Mastitis can occur as a result of milk stasis from engorgement or blocked milk duct or as a consequence of unresolved nipple trauma. Inflammation is typically localised, confined to one lobe, often the upper outer quadrant of the breast. The inflammatory response can lead to localised redness and tenderness, extreme malaise, flu-like symptoms and muscular aching. Local treatment with hot and cold compresses and gentle hand expression can alleviate symptoms, and analgesics and antipyretics are helpful. Women should be advised to not restrict feeding, as good breast drainage will usually alleviate the problem. Antibiotic therapy is rarely necessary, as most cases are non-infective, benign and self-limiting. Infective mastitis should be diagnosed by microbiological techniques to ensure correct treatment. In all cases mothers should be managed symptomatically. Where antibiotic therapy is indicated, prolonged treatment (10–14 days) may be necessary to avoid recurrence.

Fraser DM, Cullen L. Postnatal management and breastfeeding. Curr Obstet Gynaecol. 2006;16:65–71.

Stress incontinence is the most common urinary problem to occur after childbirth, and studies have demonstrated that the problem can persist for months or even years. Incidence does not appear to be associated with mode of delivery. However, it can affect the physical, psychological and social well-being, and women therefore should be asked about this postnatally. Training in the use of pelvic floor exercises appears to be effective in reducing stress incontinence, and referral to a physiotherapist is recommended.

Detrusor instability is the second most common cause of urinary incontinence in postpartum women. This can be a problem for postnatal mothers, although studies suggest it is more problematic during pregnancy.

The incidence of urinary tract infection after childbirth is around 2–4 %. Risk factors include previous history, caesarean section, instrumental birth, bladder catheterisation and epidural analgesia. A good aseptic technique will reduce the risks. Management consists of appropriate antibiotic therapy and analgesia.

Vesicovaginal fistula is rare in the developed world but should be suspected in women who complain of continuous leakage of urine, particularly if they give a history of traumatic childbirth.

Fraser DM, Cullen L. Postnatal management and breastfeeding. Curr Obstet Gynaecol. 2006;16:65–71.

The symptoms and signs of VTE include leg pain and swelling (usually unilateral), lower abdominal pain, low-grade pyrexia, dyspnoea, chest pain, haemoptysis and collapse. It is up to ten times more common in pregnant women than in nonpregnant women of the same age and can occur at any stage of pregnancy, but the puerperium is the time of highest risk. When suspected, objective testing should be performed expeditiously and treatment with low-molecular-weight heparin (LMWH) started until the diagnosis is excluded by objective testing, unless treatment is strongly contraindicated. Where there is clinical suspicion of acute PTE, a chest X-ray should be performed. Compression duplex Doppler should be performed where this is normal. If both tests are negative with persistent clinical suspicion of acute PTE, a ventilation–perfusion (V/Q) lung scan or a computed tomography pulmonary angiogram (CTPA) should be performed.

RCOG Green-Top guideline No. 37b. The acute management of thrombosis and embolism during pregnancy and the puerperium.

Early diagnosis of a uterine scar rupture followed by expeditious laparotomy and resuscitation is essential to reduce associated morbidity and mortality in the mother and infant. There is no single pathognomonic clinical feature that is indicative of uterine rupture, but the presence of any of the following peripartum should raise the concern of the possibility of this event:

The diagnosis is ultimately confirmed at emergency caesarean section or postpartum laparotomy.

RCOG Green-Top guideline No. 45 – Birth after previous Caesarean birth.

The Royal College of Obstetricians and Gynaecologists (RCOG) guidelines on PPH refer to a blood loss of more than 1000 ml as PPH. This is further subclassified into ‘moderate PPH’ (1000–2000 ml) and ‘severe PPH’ (>2000 ml). Loss of >2 L of blood and/or the presence of haemodynamic instability would necessitate a blood transfusion to replace volume and oxygen carrying capacity. In addition, to compensate for the ‘washout phenomenon’, blood products (clotting factors, fibrinogen and platelets) should be administered. The management of PPH identifies four components, all of which must be undertaken simultaneously.

These are effective communication, resuscitation, monitoring and investigation as well as arresting of bleeding. In addition to these, prompt diagnosis of the aetiology, a ‘multidisciplinary’ approach, appropriate post-PPH care in ITU or HDU setting and communication with relatives and debriefing of patient form the cornerstones of good clinical care to optimise outcome.

Moore J, Chandraharan E. Management of massive postpartum haemorrhage and coagulopathy. Obstet Gynaecol Rep Med. 20(6):174–80.

After delivery, the placental bed, caesarean section and episiotomy wounds and cervical and vaginal lacerations are all susceptible to bacterial infection. Prolonged rupture of membranes, prolonged labour, operative vaginal delivery, caesarean section, pre-existing vaginal infection or history of group B streptococcal (GBS) infection, postpartum haemorrhage, wound haematoma, retained pieces of placenta, membranes or intrauterine clot and retained swabs all increase the risk of postpartum infection. The condition presents with lower abdominal pain, fever and offensive vaginal discharge or secondary postpartum haemorrhage. Management consists of broad-spectrum antibiotics with coverage for anaerobic organisms as well.