Complications after the Birth

There are several different conditions which result in high blood pressure during  pregnancy. You may have been given a diagnosis of either:

Essential hypertension - high blood pressure presenting before 20 weeks pregnant.

Pregnancy induced (gestational) hypertension - high blood pressure presenting after 20 weeks pregnant.

Pre-eclampsia - high blood pressure presenting after 20 weeks pregnant with protein in your urine.

Severe pre-eclampsia - very high blood pressure presenting after 20 weeks pregnant with symptoms including protein in your urine and abnormal blood tests.

HELLP syndrome - very high blood pressure presenting after 20 weeks pregnant with symptoms including protein in your urine and very abnormal blood tests including haemolysis, elevated liver enzymes and low platelets. 

What happens after delivery whilst I am still in hospital?

You will be monitored closely. As pre-eclampsia can worsen in the first few days after delivery and, up to half of the women who develop eclampsia (convulsions) do so after delivery, you may need to stay in hospital for several days. During this time your blood pressure will be regularly measured.

You may need to continue taking medication to lower your blood pressure. Your medication may be changed but you will be given a medication which is safe during breast feeding.

You may need repeat blood tests if these were abnormal during pregnancy or labour.

What happens after I go home?

Your community midwife/maternity care assistant will continue to monitor your blood pressure during their visit. If your blood pressure starts to fall you may be advised to reduce or stop medication. Most women who start on blood pressure medication during pregnancy can stop their medication a few days after birth.

If you still need to take blood pressure medication after two weeks you will be asked to contact your GP for further advice. If you were on blood pressure medication before you were pregnant you are likely to need to continue the medication in the long term.

If your blood tests are still abnormal you may need further tests and these will be done at your GP practice.

Are there any symptoms I should look out for?

If you had pre-eclampsia you should look out for any of the following symptoms and contact your community midwife urgently if you are concerned:

• Severe headache
• Blurred or altered vision
• Confusion
• Sudden swelling of your face, hands or feet.

Do I require any follow up?

If you:

• are still taking medication for your blood pressure at two weeks you should see your GP
• are still taking medication which was started during pregnancy at 6 weeks after birth your GP may need to do some more investigations to look for the cause of your high blood pressure.
• had protein in your urine during pregnancy you should have a urine sample tested at your eight week check.

You will be offered an appointment to see your obstetrician at the hospital if you had any of the following problems:

• Delivery before 28 weeks because of pre-eclampsia
• Eclampsia
• Admission to the Intensive Care Unit (ITU) after your delivery
• HELLP syndrome.

How can I prevent high blood pressure in my next pregnancy?

It has been shown that women who are overweight have an increased risk of high blood pressure in pregnancy. You should aim to have a normal BMI (19–24 kg/m2) before you conceive your next pregnancy.

All women who have high blood pressure in pregnancy are advised to take low dose (75mg) Aspirin per day from 12 weeks until birth in their next pregnancy to reduce the risk of high blood pressure. Aspirin is known to be safe to take in pregnancy although was not originally designed for this use. Your GP would need to prescribe this for you in any future pregnancy.

In a future pregnancy you would be advised to be under the care of a consultant obstetrician and would be seen at least once in the hospital antenatal clinic early in the pregnancy.

What are my future risks?

If you had a diagnosis of gestational hypertension you:

• have a risk of gestational hypertension between 16- 47%
• have a risk of pre-eclampsia between two - seven % in your next pregnancy
• have an increased risk of hypertension in later life and so you are advised to have a blood pressure check every five years.

If you had a diagnosis of pre-eclampsia you:

• have a risk of gestational hypertension between 13-53%
• have a risk of pre-eclampsia of 16% in your next pregnancy
• have an increased risk of hypertension in later life so you are advised to have a blood pressure check annually.

If you had a diagnosis of severe pre-eclampsia, eclampsia or HELLP syndrome:

• if you delivered between 28-34 weeks you have a 25% risk of pre-eclampsia in your next pregnancy
• if you delivered before 28 weeks you have a 55% risk of pre-eclampsia in your next pregnancy
• you have an increased risk of hypertension and its complications in later life and should have a blood pressure check annually.

For more information visit www.nhs.uk/conditions/pregnancy-and-baby/pages/hypertension-blood-pressure-pregnant

Pre-eclampsia

Pre-eclampsia is a condition that typically occurs after 20 weeks of pregnancy. It is a combination of raised blood pressure (hypertension) and protein in your urine (proteinuria). The exact cause of pre-eclampsia is not understood.

Often there are no symptoms and it may be picked up at your routine antenatal appointments when you have your blood pressure checked and urine tested. This is why we ask you to bring a urine sample to your appointments.

Pre-eclampsia is common. It is usually mild and normally has very little effect on pregnancy. However, it is important to know if you have the condition because, in a small number of cases, it can develop into a more serious illness. Severe pre-eclampsia can be life-threatening for both mother and baby.

The symptoms tend to occur later on in pregnancy but can also occur for the first time only after birth.

The symptoms of severe pre-eclampsia include:

• severe headache that doesn’t go away with simple painkillers
• problems with vision, such as blurring or flashing before the eyes
• severe pain just below the ribs
• heartburn that doesn’t go away with antacids
• rapidly increasing swelling of the face, hands or feet
• feeling very unwell.

These symptoms are serious and you should seek medical help immediately. If in doubt, contact your midwife.

In severe pre-eclampsia, other organs, such as the liver or kidneys, can sometimes become affected and there can be problems with blood clotting. Severe pre-eclampsia may progress to convulsions or seizures before or just after your baby’s birth. These seizures are called eclamptic fits and are rare.

Does pre-eclampsia effect my baby?

Pre-eclampsia affects the development of the placenta (afterbirth), which may prevent your baby growing as it should. There may also be less fluid around your baby in the womb. If the placenta is severely affected, your baby may become very unwell. In some cases, your baby may even die in the womb. Monitoring aims to pick up those babies who are most at risk.

What are the risks of pre-eclampsia and how can I prevent it?

Pre-eclampsia can occur in any pregnancy but you are at higher risk if:

• this is your first pregnancy
• you have a pregnancy interval of more than 10 years
• you are 40 years or older
• you have a Body Mass Index (BMI) of 35 or more with a family history of pre-eclampsia
• this is a multiple pregnancy
• if you had hypertensive disease during a previous pregnancy
• you have an autoimmune disease such as lupus or anti-phospholipid syndrome
• you have Raised Blood Pressure Pre pregnancy Renal disease Type 1 or 2 diabetes.

If any of these apply to you, you should be advised to take low-dose aspirin (75 mg) once a day from 12 weeks of pregnancy, to reduce your risk.

How is pre-eclampsia monitored?

If you are diagnosed with pre-eclampsia, you should attend hospital for assessment.  While you are at the hospital, your blood pressure will be measured regularly and you may be offered medication to help lower it.  Your urine will be also tested to measure the amount of protein it contains. Your baby’s heart rate will be monitored and you may have ultrasound scans to measure your baby’s growth and wellbeing.   You will also have blood tests done, one of which will measure the amount of growth hormone made by your placenta, which is affected by pre-eclampsia. If the test shows lower than expected levels of placental growth factor (PlGF), we will use this information along with other factors to suggest how to manage the condition in the safest way for your pregnancy.  This could be more frequent visits to your community midwife or possibly admission to hospital for observation.  If the test shows normal levels of placental growth hormone and your blood pressure is normal, it is likely you will go home with a plan for your next midwife contact.  You will be asked to keep an eye on your symptoms during this time and contact your midwife if anything changes.  No diagnostic test is 100% accurate but your care team will use the result of this to make recommendations about your care along with the results of the other bloods tests, your blood pressure and urine checks, and any symptoms you are having. You will continue to be monitored closely to check that you can safely carry on with your pregnancy.   This may be done on an outpatient basis if you have mild pre-eclampsia.  You are likely to be advised to have your baby at about 37 weeks of pregnancy or earlier if there are concerns about you or your baby. This may mean you will need to have labour induced or, if you are having a caesarean section, to have it earlier than planned.

How is severe pre-eclampsia treated?

The only way to prevent serious complications is for your baby to be born. Each pregnancy is unique and the exact timing will depend on your own particular situation. This should be discussed with you. There may be enough time to induce your labour. In some cases, the birth will need to be by caesarean section.
Treatment includes medication (either tablets or via a drip) to lower and control your blood pressure. You will also be given medication to prevent eclamptic fits if your baby is expected to be born within the next 24 hours or if you have experienced an eclamptic fit.

You will be closely monitored on the Central Delivery Suite (CDS) at Southmead Hospital. In more serious cases, you may need to be admitted to an intensive care or high dependency unit. Our CDS has the capability to deliver high dependency care.

What happens after the birth of my baby?

Pre-eclampsia usually goes away after birth. However, if you have severe pre-eclampsia, complications may still occur within the first few days and so you will continue to be monitored closely. You may need to continue taking medication to lower your blood pressure.

If your baby has been born early or is smaller than expected, he or she may need to be monitored. There is no reason why you should not breastfeed should you wish to do so.

You may need to stay in hospital for several days. When you go home, you will be advised on how often to get your blood pressure checked and for how long to take your medication.
You should have a follow-up with your GP six to eight weeks after the birth for a final blood pressure and urine check.

If you had severe pre-eclampsia or eclampsia, you should have a postnatal appointment with your obstetrician to discuss the condition and what happened. If you are still on medication to treat your blood pressure six weeks after the birth, or there is still protein in your urine on testing, you may be referred to a specialist Consultant.

Does pre-eclampsia affect future pregnancies?

Some women will get it again in a future pregnancy. You will be given information about the chance, in your individual situation, of getting pre-eclampsia in a future pregnancy and about any additional care that you may need. It is advisable to contact your midwife as early as possible once you know you are pregnant again.

For more information visit www.nhs.uk/conditions/pre-eclampsia

Many women experience tears to some extent during childbirth as the baby stretches the vagina. For some women, the tear may be deeper and involve the muscle at the bottom of their back passage, called the ‘anal sphincter’. This muscle is important in preventing the leakage of gas (‘wind’) or faeces (‘poo’) during normal daily activities. Therefore, it is very important to identify a 3rd or 4th degree tear and repair it properly. If the tear involves only the anal sphincter muscle, it is called a 3rd degree tear. If the tear extends further into the lining of the anus or rectum, it is known as 4th degree tear.

How common are 3rd or 4th degree tears?

Overall, a 3rd or 4th degree tear occurs in about three in 100 women having a vaginal birth. It is slightly more common in women having their first vaginal birth, compared to women who have had a vaginal birth before.

What increases my risk of a 3rd or 4th degree tear?

These types of tears usually happen unexpectedly during birth and most of the time it is not possible to predict when it will happen, however, it is more likely to happen if:

• This is your first vaginal birth
• your baby is born facing upwards
• You have a large baby
• You have a long labour
• You need help with the birth by forceps or ventouse
• You have had a 3rd or 4th degree tear before.

What will happen if I have a 3rd or 4th degree tear?

This will need to be repaired in the operating theatre under an epidural or spinal anaesthetic or very occasionally a general anaesthetic. During the procedure, antibiotics are given to prevent infection and a catheter (tube) is passed into the bladder to allow drainage of urine.

After your repair, it is recommended that you take the following medications:

• Regular pain killers. Do not wait until you are in pain, but take them on regular basis for the first few days and subsequently as you require them
• A course of oral antibiotics for one week to reduce the risk of infection that could lead to break down of the repair
• Laxatives for approximately two weeks to make it easier and more comfortable to open your bowels.

None of the medications will prevent you from breastfeeding your baby, however, if you have any concerns please speak to your midwife.

You will be advised to:

• Wash your hands before as well as after using the toilet
• Wash your perineum after every visit to the toilet, preferably with warm water
• Pat/wipe the area dry with toilet paper. Always wipe, front to back to avoid contamination from your back passage
• Change your sanitary towels regularly, at least every three to four hours
• Avoid standing or sitting for long periods
• Check your perineum for signs of infection. If the area becomes hot, swollen, weepy, smelly, very painful or start to open, or you develop a temperature or start feeling unwell, please let your midwife or GP know
• Begin doing your pelvic floor exercises as soon as you can – this will strengthen the muscles around the vagina and anus, increase the blood supply and help with healing.

You will be offered physiotherapy advice about pelvic floor exercises before going home.

What can I expect to go home?

After having any tear or an episiotomy, it is normal to feel pain or soreness around the tear for two to three weeks after giving birth, particularly when walking or sitting. Passing urine can also cause stinging. Continue to take your painkillers when you go home.

Most of the stitches are dissolvable and the tear should heal within a few weeks, although this can take longer. The stitches can irritate as healing takes place and uou may notice some stitch material fall out, both are normal.

To start with, some women feel that they pass wind more easily or need to rush to the toilet to open their bowels. Most women make a good recovery, particularly if the tear is recognised and repaired at the time. Six to eight in ten women will have no symptoms a year after birth.

When can I have sex?

It is best to resume sex after the stiches have healed and the bleeding has stopped but there is no right or wrong time. For some people, it is within a few weeks but for others it can be when they feel ready.

Follow up

If you had a 3rd degree tear, you will be contacted by one of the gynaecology specialist nurses after three months from having your baby to ask whether you are still having problems such as: uncontrollable leakage of wind, staining of underwear with faeces or uncontrollable leakage of faeces.  If you are having any of these or other problems, you will be referred to the uro-gynaecology clinic, where we see women with problems of the pelvic floor. If you have really troublesome problems, talk to your midwife or GP so that you can be seen sooner than three months.

If you had a 4th degree tear, you will be referred to the uro-gynaecology clinic three months after having your baby. If you have really troublesome problems, talk to your midwife or GP so that you can be seen sooner than three months.

What about having another baby?

There is no reason to suggest having a vaginal birth next time is not possible. You will be able to discuss your options for future birth (vaginal delivery or planned caesarean section) with an obstetrician early in your next pregnancy. Your individual circumstances and preferences will be taken into account. Please book with your midwife early in the next pregnancy, so that you can be referred to be seen in Antenatal clinic by a Consultant Obstetrician to discuss your options for delivery.

It is normal to bleed from your vagina after you have a baby. This blood mainly comes from the area in your womb (uterus) where the placenta was attached, but it may also come from any cuts and tears caused during the birth. Bleeding is usually heaviest just after birth and gradually becomes less over the next few hours; and reduces further over the next few days. The colour of the blood should change from bright red to brown over a few weeks and will usually have stopped by the time your baby is 12 weeks old. Sometimes bleeding during or after birth is heavier than normal; for more information please read the Royal College of Obstetricians and Gynaecologists (RCOG) detailed guidelines on Heavy bleeding after birth (postpartum haemorrhage).