Maternity risk: It doesn’t end with birth. It begins when new mothers think they are normal and resume their lives

1) Puerperal infections
2) Secondary postpartum haemorrhage (PPH)
3) Urinary complications – urinary retention, incontinence, UTI
4) Breast complications – failing lactation, acute mastitis, breast abscess
5) Puerperal thromboembolic disorders
6) Obstetric palsies- compression injury to lumbosacral plexus, iliohypogastric and ilioinguinal injuries in caesarean section, foot drop
7) Endocrine disorders – postpartum thyroiditis, Sheehan’s syndrome
8) Puerperal psychosis, postpartum blues, depression

Puerperal infections: Clinical manifestations include elevated postpartum temperature (100.4-degree F) accompanied by chills, lower abdominal pain, tenderness, and severe infection displayed in biochemical examination. Women with above symptoms should be evaluated for endometritis. Late postpartum endometritis occurs more than seven days after delivery. Risk factors include chorioamnionitis. Endometritis usually requires treatment with intravenous antibiotics, with most evidence supporting the use of gentamicin and clindamycin.

Prevention: During delivery, digital anal examination should be avoided. The frequency of vaginal examination should be reduced to decrease the incidence of retrograde infection. Indications of caesarean section and lateral episiotomy should be strictly grasped, and the maternal management should be strengthened to prevent postpartum haemorrhage and reduce the injury of the birth canal due to delivery. During puerperium, it is recommended to get enough sleep, strengthen nutrition and improve the body’s immunity.

Secondary PPH: This is defined as significant vaginal bleeding between 24 hours after delivery up to 12 weeks. This can be because of retained products of conception (RPOC). Basically these are intrauterine tissue that develops after conception and persists after medical and surgical pregnancy termination, miscarriage and vaginal or caesarean delivery. Other reasons are endometritis, uterine artery pseudoaneurysm, coagulopathy and gestational trophoblastic neoplasia. In the last condition, a tumour develops inside the uterus from tissue that forms after conception.

Women with secondary PPH may need to be examined in the emergency department for prompt evaluation, including an ultrasound test. Treatment may include uterotonics, uterine curettage or antibiotics usage for endometritis.

Thromboembolic disorders: The risk of deep vein thrombosis, pulmonary embolism, HELLP, amniotic fluid embolism and microangiopathies is five times higher in puerperium than pregnancy. Such patients should be treated with anticoagulants for at least six weeks postpartum and potentially longer if there are other risk factors.

Thyroid disorders: Postpartum thyroiditis can affect 10 per cent of women during the first year with similar rates of hyperthyroidism and hypothyroidism. These require thyroid hormone therapy.

Postpartum psychosis: Its prevalence is 1-2/1,000 childbirths, and the rate is 100 times higher in women with bipolar disorder or a previous history of postpartum psychosis. Approximately four per cent of women with postpartum psychosis commit infanticide. Women with postpartum depression commonly experience comorbid obsessive thoughts (41-57 per cent), which include obsessional ego-dystonic images of harm to their infant, with preservation of rational judgement and reality testing.

Prevention: Given the higher risk of relapse and recurrence in women with bipolar disorder or postpartum psychosis is imperative. Preventing sleep loss near delivery may avert an episode of postpartum psychosis, prophylaxis is imperative. There is no consensus on what mood stabilizer or antipsychotic should be the first-choice agent for prevention of recurrence of postpartum psychosis. In selecting pharmacotherapy, the clinician should primarily consider the patient’s history of effective treatment for mood episodes. Lithium is the mood stabilizer with the most evidence for prophylaxis of psychosis. A careful and complete investigation of any woman with a postpartum mood disorder may determine the presence of psychosis and prevent infanticide.

Postpartum care: The maternal self-care domain is broadly defined as the mother’s ability (and willingness) to take care of herself both physically and emotionally. Proper nourishment, taking time out for oneself when necessary, attention to hygiene and physical appearance, adequate sleep, willingness to delegate and the ability to set boundaries are practical applications of self-care in motherhood. The above should be coupled with the education of mothers by health professionals about the need for postpartum visits, the need to address any signs and symptoms of abnormality, prevent complications and resume normal rhythms.