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Journal of Midwifery & Women’s Health www.jmwh.

org
Original Review

Puerperal Infections of the Genital Tract: A Clinical
Review
CEU
Deborah Brandt Karsnitz, CNM, DNP

Puerperal genital tract infections, although less common in the 21st century, continue to affect maternal mortality and morbidity rates in the United
States. Puerperal genital tract infections include endometritis as well as abdominal and perineal wound infections. These infections interrupt
postpartum restoration, increase the potential for readmission to a health care facility, and can interfere with maternal-infant bonding. In addition,
unrecognized or improperly treated genital tract infection could extend to other sites via venous circulation or the lymphatic system and increase
the risk of severe complications or sepsis. Midwives are leaders in education, low rates of intervention, and prompt recognition of deviation from
normal. Because puerperal genital tract infection usually begins after discharge, detailed education for women will encourage preventative health
care, prompt recognition, and treatment.
J Midwifery Womens Health 2013;58:632–642  c 2013 by the American College of Nurse-Midwives.

Keywords: genital tract infection, puerperal infection, postpartum, infection, fever, sepsis, wound infection, endometritis

INTRODUCTION article will primarily focus on puerperal infections of the
Puerperal genital tract infection has historically been one of genital tract.
the leading causes of morbidity and mortality globally and
in the United States.1, 2 Although prior reports have shown METHODS
a decreased trend in puerperal genital tract infection since In order to identify the most recent literature for this review, a
the early 20th century, infection still accounts for 11% of literature search was conducted using multiple electronic data
pregnancy-related deaths in the United States.3, 4 bases including PubMed, MEDLINE, CINAHL, Cochrane
Reports also indicate that for every case of maternal death, Database, and Google Scholar. Publications from the Ameri-
several unreported cases of significant morbidity occur.5, 6 In can College of Obstetrics and Gynecology and the Centers for
fact, during the past decade the incidence of severe puerperal Disease Control and Prevention (CDC) were also searched.
sepsis has increased in the United States and other developed Search terms included “puerperal infection” and “genital tract
countries.7, 8 Potential causes of this increase in genital tract infection” as well as “systematic reviews,” “meta-analysis,” and
infection and sepsis may include surveillance issues such as “randomized control trials.” Articles found were incorporated
improved data gathering and tracking and inclusion of di- into the following clinical review.
rect and indirect pregnancy related causes up to one year af-
ter pregnancy,4 but also may include the rise in surgical birth, PUERPERAL INFECTION: DEFINITIONS AND
obesity, chronic health disorders, lack of education, and de- HISTORY
ficient prenatal care.5 Lack of access to care prohibits early
treatment and increases the risk of maternal morbidity and Puerperal fever most often results from an infection, genital or
mortality.3, 5 otherwise.11 Other conditions such as dehydration, breast en-
Puerperal genital tract infection disrupts postpartum gorgement, or thrombophlebitis could be the origin of fever
restoration, increases maternal anxiety, can hinder maternal- during the postpartum period but usually last 24 hours or
infant bonding, and has a negative impact on breastfeeding.9 less.14 The United States Joint Commission on Maternal Wel-
In addition, puerperal genital tract infection increases the fare classifies puerperal fever as a temperature increase above
likelihood of readmission to a hospital.9 Consequently, over- 100.4◦ F (38◦ C) which occurs after the initial 24 hours and for
all health care costs increase and productivity is delayed both 2 or more days during the first 10 days postpartum.15 On-
at home and at work.9, 10 Judicious hand washing, asepsis, set of a fever greater than 102.2◦ F (39.0◦ C) early postpartum
and antimicrobial therapy have decreased morbidity and (within 24 hours) and post cesarean birth could be secondary
mortality.11, 12 However, women remain at risk, particularly to Group A Streptococcus.16
following cesarean birth.3, 13 Furthermore, delayed recogni- The term puerperal infection has been used interchange-
tion of a puerperal infection postpones initiation of proper ably with genital tract infection. However, infection during
treatment and increases the likelihood of severe infection, the puerperium can occur elsewhere in the body, including
extended complications, or sepsis.8 Although all puerperal the breasts and the urinary and respiratory systems.17, 18
infections demand critical assessment and management, this In addition, the term puerperal morbidity has been used
interchangeably with puerperal infection despite different
definitions. Definitions of puerperal morbidity as an illness
Address correspondence to Deborah Brandt Karsnitz, CNM, DNP. within the first 10 days postpartum that exhibits a temper-
Phone: 502-541-1818. E-mail: deborah.karsnitz@frontier.edu ature of 100.4◦ F (38.0◦ C) or greater on any 2-day period

632 1526-9523/09/$36.00 doi:10.1111/jmwh.12119 
c 2013 by the American College of Nurse-Midwives

11 Puerperal Fever Temperature ⬎100. but occurring after the first 24 days postpartum. Definition used interchangeably with puerperal infection. Zwart.jmwh. 21 Writ. 16.20 Puerperal Genital Tract Infections specific to the genital tract. 21 to define any genital tract infection). ✦ Puerperal infections and sepsis remains a factor in maternal morbidity and mortality in the United States.15 Van Dillen. such as mood and anxiety disorders rooms. and (more recently) H1N1 influenza.16 Cunningham et al. 16 To further confound the matter.7. abnormal vaginal discharge. He eventually realized ings by Hippocrates and some ancient Hindu scripts dat. that midwives were washing their hands before touching the ing back to 1500 BC suggest concerns with childbed fever.18 WHO.4◦ F or 38.0◦ C) lasting 24 hours and one or more of the following: pelvic pain. tuberculosis. Schutte & van Roosmalen. diagnosis. 19 focus on infectious illness. and prompt treatment will decrease genital tract infection complications or sepsis.20 Sources: Maharaj & Teach.3 women they cared for.18 11 Puerperal Morbidity All complications occurring during the puerperium.11. crowded clinic staffed by midwives. ✦ Puerperal infections of the genital tract increase hospital readmission and may interfere with breastfeeding. aseptic techniques. 20 Table 1 defines The 19th century brought hope as Oliver Wendall Holmes various common puerperal definitions. ✦ Education and close postpartum follow-up will help women and providers identify subtle signs and symptoms of genital tract infection. urinary tract. Once hand washing was instituted in Table 1.11 Definition used interchangeably with Infection puerperal morbidity.18 without scientific study. abnormal odor. linens were not properly and other medical conditions directly or indirectly related cleaned. after the initial 24 hours15. lying-in became popular in some morbidity during the puerperium includes complications European hospitals. in the United States and later Ignaz Semmelweis in Europe identified the nature of puerperal infections. Common Definitions in describing postpartum infection Common Terms Definitions Comments Puerperium (Postpartum) Traditional definition of time period immediately following Time period varies in definition childbirth until approximately 6 weeks after childbirth. and puerperal infection. 20 Also includes other indirect infections such as HIV.11 Puerperal Sepsis Infection of the genital tract occurring any time between the onset of rupture of membranes or labor and 42 days postpartum with the presence of fever (a temperature ⬎ 100. The incidence of these infections is higher after cesarean birth. conditions were poor.21 Epidemics of puerperal to pregnancy. puerperal fever. puerperal fever were reported both in Europe and North America with genital tract infection has also been used interchangeably an astounding maternal sepsis death rate of 1 in every 4 to 5 with puerperal fever and childbed fever (general terms used women. ✦ Early recognition. Yet During the 17th century. or delay in involution.org 633 .21 Women were placed in overcrowded other than infection.11.11.11 hours post birth.20 Journal of Midwifery & Women’s Health r www.11 Adair. and respiratory system. and instruments were dirty.11 Puerperal Infection Any infection occurring during the puerperium including infections of the genital tract. and antibiotics. Includes direct (directly related to pregnancy) and indirect (illness exacerbated by pregnancy) complications. breasts. ✦ Decreasing risk factors for puerperal infections of the genital tract can prevent morbidity and mortality.11.4◦ F (38◦ C) on 2 or more days during the Definition was later extended to 42 15 (Childbed Fever) first 10 days postpartum.21 Semmelweis Puerperal Infection: Historical Perspective discovered that more women were dying from puerperal fever Puerperal fever was a dreaded diagnosis before the advent of in the ward staffed by medical students than in an over- hand washing.

and colonization with group B Streptococcus.9 Belfort et al found that 2655 of 222. increased vaginal examina- Puerperal Endometritis tions.26 There is increased blood loss. or in the abdominal wound subsequent to Haemophilus influenzae cesarean birth. every clinic that adopted hand washing Aerobes saw a decrease in infection.018 cases per 1000 woman-years). when Lacto. weight gain of 28 pounds by 28 weeks had an increased 634 Volume 58. risk of wound infections (P ⬍ .23 Also. 23 Women Etiology with chorioamnionitis or prolonged rupture of membranes Inflammation of the uterine lining.27 In ad. sarean birth. bowel. can occur in the endometrium. Table 2.9.28 At the postpartum. Peptococcus taminated surroundings. Other Mycoplasma teria dominated by Lactobacilli.9 is of growing concern as obesity rates rise.11 Bacterial organisms may be en.21 In 1879. B. women without access to prenatal care sarean birth (27%). 6. or environmental Fusobacterium cause). women who were obese (BMI ⬎ 30) had a higher pared to readmission after vaginal birth (0. for example.751 (1.49 vs 0.27 Risk factors other than surgical or instrumental birth include prolonged rupture of membranes. and infection when compared to nonpregnant women. according to BMI. 22.11 Staphylococcus Epidermis Gram-negative Escherichia coli PUERPERAL GENITAL TRACT INFECTIONS Klebsiella pneumoniae Pathogenesis Enterobacter Puerperal genital tract infections most often occur at the pla. No. Gram positive A.the clinic staffed by medical students. Bacteroids dogenous (normally existing in the genital tract. it was still many years until proper treatment was developed and puerperal sepsis mortal.22. November/December 2013 . examinations.2%) initial prenatal visit women were categorized into 4 groups women were readmitted to the hospital. obesity increases the risk for infection and postpartum readmission to a hospital. commonly referred to have a higher incidence of endometritis postpartum. Clostridium or skin) or exogenous (arising from existing vaginal in- fection.052 cases per 1000 woman-years). Chlamydia species bacilli do not dominate. Group B Streptococcus (GBS). infection is more likely to occur.9 an increased mean incidence in postpartum women for all in- fections.23 Neisseria Gonorrhoeae Table 2 illustrates common bacterial organisms identified as the source for most puerperal genital tract infections and Adapted from Cunningham. hospital charts were analyzed during the first 6 weeks index (BMI) and risk for peripartal complications.22.28 An observa- In a database analysis of postpartum readmissions in tional cohort study of 4286 women compared body mass 2007.019 cases per 1000 woman. help to prevent infection. When compared to women of normal sarean birth (1. weight. poor hand washing technique. or parametrium. and women with a uterine infection was increased in women after primary ce. increased vaginal examinations. Risk Factors years). 23.21 Despite continued controversy over the Infections source of the fever.22–24 Genital tract infec- tion occurs secondary to ascension of colonized bacteria Anaerobes Peptostreptococcus following rupture of amniotic membranes or from con. D Streptococci lished that Streptococcus was the primary cause of puerperal Enterococcus fever. 23 dition.25 and Postnatal Care for Advanced Practice Nurses.11 Organisms endogenous to the genital tract are polymicrobial and consist of both aerobic and anaerobic bac.22. myometrium. postpartum hemorrhage. 23 Women are susceptible to genital tract Gram-variable Gardnerella vaginalis infection if their resistance is decreased or if bacteria have an opportunity to colonize.001).001) com. the infection rates de. retained placental fragments.23 However. endometritis is one of the most common diagnoses for In addition.21 Despite a known source. in the laceration or episiotomy af. 27 Most women with endometritis de.56 vs 0.83%). Staphylococcus Aureus ity started to decline. Pseudomonas aeruginosa ter vaginal birth. including GAS (0. and S pneumoniae (0. GBS (0.8%) was significantly higher (P ⬍ .9 Possible factors for increased readmission in- partum women have an overall 20-fold increased incidence of cluded prolonged labor. do not receive proper education or screening. Risk factors often relate to one another.22 Endometritis occurs in 1% prolonged labor leads to increased number of vaginal to 2% of births but is significantly more common after ce.31 Data from a multistate surveillance of women with iden- tified Group A Streptococcus (GAS). which might velop symptoms within the first 5 days postpartum.15 vs 0.9 In addition.26 Cesarean birth holds the greatest risk for uterine infection. Proteus species cental implantation site. and Streptococcus Pneumoniae concluded that post. Louis Pasteur estab. Bacteria Commonly Found in Puerperal Genital Tract creased over time.22. 27 as endometritis or metritis. et al (2010) and used with permission from Prenatal sepsis. Readmission after ce.

etc. severity of presen. odorless lochia. Persistent fever 100. cephalosporins.000 mm3 ) Instrumental birth Subinvolution of uterus common in endometritis that presents Prolonged rupture of membranes after the first week postpartum Prolonged labor Reprinted with permission from Varney’s Midwifery (5th ed. Intravenous gentamicin (Garamycin) and clindamycin dicate severity of infection and likewise. usually indicated by a low-grade temperature. with puerperal endometritis. Oral antimicrobial treatment is only utilized if infection oc- toms may be indistinctive and present as a vague malaise curs subsequent to vaginal birth. depending on the severity of the infection Obesity/increased BMI Malaise. uterine tenderness. and urine and blood Poor technique – provider cultures.0o C). however. 27 Monother- and have temperatures greater than 102.001) and endometritis of pediatric providers and subsequent isolation. or malodorous seropurulent lochia Intrapartum and Operative birth (primary increases White blood cell count may be elevated beyond the physiologic Postpartum risk ⬎ elective) leukocytosis of the puerperium (⬎ 20. Manage- ment is determined by the severity of illness. cephalosporin. (Cleocin) are considered the gold standard of care for mod- tation may indicate organism responsible for infection.18.23 Tharpe.18 Endometritis can be mild to severe in nature.11 Laboratory studies include: com- Postpartum hematoma plete blood count with differential (10% or greater band count Postpartum hemorrhage warrants suspicion). beta-lactamase coccus often become ill within the early postpartum period antimicrobials. anemia. Untreated vaginal infection anorexia Advanced maternal age Chills often associated with a temperature that spikes or rises Low socioeconomic status quickly Access to care Tachycardia Smoking Uterine tenderness extending laterally Poor hygiene Pelvic pain with bimanual examination Scanty.2◦ F (39.31 Frequent vaginal examinations Internal fetal or uterine monitoring Management Uterine manipulation or exploration Retained placental fragments Careful and thorough history and physical examination are essential and often guide proper assessment and identification Chorioamnionitis of the source of infection. or Table 4 lists common signs and symptoms of puerperal penicillin-B-lactamase inhibitor combination can be used for endometritis.2◦ F (38◦ C – 39◦ C) up to 104◦ F Immuno-insufficiency (40◦ C). and subinvolution.22 cannot be changed.24 nation is difficult and broad-spectrum antimicrobials will al- Abbreviation: BMI. 18 The addition of endometrial or cervical cultures to help identify pathogens is controversial.001). metabolic panel.22.31 endometritis following vaginal birth.22. 22. and appendicitis.22 It is important to note that symp. Table 3. respiratory modified. Some authors pro- Tissue trauma pose that obtaining an endometrial culture without contami- Sources: Sweet & Gibbs.11 Table 3 reviews common risk factors associated illness. propose that iden- tification of GAS infection should further include notification risk for wound infection (P ⬍ 0.18 Mild en- Presenting Signs and Symptoms dometritis.28 ally. 22 erate to severe endometritis although other regimens can Women with infection secondary to group A or B Strepto. Presenting signs and symptoms of endometritis commonly can be treated with a broad-spectrum oral antibiotic (sim- include fever. Risk Factors for Puerperal Endometritis Table 4. 29 Addition- (P ⬍ 0.22 In a review by the Journal of Midwifery & Women’s Health r www. 24. body mass index. identification of GBS or Neisseria gonorrhoeae infec- While certain risk factors for puerperal endometritis tion also indicates a need for pediatric provider notification. some clearly can be discontinued or The differential diagnosis includes pyelonephritis. chest radiograph is indicated. purulent discharge/lochia.11.).22 Faro.4◦ F – 102.jmwh.27 Degree of temperature may in.18.14 Proponents of diagnostic endometrial and cervical culture. 30 apy with a broad-spectrum penicillin. leviate most bacterial organisms. Common Signs and Symptoms of Puerperal Maternal Preexisting medical conditions Endometritis such as diabetes.29 Endometritis usually occurs early postpartum vere cases of endometritis requires physician management for (within 48 hours) but may present later in the postpartum hospitalization and intravenous antimicrobial treatment.24 Moderate to se- infection. 32 Consultation with or pelvic pain mimicking flu-like illness or urinary tract a collaborating physician is recommended. be used alternatively (eg.org 635 . ilar to treatment for mild pelvic inflammatory disease).18 period (up to 6 weeks).14. broad-spectrum penicillins).18 If respiratory illness is suspected.

The were found to be an appropriate treatment regimen for en. 39 stud. antimicrobial treatment.5-1. hematoma. milligrams. 27 If antimicrobial treat- show significant improvement within 48 to 72 hours. necrotizing fasciitis. the wound site. intravenously.17 636 Volume 58.27 Abbreviations: g. Doxycycline (Vibramycin) 100 mg orally every 12 hours and Oral regimen only used for mild infection after vaginal birth. No. were compared for effi. Viral endometritis secondary to herpes simplex virus In the absence of complications. other aerobic units every 6 hours streptococci and enterococci Cefoxitin (Mefoxin) 1–2 g every 6 hours Used in mild to moderate infection Oral Regimens Ofloxacin (Floxin) 400 mg orally every 12 hours OR metronidazole Oral regimen only used for mild infection after vaginal birth. IM.22. ondary complications are less common since the advent of Once appropriate treatment is initiated women typically broad-spectrum antimicrobials.22. treatment resulting in septic pelvic thrombophlebitis. toms include low pelvic pain and unresolved fever despite damycin with an aminoglycoside (relative risk [RR] 1.22–24. routine postpartum follow. kilograms. occurring in fewer than 1% of women with uter- cacy and side effects for different antibiotics.44. and sep.22 It is another leading cause of hospital tic pelvic thrombophlebitis.5 mg/kg. (Flagyl) 500 mg orally every 12 hours may be added Ofloxacin (Floxin) not recommended if breastfeeding. Clindamycin (Cleocin) 900 mg every 8 hours and aztreonam For individuals with renal dysfunction when gentamycin is (Azactam) 1–2 g every 8 hours contraindicated Clindamycin (Cleocin) 900 mg every 8 hours and Most widely studied penicillin beta-lactamase combination ampicillin-sulbactam (Unasyn) 1.5 mg/kg every 8 hours Metronidazole (Flagyl) 500 mg every 12 hours and penicillin. 29 discontinue breastfeeding.8). every day dosing. presence of bacteria causes an inflammatory response on dometritis. NOTE: metronidazole (Flagyl) Doxycycline is not contraindicated with breastfeeding if used 500 mg orally every 12 hours may be added for anaerobic coverage for a short term (less than 3 weeks).5 g every 6 hours Ampicillin (Amoxil) 2 g every 6 hours and gentamicin (Garamycin) Usually given after a vaginal birth 1. Table 5. 27 ment is ineffective. births).33 PUERPERAL WOUND INFECTION (PERINEAL AND Complications ABDOMINAL) Approximately 1% to 4% of women with endometritis af. ceftriaxone (Rocephin) 250 mg IM. the cause may be resistant organisms or women experiencing wound infection are more likely to other infections such as pneumonia or pyelonephritis. abscess.18. Fifty percent to ported findings of no additional benefit for continued oral 76% of women may have tenderness and a rope-like struc- antimicrobial treatment after discharge. 32 Women desiring intrauterine contra.22 If septic pelvic throm- of antimicrobial treatment for endometritis are described in bophlebitis is suspected. 1. penicillin. most commonly in the ovarian vein. as well as broad-spectrum antibiotics that in. Recommended Antimicrobial Regimen for Puerperal Endometritis Antibiotic Regimen for Postpartum Endometritis. intramuscularly.22 The puerperium is a route of delivery. grams. kg. which can be traumatized during surgery. Enterococci resistance – add 1. Puerperal wound infection is usually suspected when ter cesarean birth may have serious complications such as the woman expresses additional discomfort and pain at sepsis. Table 6 reviews severe complications of genital tract infec- ception must be free of infection for a 3-month period before tions. 29 If symptoms subside but readmission for obstetric complications. or cytomegalovirus should be treated with antiviral therapy.22 Pain often radiates to the groin 95% confidence interval [CI]. fever persists. physician referral is indicated. clude penicillin-resistant bacteria. Sources: Sweet & Gibbs. which included 4221 women. Intravenous clindamycin and gentamicin hypercoagulable state with increased clotting factors.22. venous walls. Generic (Brand) Provider Pearls Intravenous Regimens Clindamycin (Cleocin) 900 mg plus gentamicin (Garamycin) Gold Standard Treatment. November/December 2013 . area. placement.22 up is indicated. Sec- Table 5. mg.10 Furthermore.22 Signs and symp- failure was found more often in regimens other than clin.22 French & Smaill. This review also re. IV. 5 million Effective against Group B streptococci. Clindamycin (Cleocin) 900 mg every 8 hours IV plus gentamicin Once daily gentamicin also used alternatively to every 8 hours (Garamycin) 1. dosage. 22. Cochrane group in 2004 (later updated in 2012).5 mg/kg. Septic pelvic thrombophlebitis is uncommon (1 in 3000 ies. every 8 hours IV OR ampicillin.22 eration. 6. and ine infection after cesarean birth.27 In 15 studies. PCN.27 Selected regimens ture present on pelvic examination. viral endometritis should also be a consid- Most women may be discharged when afebrile for 24 hours.

placebo (83) before repair ensued. 34 Presenting Signs and Symptoms of Perineal Wound Infections Significant localized pain and edema are the most common re- Risk Factors ported symptoms for perineal wound infections. magnetic resonance imaging. panel.14 Pathogens most often associated with wound in. sitz baths. Chills. and both aerobes and ing. accompanies wound infection. other studies dependent Possible surgical. from aminations. 3-month audit by Johnson et al (2012) in.org 637 . streptococci. Necrotizing fasciitis High fever. under-reporting. Subcutaneous gas noted on Surgical debridement and hard “wooden” feeling of fascia.34 Variation in incidence is rupture of membranes and instrumental birth were significant attributed to lack of standardized definition.14. fourth degree extension of a laceration. computerized tomography. Perineal Wound Infection phone interviews and obstetric records and included timing and length of rupture of membranes. extension of infection with Culture and sensitivity of exudate Broad-spectrum antimicrobials edema. siotomy or perineal lacerations. Perineal wound infections have decreased with the advent of increased hip pain is also an indicator of perineal infection.34 do not always designate whether the perineal wound infection followed an episiotomy or laceration. studies . Fahrenheit. 18 In addition.8◦ F (36. CBC. 22 A secondary repair of the wound is usually A prospective.4◦ F CBC and differential. All women participating re- cent (n = 39) had 2 markers for infections. Of the women returning Journal of Midwifery & Women’s Health r www. wound infections and use of antibiotics. episiotomy or large lacerations. Signs and symptoms Duggal et al studied the administration of prophylactic an- included the presence of 2 or more specific markers: perineal timicrobials for third and fourth degree extensions of epi- pain.0◦ C) or ⬍ 96. infection (radiograph.14 In addition. episiotomy ver- 0. F.3o C or less) usually these measures. purulent discharge. poor technique during laceration or incisional repair or use of certain suture material Management (catgut) can predispose a woman to infection. CT.34 Use of instruments for birth and episiotomy limit. On occasion. P = in provider or facility for health care.24 promised skin integrity.22 Physician referral is erations (including third and fourth degree) or episiotomy. randomized blinded trial of 147 women. Celsius.34 indicated for suspicion of abscess. 22 Dysuria can be present with perineal of membranes. or fur- Women were contacted by phone at 21 days postpartum and ther complication such as necrotizing fasciitis.8% to 10% in developed countries to as high as 20% or sus perineal laceration.7. Eleven per. uncertain time risk factors. debridement and cleans- fection include S aureus. complete blood count.0◦ C).24 asked questions pertaining to signs and symptoms for perineal In a prospective. ally includes removal of sutures.14.8 Maharaj.0189). 34 Despite Low-grade temperature (101. metabolic Broad-spectrum antimicrobials (38. tachycardia/tachypnea and upon primary source of hemodynamic. and degree of laceration. preexisting medical conditions. erythema without clear borders. or other nausea/vomiting.17. wound extension. MRI.22 Abbreviations: C. fluid. as well as com. ineffective data collection. Pain may radiate to Oral anticoagulants groin or upper abdomen. and change were both significant for perineal infection (P = . CT scan) management Sources: Barton & Sibai.14. however.35 antimicrobial.14 meticulous hand washing and aseptic technique. Prolonged greater in developing countries.14. number of vaginal ex- Incidence of perineal wound infection varies greatly. and administration of a broad-spectrum anerobes. or wound dehiscence.14 Treatment usu- infection. Table 6. while 5% (n = 16) ceived a single intravenous dose of a cephalosporin (64) or had 3 markers. not necessary with the exception of the presence of a third or cluded 341 women who had undergone repair of perineal lac. exudate is present and accompanies dehis- tract infections of the uterus34 and include prolonged rupture cence of the wound. Severe Complications of Puerperal Genital Tract Infections Complication Major Signs and Symptoms Diagnostics Management Abscess Persistent fever after antimicrobial therapy Ultrasound aids diagnosis Broad-spectrum antimicrobials Surgical drainage Septic Pelvic Continual flank and lower abdominal pain Diagnosis by CT scan or MRI Broad-spectrum antimicrobials Thrombophlebitis (varies in intensity).14 However.0o F or 38.14 Risk and inflamed with edema present beyond the wound’s bor- factors for wound infections are similar to those for genital ders. Risk factors were measured from both tele.0402. wounds.14 Sweet & Gibbs.jmwh. 34 Inability to achieve good hemostasis or traumatic handling of tissue may Management of a perineal wound infection includes exam- lead to development of a hematoma and increase the risk of ination for possible abscess or hematoma. postpartum infection may still de. radiograph Crepitus may be apparent at the wound site Sepsis Fever Temperature instability ⬎ 100.18 Wound edges appear red velop at the site of a perineal laceration or episiotomy.

there is rising concern Abdominal Wound Infection for an increase in maternal sepsis and subsequent maternal Incidence reports of abdominal wound infection after ce.22 The degree of severity of an abdominal wound infection drives the management. Group B Streptococcus.29 Unreg- ulated.39 However. 18 A nationwide confidential enquiry in the Netherlands during a 13-year timeframe (1993 to 2006) reported the ma- Signs and Symptoms ternal mortality ratio directly related to sepsis as 0.24 Sepsis or other complications such as exotoxins. 22 A low-grade tempera. 70% of women with this diagnosis needed intensive ture (101. erythema. rate of wound complications (P = . ranging tify sepsis related mortality. 1 per 3334 births. 100.000 live births. indicated by the presence of fever and at least 2 of the follow.18. presence of chorioam. Management of abdominal wound infection usually requires Of note. episiotomy.22 Although no longer the leading cause of maternal morbid- ity and mortality in the United States. Chlamydia trachomatis.38 Sepsis occurred in is associated with contamination from skin flora or bacte. and other organisms. when cytokines and other abscess or septic pelvic thrombophlebitis is a concern if fever immunomodulators which normally mediate infections are persists for more than 2 days.17 Abdominal wound infection included 9 million admissions for birth.for postpartum follow-up at 2 weeks (n = 107). care hospitalization and 31. 14 of 16 (88%) women had a negative medical history antimicrobial treatment. and 7 of 16 (44%) developed sepsis during the postpartum period.38 The incidence inal wound infection increases the length of hospital stay and rose from 0. mortality here and in other countries.29 The World Health Organization’s definition of puerperal sep- sis is not really different from the definition of genital tract Risk Factors infection. nal deaths occurred after uncomplicated vaginal birth in oth- planned cesarean birth is associated with a decreased inci.000 (in the 1980s) to 1.40 dominal wound.8 To specifically iden- sarean birth also demonstrate significant variation.37 Of note. Thus.40 Severe maternal morbidity common.037). subsequently increases health care costs.3o C or less) will often accompany an ab.6 per 100. 14 Abdominal wound infections American women and women of other ethnic minorities. Nationwide Inpatient Sample (NIS) from 1998 to 2008. to 2006). and amount of blood loss also 50% of the reported deaths from sepsis occurred in African impact risk for infection. 7 mater- within one hour of incision during cesarean birth. Culture of exudates is usu- Sepsis is believed to be the result of an increased sys- ally not required. administration of prophy. most cases due to group A Streptococcus (GAS).22 Women with comorbid medical conditions were more likely to be affected.29 Puerperal sepsis is inal incision. endometritis.39 Nearly nionitis. longed rupture of membranes. and retained products of conception.7 The Center Risk factors for abdominal wound infections after cesarean for Maternal and Child Enquiries’ Saving Mothers’ Lives re- birth are similar to perineal wound risk factors and include port indicated an increase in maternal sepsis from 0.18 There were 16 maternal deaths directly related to sepsis.36 Clostridium. unusual or foul smelling vaginal discharge the antimicrobial group and 24% (14/58) in the placebo group or lochia. erwise healthy women. puerperal sepsis is a more generalized systemic inflammatory response to bacterial toxins. No.14.40 The primary cause of puerperal sepsis Presence of wound tenderness.20 However. from sepsis was 21 per 100. as well Pathogenesis as wound packing and drainage. 29 Particularly.8% of cases derived from GAS. septic PUERPERAL SEPSIS shock.29 Signs Common risk factors for puerperal sepsis include abdom- and symptoms are usually nonspecific. reclosure may be necessary. length of surgery. births (30% of all identified cases of sepsis). and edema are in 42. and possible death.73 per 100. Obesity. which tributes to this wide variation.14 Wounds may also produce exudate and on occa.8. while 8 of 16 (50%) had one or more risk factors.22 If dehiscence occurs in an ab- and 4 of 16 (25%) were an ethnic minority.13 per 100. number of vaginal examinations.14. data were extracted from the US from 2% to 16%.40 dominal wound infection. chorioamnionitis. Rarely. and pro. 8% (4/49) in ing: pelvic pain.7 to 1.39 dence of wound infection.822 rial ascension into the uterine cavity. abdom. perineal laceration. this leads to a cascade of if not treated properly.4 per length of labor.39 have decreased significantly since the introduction of pro.18 Daily debridement may be indicated.000 (from 2006 to 2008).18 Consultation or referral to collaborating temic inflammatory response to bacterial endotoxins and physician is indicated. this response can lead to organ deterioration.000 births during this time period. a report from the United Kingdom indicated an increase in maternal mortality from sepsis.40 Risk Factors In 2010. Most of the deaths occurred during the postpartum period tocols that call for administration of prophylactic antibiotics and 50% occurred after cesarean birth. septic shock may occur released in substantial numbers. In 638 Volume 58.14 Inconsistent data collection likely con.40 De- layed recognition of infection was noted in 6 of 16 women Management (38%).14 In addition. 6. be caused by numerous pathogens such as Group A Strep- lactic antimicrobials was associated with a significantly lower tococcus.20 Puerperal sepsis can had wound complications.18 critical events affecting numerous organ systems. and uterine subinvolution. with severe sepsis occurring in 1 in 10. November/December 2013 .9% of those cases was GAS.000 during a 2-year period (2004 sion wound dehiscence will occur.0o F or 38.

sity rates.12.85.39-0. appendicitis.41 A Cochrane review found that administration of to groin may indicate septic pelvic thrombophlebitis or flank prophylactic antibiotics is associated with decreases in the in- pain could indicate pyelonephritis.12 Other non. fluid therapy. dizziness. or fetal surgery heighten the risk for infection.142 women (RR 0. vi.34-0.8 Generalized body aches and malaise are not un- common and initial diagnosis could be misconstrued as a viral Cesarean Birth illness.8.42 An- and neutropenia.8 The secondary complications of gen. immediately before cesarean birth.16 Trends toward increased incidence of puerperal via contact with others.0◦ C) or less. 12 Other dis- sepsis may also include advanced maternal age.8 For example. presenting signs and symptoms of puerperal sepsis puerperal infection. eases precipitated by GAS include pharyngitis. women with advanced sepsis may develop leukopenia nificant adverse effects to the neonate were reported. is the most virulent.4◦ F (38. 22 The origin women found a decreased incidence of uterine infection if a of infection should be eradicated and may include surgical vaginal wash with povidone-iodine solution was performed removal of necrotic tissue. however. gram-negative.8. Preoperative antimicro- of the infection. However. and surgical disruption of skin integrity. Reductions in wound infection the scope of this article.19-0. hypothermia can occur with temperatures of 96.42 Eight randomized controlled trials were re- A complete blood count and metabolic panel are viewed and compared effects on subsequent uterine infection indicated.8 Compared to non- as type II diabetes.37 often indicated by hypotension (systolic ⬍ 90 mm Hg and or A meta-analysis by Constantine et al compared timing of 40 mm Hg below the baseline) and tachycardia (⬎ 120 beats administration of antibiotics (prior to skin incision vs after per minute).29 cord clamping). toms.8 In addition. 29 Tachycar. and anaerobic bacteria. 0.35.5. 95% CI.29 Laboratory results vary according to the etiology and adverse effects on the neonate. 0. 0.26 Puerperal contamination mainly tle manifestations of infection.8.8◦ F (36. muscle aches. early recognition and prompt treatment are 12. skin infections. or confusion. pain in the abdomen radiating incision.11 5047 women (RR 0.39 as is nonspecific which can delay treatment and lead to seri- do an altered immune system.48). modifying risks when Group A Streptococcus possible. 12.29 and compared outcomes for over 13.37 Physician referral is necessary. ternal infectious complications were reduced in 31 studies of ital tract infection predispose a woman to septicemia. 18 the incision.7 Consistent hand washing drastically less common.jmwh. 18. and women experiencing a concurrent skin infection or un- treated GAS pharyngitis can also have a secondary genital Presenting Signs and Symptoms tract infection. treatment of all women within 60 minutes of initiation of peral sepsis is not always clear and should be investigated. 95% CI. P = . despite being caring for women.000/mm3 . 95% CI. it is important to note were seen in 77 studies of 11.45.0◦ C) or greater and may or may not include chills or purulent vaginal PREVENTION OF GENITAL TRACT INFECTION discharge. and other treatment modalities are often Vaginal Birth indicated.42 No sig- ever. 39 Risk is diminished when the clinician pregnant women. cervical onset occurs often within the first 48 hours. Decreased endometritis was noted in 79 studies of ical fashion. 22 Midwives and other maternity care providers can reduce puerperal genital tract infection by completing a compre- hensive assessment of each woman. and practicing conscientious hand washing when Sepsis secondary to Group A Streptococcus.12 are nonspecific. and presence of comorbid medical conditions such rheumatic fever. postpartum women are 20 times more likely decreases modifiable risk factors and remains vigilant for sub. positive. pneumonia. abdominal pain. 12 It develops rapidly: reduced puerperal infection in the 1800s and continues Journal of Midwifery & Women’s Health r www.18 The origin of puer.32-0. Group A Streptococcus can be carried by nearly 30% ral illnesses. because puerperal sepsis often presents in an atyp. 37 The World Health Organization also rec- Location of pain provides a tool for determining the origin ommends antimicrobial prophylaxis 60 minutes prior to of infection.5.8 Life-threatening illness is cidence of uterine and wound infections.42). dometritis (RR 0.8.51).12 Symptoms can present as fever.29 Temperature If cesarean birth is indicated.26–0. and systemic infection. tic solution during cesarean birth have shown mixed results.012).43 dynamic therapy.8 A band count greater than 10% can indi. in advanced stages. especially children. 95% CI. and serious ma- critical to recovery.12 genital tract risk factors include acute pyelonephritis. 0. and other medical of the general population and transmitted by self or spread illnesses. ous illness.31.37 Sig- nificant reductions in febrile morbidity associated with pro- Management phylactic antibiotic were seen in 50 studies of 8141 women Review of the management of puerperal sepsis goes beyond (RR 0. 0. to develop GAS infection. contamination is still possible. Other studies reviewing vaginal cleansing with an antisep- ment with broad-spectrum antimicrobials which cover gram. other Cochrane review by Smaill and Gyte included 86 trials cate sepsis. 95% CI. 29 The most common laboratory finding is bial therapy significantly decreased the risk of postpartum en- usually a white cell count of greater than 15.8.48).961 women (RR 0. Women should receive treat. nonspecific signs and symp.7 occurs through skin-to-skin contact or respiratory spread.000 women undergoing cesarean birth with or without prophylactic antibiotics. climbing obe.12 Presentation cerclage. that.38. invasive procedures such as amniocentesis.39.addition.47.org 639 . the American College of instability is often present in developing sepsis.8 Recovery However a Cochrane review of 5 trials that randomized 1766 should begin within 48 hours to 72 hours. Obstetricians and Gynecologists recommends prophylactic dia and tachypnea are common findings. 26 Vaginal birth reduces the risk for GAS Typically.29 However.8 How.8. they include a fever of 100. hemo.

In addition. Adapted with permission from The Royal College of Obstetricians and Gynaecologists (RCOG) and the National Institutes of Health and Clinical tic procedure. decreasing the rate of cesarean births would dramati. Clinical Practice Recommendations for Reducing GBS infection. No. factors. wound.45 ter injuries. and pelvic floor exercise. common health family members when possible. are crucial preventative measures. diagnosis and treatment of lower geni. such as increased Limited vaginal examinations length of labor.7 A study in Denmark of 1871 postpartum women re. will decrease genital tract infection Infection signs and symptoms rates.7 Genital tract infections can occur from early in the Education outlining signs and symptoms of puerperal postpartum period (first few days) to 2 to 6 weeks later.10 vide opportunities for women to be assessed after discharge. as well as Midwifery care maintaining asepsis and rigorous hand washing during Routine screening and treatment of infection (antepartum) childbirth.11 Nutrition Minimal use of invasive procedures. November/December 2013 .22 Internal fe. urinary.11. Synthetic suture use cally decrease uterine infection.9.22 Prompt suturing of lacerations (if needed) Finally. and possibly instru- Delay AROM until the latter stage of labor mental or surgical birth. women are more likely to seek care at an emer.14 Puerperal during the first 4 weeks postpartum.22 Amniotomy is not a risk factor if performed during active labor but increases risk if performed Fetal scalp lead (only if indicated) during early labor or used during arrest of labor.37 Prophylactic antimicrobial treatment for third and fourth degree The Royal College of Obstetricians and Gynaecologists (RCOG) and the National Institutes of Health and Clin. this report CLINICAL PRACTICE RECOMMENDATIONS indicates that women can recognize signs and symptoms of in- Preventative measures. minimization of week postpartum visit.45 Guidelines Two-week postpartum visit (in addition to 6–8 week visit) include limiting episiotomies. Infections of the breast complications often occur within the 2-week time frame. 6. 22 (12%). standard suture techniques. 29 Routine screening for Table 7. increased patient load in emergency rooms. Excellent (NICE) 2008 Guidelines to reduce postnatal infection.17 Nonetheless.45. visit. signs and symptoms of infection. education. when to call a health care provider. Providing educational resources for postpartum com- both the woman and her health care provider are vital ac.45 If health insurance companies do not reimburse for 640 Volume 58.22 Unfortunately. most puerperal genital tract infections occur within and reviewed during postpartum teaching with inclusion of the first 2 weeks postpartum.14 be written at a reading level for the general population. plications combined with close follow-up can help women get tions needed to decrease puerperal genital tract morbidity and early treatment for puerperal infections. providers must not only recognize early signs plications.46 Ed- Consequently. Limiting episiotomy tal monitoring should only be implemented when indicated. routine postpartum examinations by midwives and postpar- tum education on perineal hygiene. prompt repair of lacerations Decrease cesarean births (excluding first degree lacerations that are not bleeding). 10 women. Judicious hand washing tum infection in women.14. vaginal. and prophylactic antibiotics for anal sphinc. Pelvic floor exercise tion of unnecessary risk. asep. 46 Delayed recognition leads to possible secondary severe com. Education should include risk care practice requests women to return just once for a 6. and prompt recognition by fection. and endometritis (2%) were reported to their for a 2-week postpartum follow-up visit may decrease sever- health care provider by 66% of postpartum women while 9% ity of complications or prevent a later emergency room reported signs and symptoms to a hospital. and symptoms of puerperal genital tract infections but pro- creased overall health care costs.to be a main strategy today. home birth was associated with decreased postpar. good nutrition.17. Postpartum education on the following topics: decreasing the number of vaginal examinations during labor management is a simple practice that can effectively reduce Perineal hygiene postpartum uterine infection.45 Postnatal care recommendations also propose Abbreviation: AROM. mortality.37. uti- lization of synthetic suture.14 Without proper recognition or early transmission. and the follow-up with a heath care provider. ucational resources should be sent home with all postpartum gency room and be readmitted to a health care facility. vaginal examinations. A 2-week postpartum office visit can facilitate early recog- vealed self-reported puerperal infection in 24% of women nition and investigation of potential infections. artificial rupture of membranes.44 Induction of labor can create a cas. 44 In a meta-analysis reviewing maternal and neona- When to call provider tal outcomes for planned home birth versus planned hospi- tal birth.11 In addition. as well as modifica. Aseptic technique cade of events that increase risk of infection. extensions ical Excellence (NICE) have recommended guidelines to Close postpartum follow-up (phone calls) reduce the incidence of postnatal infection. and respiratory infections Recommending postpartum women return to their provider (3% each). and in.17 Unfortunately.45 Resource information should and symptoms can increase the virulence of the infection.45 reporting of signs and symptoms of genital tract infection to other health care providers can impede follow-up and proper tracking of puerperal morbidity. undetected early signs need to get immediate care. Puerperal Genital Tract Infection Rates tal tract infections during the antepartum. 18 genital tract infection should begin during antepartum care However.

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