Puerperal infection (also referred to as postpartum infection in the literature) represents maternal infection within six weeks after delivery, a period also known as the puerperium. Several risk factors have been established - prolonged rupture of membranes, postpartum hemorrhage (PPH), preexisting chorioamnionitis, the need for a cesarean section, anemia, primiparity and giving birth in unhygienic conditions (for example, home birth) [1] [2] [3]. A majority of the risk factors are related to birth-related events with most of the infections developing within 24 hours after labor [1]. However, one of the main factors in the pathogenesis of puerperal infections is the lack of adequate postnatal follow-up, which leads to delayed recognition and increased risk for complications [1]. The presence of a high fever (> 38°) is one of the most important signs of a puerperal infection, while additional symptoms are related to the type of infection [3] [4] [5]:

• Endometritis - In the case of infection of the upper genital tract, fever is accompanied by bleeding, foul smelling lochia (uterine discharge after birth) and uterine tenderness [5]. Enterobacteriaceae such as Escherichia coli, Klebsiella pneumoniae, Proteus spp., staphylococci, enterococci, and streptococci, as well as Bacteroides and Prevotella spp. have been identified as causative agents [5]
• Surgical site infections - Cesarean delivery unequivocally predisposes women to a puerperal infection, which is why prophylactic antibiotic therapy is always necessary. Unfortunately, between 3-15% of women suffer from an infection at the site of the surgical incision, and localized pain is the main symptom [5]. Recognized risk factors are diabetes mellitus, obesity, previous use of corticosteroids and preexisting infections [3] [4]. Enterococci, anaerobic bacteria, and group B streptococcus are described as causes [5].
• Urinary tract infections (UTIs) - Important for their propensity to progress to disseminated infections and even sepsis, UTIs are important to recognize early on, although only a quarter of women with a UTI will complain of dysuria and UTI-specific symptoms [5].
• Mastitis - Depending on the severity of infection, puerperal mastitis can present as unilateral breast tenderness with swelling in milder cases, or diffuse bilateral discomfort, pain and the formation of abscesses in severe forms, causing fever and malaise [5]. Staphylococcus aureus and coagulase-negative staphylococci are documented causes [5].
• Sepsis - Responsible for about 15% of all maternal deaths and considered to be one of the most important causes of maternal death, puerperal sepsis is a life-threatening systemic infection predominantly caused by group A streptococcus [2] [4] [6] [7]. Fever, dyspareunia and chronic pelvic pain and a poor overall condition of the mother are main complaints [1].
• Septic pelvic thrombophlebitis (SPT) and episiotomy infections - SPT denotes the infection of the pelvic veins with a significant risk for systemic dissemination, and symptoms such as pain and fever in spite of antibiotic therapy [5]. Episiotomy infections are quite rare, but still important causes of infections in the puerperium, with symptoms of local swelling, purulent discharge, pain, and fever in most severe cases [5].
• Respiratory infections - Influenza virus, particularly in the developing countries, remains an important cause of maternal death, and the appearance of symptoms suggestive of a respiratory tract infection must be taken seriously [4] [5].

• Fever

  Fever, dyspareunia and chronic pelvic pain and a poor overall condition of the mother are main complaints. [symptoma.com]

  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. [medical-dictionary.thefreedictionary.com]

  Streptococci: Sore throat; Scarlet fever, Impetigo, Bacterial endocarditis, Rheumatic fever, Acute glomerulonephritis. [biologydiscussion.com]

  While the vast majority of these are due to infection of the genital tract, fever has many other potential causes, as described below. [sharinginhealth.ca]

  See More First Known Use of puerperal fever 1716, in the meaning defined above Learn More about puerperal fever Resources for puerperal fever Statistics for puerperal fever More Definitions for puerperal fever Medical Definition of puerperal fever : an [merriam-webster.com]

• Pain

  Fever, dyspareunia and chronic pelvic pain and a poor overall condition of the mother are main complaints. [symptoma.com]

  Fever due to mastitits or breast abscess may have swelling of the breast pain on touching redness Urinary infection usually presents as: pain with passing urine (dysuria) lower abdominal pain fever with chills occasionally blood stained urine If it [sharinginhealth.ca]

  Encourage the woman to ask for pain medications before the pain becomes severe/intolerable. Pain is a lot easier to control before it becomes severe. Apply local heat using heat lamp or sitz bath as indicated. [rnpedia.com]

  Infections of the urinary tract are indicated by fever, frequent and painful urination, and back pain. An episiotomy and a cesarean section carry the risk of a wound infection. [medical-dictionary.thefreedictionary.com]

• Chills

  Puerperal Infection T he symptoms are high elevation in body temperature, face paling, chilling, severe acute pain in lower abdomen and bad smelling secretions from the uterus, The means of protection ( prophylaxis ) are sterilizing the surgical tools [online-sciences.com]

  The ovarian veins may then become involved because they drain the upper uterus CLINICAL FINDINGS - display some clinical improvement of their pelvic infection following antimicrobial treatment, however continue to have fever - asymptomatic except for chills [wattpad.com]

  Parametritis (pelvic cellulitis) commonly produces elevated temperature of more than 38.6°C (102° to 104°F), chills, abdominal pain, subinvolution of uterus, tachycardia, and lethargy. [rnpedia.com]

  Note presence of chills or reports of anorexia or malaise. Rationale: Elevations in vital signs accompany infection; fluctuations, or changes in symptoms, suggest alterations in client status. [freenursingcareplan.blogspot.com]

• Malaise

  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. [medical-dictionary.thefreedictionary.com]

  Mastitis - Depending on the severity of infection, puerperal mastitis can present as unilateral breast tenderness with swelling in milder cases, or diffuse bilateral discomfort, pain and the formation of abscesses in severe forms, causing fever and malaise [symptoma.com]

  Chills, headache, malaise, and anorexia are common. Sometimes the only symptom is a low-grade fever. Pallor, tachycardia, and leukocytosis usually occur, and the uterus is soft, large, and tender. [msdmanuals.com]

  Note presence of chills or reports of anorexia or malaise. Elevations in vital signs accompany infection; fluctuations, or changes in symptoms, suggest alterations in client status. [rnpedia.com]

• High Fever

  The DHS collected information on four obstetrical complications: prolonged labour, excessive bleeding, convulsions and high fever with foul smelling discharge. [journals.plos.org]

  The presence of a high fever (> 38°) is one of the most important signs of a puerperal infection, while additional symptoms are related to the type of infection: Endometritis - In the case of infection of the upper genital tract, fever is accompanied [symptoma.com]

  There is high fever, rapid pulse, vomiting and absent intestinal sounds due to paralytic ileus. Thrombophlebitis Extension of infection to the pelvic veins leads to high fever, rapid pulse and deep seated pelvic pain. [gfmer.ch]

  Foul smelling secretion from the uterus, sometimes it may be consisting of pus High fever greater than 38 degree centigrade or 100.4 degree Fahrenheit Chills Abdominal cramps Tenderness and pain in the uterus Failure of uterus to resume to the normal [beingtheparent.com]

  Signs and symptoms of peritonitis include high fever, rapid pulse, abdominal pains, nausea, vomiting, and restlessness. Nursing Management 1. Promote resolution of the infectious process. [rnpedia.com]

• Abdominal Pain

  Symptoms are uterine tenderness, abdominal or pelvic pain, fever, malaise, and sometimes discharge. Diagnosis is clinical, rarely aided by culture. Treatment is with broad-spectrum antibiotics (eg, clindamycin plus gentamicin ). [msdmanuals.com]

  Parametritis (pelvic cellulitis) commonly produces elevated temperature of more than 38.6°C (102° to 104°F), chills, abdominal pain, subinvolution of uterus, tachycardia, and lethargy. [rnpedia.com]

  Haug Browse recently published Learning/CME Learning/CME View all learning/CME CME Partial Oral versus Intravenous Antibiotic Treatment of Endocarditis Case 4-2019: An 18-Year-Old Man with Abdominal Pain and Hematochezia Bridging the Gap Challenge Yourself [nejm.org]

  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. [medical-dictionary.thefreedictionary.com]

• Diarrhea

  Note urine output, degree of hydration, and presence of nausea, vomiting, or diarrhea. Rationale: Increased intake replaces losses and enhances circulating volume, preventing dehydration and aiding in fever reduction. 9. [freenursingcareplan.blogspot.com]

  Note urine output, degree of hydration, and presence of nausea, vomiting, or diarrhea. Increased intake replaces losses and enhances circulating volume, preventing dehydration and aiding in fever reduction. Encourage semi-Fowler’s position. [nurseslabs.com]

• Hematochezia

  Haug Browse recently published Learning/CME Learning/CME View all learning/CME CME Partial Oral versus Intravenous Antibiotic Treatment of Endocarditis Case 4-2019: An 18-Year-Old Man with Abdominal Pain and Hematochezia Bridging the Gap Challenge Yourself [nejm.org]

• Hypertension

  Puerperal Eclampsia Convulsions and coma associated with hypertension, oedema, or proteinuria occurring in a woman following delivery. [CancerWEB]. [archaicmedicalterms.com]

  Tachypnea Cervical motion tenderness Intermediate signs: Fever Pain Suprapubic tenderness Ileus Foul discharge Rare signs: Oliguria Edema Shock Jaundice Mental suppression Signs that suggest a critical illness: Increased sympathetic activity (tachycardia, hypertension [sharinginhealth.ca]

  Plans Placenta Previa | 3 Care Plans Postpartum Hemorrhage | 8 Care Plans Postpartum Thrombophlebitis | 4 Care Plans Prenatal Hemorrhage | 7 Care Plans Prenatal Substance Dependence/Abuse | 6 Care Plans Precipitous Labor | 3 Care Plans Pregnancy Induced Hypertension [nurseslabs.com]

• Jaundice

  Septicaemia High fever with severe tachycardia up to 140/min, rigors, severe headache, jaundice due to haemolysis in cl. welchii infection, hypotension and loss of consciousness. [gfmer.ch]

  Respiratory rales, consolidation, rhonchi Major signs of puerperal sepsis: Classical signs: Tachycardia Tachypnea Cervical motion tenderness Intermediate signs: Fever Pain Suprapubic tenderness Ileus Foul discharge Rare signs: Oliguria Edema Shock Jaundice [sharinginhealth.ca]

• Hip Pain

  An example of an infection recently described is pudendal-paracervical block infection, often signaled by severe hip pain. [ncbi.nlm.nih.gov]

• Withdrawn

  Non-verbal cues such as crying, grimacing, or withdrawn behavior may indicate pain. Provide instruction regarding, and assist with, maintenance of cleanliness and warmth. Promotes sense of general well-being and enhances healing. [nurseslabs.com]

• Uterine Tenderness

  At the time of uterine tenderness (Day 2, postpartum), 4 of 5 patients had gram-stained lochial smears showing a predominance of gram-positive cocci. [ncbi.nlm.nih.gov]

  Uterine tenderness is often difficult to distinguish from incisional tenderness in patients who have had a cesarean delivery. [msdmanuals.com]

  […] discharge after birth) and uterine tenderness. [symptoma.com]

  Note subinvolution of uterus, extreme uterine tenderness. Rationale: Allows early identification and treatment; promotes resolution of infection. [freenursingcareplan.blogspot.com]

• Pelvic Pain

  Fever, dyspareunia and chronic pelvic pain and a poor overall condition of the mother are main complaints. [symptoma.com]

  When parametria are affected, pain and fever are severe; the large, tender uterus is indurated at the base of the broad ligaments, extending to the pelvic walls or posterior cul-de-sac. [msdmanuals.com]

  One of pelvic pain, abnormal vaginal discharge, abnormal odour or discharge, or a delay in the reduction of uterine size must also be present. [sharinginhealth.ca]

  Furthermore, it was the leading cause of maternal mortality during 1985-2000. [2] Those who survive may develop serious complications as a result of puerperal sepsis, such as infertility and chronic pelvic pain. [3], [4] It is a common practice in the [atmph.org]

• Foul Smelling Vaginal Discharge

  A 25 year old woman (G1P1) presents to your clinic eight days postpartum, complaining of a temperature of at least 38.5 degrees Celsius over the past 3 days, and a foul-smelling vaginal discharge. [sharinginhealth.ca]

  […] endometritis: an infection of the uterine lining myometritis: an infection of the uterine muscle parametritis: an infection of the areas around the uterus Symptoms and signs may include: fever pain in the lower abdomen or pelvis caused by a swollen uterus foul-smelling [healthline.com]

  It commonly presents with fever, pelvic pain and foul-smelling vaginal discharge [ 9 ], and has been associated with neonatal sepsis [ 10, 11 ]. [journals.plos.org]

Because life-threatening sepsis and shock may develop from puerperal infections, an early diagnosis is pivotal in reducing maternal morbidity and mortality [1]. For this reason, the appearance of fever during the puerperium must raise suspicion about an infectious etiology. Firstly, a thorough patient history should be obtained, including information about the delivery (particularly if a cesarean section was performed), preexisting comorbidities and risk factors, as well as evaluation of additional symptoms, if present. A detailed physical exam could potentially determine the focus of the infection by observing localized pain, tenderness, swelling or other organ-specific symptoms [5], after which a complete laboratory workup is advised. A complete blood count (CBC), serum inflammatory markers (C-reactive protein and erythrocyte sedimentation rate, or CRP and ESR, respectively), a full coagulation panel, urinalysis, and kidney function tests must be included in the initial workup [8]. In addition, microbiological testing for blood, urine, or breast milk cultures, and wound and genital swabs, is recommended [5] [8]. Besides bacterial organisms, influenza and human immunodeficiency (HIV) viruses have been established as important causes of maternal mortality, suggesting that the clinical workup should also assess lung function, and appropriate serological or molecular testing should be performed in the presence of a suspicion of HIV or influenza infection [4].

The treatment in this study was both medical and surgical, blood transfusion was given in some cases with low hematocrit level. [ncbi.nlm.nih.gov]

[…] limited to the base of the broad ligament  The most common form of extension is laterally, along the base of the broad ligament, with tendency to extend to the lateral pelvic wall  In most women with a phlegmon, clinical improvement follows continued treatment [wattpad.com]

[…] to top Treatments If the woman is unwell, she should be admitted and agressively treated. [sharinginhealth.ca]

Treatment 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. [medical-dictionary.thefreedictionary.com]

Prognosis Antibiotic therapy and other treatment measures are virtually always successful in curing puerperal infections. Prevention Careful attention to antiseptic procedures during childbirth is the basic underpinning of preventing infection. [medical-dictionary.thefreedictionary.com]

Prognosis The majority of patients will make a full recovery with no lasting effects if treated speedily with appropriate antibiotic therapy and fluids. [patient.info]

[…] due to the underlying etiology. [icd10data.com]

Abstract Developments in etiology and treatment of puerperal infection in the last 20 years are reviewed. [ncbi.nlm.nih.gov]

For this reason, the appearance of fever during the puerperium must raise suspicion about an infectious etiology. [symptoma.com]

“The Etiology, Concept and Prophylaxis of Childbed Fever.” January 2008. Available from: http://journals.sfu.ca/socialmedicine/index.php/socialmedicine/article/viewFile/178/353. Accessed March 6, 2008. CR Starr. [austincc.edu]

Maternal sepsis: Epidemiology, etiology, and outcome. Curr Opin Infect Dis 2010;23:249-254. [http://dx.doi.org/10.1097/QCO.0b013e328339257c] 3. Van Dillen J, Zwart J, Schutte J, van Roosmalen J. Maternal sepsis: Epidemiology, etiology, and outcome. [sajog.org.za]

Abstract This is an epidemiological, prospective and non-concurrent study of the cohort type about puerperal infection from the perspective of humanized delivery care, based on information from 5,178 records of patients who went through the experience [ncbi.nlm.nih.gov]

Maternal sepsis: Epidemiology, etiology, and outcome. Curr Opin Infect Dis 2010;23:249-254. [http://dx.doi.org/10.1097/QCO.0b013e328339257c] 3. Van Dillen J, Zwart J, Schutte J, van Roosmalen J. Maternal sepsis: Epidemiology, etiology, and outcome. [sajog.org.za]

Dillen JV, Zwart J, Schutte J, Roosmalen JV (2010) Maternal sepsis: epidemiology, etiology and outcome. Curr Opin Infect Dis 23: 249-254. [omicsonline.org]

Methods Statistics Trigonometry Medical & Nursing Anatomy Anesthesiology Audiology Bacteriology Biochemistry Bioethics Biomedical Science Cardiology Cardiovascular Childbirth Chiropractic Dentistry Dermatology Diagnostic Imaging Drugs Endocrinology Epidemiology [brainscape.com]

PIP: This comprehensive review on puerperal infections covers risk factors, causative bacteria, pathophysiology, diagnosis, therapy of specific entities, and prevention. [ncbi.nlm.nih.gov]

[…] socioeconomic status poor nutrition, anemia first birth prolonged membrane rupture, or prolonged labour multiple pelvic exams during labour instrumentation during delivery retention of placental fragments in the uterus postpartum hemorrhage return to top Pathophysiology [sharinginhealth.ca]

Pathophysiology 1. Causative organisms Aerobic organisms include beta-hemolytic streptococci, Escherichia coli, Klebsiella, Proteus mirabilis, Pseudomonas, Staphylococcus aureus, and Neisseria. [rnpedia.com]

Each of these is discussed in terms of contributing factors, microbiology, clinical findings, diagnosis, treatment, prevention and complications. [ncbi.nlm.nih.gov]

Prevention Careful attention to antiseptic procedures during childbirth is the basic underpinning of preventing infection. [medical-dictionary.thefreedictionary.com]

Rationale: Helps prevent cross-contamination. 3. Provide for, and instruct client in, proper disposal of contaminated linens, dressings, chux, and peripads. Initiate/maintain isolation, if indicated. Rationale: Prevents spread of infection. 4. [freenursingcareplan.blogspot.com]

Helps prevent cross-contamination. Instruct the proper disposal of contaminated linens, dressings, and peripads. Maintain isolation, if indicated. Prevents spread of infection. [nurseslabs.com]

1. Maharaj D. Puerperal pyrexia: a review. Part I. Obstet Gynecol Surv. 2007;62(6):393-399.
2. Zainur RZ, Loh KY. "Postpartum morbidity--what we can do". Med J Malaysia. 2006;61(5):651-656.
3. Tita ATN, Andrews WW. Diagnosis and Management of Clinical Chorioamnionitis. Clin Perinatol. 2010;37(2):339-354.
4. Buddeberg BS, Aveling W. Puerperal sepsis in the 21st century: progress, new challenges and the situation worldwide. Postgrad Med J. 2015;91(1080):572-578.
5. Dalton E, Castillo E. Post partum infections: A review for the non-OBGYN. Obstet Med. 2014;7(3):98-102.
6. Aronoff DM, Mulla ZD. Postpartum Invasive Group A Streptococcal Disease in the Modern Era. Infect Dis Obstet Gynecol. 2008;2008:796892.
7. Mason KL, Aronoff DM. Postpartum Group A Streptococcus Sepsis and Maternal Immunology. Am J Reprod Immunol. 2012;67(2):91-100.
8. Hamilton SM, Stevens DL, Bryant AE. Pregnancy-Related Group A Streptococcal Infections: Temporal Relationships Between Bacterial Acquisition, Infection Onset, Clinical Findings, and Outcome. Goldstein EJC, ed. Clin Infect Dis. 2013;57(6):870-876.