# Clinical Cases: Postpartum Care

## Case 1: Postpartum Hemorrhage from Uterine Atony

### Patient Demographics
- **Age:** 29 years
- **Sex:** Female
- **Occupation:** Graphic designer

### Chief Complaint
"The patient is bleeding heavily after delivery."

### History of Present Illness
The patient is a G3P3 who just delivered a 4,200-gram infant vaginally after a prolonged second stage of labor (3 hours of pushing with epidural). Oxytocin was running during labor for augmentation. Within 10 minutes of placental delivery, the nurse notes heavy vaginal bleeding with clots. The uterus is palpated above the umbilicus and feels soft and "boggy."

### Risk Factors Present
- Prolonged labor with oxytocin augmentation
- Macrosomic infant (uterine overdistension)
- Multiparity (G3P3)
- Prolonged second stage

### Vital Signs (At Time of Recognition)
- **BP:** 100/60 mmHg (baseline was 118/72)
- **HR:** 110 bpm (baseline was 78)
- **RR:** 20 breaths/min
- **SpO2:** 98% on room air

### Initial Assessment

**Quantified Blood Loss:**
- Estimated blood loss at recognition: 800 mL (by calibrated collection drape and weighed pads)
- Ongoing heavy flow

**Four T's Assessment:**
- **Tone:** Uterus boggy, fundus above umbilicus - PRIMARY CAUSE
- **Trauma:** Cervix and vagina examined - no lacerations identified
- **Tissue:** Placenta appeared complete on inspection
- **Thrombin:** No history of coagulopathy, recent labs normal

### Diagnosis
**Primary Postpartum Hemorrhage** from Uterine Atony
- Blood loss exceeding 1,000 mL (cumulative)
- Maternal tachycardia indicating early hypovolemic response

### Immediate Management

**Step 1: Call for Help**
- Activated hemorrhage response team
- Called for additional nurses, obstetrician, anesthesiologist

**Step 2: Establish Access and Labs**
- Second large-bore IV placed (18-gauge)
- Blood sent for type and crossmatch, CBC, coagulation studies

**Step 3: Uterine Massage**
- Bimanual uterine compression initiated
- Vigorous fundal massage performed

**Step 4: Uterotonic Agents**
- **Oxytocin:** 40 units in 1L lactated Ringer's, infusing rapidly
- **Methylergonovine:** 0.2 mg IM (no hypertension)
- **Carboprost (Hemabate):** 0.25 mg IM (no asthma)
- **Misoprostol:** 800 mcg rectally

**Step 5: Tranexamic Acid**
- 1 gram IV given within 3 hours of delivery

**Step 6: Continued Monitoring**
- Cumulative blood loss tracked
- Vital signs every 5 minutes

### Response to Treatment

**After 15 minutes:**
- Uterus becoming firmer with massage and uterotonics
- Bleeding slowing
- Cumulative blood loss: 1,400 mL

**Laboratory Results:**
- Hemoglobin: 9.2 g/dL (admission was 11.8)
- Platelets: 165,000
- Fibrinogen: 280 mg/dL (normal)
- PT/INR: Normal

**Decision:**
- Blood transfusion initiated (2 units packed red blood cells)
- Conservative management successful - no need for Bakri balloon or surgery

### Final Outcome
- Total estimated blood loss: 1,500 mL
- Received 2 units PRBCs
- Hemoglobin post-transfusion: 9.8 g/dL
- Uterus firm, bleeding controlled
- Stable for transfer to postpartum unit

### Postpartum Management
- Continued oxytocin infusion for 4 hours
- Serial hemoglobin checks
- Iron supplementation
- Early ambulation with assistance (DVT prophylaxis)
- Counseling regarding increased PPH risk in future pregnancies

### Clinical Image
![Postpartum Hemorrhage Management](case_01_image.jpg)

**Image Description:** Algorithm diagram showing the stepwise management of postpartum hemorrhage, including uterine massage technique, uterotonic medications with doses and contraindications, and escalation to procedural interventions.

**Attribution:** Educational illustration adapted from ACOG hemorrhage bundle. Used for educational purposes.

---

## Case 2: Postpartum Endometritis

### Patient Demographics
- **Age:** 25 years
- **Sex:** Female
- **Occupation:** Retail sales associate

### Chief Complaint
"I have a fever and my stomach hurts since I came home from the hospital."

### History of Present Illness
The patient is postpartum day 4 following cesarean delivery for arrest of dilation. She was discharged on postpartum day 2 feeling well. She now presents with fever, lower abdominal pain, and foul-smelling vaginal discharge that began yesterday. She has been breastfeeding but notes decreased milk supply. She denies urinary symptoms, leg swelling, or shortness of breath.

### Delivery History
- Cesarean delivery at 40 weeks for arrest of dilation at 7 cm
- Membranes ruptured for 18 hours prior to delivery
- Multiple cervical examinations during labor (6 total)
- Received prophylactic antibiotics (cefazolin) prior to incision
- Operative time 45 minutes, uncomplicated

### Risk Factors for Endometritis
- Cesarean delivery (strongest risk factor)
- Prolonged rupture of membranes (>18 hours)
- Multiple vaginal examinations
- Prolonged labor

### Physical Examination Findings
- **Vital Signs:** Temperature 39.2C (102.6F), BP 110/68 mmHg, HR 108 bpm
- **General:** Appears uncomfortable, flushed
- **Abdomen:** Soft, diffuse lower abdominal tenderness, fundus at umbilicus and tender to palpation
- **Incision:** Clean, dry, intact, no erythema or drainage
- **Pelvic:** Foul-smelling lochia, uterine tenderness on bimanual exam, no adnexal masses, cervical motion tenderness present

### Diagnostic Workup
- **CBC:** WBC 18,500/mm3 with left shift (85% neutrophils)
- **Urinalysis:** Normal, no pyuria
- **Blood Cultures:** Obtained prior to antibiotics
- **Urine Culture:** Pending
- **Pelvic Ultrasound:** No fluid collection or abscess, normal postoperative appearance

### Diagnosis
**Postpartum Endometritis** (post-cesarean)
- Fever >38C within 10 days of delivery
- Uterine tenderness
- Foul-smelling lochia
- Leukocytosis with left shift

### Management Plan

**Antibiotic Therapy (Standard Regimen):**
- **Clindamycin** 900 mg IV every 8 hours
- **Gentamicin** 5 mg/kg IV every 24 hours (or divided dosing)

**Rationale for Drug Selection:**
- Polymicrobial infection (aerobic and anaerobic bacteria)
- Clindamycin provides excellent anaerobic coverage
- Gentamicin covers gram-negative organisms
- Alternative: Ampicillin-sulbactam or piperacillin-tazobactam

**Supportive Care:**
- IV fluids
- Acetaminophen for fever and comfort
- Continue breastfeeding (medications compatible)

**Monitoring:**
- Temperature curve every 4 hours
- Daily CBC
- Clinical assessment for improvement

### Clinical Course

**Day 1 of Treatment:**
- Temperature 38.4C (improved from 39.2C)
- Still having some uterine tenderness

**Day 2 of Treatment:**
- Afebrile for 24 hours
- Uterine tenderness improved
- Lochia less malodorous
- WBC decreasing to 12,000

**Day 3 of Treatment:**
- Afebrile for 48 hours
- Minimal tenderness
- Ready for discharge

### Discharge Plan
- Discontinue IV antibiotics after 24-48 hours afebrile
- NO oral antibiotics needed upon discharge (this is unique to postpartum endometritis)
- Return precautions: recurrent fever, worsening pain, wound issues
- Follow-up at postpartum visit

### Teaching Points
- Post-cesarean endometritis is more common than post-vaginal delivery
- Triple antibiotic regimen (add ampicillin) may be needed if no improvement in 48-72 hours to cover enterococcus
- Septic pelvic thrombophlebitis should be considered if fever persists despite antibiotics ("picket fence" fever pattern)
- Wound infection should be evaluated separately if incision shows concerning signs

### Clinical Image
![Postpartum Endometritis](case_02_image.jpg)

**Image Description:** Clinical illustration showing the pathophysiology of postpartum endometritis with bacterial ascent from the lower genital tract to the uterine cavity, highlighting risk factors and typical microbiology.

**Attribution:** Educational illustration. Used for medical education purposes.

---

## Case 3: Postpartum Depression

### Patient Demographics
- **Age:** 32 years
- **Sex:** Female
- **Occupation:** Software engineer (currently on maternity leave)

### Chief Complaint
"I don't feel like myself. I can't stop crying and I don't feel connected to my baby."

### History of Present Illness
The patient is 4 weeks postpartum following an uncomplicated vaginal delivery of a healthy infant. She reports persistent low mood, frequent crying episodes, difficulty sleeping even when the baby is asleep, decreased appetite, and overwhelming fatigue. She feels guilty that she is not "bonding" with her baby the way she expected and worries she is a "bad mother." She has intrusive thoughts about accidentally harming the baby (dropping, not waking up to feed) but denies any intention to harm herself or the baby. She has been isolating herself from friends and family.

### Screening Scores
- **Edinburgh Postnatal Depression Scale (EPDS):** 18/30 (score >10 suggests possible depression; >13 indicates likely depression)

### Distinguishing from "Baby Blues"
| Feature | Baby Blues | Postpartum Depression |
|---------|------------|----------------------|
| Onset | Days 2-5 postpartum | Any time in first year (peak 4-6 weeks) |
| Duration | Resolves by 2 weeks | Persists beyond 2 weeks |
| Severity | Mild mood swings | Significant functional impairment |
| Treatment | Support, reassurance | Therapy and/or medication |

This patient's symptoms began at 2 weeks and have persisted, meeting criteria for postpartum depression rather than baby blues.

### Risk Factors Present
- History of anxiety disorder
- Limited social support (spouse travels for work frequently)
- Sleep deprivation
- Difficulty with breastfeeding leading to guilt

### Mental Status Examination
- **Appearance:** Disheveled, tearful
- **Mood:** "Sad and empty"
- **Affect:** Constricted, tearful
- **Thought Content:** Guilt about mothering, intrusive thoughts about accidental harm (ego-dystonic), no suicidal ideation, no thoughts of intentional harm to infant
- **Cognition:** Intact
- **Insight/Judgment:** Good - recognizes she needs help

### Diagnosis
**Postpartum Depression** (Moderate Severity)
- Depressed mood persisting >2 weeks postpartum
- Anhedonia, guilt, sleep disturbance, appetite changes
- Functional impairment
- EPDS score 18

### Safety Assessment
- No suicidal ideation
- No homicidal ideation
- Intrusive thoughts are ego-dystonic (distressing to her, not intended actions)
- No psychotic symptoms (hallucinations, delusions)
- NOT postpartum psychosis (would require emergent intervention)

### Management Plan

**Psychotherapy:**
- Referral for cognitive behavioral therapy (CBT)
- Consider interpersonal therapy (IPT) - evidence-based for PPD
- Weekly sessions initially

**Pharmacotherapy:**
- **Sertraline** 50 mg daily (SSRI with good safety data in breastfeeding)
- Discuss that therapeutic effect takes 2-4 weeks
- Continue breastfeeding - minimal transfer to breastmilk

**Support Measures:**
- Encourage sleep when baby sleeps (partner/family to help with night feeds using expressed milk or formula supplementation)
- Connect with postpartum support groups
- Lactation consultant referral for breastfeeding difficulties
- Partner education about PPD

**Safety Planning:**
- 24-hour crisis line number provided
- Clear return precautions for worsening symptoms
- Family member (mother) to stay with patient this week

**Follow-up:**
- Phone check-in in 1 week
- Office visit in 2 weeks
- EPDS rescreening at follow-up

### Clinical Course
- At 2-week follow-up: EPDS improved to 14
- At 6-week follow-up: EPDS 8, feeling "more like myself"
- Continued sertraline and therapy for at least 6-12 months

### Teaching Points
- Screen ALL postpartum patients for depression at postpartum visits
- Postpartum depression affects 10-20% of new mothers
- SSRIs (sertraline, paroxetine) are compatible with breastfeeding
- Distinguish from postpartum psychosis (rare, psychiatric emergency)
- Untreated PPD affects maternal-infant bonding and child development

### Clinical Image
![Edinburgh Postnatal Depression Scale](case_03_image.jpg)

**Image Description:** Sample Edinburgh Postnatal Depression Scale (EPDS) questionnaire showing the 10-item screening tool used to identify postpartum depression, with scoring guidelines.

**Attribution:** Public domain screening tool. Edinburgh Postnatal Depression Scale.