What are the post-vaginal delivery management guidelines?

Post-Vaginal Delivery Management Guidelines

Vaginal delivery is the preferred mode of delivery for most women, including those with cardiac conditions, and requires standardized post-delivery care to monitor for and prevent complications.

Immediate Post-Delivery Management

Uterine Contraction Management

• Administer a slow IV infusion of oxytocin (< 2 U/min) after placental delivery to prevent maternal hemorrhage 1
• For control of postpartum bleeding, 10-40 units of oxytocin may be added to 1,000 mL of non-hydrating diluent and run at a rate necessary to control uterine atony 2
• Avoid methylergonovine due to high risk (>10%) of vasoconstriction and hypertension, particularly in women with cardiovascular disease 1
• Prostaglandin F analogues can be used to treat postpartum hemorrhage unless an increase in pulmonary artery pressure is undesirable 1

Vital Signs Monitoring

• Monitor systemic arterial pressure and maternal heart rate for at least 24 hours after delivery 1
• Continue hemodynamic monitoring for at least 24 hours after delivery, as this period is associated with important hemodynamic changes and fluid shifts that may precipitate heart failure 1
• Monitor for post-delivery fever, noting that benign single-day fever typically occurs earlier (around 4 hours postpartum) and with lower temperature elevations (average 38.2°C) compared to endometritis (30 hours postpartum, average 38.9°C) 3

Bleeding Assessment

• Directly measure abnormal bleeding across all settings in the delivery suite 1
• Abnormal bleeding is defined as >500 ml after vaginal delivery 1
• Early recognition through changing bed linen and pads immediately after delivery and systematically weighing blood-soaked pads correlates with the fall in Hb concentration 1

Post-Delivery Complications Management

Hemorrhage Management

• If abnormal bleeding is recognized, the obstetrician, anesthetist, and senior midwife should attend the mother 1
• Obtain blood for full blood count, clotting studies, group and screen, and venous blood gas for rapid Hb measurement and lactate 1
• Post-partum anemia is defined by hemoglobin <11 g/dL at 48 hours 4
• For severe bleeding:
  1. If coagulation test results are unknown and bleeding continues after four units of RBC, administer four units of FFP and maintain 1:1 ratio until test results are available 1
  2. Consider fibrinogen replacement with cryoprecipitate or fibrinogen concentrate if laboratory Clauss fibrinogen is <3 g/L (especially <2 g/L) with ongoing bleeding 1
  3. Point-of-care testing is recommended for monitoring hemostatic function during obstetric hemorrhage 1

Perineal Care

• NSAIDs are effective for perineal pain and uterine involution 4
• For broken down perineal wounds, suturing is preferred for large dehisced wounds 4
• Infection of perineal scar requires oral broad-spectrum antibiotics and local nursing 4
• Provide hygiene advice to all women with episiotomy or perineal tear 4
• For obstetric anal sphincter injuries, antibiotic prophylaxis is recommended 4

Thromboembolic Risk Management

• Thromboembolic risk after vaginal birth is approximately 1‰ 4
• Implement meticulous leg care, elastic support stockings, and early ambulation to reduce thromboembolic risk 1
• Consider thromboprophylaxis with LMWH and graduated compression stockings based on risk factors 4

Special Considerations for Women with Cardiac Conditions

Monitoring Requirements

• For women with cardiac conditions, continue hemodynamic monitoring for at least 24 hours after delivery 1
• Pulse oximetry and continuous ECG monitoring should be utilized as required 1
• A Swan-Ganz catheter for hemodynamic monitoring is rarely indicated due to risks of arrhythmia provocation, bleeding, and thromboembolic complications 1

Anticoagulation Management

• For women with mechanical heart valves on anticoagulation:
  • Resume unfractionated heparin 4-6 hours after delivery if there are no bleeding complications 1
  • For urgent delivery in a patient still on UFH or LMWH, consider protamine 1

Discharge Planning and Follow-up

• Monitor for at least 24-48 hours after delivery for women with cardiac conditions due to risk of pulmonary edema from fluid shifts 1
• Search for anemia only in women who have bled during delivery or who present symptoms of anemia 4
• Oral iron supplementation should only be proposed in cases of biologically proven anemia 4

Common Pitfalls and Caveats

• Avoid rapid infusion of oxytocin as it can cause systemic hypotension 1
• During the immediate post-partum period, complications may be unrecognized or confused with natural post-partum evolution, requiring strong vigilance from practitioners 4
• This vigilance is especially necessary when maternal residence durations are shortened 4
• Avoid methylergonovine in women with cardiovascular disease due to risk of vasoconstriction and hypertension 1
• Be aware that vulvar hematomas, though rare, can rupture during delivery requiring rapid hemostasis 5