A 23-year-old woman, gravida 1 para 1, is evaluated on the postpartum floor due to increased perineal pain. The patient underwent a spontaneous vaginal delivery 8 hours ago after pushing for 3 hours. She had a second-degree perineal laceration repaired immediately after delivery. For the past 30 minutes, the patient has had increasing perineal pain, particularly with voiding. Temperature is 37.4 C (99.3 F), blood pressure is 132/86 mm Hg, and pulse is 90/min. On abdominal examination, there is no rebound or guarding and the uterus is firm and palpable below the umbilicus. The patient's pad contains a small amount of dark red blood, and no clots are expressed with uterine massage. The perineum and labia majora are edematous. The laceration repair appears intact with no purulent drainage but is tender to palpation. Which of the following is the best next step in management of this patient?

Question

A 23-year-old woman, gravida 1 para 1, is evaluated on the postpartum floor due to increased perineal pain.  The patient underwent a spontaneous vaginal delivery 8 hours ago after pushing for 3 hours.  She had a second-degree perineal laceration repaired immediately after delivery.  For the past 30 minutes, the patient has had increasing perineal pain, particularly with voiding.  Temperature is 37.4 C (99.3 F), blood pressure is 132/86 mm Hg, and pulse is 90/min.  On abdominal examination, there is no rebound or guarding and the uterus is firm and palpable below the umbilicus.  The patient's pad contains a small amount of dark red blood, and no clots are expressed with uterine massage.  The perineum and labia majora are edematous.  The laceration repair appears intact with no purulent drainage but is tender to palpation.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_da5d_ccfa_bc81_c3a229e6b160_MD0003_00 During vaginal delivery, constant, increased pressure (eg, fetal head, maternal pushing) on maternal tissues causes vaginal, labial, and perineal edema. The vagina has increased elasticity to accommodate the fetal head, but other structures, such as the perineum, are less elastic and more likely to lacerate. Therefore, perineal lacerations are common after vaginal delivery, particularly in a primigravidas. Perineal lacerations are classified based on depth. This patient has a second-degree perineal laceration, which disrupts the vaginal mucosa, perineal skin, and perineal body (ie, bulbocavernosus muscle). Second-degree perineal lacerations typically have no long-term sequelae because they heal quickly (due to high vascularity of vaginal tissue) and do not cause extensive muscle damage. This contrasts with more extensive lacerations, which disrupt the anal sphincter muscles (third-degree) and rectal mucosa (fourth-degree) and can lead to anal or fecal incontinence. Although second-degree perineal lacerations heal quickly, patients in the immediate postpartum period often have localized pain, particularly with voiding (due to the proximity of the laceration to the urethra), and perineal edema. This pain is normal (ie, not a sign of infection) and requires only supportive care with nonsteroidal anti-inflammatory drugs and sitz baths. (Choices A, D, and E) In contrast to this patient's second-degree perineal laceration, infected perineal lacerations typically present with fever, wound breakdown (ie, nonintact repair), and purulent drainage. Patients with infected perineal lacerations require antibiotic therapy, suture removal, and surgical debridement. (Choice B) Exploratory laparotomy is indicated for an acute abdomen. This patient has normal vital signs, a firm uterine fundus (ie, no atony), a benign abdominal examination (eg, no rebound or guarding), and minimal vaginal bleeding. Educational objective: Perineal lacerations are common after vaginal delivery and typically cause perineal edema and pain with urination. Uncomplicated perineal lacerations (eg, no fever or purulence) are managed conservatively (eg, nonsteroidal anti-inflammatory drugs, sitz baths). References: ACOG committee opinion no. 736: optimizing postpartum care. (http://www.ncbi.nlm.nih.gov/pubmed/29683911) Oral nonsteroidal anti-inflammatory drugs (single dose) for perineal pain in the early postpartum period. (http://www.ncbi.nlm.nih.gov/pubmed/27412362)

A 23-Year-Old Woman, Gravida 1 Para 1, Is Evaluated on the Postpartum