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Pronunciations anesthesia clindamycin embolism hemorrhage mastitis nephritis peritonitis phlebitis pulmonary embolism pyelonephritis sepsis thrombophlebitis uterine uterus

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 may 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 seldom occur because doctors try to prevent or treat conditions that can lead to infections. However, infections, if they develop, may be serious. Thus, if women have a temperature of more than 100.4° F at any time during the first week after delivery, they 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

• Bacteria can infect the uterus and surrounding areas soon after delivery.
• Such infections commonly cause pain in the lower abdomen, fever, and a foul-smelling discharge.
• Diagnosis is usually based on symptoms and results of a physical examination.
• Antibiotics usually cure the infection.

Postpartum infections usually begin in the uterus. Such infections may develop if membranes containing the fetus (amniotic sac) are infected and cause a fever during labor. They include infection of the uterine lining (endometritis), uterine muscle (myometritis), or areas around the uterus (parametritis).

Causes

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 the following:

• Anemia
• Bacterial vaginosis
• Repeated vaginal examinations
• Internal monitoring of the fetus (which requires rupture of the membranes)
• A long delay (often more than 18 hours) between rupture of the membranes and delivery
• Prolonged labor
• Cesarean delivery
• Placental fragments remaining in the uterus after delivery
• Excessive bleeding after delivery (postpartum hemorrhage)
• Young age
• Low socioeconomic group

The chances of developing uterine infection depend mainly on the type of delivery:

• Normal vaginal deliveries: 1 to 3%
• Caesarean deliveries that have been scheduled and are done before labor starts: 5 to 15%
• Caesarean deliveries that are not scheduled and are done after labor starts: 15 to 20%

Symptoms

Symptoms commonly include pain in the lower abdomen or pelvis, fever (usually within 1 to 3 days after delivery), paleness, chills, a general feeling of illness or discomfort, and often headache and loss of appetite. The heart rate is often rapid. The uterus is swollen, tender, and soft. Typically, there is a malodorous discharge from the vagina, which varies in amount. But sometimes the only symptom is a low-grade fever.

When the tissues around the uterus are infected, they swell, causing significant discomfort. Women typically have severe pain and a high fever.

Some severe complications can occur but not often. They include the following:

• Inflammation of the membranes that line the abdomen (peritonitis)
• Blood clots in the pelvic veins (pelvic thrombophlebitis)
• A blood clot that travels to the lung and blocks an artery there (pulmonary embolism)
• High levels of poisonous substances (toxins) produced by the infecting bacteria in the blood, which leads to sepsis or toxic shock.

In sepsis and toxic shock, blood pressure falls dramatically and the heart rate is very rapid. Severe kidney damage and even death may result. This is rare, especially with prompt diagnosis and early treatment for postpartum fever.

Diagnosis and Treatment

An infection may be diagnosed based mainly on results of a physical examination. Sometimes an infection is diagnosed when women have a fever and no other cause is identified.

Usually, doctors take a sample of urine and send it to be cultured and checked for bacteria. Occasionally, a blood sample is cultured.

If the uterus is infected, women are usually given antibiotics (usually clindamycin Some Trade Names
CLEOCIN
plus gentamicin) intravenously until they have had no fever for 48 hours. Afterward, most women do not need to take antibiotics by mouth.

Bladder and Kidney Infections

A bladder infection (cystitis) sometimes develops postpartum, and the risk is increased when a catheter is placed in the bladder to relieve a buildup of urine during and after labor. A kidney infection (pyelonephritis) is caused by bacteria spreading from the bladder to the kidney after delivery. Sometimes a bladder or kidney infection develops because bacteria that were in the bladder during pregnancy cause no symptoms until after delivery.

Bladder and often kidney infections cause painful or frequent urination. Kidney and some bladder infections cause fever. Kidney infections may cause pain in the lower back or side, a general feeling of illness or discomfort, and constipation.

Diagnosis and Treatment

The diagnosis is based on examination and analysis of a urine sample. With kidney infections and some bladder infections, the sample may be cultured to identify the bacteria.

Typically, women are given an antibiotic intravenously for kidney infection or by mouth for bladder infection. 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 (such as ceftriaxone Some Trade Names
ROCEPHIN
alone or ampicillin Some Trade Names
PRINCIPEN
plus gentamicin) are given until the woman has had no fever for 48 hours. Often, antibiotics are given by mouth for an even longer period of time. 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 Breast Disorders: Breast Infection and Abscess) 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. If the baby is not positioned correctly during breastfeeding, cracking and soreness can develop.

An infected breast usually appears red and swollen and feels warm and tender. Only part of the breast may be red and sore. Women may have a fever. A fever that develops later than 10 days after delivery is often caused by a breast infection.

Rarely, breast infections result in a collection of pus (abscess). The area around the abscess swells, and pus may drain from the nipple.

Doctors base the diagnosis on results of a physical examination.

Did You Know... If a breast infection develops after delivery, women should usually continue to breastfeed.

Treatment

Breast infections are treated with antibiotics, such as dicloxacillin or erythromycin Some Trade Names
E-MYCINERYTHROCIN
. Women are encouraged to drink plenty of fluids. Women who have a breast infection and are breastfeeding should continue to breastfeed. Proper emptying of the breast is part of the treatment and decreases the risk of a breast abscess.

Breast abscesses are treated with antibiotics and are usually drained surgically. This can be performed using local anesthesia but may require intravenous sedation or general anesthesia.

Last full review/revision November 2008 by Julie S. Moldenhauer, MD