A 20-year-old woman, gravida 2 para 2, is evaluated in the postpartum unit 8 hours after vaginal delivery. She is experiencing fatigue, perineal discomfort, and bloody vaginal discharge. The patient has voided 3 times since delivery. She was admitted to the hospital for rupture of membranes at 40 weeks gestation and, after a prolonged induction, had an uncomplicated vaginal delivery under epidural anesthesia with a second-degree laceration that was immediately repaired. The placenta delivered spontaneously, after which the patient had an episode of rigors and chills for 30 minutes that has not recurred. Estimated delivery-related blood loss was 300 mL; the patient received an oxytocin infusion for 4 hours after delivery. Temperature is 37.9 C (100.2 F), blood pressure is 120/80 mm Hg, and pulse is 76/min. Pelvic examination shows an intact perineal repair with minimal bloody discharge and small blood clots on the perineal pad. The uterine fundus is firm, nontender, and palpable at the umbilicus. Which of the following is the best next step in management of this patient?

Question

A 20-year-old woman, gravida 2 para 2, is evaluated in the postpartum unit 8 hours after vaginal delivery.  She is experiencing fatigue, perineal discomfort, and bloody vaginal discharge.  The patient has voided 3 times since delivery.  She was admitted to the hospital for rupture of membranes at 40 weeks gestation and, after a prolonged induction, had an uncomplicated vaginal delivery under epidural anesthesia with a second-degree laceration that was immediately repaired.  The placenta delivered spontaneously, after which the patient had an episode of rigors and chills for 30 minutes that has not recurred.  Estimated delivery-related blood loss was 300 mL; the patient received an oxytocin infusion for 4 hours after delivery.  Temperature is 37.9 C (100.2 F), blood pressure is 120/80 mm Hg, and pulse is 76/min.  Pelvic examination shows an intact perineal repair with minimal bloody discharge and small blood clots on the perineal pad.  The uterine fundus is firm, nontender, and palpable at the umbilicus.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_da51_49c7_bc81_b9b05ee3313b_MD0003_00 The immediate postpartum period (ie, hours to days) is marked by physiologic changes that begin immediately after placental delivery: Increased oxytocin levels (endogenous and administered) cause uterine contraction, which compresses placental bed vessels and protects against postpartum hemorrhage. As the uterus involutes, it rapidly decreases in size, becoming firm and palpable 1-2 cm above or below the umbilicus. Involution also generates subsequent lochia (shedding of the uterine decidua and blood), which initially appears bloody with small clots and can continue for several weeks. Increased prolactin levels stimulate breast milk excretion and milk letdown over the course of hours to days. Infant suckling further increases maternal prolactin and oxytocin levels (ie, positive feedback). Decreased estrogen and progesterone levels may cause postpartum chills and shivering, with subsequent mild hyperthermia/low-grade fever in the first 24 hours after delivery. This patient's postpartum course is normal (eg, shivering, firm contracted uterus, normal lochia). Therefore, only routine postpartum care with pain management, perineal care, and lactation support is indicated. (Choices A, C, and E) Postpartum fever is a temperature ≥38.0 C (100.4 F), exclusive of the first 24 hours after delivery. This patient's temperature of 37.9 C (100.2 F) at 8 hours postpartum is most consistent with mild hyperthermia from normal postpartum shivering. She has no signs of infection (eg, nontender uterus, intact perineal laceration repair, normal voiding) or retained placenta (eg, firm uterus, normal lochia) and therefore does not require broad-spectrum antibiotics, pelvic ultrasound, or urinalysis/urine culture. (Choice B) Oxytocin treats postpartum uterine atony, which typically presents as a boggy, or poorly contracted, uterus and postpartum hemorrhage. This patient's uterus is well contracted, and her minimal bloody discharge is consistent with normal lochia. Educational objective: In the immediate postpartum period, physiologic changes include uterine contraction, lochia, breast milk excretion and milk letdown, and chills and shivering causing hyperthermia or low-grade fever. These changes are hormone-mediated (eg, increased oxytocin/prolactin levels, decreased estrogen/progesterone levels). Patients with these normal findings are managed with routine postpartum care. References: Lochia patterns among normal women: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/23101487) Shaking rigors in parturients. (http://www.ncbi.nlm.nih.gov/pubmed/18839822) Postpartum haemorrhage: prevention. (http://www.ncbi.nlm.nih.gov/pubmed/21463537)

A 20-Year-Old Woman, Gravida 2 Para 2, Is Evaluated in the Postpartum