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INTRODUCTION

KEY QUESTIONS

  • What is the differential diagnosis of postpartum fever, and how is it managed?

  • What are common lower-extremity postpartum neuropathies, and how can they be prevented?

  • Why is exclusive breastfeeding important, and what is the role of the OB/GYN hospitalist in supporting this initiative?

  • How do you counsel a patient about postpartum contraception and the immediate placement of long-acting reversible contraceptives (LARCs)?

The postpartum period begins immediately after delivery and continues for 6 to 8 weeks. During this time, many changes occur to a woman’s physical, psychological and social state. The obstetrics and gynecology (OB/GYN) hospitalist plays a critical role in the evaluation and management of these patients. This chapter discusses the hospitalist’s role in managing common postpartum concerns, including postpartum fever, neuropathies, breastfeeding, and contraception. (Postpartum hemorrhage, another complication, is discussed separately in Chapter 41.)

POSTPARTUM FEVER

CASE 44-1

A 24-y.o. gravida 1 para 1, 2 days postoperative from a primary C-section, is evaluated for a fever of 39°C. Her pregnancy had been uncomplicated, and she was GBS negative. She presented to the hospital at 38 6/7 weeks gestation with ruptured membranes and was given oxytocin to augment labor. She progressed slowly, and after more than 16 hours of labor, she was diagnosed with arrest of dilatation at 8 cm. A primary C-section was performed and was uncomplicated. She was given 2 g of cefazolin prior to skin incision.

BACKGROUND

The US Joint Commission on Maternal Welfare defines maternal postpartum febrile morbidity as an oral temperature of 38.0°C or more on any two of the first 10 days postpartum, exclusive of the first 24 hours. The first 24 hours are excluded because low-grade fever during this period is common and often resolves spontaneously, especially after vaginal birth.1

There are maternal, intrapartum, and perioperative factors that increase the risk of postpartum fever. Maternal factors include poor nutrition, diabetes mellitus, and anemia. Intrapartum factors consist of prolonged labor, prolonged rupture of membranes (>18 hours), use of intrauterine monitors, frequent cervical examinations, and intrauterine infection or inflammation. Perioperative factors include operative vaginal delivery and cesarean delivery.28

Because the differential diagnosis for postpartum fever is quite broad, a thorough physical exam should be performed, including pelvic, wound, and breast exams. In addition, a urinalysis should be sent to evaluate for a urinary tract infection (UTI) as well as a complete blood count (CBC) to evaluate for leukocytosis. Imaging is usually reserved for patients with clinical findings or when there is no response to empiric therapy. The goal is to identify the source of the fever and to direct therapy accordingly. The differential diagnosis includes endometritis, lactational mastitis, wound infection, UTI, pneumonia, atelectasis, drug reaction, Clostridium difficile–associated diarrhea, thromboembolic disease, septic pelvic thrombophlebitis (SPT), and anesthesia complications. Some important causes of postpartum fever are discussed next.

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