What is the recommended postpartum evaluation and frequency after vaginal delivery?

Recommended Postpartum Evaluation After Vaginal Delivery

After all vaginal deliveries, a systematic evaluation of perineal trauma should be performed, including visual inspection, thorough perineal examination, and digital rectal examination to detect potential obstetric anal sphincter injuries (OASIS). 1

Immediate Postpartum Evaluation (First 24 Hours)

Physical Examination Components

• Systematic perineal assessment:

  • Visual inspection of the perineum
  • Thorough perineal examination
  • Digital rectal examination (crucial for detecting OASIS)
  • Assessment of perineal lacerations and their degree 1

• Vital signs monitoring:

  • Blood pressure
  • Heart rate
  • Temperature 2

• Bleeding assessment:

  • Quantification of blood loss (>500 mL constitutes postpartum hemorrhage)
  • Evaluation of uterine tone and fundal height 3
  • Inspection for genital tract trauma 2

• Uterine assessment:

  • Evaluation of uterine involution
  • Uterine massage if tone is inadequate 3

Frequency of Evaluation in First 24 Hours

• Vital signs and bleeding assessment: Every 15 minutes for first hour, then every 30 minutes for second hour, then hourly for 4 hours if stable
• Uterine tone assessment: Same frequency as vital signs
• Pain assessment: With each vital sign check

Ongoing Postpartum Evaluation (24 Hours to 6 Weeks)

Physical Examination Components

• Continued monitoring of:

  • Blood pressure
  • Heart rate
  • Bleeding
  • Uterine involution
  • Genital pain
  • Urination
  • Temperature
  • Bowel function
  • Signs of phlebitis 2

• Perineal assessment:

  • Evaluation of episiotomy or laceration healing
  • Signs of infection or dehiscence 2

Frequency of Ongoing Evaluation

• Daily assessment during hospitalization
• Follow-up examination at approximately 6 weeks postpartum

Special Considerations

Laboratory Testing

• Hemoglobin assessment is only recommended for women who experienced significant bleeding during delivery or who present with symptoms of anemia (defined as Hb <11 g/dL at 48 hours postpartum) 2

Imaging

• Ultrasound is not routinely indicated in the immediate postpartum period unless there are concerns for retained placental tissue or abnormal bleeding
• When indicated, transvaginal ultrasound combined with transabdominal approach is the primary modality of choice 1
• Normal postpartum ultrasound findings include:
  • Mean endometrial stripe thickness: 1.1 ± 0.6 cm
  • Mean uterine length: 16.1 ± 1.7 cm
  • Mean uterine width: 8.7 ± 1.0 cm
  • Echogenic material in the uterine cavity (seen in approximately 40% of normal postpartum women) 4

Management of Common Complications

Perineal Pain Management

• Oral NSAIDs are effective for perineal pain and promoting uterine involution 2
• Ice packs, heating pads, hydrocortisone, and local anesthetic application to the perineum as adjunctive approaches 1

Perineal Wound Complications

• For broken down perineal wounds, suturing is preferred for large dehiscence
• Infection of perineal scar requires oral broad-spectrum antibiotics and local wound care 2
• Hygiene advice should be given to all women with episiotomy or perineal tear 2

Postpartum Hemorrhage

• Immediate intervention with uterine massage and oxytocin administration (10-40 units in 1000mL IV fluid)
• Early administration of tranexamic acid (1g IV within 3 hours of bleeding onset) for clinically diagnosed hemorrhage 3

Pitfalls and Caveats

1. Missed OASIS: Up to 35% of anal sphincter injuries may be missed without proper examination. Always perform a digital rectal examination after vaginal delivery 1

2. Delayed Recognition of Complications: During the immediate postpartum period, complications may be confused with normal postpartum changes, requiring vigilant monitoring 2

3. Ovarian Vein Thrombosis: Consider this diagnosis in patients readmitted with presumed endometritis after vaginal delivery who don't respond to antibiotics 5

4. Postpartum Preeclampsia: Monitor for de novo hypertension or worsening of existing hypertension, which may indicate postpartum preeclampsia 2

5. Thromboembolic Risk: The risk after vaginal birth is approximately 1‰. Consider thromboprophylaxis with LMWH based on individual risk factors 2