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7 Changes andPotential Complications During Puerperium
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Table 7.12 Indications for CT and/or MRI in suspected
neuropathy
Fever
Neurological symptoms with worsening pattern
Immunosuppression
Coagulopathy
Symptoms localized to the spinal cord
Clinical manifestations include sensory and
motor changes in the affected nerve territories.
Risk factors for neuropathy include macrosomia, non-cephalic fetal presentation, sensory
block, prolonged lithotomy position, second
stage of prolonged labor, extremes of maternal
weight, and inappropriate use of leg retractors
[2, 4].
The diagnosis is usually clinical and can be
complemented with an imaging study in the situations listed in Table7.12.
The treatment is essentially based on painkillers [4]. The rst-line treatments are antiinammatory drugs. All drugs administered
should be assessed for compatibility with breastfeeding. Physiotherapy may be indicated in
selected cases.
The prognosis of most neuropathies is good,
with resolution in days to weeks, in which the
average recovery time is about 8weeks [2].
blood will be accumulating in the abdominal
and pelvic cavity, particularly after a cesarean
section.
7.9 Routine Postpartum Care
7.9.1 Joint Accommodation
Rooming-in is a practice that allows the healthy
newborn to stay with the mother right after birth,
24h a day in the same environment before discharge from hospital [2]. This is even one of the
prerequisites required for the Baby Friendly
Hospital certication promoted by the World
Health Organization and the UNICEF.It seems
that close contact between mother and child plays
a crucial role in bonding from an early stage, still
allowing for a positive reinforcement of
breastfeeding.
Some studies have already shown that children separated from their mother at an early stage
were more susceptible to abandonment, abuse,
and being victims of violence [4].
7.9.2 Maternal Clinical Surveillance
7.8 Postpartum Hemorrhage
Postpartum hemorrhage occurs if blood loss from
the genital tract is very abundant and/or is associated with hemodynamic impairment. In developed countries, it complicates 3% of births and is
an important cause of maternal mortality [2].
This number increases especially in underdeveloped countries.
The most frequent causes are uterine atony
(80% cases), partial or complete retention of the
placenta, and lesions of the genital tract. Less
frequent causes are uterine rupture, maternal
coagulopathy, placental accretism, and uterine
inversion [2].
The proposed approach varies according to
the protocol of different countries.
You should think that in a woman with hemodynamic instability without visible bleeding,
In a puerperal woman, the following should be
evaluated [2]:
– Vital parameters (temperature, blood pressure,
and pulse)
– Lochia (in abundance should motivate investi-
gation of causes of postpartum hemorrhage)
– State of uterine contraction or Pinard safety
globe
– Perineum (edema, dehiscence, purulent exu-
date, or other signs of infection)
7.9.3 Laboratory Evaluation
• Blood count
– Indications: pre-delivery anemia, postpar-
tum hemorrhage, or anemia symptoms
– No indication to be asked for a routine, that
is, an uncomplicated delivery
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F. Cordeiro and M. Gomes-Ferreira
• Leukogram
– Indications: clinical suspicion of infection
– At birth, a leukocytosis of 10,000–15,000
cells/microL may be present
7.9.4 Breastfeeding
Breast milk is a living, complete, and suitable
food for practically all newborns. It should ideally be given exclusively until at least the sixth
month, given the numerous advantages, both in
the short and long term.
Regarding some practical aspects about breast-
feeding, we have to consider the following [3]:
– The newborn must be breastfed freely, that is,
whenever requested.
– It is important to understand the amount of
milk the newborn is getting from the feed, so
the duration should not be considered a deter-
mining factor. Most breastfeed about 90% of
what they need in 4 min. Prolonged breastfeeding (>30 min) means that the newborn
uses the nipple as a pacier, which increases
the risk of breast ssures and eventually
mastitis.
– One breast should be emptied, and then the
second should be offered, thus maintaining
the pace of milk production.
– The milk obtained in the rst days is called
colostrum, which has a greater amount of
water and lactose. In the subsequent days, the
amount of fat present increases.
– The proper growth of the newborn must be
monitored by weight, a function that is the
responsibility of the health professional.
– The environment must be peaceful in order to
stimulate milk production.
Breastfeeding has a lot of well-known benets
(Fig.7.7) [3].
Fig. 7.7 Breastfeeding
benets
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It is also necessary to pay attention to some
contraindications (Table7.13) [2]:
7.9.5 Prevention ofVenous
Thromboembolism
In the presence of temporary contraindications, the administration of articial milk per
cup, spoon, or syringe and breast stimulation and
emptying are indicated.
If there are absolute contraindications, the
mother should receive therapy to suppress lactation and feeding of the newborn should be made
with articial milk by teat.
Venous thromboembolism (VTE) was the main
cause of direct maternal mortality in developed
countries. It is known that the risk is about ve
times higher during pregnancy, compared to a
nonpregnant woman, and that this risk can be
about ten times higher in the puerperium. The
early puerperium is the period associated with
the greatest risk [4].
Table 7.13 Breastfeeding contraindications
Temporary
contraindications Denitive contraindications
– Chickenpox or
herpes virus
infection
– Untreated
tuberculosis
– Temporary
incompatible
medication
Table 7.14
Categories High risk Intermediate risk Low risk
Risk
factors
Indicated
therapy
Venous thromboembolism risk categories [2]
– Previous VTE
– Any woman who has
undergone thromboprophylaxis
during pregnancy
≥1RF: HBPM during 6weeks
of puerperium
– HIV
– Newborns with rare
metabolic disorders (e.g.,
phenylketonuria and
galactosemia)
– Chronic incompatible
medication
– Hereditary or acquired thrombophilia
(asymptomatic)
– Medical pathology with thrombotic
risk (SLE, heart disease, nephrotic
syndrome, sickle cell disease,
inammatory bowel diseases)
– Morbid obesity
– Prolonged hospital stay (>3days)
≥1RF: HBPM at least till discharge, but
may extend to 6weeks of puerperium
In a schematic way, we can arrange the risk
factors in three risk categories: low, moderate,
and high (see Table7.14).
The existence of some factors, as well
as a combination of these, may determine
the indication for thromboprophylaxis [2].
However, some may have only a transitory
character, as well as new complications may
arise, which require a frequent reassessment of
risk.
– Cesarean
– Age >35years
– Obesity
– Multiparity (≥3)
– Venous
insufciency of the
lower limbs
– Smoking (<10
cigarettes/day)
– Active infectious
process
– Preeclampsia
– Prolonged labor
(>24h)
– Severe postpartum
hemorrhage
– Blood transfusion
– Postpartum surgery
≥2RF: HBPM at least
till discharge
1 RF: Prevent
dehydration, stimulate
early walking
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F. Cordeiro and M. Gomes-Ferreira
Low-molecular-weight heparins (LMWHs)
are the drugs of choice for prophylaxis and
venous thromboembolism in pregnancy and
puerperium. Unfractionated heparin can also be
used, although it is dependent on aPTT monitoring. Doses are adjusted to weight.
For the small number of women who underwent coumarin therapy during pregnancy, HBPM
in therapeutic dose should be instituted in the
puerperium, and can be restarted later, since they
are safe in breastfeeding.
Postpartum approach:
– How long does it take to introduce LMWH
after removing the epidural catheter?
• Prophylactic dose 6h after
• Therapeutic dose 12h after
The contraindications or need to suspend anticoagulation is described in Table7.16 [2].
7.9.6 Prophylaxis ofRhD
Alloimmunization
inthePuerperium
Prophylaxis with anti-D immunoglobulin is indicated in the immediate postpartum period
(<72h), if mother is RhD negative and the newborn RhD positive.
7.9.7 Pelvic Floor Exercises
A randomized study showed that pelvic muscle
exercises at an early stage of the puerperium do
not have a protective role against urinary incontinence and that they can even be harmful to the
levator ani muscle complex.
7.10 Discharge Planning
7.10.1 Length ofStay
There is low-quality evidence on the main studies
associated with the ideal length of stay after
delivery.
According to ACOG recommendations, discharge should happen 48h after a vaginal delivery or 72h after a cesarean delivery (excluding
the day of delivery). Obviously, evaluation is a
dynamic process, and several aspects should be
reviewed. The parameters include maternal vital
signs, mucous membranes’ color, uterine contraction, lochia, ability to tolerate diet and walking, pain control, and ability to care for herself
and the newborn. All puerperal complications
listed in the previous topics should be excluded.
7.10.2 Health Education
Table 7.15 Low-molecular-weight heparin doses [2]
Weight (Kg) Enoxaparin Dalteparin
<50 20mg/day 2.500 UI/day
50–89 40mg/day 5.000 UI/day
90–130 60mg/day 7.500 UI/day
131–170 80mg/day 10.000 UI/day
>170 0.6mg/kg/day 75 UI/kg/day
Table 7.16
anticoagulation
Active bleeding
Heparin-induced allergy or thrombocytopenia
Uncontrolled arterial hypertension (≥180 and/or
110mmHg)
Thrombocytopenia (<70,000 pL/μL) or coagulopathy
(INR >1.5)
Renal impairment (creatinine >1.5mg/dL)
Contraindications or need to suspend
All women need to be informed about what to
expect during puerperium, namely the postpartum changes that occur on a physiological basis.
Warning signs will help mothers to distinguish
from pathological changes. The main warning
signs include [4]:
– Fever
– New or worsening perineal or uterine pain
– Purulent exudate from the C-scar or perineum
– Excessive vaginal bleeding
– Breast inammatory signs
– Urinary tract infection symptoms
– Dyspnea or chest pain
– Leg pain or swelling
– Mood disturbance
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7.10.3 Physical Activity
Unfortunately, there are no data to strain the recommendations on postpartum physical activity.
The return to routine activities is something individually decided and is essentially conditioned
by postpartum pain.
The most recommended approach suggests
telling the mother to do the normal activities [2]
(exercise, housework, driving, sexual intercourse) when she is comfortable, in order to prevent the pain and/or excessive fatigue.
The most asked issue is about sexual intercourse. A woman should wait at least 2weeks till
the perineum is completely healed and contraception is prescribed. She needs to feel comfortable about it, and this question should be
discussed by the couple.
7.10.4 Contraception
Most women initiate sexual relations between 4
and 6weeks postpartum, which is the most common time for a postpartum medical visit. But the
contraception issue should be discussed before
discharge.
The contraception is recommended to be initiated 21 days after delivery. In women not
exclusively breastfeeding, ovulation can occur
on the rst month, and even in those who breastfeed exclusively, the risk of pregnancy is <5%.
The combined contraceptives should be avoided,
once the estrogens pass through the blood-milk
barrier.
Family planning needs to be discussed.
Adverse outcomes in pregnancy could occur in
short (<6months) and long (>5years) interpregnancy intervals [2]. Optimal interval is approximately 18–59months. In case of older women or
a family history of early menopause, these recommendations may not be applied.
7.10.5 Follow-Up Visits [2]
The timing of the postpartum visit should be individualized and woman centered.
The initial assessment in pregnancy and puerperium with no risk should be followed up with
ongoing care as needed, and no later than 6weeks
after birth.
Women with chronic medical conditions, such
as hypertensive disorders, diabetes, thyroid disorders, renal disease, mood disorders, and substance use disorders, should be counseled to book
a follow-up appointment with their obstetriciangynecologists or primary care providers earlier.
All the potential problems should be searched
and addressed. Past problems are important to be
reviewed.
7.11 Conclusion
The puerperium is a variable period of time that
marks the transition from a pregnant to a nonpregnant state, in which various involutive and
recovery processes of the maternal organism
occur. From a clinical point of view, it is relatively complex, which requires the doctor to have
detailed knowledge about the existing changes.
Only by understanding the physiological changes
of this period is it possible to understand what is
pathological and to provide a correct approach
that allows the resolution of any possible
complication.
References
1. Cunningham F, Leveno KJ, Bloom SL, etal. The puer-
perium. In: Williams obstetrics. 25th ed. New York:
McGraw-Hill; 2018. p.652–702.
2. Berens P.Overview of the postpartum period: physi-
ology, complications, and maternal care. UpToDate.
27 Jan 2020. https://www.uptodate.com/contents/
overview- of- the- postpartum- period- physiology-
complications- and- maternal- care.
3. ACOG committee opinion no. 736: optimizing post-
partum care. Obstet Gynecol. 2018;131:e140.
4. Chalmers B, Mangiaterra V, Porter R.WHO principles
of perinatal care: the essential antenatal, perinatal, and
postpartum care course. Birth. 2001;28(3):202–7.
5. Demic S, Cheng S. Modeling the dynam-
ics of disease states in depression. PLoS One.
2014;9(10):e110358.
6. e-lactancia. 2002. http://e- lactancia.org. Accessed 2
May 2020.
Part III
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Preoperative Consultation
Informed Consent
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andMedicolegal Aspects
BernardoHontanilla andAndrésRosMagallón
8
Take-Home Points
• Prevention is often the best approach to litigation. Seek legal counsel from an experienced
attorney/solicitor when setting up your practice and before undergoing signicant
changes.
• Patients’ expectations about the results achievable by surgery may also be a source of liability. Take time to explore and correct them.
• Patients seeking post-maternity surgery
should be explained in detail the risks or consequences associated with combined procedures, future pregnancies, and lactation when
appropriate.
• The content of your advertisements, of the
informed consent, and of what you explain in
your practice are often understood as terms of
the contract between you and the patient, and
therefore binding.
8.1 Introduction
Patient care is a heavily regulated interaction, no
matter the legal system nor the medical subspecialty considered. It is affected by both general
regulations concerning trade and specic regulations that protect the privacy of the patient or
B. Hontanilla (*) · A. R. Magallón
Department of Plastic, Reconstructive and Aesthetic
Surgery, Clínica Universidad de Navarra,
Pamplona, Spain
e-mail: bhontanill@unav.es; arosm@unav.es
state the boundaries of the doctor-patient
relationship.
Although both medicine and law are liberal
professions, the practice of medicine is far more
informal than the practice of law, which is more
reliant on the written word. In aesthetic surgery,
the nuances and uncertainty of the medical
assessment are magnied, as it focuses on subjective matters such as beauty and self-image.
This chapter provides an overview of the different types of criminal and civil liability a plastic
surgeon can face when practicing aesthetic surgery, the possible pitfalls when treating a postmaternity patient, and which points to address
when writing and implementing a proper
informed consent [1].
8.1.1 Sources ofLitigation
Far from the image of doctors standing trial
depicted in television, the most common interaction with the legal system is when it is required
from us that we provide an ofcial narrative
about a patient under our care or a deposition to
characterize an injury and its scarring or the disability caused by it. It is also fairly common to be
summoned to court to provide live testimony
about the appropriateness of a diagnosis or procedure performed by a colleague.
In aesthetic surgery, a growing trend among
patients is believing themselves blameless while
expecting a perfect result, without regard for the
© Springer Nature Switzerland AG 2023
M. Gomes-Ferreira, J. Olivas-Menayo (eds.), Post-maternity Body Changes,
https://doi.org/10.1007/978-3-030-43840-1_8
147
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B. Hontanilla and A. R. Magallón
instructions nor the possible complications
explained in the interview. This discrepancy
between the patient’s expectations and their willingness to understand the uncertainty of medicine or to take responsibility in their care is often
a source of disappointment, anger, and eventually
a lawsuit against the plastic surgeon.
However, it is our responsibility to explore the
motives underlying the patient’s request, to be
able to shed some light on the preconceptions
that she brought to the interview. Those patients
who after a detailed explanation of the limits of
surgery and the extent of the result that can be
expected with a procedure keep demanding unrealistic results, hint distrust towards the surgeon,
or seem to not grasp the importance of the complications explained are patients that should not
be subjected to surgery. In a nutshell, if the risks
of a procedure outweigh its results, it should not
be performed, as it occurs with non- aesthetic procedures [2].
8.1.1.1 Preventing Litigation
It is difcult to imagine someone reasonable who
has been treated with care, dignity, and respect
seeking a way to get back at you or your practice,
even if something goes wrong. On the other hand,
if a patient feels that she is not listened to, that
she has been abandoned by you, or that you are
not trustworthy, she is likely to be disgruntled
and willing to complain or sue. In order to prevent patient complaints and therefore litigation,
the best policy is treating patients with the dignity and respect they deserve, making them feel
that they are listened to and that you are available
for them, and when things take a wrong turn, own
your mistakes and look after them throughout
their complications.
No matter with how much care you treat your
patients, there will always be some that complain. It is nonetheless important to reduce their
number, so the only left complaining are those
with unreasonable claims [3].
8.1.2 Issues withPost-maternity
Patients
The post-maternity patient poses a signicant
challenge, as she often demands aesthetic procedures combined with gynecologic procedures—
i.e., abdominoplasty after C-section—with the
increased risk of complications that it entails.
Furthermore, a prolonged stay in the hospital or a
complication due to a combined procedure can
affect the ability of the patient to breastfeed or
take care of her child. As this is a sensitive issue,
it is best discussed beforehand with the patient,
so she can understand the risks associated with
her particular postoperative status and the effect
that complications of her surgery could have on
her child.
Another possible scenario is that of a patient
seeking contour improvement surgery well after
having her child. The main risk of this kind of
patient is that she is less likely to identify the
changes after her pregnancy as the source of her
desire for contour-improving surgery, thus not
prompting a question about previous pregnancies
or further desire of pregnancy/motherhood.
Failing to address the possible desire of pregnancy when assessing the suitability for contourimproving surgery is a mistake that can have
serious consequences, as it is the case with
abdominoplasty and/or transverse rectus sheath
plication. Both these procedures involve a
decrease in abdominal capacity, limiting the
available space for the fetus to grow, were the
patient to become pregnant again. Further unfavorable outcomes such as contour irregularities
or deformities can also be produced as a result of
the changes associated with pregnancy after a
contour-improving surgery. Asking about the
desire of pregnancy/motherhood of the patient
and previous pregnancies is crucial when assessing the suitability for abdominal contour improvement surgery in a patient.
A third scenario where a post-maternity
patient should be evaluated with special care is
when she requests breast reduction or breast lift
surgery. Both these surgeries shape the breast
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parenchyma, damaging the lactiferous ducts and
the breast lobules. This can impair future lactogenesis and milk excretion, affecting both the
child, by difculty in breastfeeding, and the
mother, causing lacteal cysts to appear in the
breast where the parenchyma was altered.
Lastly, the post-maternity patient can present
with underlying personality disorders or mental
illnesses, some of which can arise after childbirth
or during pregnancy. The greatest risk with such
kind of patients is that the informed consent may
be nullied if the patient is deemed not able to
understand its content or its implications for her
health when it was obtained, generating in turn a
range of civil and/or criminal liabilities.
Therefore, it is not advisable, be it a postmaternity patient or not, to operate on a patient
currently suffering from a mental illness or personality disorder without having him or her
assessed by an experienced psychiatrist. Then
can it be determined if the underlying disorder
affects the decision-making ability of the patient,
and whether this disorder is expected to be permanent or transient.
As both postpartum and lactation are sensitive
periods for both parents, the possible complications affecting them should be discussed in depth
in the interview and written down in the informed
consent, along with the current desire for future
pregnancies and the past gynecologic history of
the patient.
Pearls and Pitfalls
Always assess the social environment of the
patient, her desire for pregnancy, if she intends to
breastfeed her children, and if there has been any
signicant change of mood or any seemingly
unfounded worry that could conceal an underlying psychiatric disorder.
and punishes these kind of acts, either by producing a criminal code or by setting legal precedents
through judicial decisions of courts in common
law countries.
Due to the nature of the acts performed in aesthetic surgery, which are the cause of differences
between professionals and conict with the public administration, the activity of aesthetic surgery has both legal and economic ramications.
Aesthetic surgery is without any doubt a legitimate part of medicine, as it does improve the
health of the individuals that are subject to it.
However, as it is performed voluntarily and due
to the absence in most cases of physical illnesses,
the assessment of its indications and therefore its
legal classication remains difcult. It is our
objective to promote the culture of compliance
regarding the practice of aesthetic surgery and to
allow the description of procedures and best
practice guidelines to identify and classify the
legal and operative risks that aesthetic surgeons
face on a daily basis.
8.2.1 Sources ofCriminal Liability
As the specic crimes may vary in its punishment
or denition in the different legal systems, we
present the following broad concepts that have an
analogousness in most of them, although the precise characteristics may vary. It is to be noted that
in civil law systems, analogy is not allowed in
criminal law, and only the typied crimes do constitute a crime; therefore, the crimes of this section may not be considered as such where you
practice. We advise consulting with an experienced attorney in your region to conduct a risk
assessment or to provide legal defense if you so
require.
8.2 Criminal Oenses
inAesthetic Surgery
A crime or a criminal offense is often dened as
an unlawful act such as assault or tax evasion that
is harmful not only to an individual but also to
society as a whole. It is the state that prosecutes
8.2.1.1 Injuries
As it has been stated before, aesthetic surgery is
performed voluntarily, on patients who do not
have a physical disease and seek gratication
through a better self-image. It is in this eld in
which it is understandable that negligence or lack
of ability can nd their place in the commission
of these crimes, a topic which is often studied as
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B. Hontanilla and A. R. Magallón
a part of legal and forensic medicine. The usage
of modern imaging tools to manipulate an image
to present the desired result of the patient can
generate a contractual liability in the form of a
warranty of a result, moreover when that image is
printed and given to the patient without further
clarication. If in such a case the result is not the
promised, or if during the surgery an injury is
produced, or, even worse, if the patient dies, the
doctor can face criminal charges, and as the contract between the surgeon and the patient warranted a result instead of merely warranting the
best ability of the surgeon, the informed consent
may be only considered an attenuation or even
completely void.
! Attention
Every surgical act is an aggression by itself. Do
not perform an aesthetic surgery procedure without a valid signed informed consent.
8.2.1.2 Breach ofPrivacy
This relates specically to the duty of secrecy
that we owe to our patients. Depending on the
jurisdiction, the punishment is only due to the
diffusion, or due to both the diffusion of secrets
that are entrusted to us and the acquisition of private information that we do not have consent or
permission to access. In the particular case of
aesthetic surgery, it is common to take images of
the patients to observe and compare the preoperative and postoperative results. Usually, an
informed consent document allowing those photographs is passed, but it is not rare that the
patients only consent to have their photographs
preserved in their electronic medical history.
Frequently, the photographs are taken with smartphones or similar devices, and even when the surgeon performs his or her due diligence and
transfers the images to the EMH, a copy of the
photograph remains on the phone, which is a
known vulnerability to breach of privacy. Even
more concerning is the fact that those images,
even though some surgeons do not have the specic permission to do it, are shown in congresses
or courses. Another instance of breach of privacy
is sharing those pictures in direct messaging
groups with other surgeons when none of them
needs to know the existence of those photos.
8.2.1.3 Fraud
In the eld of aesthetic surgery and cosmetic
medicine, there are several devices and drugs that
anyone with a bare minimum understanding of
the trade knows that they do not have any effect,
being equally effective as placebo. Such devices
or drugs, although they can be eventually
approved by the government or by one of its
institutions, have seldom any clinical trial that
supports the claims made by their marketers. In
Europe, the more loose legislation of some member countries has been the gateway for some cosmetic products under the classication of medical
devices. Eventually, these products have been
recalled, but the damage to the patients is already
done. The usage of such products knowingly
deceiving the patient about the reach of their
effectiveness can end with a criminal charge of
fraud. Another instance of fraud is the off-label
use of a product with the intent to deceive the
patient, i.e., by providing a service of less value
or quality than it was advertised. It is to be noted
that off-label usage of a product or drug when
properly explained to the patient and with their
consent does not generate criminal nor civil
liability.
8.2.1.4 False Advertising
Although the doctor-patient relationship aims to
establish a warranty for the best ability of the surgeon and due diligence, there are also partial warranties of result that relate to some procedures
that a doctor must perform when having a patient
under their care; in the eld of aesthetic surgery,
one of such partial warranties of result relates to
the informed consent (and its verbal clarication
to the patient). Furthermore, the warranty for the
best ability of the surgeon can turn into a warranty of result if the clarication is performed
without care. The competitive pressure to attract
patients can make a surgeon give into publishing
his or her best results, hiding the cases that had
complications, or not publishing their complications’ rate. There have been instances of postop-
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