Postpartum Infections
Immediately after delivery, the woman's temperature often increases. A temperature of 101° F (38.3° C) or higher during the first 12 hours after delivery could indicate an infection but usually does not. Nonetheless, in such cases, the woman should be evaluated by her doctor or midwife. A postpartum infection is usually diagnosed after 24 hours have passed since delivery and the woman has had a temperature of 100.4° F (38° C) or higher on two occasions at least 6 hours apart. Postpartum infections are rare, because doctors try to prevent or treat conditions that can lead to infections. However, infections may be serious. Thus, if a woman has a temperature of more than 100.4° F at any time during the first week after delivery, she should call the doctor.
Postpartum infections may be directly related to delivery (occurring in the uterus or the area around the uterus) or indirectly related (occurring in the kidneys, bladder, breasts, or lungs).
Infections of the Uterus
Postpartum infections usually begin in the uterus. If an infection of the membranes containing the fetus (amniotic sac) caused a fever during labor, an infection of the uterine lining (endometritis), uterine muscle (myometritis), or areas around the uterus (parametritis) may result.
Causes and Symptoms
Bacteria that normally live in the healthy vagina can cause an infection after delivery. Conditions that make a woman more likely to develop to infection include anemia, preeclampsia (see Section 22, Chapter 258), repeated vaginal examinations, a delay of longer than 18 hours between rupture of the membranes and delivery, prolonged labor, a cesarean section, placental fragments remaining in the uterus after delivery, and excessive bleeding after delivery (postpartum hemorrhage).
Symptoms commonly include paleness, chills, headache, a general feeling of illness or discomfort, and loss of appetite. The heart rate is rapid, and the number of white blood cells is abnormally high. The uterus is swollen, tender, and soft. Typically, there is a malodorous discharge from the vagina, which varies in amount.
When the tissues around the uterus are infected, they swell, holding the swollen, tender uterus rigidly in place. The woman has severe pain and a high fever.
The abdominal lining can become inflamed, causing peritonitis. Blood clots may form in the pelvic veins, causing pelvic thrombophlebitis. A blood clot may travel to the lung and block an artery there, causing pulmonary embolism. Poisonous substances (toxins) produced by the infecting bacteria may reach high levels in the bloodstream, leading to toxic shock. In toxic shock, blood pressure falls dramatically and the heart rate is very rapid. Toxic shock may result in severe kidney damage and even death.
Diagnosis and Treatment
An infection is usually diagnosed based on results of a physical examination. Samples of urine, blood, and the vaginal discharge are cultured for bacteria.
If the uterus is infected, the woman is usually given an antibiotic intravenously until she has had no fever for 48 hours. For a few days afterward, she may be given antibiotics by mouth.
Bladder and Kidney Infections
A bladder infection (cystitis) sometimes develops when a catheter is placed in the bladder to relieve a buildup of urine during and after labor. Or bacteria may be present in the bladder during pregnancy but cause no symptoms until after delivery. A kidney infection (pyelonephritis) is caused by bacteria spreading from the bladder to the kidney after delivery.
Symptoms may include a fever and painful or frequent urination. Infection that has reached the kidneys may cause pain in the lower back or side, a general feeling of illness or discomfort, and constipation.
Typically, a woman is given an antibiotic. If there is no evidence that the bladder infection has spread to the kidneys, antibiotics may be given for only a few days. If a kidney infection is suspected, antibiotics are given until the woman has had no fever for 48 hours. Urine samples are cultured to identify the bacteria. After culture results are available, the antibiotic may be changed to one that is more effective against the bacteria present. Drinking plenty of fluids helps keep the kidneys functioning well and flushes bacteria out of the urinary tract. Another urine sample is cultured 6 to 8 weeks after delivery to verify that the infection is cured.
Breast Infection
A breast infection (mastitis (see Section 22, Chapter 251)) can occur after delivery, usually during the first 6 weeks and almost always in women who are breastfeeding. If the skin of or around the nipples becomes cracked, bacteria from the skin can enter the milk ducts and cause an infection. An infected breast usually appears red and swollen and feels warm and tender. The woman may have a fever. A fever that develops later than 10 days after delivery is often caused by a breast infection, although it may be caused by a bladder infection.
Breast infections are treated with antibiotics. Women who have a breast infection and are breastfeeding should continue to breastfeed. Breastfeeding decreases the risk of a breast abscess (a collection of pus), which is rare. Breast abscesses are treated with antibiotics and are usually drained surgically.
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