You are on page 1of 11

Puerperal Infection
The term puerperal infection refers to a bacterial infection following childbirth. The infection
may also be referred to as puerperal or postpartum fever. The genital tract, particularly the uterus,
is the most commonly infected site. In some cases infection can spread to other points in the
body. Widespread infection, or sepsis, is a rare, but potentially fatal complication.
Puerperal infection affects an estimated 1-8% of new mothers in the United States. Given
modern medical treatment and antibiotics, it very rarely advances to the point of threatening a
woman's life. An estimated 2-4% of new mothers who deliver vaginally suffer some form of
puerperal infection, but for cesarean sections, the figure is five-10 times that high.
Deaths related to puerperal infection are very rare in the industrialized world. It is estimated
three in 100,000 births result in maternal deathdue to infection. However, the death rate in
developing nations may be 100 times higher.
Postpartum fever may arise from several causes, not necessarily infection. If the fever is related
to infection, it often results from endometritis, an inflammation of the uterus. Urinary tract,
breast, and wound infections are also possible, as well as septic thrombophlebitis, a blood clotassociated inflammation of veins. A woman's susceptibility to developing an infection is related
to such factors as cesarean section, extended labor, obesity, anemia, and poor prenatal nutrition.
Causes and symptoms
The primary symptom of puerperal infection is a fever at any point between birth and 10 days
postpartum. A temperature of 100.4F (38C) on any two days during this period, or a fever of
101.6F (38.6C) in the first 24 hours postpartum, is cause for suspicion. An assortment of
bacterial species may cause puerperal infection. Many of these bacteria are normally found in the
mother's genital tract, but other bacteria may be introduced from the woman's intestine and skin
or from a healthcare provider.
The associated symptoms depend on the site and nature of the infection. The most typical site of
infection is the genital tract. Endometritis, which affects the uterus, is the most prominent of
these infections. Endometritis is much more common if a small part of the placenta has been
retained in the uterus. Typically, several species of bacteria are involved and may act
synergisticallythat is, the bacteria's negative effects are multiplied rather than simply added
together. Synergistic action by the bacteria can result in a stubborn infection such as anabscess.
The major symptoms of a genital tract infection include fever, malaise, abdominal pain, uterine
tenderness, and abnormal vaginal discharge. If these symptoms do not respond to antibiotic
therapy, an abscess or blood clot may be suspected.
Other causes of postpartum fever include urinary tract infections, wound infections, septic
thrombophlebitis, and mastitis. Mastitis, or breast infection, is indicated by fever, malaise, achy
muscles, and reddened skin on the affected breast. It is usually caused by a clogged milk duct
that becomes infected. Infections of the urinary tract are indicated by fever, frequent and painful
urination, and back pain. Anepisiotomy and a cesarean section carry the risk of a wound

infection. Such infections are suggested by a fever and pus-like discharge, inflammation, and
swelling at wound sites.
Fever is not an automatic indicator of puerperal infection. A new mother may have a fever owing
to prior illness or an illness unconnected to childbirth. However, any fever within 10 days
postpartum is aggressively investigated. Physical symptoms such as pain, malaise, loss of
appetite, and others point to infection.
Many doctors initiate antibiotic therapy early in the fever period to stop an infection before it
advances. A pelvic examination is done and samples are taken from the genital tract to identify
the bacteria involved in the infection. The pelvic examination can reveal the extent of infection
and possibly the cause. Blood samples may also be taken for blood counts and to test for the
presence of infectious bacteria. Aurinalysis may also be ordered, especially if the symptoms are
indicative of a urinary tract infection.
If the fever and other symptoms resist antibiotic therapy, an ultrasound examination or computed
tomography scan (CT scan) is done to locate potential abscesses or blood clots in the pelvic
region. Magnetic resonance imaging (MRI) may be useful as well, in addition to a heparin
challenge test if blood clots are suspected. If a lung infection is suspected, a chest x ray may also
be ordered.
Antibiotic therapy is the backbone of puerperal infection treatment. Initial antibiotic therapy may
consist of clindamycin and gentamicin, which fight a broad array of bacteria types. If the fever
and other symptoms do not respond to these antibiotics, a third, such as ampicillin, is added.
Other antibiotics may be used depending on the identity of the infective bacteria and the
possibility of an allergic reaction to certain antibiotics.

Postpartum Infection
Postpartum infections comprise a wide range of entities that can occur after vaginal and cesarean
delivery or during breastfeeding. In addition to trauma sustained during the birth process or
cesarean procedure, physiologic changes during pregnancy contribute to the development of
postpartum infections.[1] The typical pain that many women feel in the immediate postpartum
period also makes it difficult to discern postpartum infection from postpartum pain.

Postpartum patients are frequently discharged within a couple days following delivery. The short
period of observation may not afford enough time to exclude evidence of infection prior to
discharge from the hospital. In one study, 94% of postpartum infection cases were diagnosed
after discharge from the hospital.[2]Postpartum fever is defined as a temperature greater than
38.0C on any 2 of the first 10 days following delivery exclusive of the first 24 hours.[3] The
presence of postpartum fever is generally accepted among clinicians as a sign of infection that
must be determined and managed.
Local spread of colonized bacteria is the most common etiology for postpartum infection
following vaginal delivery. Endometritis is the most common infection in the postpartum period.
Other postpartum infections include (1) postsurgical wound infections, (2) perineal cellulitis, (3)
mastitis, (4) respiratory complications from anesthesia, (5) retained products of conception,
(6) urinary tract infections (UTIs), and (7) septic pelvic phlebitis. Wound infection is more
common with cesarean delivery.
United States
Overall US rates for incidence and prevalence of postpartum infections is lacking. In a study by
Yokoe et al in 2001, 5.5% of vaginal deliveries and 7.4% of cesarean deliveries resulted in a
postpartum infection.[2] The overall postpartum infection rate was 6.0%. Endometritis accounted
for nearly half of the infections in patients following cesarean delivery (3.4% of cesarean
deliveries). Mastitis and urinary tract infections together accounted for 5% of vaginal deliveries.

In most reviews, maternal death rates associated with infection range from 4-8%, or
approximately 0.6 maternal deaths per 100,000 live births.
A pregnancy-related mortality surveillance by the Centers for Disease Control and Prevention
indicated infection accounted for about 11.6% of all deaths following pregnancy that resulted in
a live birth, stillbirth, or ectopic.[4]

The risk of postpartum urinary tract infection is increased in the African American, Native
American, and Hispanic populations.[5]
The history and course of the delivery is important in the evaluation of postpartum patients.
Ascertain if the delivery was vaginal or cesarean.
Ascertain if premature rupture of the membranes occurred.
Determine if the patient had any prenatal care.
Determine if the patient was diagnosed or treated for any infections during pregnancy or
during the antepartum period.
Assess the patient's symptoms.
Features vary depending on the source of infection and may include the following:
o Flank pain, dysuria, and frequency of UTIs
o Erythema and drainage from the surgical incision or episiotomy site, in cases of
postsurgical wound infections
o Respiratory symptoms, such as cough, pleuritic chest pain, or dyspnea, in cases of
respiratory infection or septic pulmonary embolus
o Fever and chills
o Abdominal pain
o Foul-smelling lochia
o Breast engorgement in cases of mastitis
Focus the physical examination on identifying the source of fever and infection. A complete
physical examination, including pelvic and breast examinations, is necessary. Findings may
include the following:

o Endometritis may be characterized by lower abdominal tenderness on one or both

sides of the abdomen, adnexal and parametrial tenderness elicited with bimanual
examination, and temperature elevation (most commonly >38.3C).
o Some women have foul-smelling lochia without other evidence of infection.
Some infections, most notably caused by group A beta-hemolytic streptococci, are
frequently associated with scanty, odorless lochia.
Wound infections
o Patients with wound infections, or episiotomy infections, have erythema, edema,
tenderness out of proportion to expected postpartum pain, and discharge from the
wound or episiotomy site.
o Drainage from wound site should be differentiated from normal postpartum lochia
and foul-smelling lochia, which may be suggestive of endometritis.
Mastitis: Patients with mastitis have very tender, engorged, erythematous breasts.
Infection frequently is unilateral.
Urinary tract infections: Patients with pyelonephritis or UTIs may have costovertebral
angle tenderness, suprapubic tenderness, and an elevated temperature.
Respiratory tract infections: Evaluate for tachypnea, rales, crackles, rhonchi,and
Septic pelvic thrombophlebitis: Patients with septic pelvic thrombophlebitis, although
rare, may have palpable pelvic veins. These patients also have tachycardia that is out of
proportion to the fever.

Causes and risk factors may include the following:
o Route of delivery is the single most important factor in the development of
o The risk of endometritis increases dramatically after cesarean delivery.[6, 7]
o However, there is some evidence that hospital readmission for management of
postpartum endometritis occurs more often in those who delivered vaginally.[7]
o Other risk factors include prolonged rupture of membranes, prolonged use of
internal fetal monitoring, anemia, and lower socioeconomic status.[6]
o Perioperative antibiotics have greatly decreased the incidence of endometritis.[6]
o In most cases of endometritis, the bacteria responsible are those that normally
reside in the bowel, vagina, perineum, and cervix.
o The uterine cavity is usually sterile until the rupture of the amniotic sac. As a
consequence of labor, delivery, and associated manipulations, anaerobic and
aerobic bacteria can contaminate the uterus.
Wound infections
o Most often, the etiologic organisms associated with perineal cellulitis and
episiotomy site infections are Staphylococcus or Streptococcusspecies and gramnegative organisms, as in endometritis.
o Vaginal secretions contain as many as 10 billion organisms per gram of fluid. Yet,
infections develop in only 1% of patients who had vaginal tears or who underwent

o Those who underwent cesarean delivery have a higher readmission rate for wound
infection and complications than those who delivered vaginally.[8]
Genital tract infections
o Increased risk related to the duration of labor (ie prolonged labor increases risk of
infection), use of internal monitoring devices, and number of vaginal
o Genital tract infections are generally polymicrobial.
o Gram-positive cocci and Bacteroides and Clostridium species are the predominant
anaerobic organisms involved. Escherichia coli and gram-positive cocci are
commonly involved aerobes.
o The most common organism reported in mastitis is Staphylococcus aureus.
o The organism usually comes from the breastfeeding infant's mouth or throat.
o Thrombosis
o Numerous factors cause pregnant and postpartum women to be more susceptible
to thrombosis. Pregnancy is known to induce a hypercoagulable state secondary to
increased levels of clotting factors. Also, venous stasis occurs in the pelvic veins
during pregnancy.
o Although relatively rare, septic pelvic thrombosis is occasionally observed in the
postpartum patient, who might have fever.
Urinary tract infections
o Bacteria most frequently found in UTIs are normal bowel flora, includingE
coli and Klebsiella,Proteus, and Enterobacter species.
o Any form of invasive manipulation of the urethra (eg, Foley catheterization)
increases the likelihood of a UTI.
General risk factors
o History of cesarean delivery
o Premature rupture of membranes
o Frequent cervical examination (Sterile gloves should be used in examinations.
Other than a history of cesarean delivery, this risk factor is most important in
postpartum infection.)
o Internal fetal monitoring
o Preexisting pelvic infection including bacterial vaginosis
o Diabetes
o Nutritional status
o Obesity

Differential Diagnoses
Breast abscess
Deep vein thrombosis
Pelvic Inflammatory Disease

Tuboovarian Abscess
Urinary Tract Infection, Female
Laboratory Studies
Laboratory studies are directed at elucidating the severity of illness as well as the etiology of the
infection. Mild cases of mastitis usually do not require laboratory investigation. Wound
infections and infections of the genital tract makes it more difficult to ascertain the extent of
involvement. Laboratory studies should include the following:
Complete blood count
Blood cultures, if sepsis is suspected
Urinalysis, with cultures and sensitivity tests
Cervical or uterine cultures
Wound cultures, if appropriate
Lactate, if sepsis suspected
Coagulation studies, if pelvic thrombosis, deep vein thrombosis, pulmonary embolism, or
invasive treatment (eg, surgical procedure) is being considered
Imaging Studies
Pelvic ultrasonography may be helpful in detecting retained products of conception,
pelvic abscess, or infected hematoma.
Contrast-enhanced CT or MRI are useful in establishing the diagnosis of septic pelvic
In some cases, a contrast-enhanced CT examination of the abdomen and pelvis may be
helpful if concurrent concern is present for other non-pregnancyrelated
abdominal/pelvic sources of the infection (eg, appendicitis, colitis).
Prehospital Care
The most important aspect of prehospital care in a postpartum patient with a suspected infection
is to ensure adequate fluid volume and to prevent sepsis and shock.

Provide aggressive fluid management.

Begin cardiac monitoring and administer oxygen.
Emergency Department Care
ED care is focused on identifying the source of the infection, followed by appropriate
antimicrobial therapy and referral.
Postpartum endometritis treatment
o In most cases, initial antimicrobial treatment is a combination of an
aminoglycoside and clindamycin. Alternatively, an aminoglycoside plus
metronidazole with or without ampicillin may also be used.[11]

o Mild cases of endometritis after vaginal delivery may be treated with oral
antimicrobial agents (eg, doxycycline, clindamycin).
o Moderate-to-severe cases, including those involving cesarean deliveries, should
be treated with parenteral broad-spectrum antimicrobials.
o A review of trials for antibiotic regimens for the treatment of endometritis by
French and Smaill in 2004 concluded that gentamicin in combination with
clindamycin is appropriate for endometritis.[12]
o In general, the patient's condition rapidly improves after antibiotics are
Wound infection or episiotomy infection treatment
o Drainage, debridement, and irrigation may be required.
o Broad-spectrum antibiotics should be administered.
Mastitis treatment
o Administer a penicillinase-resistant antibiotic such as cephalexin, dicloxacillin or
cloxacillin, or clindamycin in penicillin-allergic patients.[11]
o Use local measures, such as ice packs, analgesics, and breast support.[11]
o The mother should be told to continue to breastfeed the baby.
o Continued breastfeeding prevents breast engorgement and subsequent pain.
o If a breast abscess is present, or breastfeeding is not possible, a breast pump
should be used in lactating women.[11]
o Mastitis could lead to abscess formation, which may require surgical drainage.
UTI treatment
o Administer fluids, if evidence of dehydration exists.
o Appropriate antibiotics should be used. These typically are trimethoprimsulfamethoxazole, nitrofurantoin, ciprofloxacin, levofloxacin, or ofloxacin.[13, 14, 15]
o The above antibiotics (including fluoroquinolones) for UTI are considered safe by
the American Academy of Pediatrics (AAP) for nursing infants, with no reported
effects seen in infants who are breastfeeding.[13, 14]
o Although the AAP considers fluoroquinolones to be safe for breastfeeding
mothers, they also recommend that the safest drug should be prescribed.
Fluoroquinolones are excreted in breast milk with unknown absorption by the
infant. The potential for pediatric cartilage and joint damage were extrapolated
from juvenile animal studies.[16, 17] For this reason, fluoroquinolones should not be
first-line therapy and temporary discontinuation of breastfeeding should be
considered.[16, 18]
o Trimethoprim-sulfamethoxazole and nitrofurantoin are to be avoided in mothers
with breastfeeding infants with G-6-PD deficiency.[13, 14]
o When possible, the medication should be taken just after the patient has breastfed
the infant to minimize drug exposure.[13]
o Fever and flank pain should raise suspicion for pyelonephritis, and inpatient
hospital admission should be considered. Ampicillin and gentamicin may also be
given to lactating mothers with no reported effects on breastfeeding infants.[13]
Septic pelvic phlebitis treatment

o Broad-spectrum antibiotics should be administered. Initial choice of antibiotics

should cover gram-positive, gram-negative, and anaerobic organisms. Ampicillin
and gentamicin with metronidazole or clindamycin is a common regimen.[11, 10]
o Anticoagulation may be used, and it should be noted that there exist no universal
guideline or recommendation for anticoagulation therapy in septic pelvic
thrombosis. Initial bolus of 60 units/kg (4000 units maximum) followed by 12
units/kg/h (maximum of 1000 units/h) is recommended.[6] The aPTT is monitored
for 2-3 times the normal value.[11, 10]
o Alternatively, low-molecular weight heparin may be used with a dose of 1 mg/kg.
[11, 10]

Obstetric consultation must be obtained in cases of endometritis, postsurgical wound infections
and cellulitis, retained products of conception, and septic pelvic phlebitis. If an
obstetrician/gynecologist is unavailable, seek consultation with a general surgeon.
Medication Summary
Antibiotics are the mainstay of treatment. Pain medications also are important, because patients
often have discomfort. Patients with septic pelvic thrombophlebitis must undergo anticoagulation
therapy, and they should receive broad-spectrum antibiotics.
Class Summary
Antibiotic coverage for Bacteroides, group B and A streptococci, Enterobacteriaceae organisms,
and Chlamydia trachomatis in endometritis is suggested. Wound and episiotomy site infections
require broad-spectrum antibiotics as well, because of the polymicrobial nature of the local flora.
Consider coverage primarily for Staphylococcus aureus infection in postpartum mastitis.
Second-generation cephalosporin indicated for gram-positive coccal and gram-negative rod
infections. Infections caused by cephalosporin-resistant or penicillin-resistant gram-negative
bacteria may respond to cefoxitin. Must be used with clindamycin or doxycycline and an
aminoglycoside for the treatment of endometritis, for which it is a drug of choice. Particularly
important in early postpartum (first 48 h) infections.
Inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S
ribosomal subunits of susceptible bacteria. Must be used with other drugs for endometritis. Used
often for outpatient therapy for late postpartum (48 h to 6 wk after delivery) treatment.
Gentamicin (Garamycin)

Aminoglycoside antibiotic used for gram-negative bacterial coverage. Commonly used with an
agent against gram-positive organisms in treatment of endometritis. Consider if penicillins or
other less toxic drugs are contraindicated, when clinically indicated, and in mixed infections
caused by susceptible staphylococci and gram-negative organisms. Dosing regimens are
numerous and adjusted on the basis of CrCl and changes in volume of distribution. Gentamicin
may be given IV/IM.
Inhibits bacterial protein synthesis by inhibiting peptide chain initiation at the bacterial ribosome
where it binds preferentially to the 50S ribosomal subunit, causing bacterial growth inhibition.
Must be used with other drugs in the treatment of endometritis. Second drug of choice, after
dicloxacillin, in postpartum mastitis.
Bactericidal antibiotic that inhibits cell wall synthesis. Used in treatment of infections caused by
penicillinase-producing staphylococci. Primary drug of choice used for postpartum mastitis to
cover S aureus.
Used with heparin and third-generation parenteral cephalosporin in the treatment of septic pelvic
vein thrombophlebitis to cover streptococci and Bacteroides andEnterobacteriaceae species.
First-generation cephalosporin used to cover S aureus in mastitis. Encourage the mother to
continue breastfeeding to shorten duration of symptoms. Another DOC for postpartum mastitis
Further Inpatient Care
Patients with early postpartum endometritis (especially after cesarean delivery) should be
admitted, as should any patient with suspected septic pelvic vein thrombosis. Postsurgical wound
infections may also require inpatient management, particularly if there is extensive involvement
of surrounding soft tissues, intractable pain, and fever.
Further Outpatient Care
All patients with a postpartum infection should undergo follow-up with an obstetrician.

Septic shock

The prognosis for postpartum infections is good with prompt and appropriate therapy.
Patient Education
For patient education resources, see the Pregnancy and Reproduction Center, as well
as Postpartum Perineal Care