In rare cases, fractures of the sacrum or pubic ramus are caused by even uncomplicated deliveries (Alonso-Burgos, 2007; Speziali, 2015). As discussed in Chapter 58 (p. 1129), the latter are more likely with osteoporosis associated with heparin or corticosteroid therapy (Cunningham, 2005). In rare bur serious cases, bacterial osteomyelitis-osteitis pubis-can be devastating. Lawford and coworkers (2010) reported such a case that caused massive vulvar edema.
he D-negative woman who is not isoimmunized and whose newborn is D-positive is given 300 -1g of anti-D immune globulin shortly after delivery (Chap. IS, p. 305). Women who are not already immune to rubella or varicella are excellent candidates for vaccination before discharge (Swamy, 2015). hose who have not received a tetanus/diphtheria or inluenza vaccine should be given these (American College of Obstetricians and Gynecologists, 2017 c). Morgan and colleagues (2015) reported that implementation of a best-practices alert in the electronic medical record was associated with a tetanus/diphtheria immunization rate of 97 percent at Parkland Hospital. Vaccination is also discussed in Chapter 9 (p. 171).
Following uncomplicated vaginal delivery, hospitalization is seldom warranted for more than 48 hours. A woman should receive instructions concerning anticipated normal physiological puerperal changes, including lochia patterns, weight loss from diuresis, and milk let-down. She also should receive instructions concerning fever, excessive vaginal bleeding, or leg pain, swelling, or tenderness. Persistent headaches, shortness of breath, or chest pain warrant immediate concern.
Hospital-stay length following labor and delivery is now regulated by federal law (Chap. 32, p. 616). Currently, the norms are hospital stays up to 48 hours following uncomplicated vaginal delivery and up to 96 hours following uncomplicated cesarean delivery (American Academy of Pediatrics, 2017; Blumenfield, 2015). Earlier hospital discharge is acceptable for appropriately selected women if they desire it .
During the hospital stay, a concerted efort is made to provide family planning education. Various forms of contraception are discussed throughout Chapter 38 and sterilization procedures in Chapter 39.
Women not breastfeeding have return of menses usually within 6 to 8 weeks. At times, however, it is diicult clinically to assign a speciic date to the first menstrual period after delivery. A minority of women bleed small to moderate amounts intermittently, starting soon after delivery. Ovulation occurs at a mean of 7 weeks, but ranges from 5 to 11 weeks (Perez, 1972). hat said, ovulation before 28 days has been described (Hytten, 1995). hus, conception is possible during the artiicially deined 6-week puerperium. Women who become sexualy active during the puerperium, and who do not desire to conceive, should initiate contraception. Kelly and associates (2005) reported that by the third month postpartum, 58 percent of adolescents had resumed sexual intercourse, but only 80 percent of these were using contraception. Because of this, many recommend long-acting reversible contraceptives-LARC (Baldwin, 2013).
Women who breastfeed ovulate much less frequently compared with those who do not, but variation is great. Timing of ovulation depends on individual biological variation and the intensity of breastfeeding. Lactating women may first menstruate as early as the second or as late as the 18th month after delivery. Campbell and Gray (1993) analyzed daily urine specimens to determine the time of ovulation in 92 lactating women. As shown in Figure 36-8, breastfeeding in general delays resumption of ovulation, although as already empha 8..) 50