Illustration: Tallulah Fontaine
For many women, the recovery from giving birth involves patience, sleep deprivation, and more face time with friends and family than doctors. Some of us, though, will experience postpartum symptoms and health issues that are usually rare, but could be life-threatening if left untreated.
“Childbirth is natural, but there are some bad things that can happen if we don’t pay attention,” says Robyn MacQuarrie, an OB-GYN with South Shore Women’s Health in Bridgewater, Nova Scotia. “For us, the balance is in not overanalyzing, but keeping women and their babies safe.”
With the help of three experts, we’ve put together a (slightly scary) list of postpartum conditions you ought to know about and watch out for in the days and weeks after delivery.
Warning signs and symptoms: An increase in heavy bleeding (soaking several pads per hour).
The lowdown: Postpartum hemorrhage is one of the five most common complications or conditions that put mothers at risk in the days and weeks after childbirth, says MacQuarrie. But it’s still pretty rare, affecting less than five per cent of women who give birth. It often occurs immediately after delivery, but it could occur up to about a month postpartum. Women who have C-sections, vacuum or forceps-assisted deliveries, a twin pregnancy or multiples, prolonged labours or who suffer from obesity or blood pressure disorders are at elevated risks for hemorrhaging. The condition is life-threatening if left untreated, meaning anyone who suspects they might be suffering a hemorrhage should immediately seek medical help.
“Typically when we send somebody home, their bleeding gets a little bit lighter every day,” says MacQuarrie. “If you start to see an increase in the amount of bleeding and a really heavy flow two weeks out, that wouldn’t be normal,” she says. “We’d want to see you.”
The common causes of an immediate postpartum hemorrhage include tears and uterine atony, a condition that causes the uterus, which is a muscle, to lose its tone and ability to contract well (and stop blood flow) after delivering a baby. A more delayed postpartum hemorrhage could be caused by a uterine infection or retained placenta (meaning some of the placenta remained in the uterus after delivery).
Warning signs and symptoms: Fever; excessive bleeding and clots; cramping.
The lowdown: This condition is just what it sounds like—a part of the placenta, which is typically delivered in the half-hour after your baby is born—remains inside the uterus after delivery. This can happen for several reasons: the uterus did not contract enough to push the placenta from the womb, the cervix closes before all of the placenta is expelled or the placenta was unable to naturally detach from the uterus and will need to be removed manually. Most doctors are in the habit of examining the placenta after it is delivered to ensure no tissue was left behind, but retained tissue can be difficult to detect if it comes out in pieces. (Sometimes a random branch of the placenta is missed.) Symptoms of a retained placenta—heavy bleeding is the main symptom, as well as fever and pain—tend to show themselves as early as 24 hours after delivery and as late as ten or more days post-birth, says Elin Raymond, a physician at Open Arms OB/GYN in Toronto.
Sufferers are at risk of postpartum hemorrhage (see above), meaning a diagnosis of retained placenta comes with either an immediate manual removal (if you just gave birth) or, if the retained placenta is detected later, a trip to the operating room, where you will undergo a dilation and curettage to remove the troublesome tissue.
Warning signs and symptoms: Fever above 38 degrees Celsius; chills; exhaustion; dizziness and feeling generally unwell. Urinary tract infections and mastitis can also precede it or cause it.
The lowdown: Sepsis sounds scary, and that’s because it is. An advanced, life-threatening stage of infection in which the body begins to shut down, it can be caused by a range of common postpartum infections. Urinary tract, bladder, breast, blood and even uterine infections, known as endometritis—if left untreated or if unresponsive to antibiotics—could each be precursors to sepsis. These infections can be linked to the normal procedures the body is exposed to during pregnancy and delivery (think cervical exams, delivery, stitches, etc.), which may increase the likelihood of coming into contact with harmful bacteria.
MacQuarrie says that a bladder infection is one of the common causes. The infection then gets into the blood stream or causes an infection of the uterus.
"And it can also just be bad luck, to be honest," adds Boroditsky.
“Once the infection moves from the area in which it originated into the blood stream, we start getting sepsis,” says MacQuarrie. “And people become incredibly unwell very quickly.”
In addition to nausea and vomiting, patients in sepsis often stop peeing, suffer high fevers and experience a blood pressure drop.
“If somebody presents in full sepsis, it's hard to even get an IV into them to get the fluids in to resuscitate them,” MacQuarrie says. “And that’s why we say if something feels unusual, we want to see you again.”
Warning signs and symptoms: Severe, migraine-like headache that gets worse when sitting or standing, and better when lying down.
The lowdown: Headaches are not uncommon in sleep-deprived, post-childbirth women but a severe headache that comes with neck pain, nausea and sensitivity to bright lights—and that settles if you lie down—is likely a post-dural puncture headache, also known as an epidural headache.
Roughly one in 100 women who undergo epidurals suffer these headaches, which are caused by a puncture to the membrane that contains the cerebrospinal fluid. That fluid encases the spinal cord and brain. Leaks out of the puncture create a pressure imbalance in the fluid, which results in a crippling headache.
“They typically develop before women leave the hospital, but sometimes it can take up to two or three days to fully declare itself,” says MacQuarrie. “If you have those symptoms it’s worth going back to the hospital and getting checked out.”
While some headaches respond to pain medication, the most common fix requires an anesthetist to inject some of the woman’s own blood into the spinal fluid (known as a blood patch) to increase pressure and create a clot that will stop leaks. Relief from the headache, MacQuarrie says, is immediate.
Warning signs and symptoms: A red or swollen calf; shortness of breath; chest pain; pain while breathing; increased heart rate.
The lowdown: Blood clots in the circulatory system are one of the biggest threats to women during and up to six weeks after pregnancy, when increased estrogen and other blood-clotting proteins make women "hypercoagulable," or more likely to develop clots.
Women who smoke, have diabetes, are over 35, on bed rest, recovering from C-sections or who suffer from obesity are at higher risks of developing clots, says Michael Boroditsky, a Winnipeg-based OB-GYN and an assistant professor at the University of Manitoba’s Department of Reproductive Science, Obstetrics and Gynaecology.
While DVTs tend to occur in the leg, they can technically form in any vein bringing blood back to the heart. They can also be hard to detect.
“The symptoms can be very subtle,” MacQuarrie says. “All pregnant women swell. What you’re looking for is swelling on one leg more than the other—one leg may be red and hot to the touch. If you find yourself seriously short of breath—sometimes it can feel like severe anxiety—we’d want to take a look at you.”
Clots can be treated with blood thinners once they're detected. However, if a clot moves through the circulatory system and reaches the lungs (this is known as a pulmonary embolism, or PE) it can be life-threatening (Serena Williams nearly died from one following the birth of her daughter in 2017).
Warning signs and symptoms: Severe heart attack-like pain in the right upper rib cage or chest; difficulty breathing; nausea; vomiting.
The lowdown: Pregnant women are rarely told to expect the arrival of gall-related issues during or after pregnancy, but surprisingly painful complications with the small organ can accompany or follow the arrival of a new baby. “We know the gallbladder slows down along with your digestive system during pregnancy… and it sort of gets jammed up,” says MacQuarrie.
The gallbladder’s role is to release enzymes that help break down fats and move them through the body. But the increased estrogen that comes with pregnancy can throw off the balance of those enzymes, resulting in the formation of gallstones or a gravel-like sludge that causes gallbladder swelling and pain, particularly after eating.
If gallstones develop they can be removed, as can the entire gallbladder, but ideally only after the second trimester or after delivery, says MacQuarrie. Left untreated, gallbladder issues can result in infection or rupture.
Warning signs and symptoms: Headache; blurred vision; pain in right-side chest and upper abdomen; indigestion; severe swelling.
The lowdown: Most of us have heard of preeclampsia, the treatable condition marked by high blood pressure and high urine protein that occurs midway through pregnancy. A lesser known (but more life-threatening) variant is HELLP syndrome (H stands for hemolysis, the breaking down of red blood cells, EL stands for elevated liver enzymes and LP stands for low platelet count).
“With HELLP, your body goes through a specific, acute, severe life-threatening change. And that usually happens before you deliver. Rarely, it can also happen after,” says Boroditsky.
He explains that HELLP syndrome is a variant of preeclampsia. (Eclampsia is diagnosed when a seizure occurs.) Women may experience seizures up to a week after delivery, or a stroke triggered by high blood pressure. Bleeding in the liver, as well as swelling in the lower legs, hands, face and even the whites of the eyes (known as ocular edema) can also occur, says Boroditsky.
“This is really rare, but it can be maternally life-threatening,” he says, adding, “The only treatment is delivery. You cure it by delivering the baby and the placenta.”
Warning signs and symptoms: Fever; chills; severe sweating; tingling; insatiable thirst; increasing pain or general feelings of being unwell.
The lowdown: Infection with the notoriously dangerous strep A bacteria is so rare that Boroditsky doesn’t mention it to his patients. It’s tough to detect, but can quickly result in sepsis, flesh-eating disease and death.
“It is rare, really rare. But it can happen in anyone, from anything, even in a routine, normal vaginal delivery,” Boroditsky says. Women who experience more interventions during delivery, from pelvic exams to the insertion of forceps, vacuum, a Foley catheter or perineal stitches, are at elevated risks to contract infection.
“Anything that you put into the body can be an impetus for infection,” Boroditsky says. Because the signs of GAS mirror other common, treatable infections (fever, chills, feelings of tiredness, dehydration or nausea), it’s hard to detect it in time to beat it.
“It is so aggressive and so quick, and causes end-organ failure so rapidly, that we have to be really on the ball to catch it,” says Boroditsky.
GAS can be treated with antibiotics. Women who develop flesh-eating disease (known as necrotizing fascitis) may need surgery to remove the infected tissue or limb.
Even if you are feeling uncertain, doctors urge women who feel they may have postpartum symptoms of any of the above conditions to seek help. Call your midwife or your OB, or go to the ER. "Sometimes women think, 'Oh, they sent me home from the hospital, I shouldn't go back,'" says MacQuarrie. "But we depend on people coming back.” Realistically, hospitals can’t admit and observe everyone who might develop symptoms, MacQuarrie explains. Doctors rely, to some extent, on new moms monitoring themselves. “Come back if your symptoms persist or worsen, and please don't worry about being a bother."