
Quantity
PPP onset and prevalence
Value
~10–15% of postpartum women
Symbol
—
Quantity
PPD prevalence
Important facts
- PREVALENCE: Baby blues ~80% of mothers (mild, self-limited). PPD ~10–15% (persistent, needs treatment). PPP ~0.1–0.2% (rare but severe).
- BABY BLUES timing: Onset within DAYS, resolves within ~2 WEEKS. Reassurance, rest, support sufficient.
- PPD timing: Onset within WEEKS TO MONTHS (first year). Does NOT resolve on its own without treatment.
- PPP timing: Onset within FIRST 1–2 WEEKS (acute). Medical emergency.
- PPD RISK FACTORS: Prior depression/anxiety, hormonal shifts, sleep deprivation, lack of partner/family support, difficult birth, ill/premature newborn, multiparity, marital conflict.
- PPD SYMPTOMS: Persistent sadness, hopelessness, guilt ('bad mother'), fatigue, insomnia/hypersomnia, appetite changes, poor concentration, anhedonia (loss of pleasure), thoughts of self-harm or infanticide.
- PPP SYMPTOMS: Delusions (false beliefs, e.g., baby is 'the devil'), hallucinations (usually auditory, command hallucinations common), paranoia, disorganized speech, confusion, agitation, inability to care for self/infant.
- SCREENING: Use EDINBURGH POSTNATAL DEPRESSION SCALE (EPDS) at 4–6 weeks postpartum. Screen ALL mothers.
- PPD MANAGEMENT: Psychotherapy (cognitive-behavioral, interpersonal). Antidepressants — SSRIs preferred in lactation (sertraline, paroxetine low transfer to milk). Assess for suicidal/infanticidal ideation at each visit.
- PPP MANAGEMENT: PSYCHIATRIC HOSPITALIZATION REQUIRED. Antipsychotics (haloperidol, risperidone) + mood stabilizers (lithium, valproate). NEVER leave mother alone with infant — risk of infanticide.
Key definitions
Postpartum (Baby) Blues
Example
Day 3 postpartum: mother tearful, irritable, anxious, but caring for baby, eating, sleeping normally. Resolves by day 10 with reassurance.
Mild, transient mood disturbance (tearfulness, anxiety, irritability) within days of birth, resolving within ~2 weeks. Mother REMAINS IN TOUCH WITH REALITY.
Postpartum Depression (PPD)
Example
Week 4 postpartum: mother feels hopeless, unable to enjoy baby, poor sleep despite opportunity, thoughts of 'my baby would be better off without me' — PPD diagnosed; SSRI + therapy started.
Major depressive episode within first year postpartum. Persistent (weeks–months) sadness, hopelessness, guilt, fatigue, sleep/appetite disturbance, poor concentration, loss of interest in activities or infant. REQUIRES TREATMENT.
Postpartum Psychosis (PPP)
Example
Day 7 postpartum: mother confused, hearing voices commanding her to harm baby, paranoid thoughts about husband. Admitted to psychiatric ICU; antipsychotic + mood stabilizer started.
PSYCHIATRIC EMERGENCY. Delusions, hallucinations, disorganized thinking, BREAK FROM REALITY. Often COMMAND HALLUCINATIONS to harm infant. Onset within 1–2 weeks. Strongly associated with bipolar disorder.
Diagrams to know
- Mood disorder timeline & severity: Baby blues (days, mild, self-resolves) → PPD (weeks–months, moderate–severe, needs Rx) → PPP (1–2 weeks, SEVERE, psychotic, emergency).
NORMAL POSTPARTUM INVOLUTION (Baseline for Recognizing Deviations)
Common values
Value
~1 cm (1 fingerbreadth) per day
Symbol
—
Quantity
Fundal descent rate
Value
Day 10 postpartum
Symbol
—
Quantity
Fundus non-palpable by
Value
Days 1–3
Symbol
—
Quantity
Lochia rubra duration
Value
Days 4–10
Symbol
—
Quantity
Lochia serosa duration
Value
Days 11–42 (up to 6 weeks)
Symbol
—
Quantity
Lochia alba duration
Value
Non-foul (fleshy, metallic OK)
Symbol
—
Quantity
Lochia odor normal
Important facts
- FUNDUS FIRMNESS: Immediately postpartum, fundus is FIRM (well-contracted). If BOGGY or SOFT → uterine atony. Massage firms it.
- FUNDUS HEIGHT: Immediately postpartum, fundus at or just BELOW umbilicus. Descends ~1 cm/day (1 fingerbreadth/day). Non-palpable by day 10.
- FUNDUS POSITION: Should be MIDLINE. If deviated to the side (usually right) → FULL BLADDER displacing it. Empty bladder immediately.
- FUNDUS DEVIATION left or down = possible hematoma or mass. Assess.
- LOCHIA RUBRA (days 1–3): Dark red color from RBCs, fresh blood. Small clots normal (grape-sized or smaller).
- LOCHIA SEROSA (days 4–10): Pinkish-brown transition phase. Contains blood, serum, WBCs, endometrial tissue.
- LOCHIA ALBA (days 11–42, up to 6 weeks): Yellowish-white from WBCs, tissue. Last stage before cessation.
- LOCHIA AMOUNT: Days 1–2 can be heavy (saturating 1 pad/hour normal). By day 3+, should decrease. Heavy or increasing bleeding beyond day 3 = abnormal.
- LOCHIA ODOR: Should NOT be foul. Foul smell = infection (endometritis). Foul lochia + fever + fundal tenderness = endometritis.
- LOCHIA RETURN TO RUBRA after serosa/alba has begun = ABNORMAL, suggests subinvolution or retained tissue.
Key definitions
Involution
Example
Fundus firm at umbilicus immediately postpartum, descends to non-palpable by day 10 — normal involution.
Return of reproductive organs (especially uterus) to non-pregnant state. Fundus descent, lochia progression, cervical closure, return of menstruation.
Lochia
Example
Days 1–3: dark red (lochia rubra). Days 4–10: pinkish-brown (lochia serosa). Days 11–42: yellowish-white (lochia alba).
Vaginal discharge postpartum; blood, decidua, WBCs. Progresses through three stages: rubra, serosa, alba. NEVER foul-smelling; foul odor = infection.
Diagrams to know
- Normal fundal descent: Day 0 (at/below umbilicus) → Day 1 (1 cm below) → Day 2 (2 cm below) → ... → Day 10 (non-palpable in abdomen).
- Normal lochia progression: Rubra (dark red, clots OK) → Serosa (pink-brown) → Alba (yellowish-white). NO foul odor at any stage.
Must remember
PPH DIAGNOSIS: >500 mL (vaginal) OR >1,000 mL (cesarean) OR hemodynamic instability. Number-one cause = UTERINE ATONY (boggy fundus). FIRST ACTION = fundal massage (before drugs).
FUNDUS OFF MIDLINE (deviated, usually right) = FULL BLADDER. Empty immediately; bladder prevents contraction. Do NOT assume atony without checking.
BRIGHT-RED, STEADY BLEEDING with FIRM FUNDUS = TRAUMA (lacerations/hematoma), NOT atony. Look for cervical/vaginal tears or hematoma; may require surgical repair.
METHYLERGONOVINE (0.2 mg IM) CONTRAINDICATED IN HYPERTENSION/PREECLAMPSIA — raises BP dangerously. ALWAYS CHECK BP BEFORE DOSE. Oxytocin is safe in hypertension.
CARBOPROST (250 mcg IM) CONTRAINDICATED IN ASTHMA — causes bronchospasm. Common side effects: diarrhea, fever, flushing.
PUERPERAL INFECTION = fever ≥38°C on ANY 2 days within FIRST 10 postpartum days (EXCLUDING day 1). Endometritis most common; position in SEMI-FOWLER for lochia drainage. Foul lochia + fever + uterine tenderness = endometritis.
MASTITIS: Unilateral, wedge-shaped area; fever; Staphylococcus aureus from cracked nipple. KEEP BREASTFEEDING/PUMPING — emptying therapeutic, milk is safe. Antibiotics: dicloxacillin or cephalexin (anti-staph).
DVT MANAGEMENT: Elevate leg, WARM MOIST COMPRESSES, anticoagulation. DO NOT MASSAGE LEG — risk of embolism. Heparin/enoxaparin first-line (safe in pregnancy/lactation). Monitor aPTT or anti-Xa. Antidote = protamine sulfate.
PE IS MEDICAL EMERGENCY: Sudden dyspnea, pleuritic chest pain, tachypnea, tachycardia. Give oxygen, anticoagulate, ICU monitoring. Postpartum women hypercoagulable (Virchow's triad: clotting factors ↑, stasis, vessel injury).
POSTPARTUM PSYCHOSIS = psychiatric emergency. Delusions, hallucinations, COMMAND HALLUCINATIONS to harm infant, break from reality. NEVER LEAVE ALONE WITH BABY. Requires hospitalization, antipsychotics + mood stabilizers. PPD (depression, no psychosis) = needs SSRI + therapy. Baby blues (tearfulness, 2 weeks) = supportive care only.
Last minute tips
UTEROTONIC CONTRAINDICATIONS ARE BOARD FAVORITES. Methylergonovine = contraindicated in hypertension (check BP first). Carboprost = contraindicated in asthma (bronchospasm). Oxytocin = SAFE in hypertension — it is the backup if BP is elevated.
DO NOT MASSAGE A DVT LEG. This is a classic 'trick' question. Massage can dislodge clot → PE. Instead: elevate, warm compresses, anticoagulate. Heparin/enoxaparin safe in pregnancy & lactation; warfarin teratogenic (antepartum only).
MASTITIS = KEEP BREASTFEEDING. Stopping worsens stasis and abscess risk. Milk from infected breast is SAFE (stomach acid kills bacteria). This is tested because students often incorrectly advise stopping nursing.
POSTPARTUM PSYCHOSIS vs. DEPRESSION vs. BLUES — Know the differences by REALITY CONTACT. Baby blues & PPD = reality intact. PPP = break from reality (delusions, command hallucinations). PPP is an EMERGENCY (infanticide risk); PPD needs SSRI + therapy; blues need reassurance only.
NORMAL LOCHIA NEVER SMELLS FOUL. Foul odor = infection (endometritis). Normal progression: rubra (days 1–3, dark red) → serosa (days 4–10, pink-brown) → alba (days 11–42, yellowish-white). Return to bright-red after serosa = abnormal (retained tissue or subinvolution).
Comparison tables
Postpartum Hemorrhage: Early (Primary) vs. Late (Secondary)
| Feature | Early PPH | Late PPH |
|---|---|---|
| Timing | Within FIRST 24 hours | 24 hours to 6–12 weeks |
| Most Common Cause | Uterine atony (boggy fundus) | Retained placental fragments or subinvolution |
| Clinical Presentation | Heavy lochia immediately after birth; boggy fundus | Return of bright-red lochia or increased bleeding weeks postpartum |
| Diagnosis Threshold | >500 mL vaginal OR >1,000 mL cesarean | Same thresholds apply |
| Primary Intervention | Fundal massage, empty bladder, oxytocin | Curettage to remove retained tissue; antibiotics if infection |
Postpartum Mood Disorders: Baby Blues vs. PPD vs. PPP
| Feature | Baby Blues | Postpartum Depression | Postpartum Psychosis |
|---|---|---|---|
| Onset | Within DAYS | Within WEEKS–MONTHS | Within 1–2 WEEKS |
| Duration (Untreated) | ~2 WEEKS (self-limited) | WEEKS–MONTHS (persistent, needs Rx) | Variable if untreated (dangerous) |
| Severity | MILD | MODERATE–SEVERE | SEVERE (EMERGENCY) |
| Reality Contact | INTACT — mother knows baby is real, cares for baby | INTACT — mother knows reality but feels hopeless/guilty about it | BROKEN — delusions, hallucinations, command voices to harm infant |
| Key Symptoms | Tearfulness, anxiety, irritability, mood swings | Persistent sadness, hopelessness, guilt, sleep/appetite change, poor concentration, anhedonia, suicidal/infanticidal thoughts | Delusions, hallucinations (usually auditory), paranoia, disorganized thinking, confusion, agitation |
| Treatment | REASSURANCE, rest, support. Self-resolves. | Psychotherapy + SSRIs (sertraline preferred in lactation). Assess for self-harm/infanticide. | PSYCHIATRIC HOSPITALIZATION. Antipsychotics + mood stabilizers. NEVER leave alone with infant. |
| NLE Tip | Transient, supportive care only | Requires pharmacologic + psychologic intervention | Medical emergency; risk of infanticide; hospitalize |
Uterotonic Drugs: Choice by Scenario
| Drug | Dose | FIRST-LINE? (Y/N) | Contraindication | Key Side Effect/Note |
|---|---|---|---|---|
| Oxytocin | 10–40 units/L IV infusion OR 10 units IM | YES — First-line | None (safe in hypertension) | Water intoxication risk if large IV volumes; never push as IV bolus |
| Methylergonovine | 0.2 mg IM (may repeat) | NO — Second-line | HYPERTENSION/PREECLAMPSIA (raises BP dangerously) | CHECK BP BEFORE EACH DOSE. Sustained contraction may cause uterine tetany (pain) |
| Carboprost | 250 mcg IM q15–90 min (max 8 doses) | NO — Third-line | ASTHMA (bronchospasm) | Diarrhea, fever, flushing, shivering. More side effects than others |
| Misoprostol | 600–1,000 mcg rectally/orally | NO — Adjunct/resource-limited settings | None (well-tolerated) | Fever/shivering. No cold chain needed; useful in low-resource areas. Less potent than IV oxytocin |
Anticoagulant Choice: DVT/PE Management in Postpartum
| Anticoagulant | Route | Monitoring | Safe in Pregnancy? | Safe in Lactation? | Antidote |
|---|---|---|---|---|---|
| Heparin (unfractionated) | IV, SC | aPTT (target 1.5–2.5× control) | YES | YES | Protamine sulfate |
| LMWH (e.g., enoxaparin) | SC | Anti-Xa level (if renal impairment) | YES | YES | Protamine sulfate (partial reversal) |
| Warfarin | PO | INR (target 2–3) | NO — Teratogenic (embryopathy, fetal bleeding) | YES | Vitamin K (phytonadione) |
| NLE Context | First-line for DVT/PE in postpartum (no placental crossing) | Preferred in many postpartum protocols (longer half-life, SC dosing) | AVOID antepartum; OK postpartum/lactation | — |
Mastitis vs. Breast Engorgement vs. Plugged Duct
| Feature | Mastitis | Engorgement | Plugged Duct |
|---|---|---|---|
| Onset | 2–4 weeks postpartum | Days 3–5 postpartum | Variable (any time during lactation) |
| Affected Area | UNILATERAL, WEDGE-SHAPED | BILATERAL, diffuse | Localized lump/area |
| Skin Appearance | Red, warm, edematous | Shiny, tight, red (milder) | Normal or slightly red |
| Systemic Symptoms | Fever, chills, body aches, malaise | Usually none (afebrile) | Usually none (afebrile) |
| Cause | Bacterial infection (S. aureus) from cracked nipple | Milk accumulation from engorgement (not infection) | Milk duct obstruction (retained milk) |
| Management | CONTINUE breastfeeding, antibiotics (dicloxacillin), warm compresses, rest | Frequent emptying, cold compresses, analgesics, proper latch | Frequent emptying, warm compresses, gentle massage, position changes |
| NLE Tip | Fever + unilateral wedge = mastitis. Key: KEEP BREASTFEEDING. | Afebrile, bilateral, days 3–5 = engorgement (not infection) | Afebrile, localized lump = suspect duct occlusion; massage, feed frequently |
Diagrams
Postpartum Hemorrhage: Decision Tree for Early PPH Management
Diagnostic and management flowchart for early postpartum hemorrhage. Starts with fundal assessment (firm vs. boggy) and guides decisions on massage, uterotonic selection, bladder emptying, and escalation to advanced interventions.
Normal Postpartum Involution Timeline: Fundal Descent & Lochia Progression
Timeline showing normal fundal descent (1 cm/day, non-palpable by day 10) and lochia color progression (rubra → serosa → alba). Deviations from this pattern (high fundus, boggy fundus, foul lochia, return to bright red) signal complications.
Postpartum Complications Overview: The '5 Ps' Concept
Hierarchical overview of all major postpartum complications: hemorrhage (early/late, 4 Ts), infection (endometritis, wound, UTI), mastitis, thromboembolic disease (DVT/PE), and mood disorders (blues/PPD/PPP). Shows key diagnostic features and management approach for each.
Postpartum Mood Disorder Spectrum: Progression from Blues to Psychosis
State diagram showing the spectrum of postpartum mood disturbances. Baby blues (self-limited in ~2 weeks) may progress to PPD (persistent, needs treatment) or rarely to PPP (psychotic, emergency). Distinguishes by reality contact and duration.
Uterotonic Drug Selection: Which Drug, When?
Drug selection flowchart for managing uterine atony. Accounts for contraindications (hypertension rules out methylergonovine; asthma rules out carboprost). Shows escalation pathway: oxytocin → methylergonovine → carboprost/misoprostol → mechanical interventions.