A common cause of childbirth-related death, puerperal infection is a postpartum infection of the uterus and higher structures, with a characteristic fever pattern. It can result in endometritis, parametritis, pelvic and femoral thrombophlebitis, and peritonitis. The prognosis is good with treatment.
Microorganisms that commonly cause puerperal infection include group B streptococci, coagulase-negative staphylococci, Clostridium perfringens, Bacteroides fragilis, and Escherichia coli. Most of these organisms are considered normal vaginal flora but are known to cause puerperal infection in the presence of certain predisposing factors:
❑ prolonged and premature rupture of the membranes
❑ prolonged (more than 24 hours) labor
❑ frequent or unsanitary vaginal examinations or unsanitary delivery
❑ retained products of conception
❑ hemorrhage
❑ maternal conditions, such as anemia or debilitation from malnutrition
❑ cesarean birth (20-fold increase in risk for puerperal infection).
In the United States, puerperal infection develops in about 6% of maternity patients.
A characteristic sign of puerperal infection is fever (at least 100.4° F [38° C]) that occurs in the first 24 hours in the first 9 days postpartum. This fever can spike as high as 105° F (40.6° C) and is commonly associated with chills, headache, malaise, restlessness, and anxiety. Abortion or miscarriage isn’t usually associated with this infection and fever.
Accompanying signs and symptoms depend on the infection’s extent and site and may include:
❑ endometritis: heavy, sometimes foul-smelling lochia; tender, enlarged uterus; backache; severe uterine contractions persisting after childbirth
❑ parametritis (pelvic cellulitis): vaginal tenderness and abdominal pain and tenderness (pain may become more intense as infection spreads).
The inflammation may remain localized, may lead to abscess formation, or may spread through the blood or lymphatic system. Widespread inflammation may cause:
❑ pelvic thrombophlebitis: severe, repeated chills and dramatic swings in body temperature; lower abdominal or flank pain; and, possibly, a palpable tender mass over the affected area, which usually develops near the second postpartum week
❑ femoral thrombophlebitis: pain, stiffness, or swelling in a leg or the groin; inflammation or shiny, white appearance of the affected leg; malaise; fever; and chills, usually beginning 10 to 20 days postpartum (these signs may precipitate pulmonary embolism)
❑ peritonitis: body temperature usually elevated, accompanied by tachycardia (greater than 140 beats/minute), weak pulse, hiccups, nausea, vomiting, and diarrhea; constant and possibly excruciating abdominal pain.
Development of the typical clinical features, especially fever within 48 hours after delivery, suggests a diagnosis of puerperal infection. Uterine tenderness is also highly suggestive.
A culture of lochia, incisional exudate (from cesarean incision or episiotomy), uterine tissue, or material collected from the vaginal cuff that reveals the causative organism may confirm the diagnosis, but such cultures are generally contaminated with vaginal flora and aren’t considered helpful.
Within 36 to 48 hours, white blood cell count usually demonstrates leukocytosis (15,000 to 30,000/µl).
Typical clinical features usually suffice for diagnosis of endometritis and peritonitis. In parametritis, pelvic examination shows induration without purulent discharge.
Diagnosis of pelvic or femoral thrombophlebitis is suggested by characteristic clinical signs, venography, Doppler ultrasonography, palpable veins inside the thigh and calf, pain in the calf when pressure is applied on the inside of the foot, and pain on passive dorsiflexion of the foot with the knee extended (Homans’sign). Homans’ sign should be elicited passively by asking the patient to dorsiflex the foot. Active dorsiflexion could lead to embolization of a clot.
Treatment of puerperal infection usually begins with I.V. infusion of a broad-spectrum antibiotic to control the infection and prevent its spread while awaiting culture results. After identification of the infecting organism, a more specific antibiotic should be administered. (An oral antibiotic may be prescribed after hospital discharge.)
Ancillary measures include analgesics for pain; antiseptics for local lesions; and antiemetics for nausea and vomiting from peritonitis. Isolation or transfer from the maternity unit generally isn’t appropriate.
Supportive care includes bed rest, adequate fluid intake, I.V. fluids when necessary, and measures to reduce fever. Sitz baths and heat lamps may relieve discomfort from local lesions.
Surgery may be necessary to remove any remaining products of conception or to drain local lesions such as an abscess in parametritis.
Management of septic pelvic thrombophlebitis consists of heparinization for about 10 days in conjunction with broad-spectrum antibiotic therapy.
❑ Monitor vital signs every 4 hours (more frequently if peritonitis has developed) and intake and output. Enforce strict bed rest.
❑ Frequently inspect the perineum. Assess the fundus and palpate for tenderness (subinvolution may indicate endometritis). Note the amount, color, and odor of vaginal drainage, and document your observations.
❑ Administer antibiotics and analgesics, as ordered. Assess and document the type, degree, and location of pain as well as the patient’s response to analgesics. Give the patient an antiemetic to relieve nausea and vomiting, as necessary.
❑ Provide sitz baths and a heat lamp for local lesions. Change bed linen and perineal pads and under pads frequently. Keep the patient warm.
❑ Elevate the thrombophlebitic leg about 30 degrees. Provide warm soaks. Watch for signs of pulmonary embolism, such as cyanosis, dyspnea, and chest pain.
❑ Offer reassurance and emotional support. Thoroughly explain all procedures to the patient and her family.
❑ If the mother is separated from her neonate, provide her with frequent reassurance about his progress. Encourage the father to reassure the mother about the neonate’s condition as well.
To prevent puerperal infection:
❑ Maintain sterile technique when performing a vaginal examination. Limit the number of vaginal examinations performed during labor. Take care to wash your hands thoroughly after each patient contact.
❑ Instruct all pregnant patients to call their physicians immediately when their membranes rupture. Warn them to avoid intercourse after rupture or leak of the amniotic sac.
❑ Keep the episiotomy site clean and teach the patient how to maintain good perineal hygiene.
❑ Screen personnel and visitors to keep persons with active infections away from maternity patients.
Review other book chapters online related to Puerperal disorders:
Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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Title: Professional Guide to Diseases (Eighth Edition)
Authors: Springhouse
Publisher: Lippincott Williams & Wilkins
Copyright: 2005
ISBN: 1-58255-370-X
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