Twenty-four-year-old woman, 28 hours after vaginal delivery, presents with fever and diffuse tenderness on bimanual exam and a tender uterus. Most likely diagnosis and next step?

• A. Endometritis; IV antibiotics
• B. Uterine atony; IV fluids
• C. Pelvic abscess; surgical drainage
• D. Wound infection; oral antibiotics

Answer: (A)

Postpartum fever with a tender, diffusely tender uterus is classic for endometritis, an infection of the endometrium after delivery. The combination of fever and uterine tenderness several hours after birth points toward an infectious process in the uterus rather than atony (which causes heavy bleeding from a noncontracting uterus) or a wound infection (which would involve the incision area). The appropriate next step is to start broad-spectrum IV antibiotics that cover the usual postpartum pathogens, including anaerobes and gram-negatives. A common regimen is IV clindamycin plus gentamicin, with alternatives like ampicillin-sulbactam depending on local protocols and allergy history. If there’s poor response or concern for an abscess or sepsis, further evaluation and possible imaging or intervention would be needed.