From the Guidelines
The best next step in management for this patient is to observe her closely and continue routine postpartum care. The patient's presentation is consistent with normal postpartum changes, including the mild temperature elevation (37.9°C/100.2°F), which commonly occurs in the first 24 hours after delivery due to dehydration and the physical exertion of labor 1. Her uterine fundus is appropriately firm and at the expected location (umbilicus), indicating normal uterine involution. The perineal repair is intact with expected lochia (vaginal discharge). The episode of rigors and chills immediately after placenta delivery is a common physiologic response and has not recurred. Her vital signs are otherwise stable, and she has been voiding normally.
While monitoring, healthcare providers should continue routine postpartum assessments including:
- Vital signs every 4-8 hours
- Fundal checks
- Lochia evaluation
- Pain management, which may include acetaminophen, ibuprofen, ice packs, and opiates only if needed, as well as sitz baths twice daily until the first wound check 1
- Consideration of stool softeners, such as polyethylene glycol 4450 or mineral oil, twice daily for six weeks postpartum to achieve toothpaste consistency stools, especially if there is concern for anal sphincter compromise 1
If her temperature rises above 38°C (100.4°F) on two occasions at least 6 hours apart (excluding the first 24 hours), or if she develops other concerning symptoms like increasing pain, foul-smelling discharge, or hemodynamic instability, further evaluation for postpartum infection would be warranted. It is also crucial to ensure proper documentation of the laceration type and repair technique, arrange early follow-up within two weeks, ideally in a specialized postpartum perineal clinic, and provide patient education on the degree of injury 1.
Given the potential for short- and long-term morbidity associated with perineal trauma, particularly obstetrical anal sphincter injuries (OASIS), it is essential to optimize surgical repair and postoperative recovery, which may include the use of a checklist to ensure adherence to critical care processes 1. However, in this case, since the patient's presentation and repair appear to be uncomplicated, close observation and routine postpartum care are the most appropriate next steps, with a focus on preventing potential complications and ensuring the best possible outcomes for the patient 1.
From the Research
Patient Assessment and Management
The patient is experiencing fatigue, perineal discomfort, and bloody vaginal discharge 8 hours after vaginal delivery. Key findings include:
- Temperature: 37.9 C (100.2 F) 2, 3, 4, 5
- Blood pressure: 120/80 mm Hg
- Pulse: 76/min
- Pelvic examination: intact perineal repair with minimal bloody discharge and small blood clots on the perineal pad
- Uterine fundus: firm, nontender, and palpable at the umbilicus
Vital Sign Monitoring
Monitoring the patient's vital signs, including temperature, is crucial in assessing her condition and identifying any potential complications 6, 4, 5. The patient's temperature is slightly elevated, which may indicate a possible infection or other complication.
Next Steps in Management
Based on the patient's symptoms and vital signs, the best next step in management would be to:
- Continue to monitor the patient's vital signs, including temperature, closely 2, 3, 4, 5
- Assess the patient's perineal repair and vaginal discharge for any signs of infection or bleeding
- Consider ordering laboratory tests, such as a complete blood count, to rule out any underlying infections or complications
- Provide the patient with pain management and comfort measures, as needed, to address her perineal discomfort and fatigue.