Postpartum infections, also known as childbed fever and puerperal
fever, are any bacterial infections of the female reproductive tract
following childbirth or miscarriage. Signs and symptoms usually
include a fever greater than 38.0 °C (100.4 °F), chills,
lower abdominal pain, and possibly bad-smelling vaginal discharge.
It usually occurs after the first 24 hours and within the first ten
days following delivery.
The most common infection is that of the uterus and surrounding
tissues known as puerperal sepsis or postpartum metritis. Risk
factors include Cesarean section, the presence of certain bacteria
such as group B streptococcus in the vagina, premature rupture of
membranes, multiple vaginal exams, manual removal of the placenta, and
prolonged labour among others. Most infections involved a number
of types of bacteria. Diagnosis is rarely helped by culturing of
the vagina or blood. In those who do not improve, medical imaging
may be required. Other causes of fever following delivery include
breast engorgement, urinary tract infections, infections of the
abdominal incision or episiotomy, and atelectasis.
Due to the risks following C-section, it is recommended that all women
receive a preventive dose of antibiotics such as ampicillin around the
time of surgery. Treatment of established infections is with
antibiotics, with most people improving in two to three days. In
those with mild disease, oral antibiotics may be used; otherwise
intravenous antibiotics are recommended. Common antibiotics include
a combination of ampicillin and gentamicin following vaginal delivery
or clindamycin and gentamicin in those who have had a C-section. In
those who are not improving with appropriate treatment, other
complications such an abscess should be considered.
In 2015, about 11.8 million maternal infections occurred. In the
developed world about one to two percent develop uterine infections
following vaginal delivery. This increases to five to thirteen
percent among those who have more difficult deliveries and fifty
percent with C-sections before the use of preventative antibiotics.
In 2015, these infections resulted in 17,900 deaths down from 34,000
deaths in 1990. They are the cause of about 10% of deaths around
the time of pregnancy. The first known descriptions of the
condition date back to at least the 5th century BCE in the writings of
Hippocrates. These infections were a very common cause of death
around the time of childbirth starting in at least the 18th century
until the 1930s when antibiotics were introduced. In 1847, in
Ignaz Semmelweiss through the use of handwashing with
chlorine decreased death from the disease from nearly twenty percent
to two percent.
1 Signs and symptoms
2.1 Risk factors
3.1 Differential diagnosis
6.1 "The Doctor's Plague"
6.2 Prevention via hygienic measures
6.3 Notable cases
8 Further reading
9 External links
Signs and symptoms
Signs and symptoms usually include a fever greater than 38.0 °C
(100.4 °F), chills, low abdominal pain, and possibly bad
smelling vaginal discharge. It usually occurs after the first 24
hours and within the first ten days following delivery.
After childbirth a woman's genital tract has a large bare surface,
which is prone to infection.
Infection may be limited to the cavity
and wall of her uterus, or it may spread beyond to cause septicaemia
(blood poisoning) or other illnesses, especially when her resistance
has been lowered by a long labour or severe bleeding. Puerperal
infection is most common on the raw surface of the interior of the
uterus after separation of the placenta (afterbirth); but pathogenic
organisms may also affect lacerations of any part of the genital
tract. By whatever portal, they can invade the bloodstream and lymph
system to cause septicemia, cellulitis (inflammation of connective
tissue), and pelvic or generalized peritonitis (inflammation of the
abdominal lining). The severity of the illness depends on the
virulence of the infecting organism, the resistance of the invaded
tissues, and the general health of the woman. Organisms commonly
producing this infection are
Streptococcus pyogenes; staphylococci
(inhabitants of the skin and of pimples, carbuncles, and many other
pustular eruptions); the anaerobic streptococci, which flourish in
devitalized tissues such as may be present after long and injurious
labour and unskilled instrumental delivery;
Escherichia coli and
Clostridium perfringens (inhabitants of the lower bowel); and
Causes (listed in order of decreasing frequency) include endometritis,
urinary tract infection, pneumonia/atelectasis, wound infection, and
septic pelvic thrombophlebitis. Septic risk factors for each condition
are listed in order of the postpartum day (PPD) on which the condition
PPD 0: atelectasis risk factors include general anesthesia, cigarette
smoking, and obstructive lung disease.
PPD 1–2: urinary tract infections risk factors include multiple
catheterization during labor, multiple vaginal examinations during
labor, and untreated bacteriuria.
PPD 2–3: endometritis ( the most common cause ) risk factors include
emergency cesarean section, prolonged membrane rupture, prolonged
labor, and multiple vaginal examinations during labor.
PPD 4–5: wound infection risk factors include emergency cesarean
section, prolonged membrane rupture, prolonged labor, and multiple
vaginal examination during labor.
PPD 5–6: septic pelvic thrombophlebitis risk factors include
emergency cesarean section, prolonged membrane rupture, prolonged
labor, and diffuse difficult vaginal childbirth.
PPD 7–21: mastitis risk factors include nipple trauma from
Puerperal fever is diagnosed when:
A temperature rise above 38 °C (100.4 °F) maintained over
24 hours or recurring during the period from the end of the first to
the end of the 10th day after childbirth or abortion. (ICD-10)
Oral temperature of 38 °C (100.4 °F) or more on any two of
the first ten days postpartum. (USJCMW)
Puerperal fever (from the Latin puer, male child (boy)), is no longer
favored as a diagnostic category. Instead, contemporary terminology
the specific target of infection: endometritis (inflammation of the
inner lining of the uterus), metrophlebitis (inflammation of the veins
of the uterus), and peritonitis (inflammation of the membrane lining
of the abdomen)
the severity of the infection: less serious infection (contained
multiplication of microbes) or possibly life-threatening sepsis
(uncontrolled and uncontained multiplication of microbes throughout
the blood stream).
Endometritis is a polymicrobial infection. It frequently includes
organisms such as Ureaplasma, Streptococcus, Mycoplasma, and
Bacteroides, and may also include organisms such as Gardnerella,
Chlamydia, Lactobacillus, Escherichia, and Staphylococcus.
A number of other conditions can cause fevers following delivery
including: urinary tract infections, breast engorgement, atelectasis
and surgical incisions among others.
Antibiotics have been used to prevent and treat these infections
however the misuse of antibiotics is a serious problem for global
health. It is recommended that guidelines be followed which outline
when it is appropriate to give antibiotics and which antibiotics are
Atelectasis: mild to moderate fever, no changes or mild rales on chest
Management: pulmonary exercises, ambulation (deep breathing and
Urinary tract infection : high fever, malaise, costovertebral
tenderness, positive urine culture.
Management: antibiotics as per culture sensitivity (cephalosporine).
Endometritis: moderate fever, exquisite uterine tenderness, minimal
Management: multiple agent IV antibiotics to cover polymicrobial
organisms: clindamycin, gentamicin, addition of ampicillin if no
response, no cultures are necessary.
Wound infection: persistent spiking fever despite antibiotics, wound
erythema or fluctuance, wound drainage.
Management: antibiotics for cellulitis, open and drain wound,
saline-soaked packing twice a day, secondary closure.
Septic pelvic thrombophlebitis: persistent wide fever swings despite
antibiotics, usually normal abdominal or pelvic exams.
Management: IV heparin for 7–10 days at rates sufficient to prolong
the PTT to double the baseline values.
Mastitis: unilateral, localized erythema, edema, tenderness.
Management: antibiotics for cellulitis, open and drain abscess if
The number of cases of puerperal sepsis per year shows wide variations
among published literature — this may be related to different
definition, recording etc. Globally, bacterial infections are the
cause of 10% of maternal deaths- this is more common in low income
countries but is also a direct cause of maternal deaths in high income
In the United States, puerperal infections are believed to occur in
between one and eight percent of all births. About three die from
puerperal sepsis for every 100,000 births. The single most important
risk factor is Caesarean section. The number of maternal deaths in
the United States is about 13 in 100,000. They make up about 11% of
pregnancy related deaths in the United States.
In the United Kingdom 1985–2005, the number of direct deaths
associated with genital tract sepsis per 100,000 pregnancies was
0.40–0.85. In 2003–2005, genital tract sepsis accounted for
14% of direct causes of maternal death.
Puerperal infections in the 18th and 19th centuries affected, on
average, 6 to 9 women in every 1,000 births, killing two to three of
them with peritonitis or septicemia. It was the single most common
cause of maternal mortality, accounting for about half of all deaths
related to childbirth, and was second only to tuberculosis in killing
women of childbearing age. A rough estimate is that about
250,000–500,000 died from puerperal fever in the 18th and 19th
centuries in England and Wales alone.
Although it had been recognized from as early as the time of the
Hippocratic corpus that women in childbed were prone to fevers, the
distinct name, "puerperal fever" appears in historical records only
from the early 18th century.
The death rate for women giving birth decreased in the 20th century in
developed countries. The decline may be partly attributed to improved
environmental conditions, better obstetrical care, and the use of
antibiotics. Another reason appears to be a lessening of the virulence
or invasiveness of
Streptococcus pyogenes. This organism is also the
cause of scarlet fever, which over the same period has also declined
markedly in severity and incidence.
The historical level of maternal deaths is probably around 1 in 100
births. Mortality rates reached very high levels in maternity
institutions in the 1800s, sometimes climbing to 40 percent of
birthgiving women (see Historical mortality rates of puerperal fever).
At the beginning of the 1900s, maternal death rates were around 1 in
100 for live births.
"The Doctor's Plague"
In his 1861 book,
Ignaz Semmelweis presented evidence to demonstrate
that the advent of pathological anatomy in Vienna in 1823 (vertical
line) was correlated to the incidence of fatal childbed fever there.
Onset of chlorine handwash in 1847 marked by vertical line. Rates for
Dublin maternity hospital, which had no pathological anatomy, is shown
for comparison (view rates). His efforts were futile, however.
From the 1600s through the mid-to-late 1800s, the majority of childbed
fever cases were caused by the doctors themselves. With no knowledge
of germs, doctors did not believe hand washing was needed.
Hospitals for childbirth became common in the 17th century in many
European cities. These "lying-in" hospitals were established at a time
when there was no knowledge of antisepsis or epidemiology, and women
were subjected to crowding, frequent vaginal examinations, and the use
of contaminated instruments, dressings, and bedding. It was common for
a doctor to deliver one baby after another, without washing his hands
or changing clothes in between.
The first recorded epidemic of puerperal fever occurred at the
Hôtel-Dieu de Paris
Hôtel-Dieu de Paris in 1646. Hospitals throughout Europe and America
consistently reported death rates between 20% to 25% of all women
giving birth, punctuated by intermittent epidemics with up to 100%
fatalities of women giving birth in childbirth wards.
In the 1800s
Ignaz Semmelweis noticed that women giving birth at home
had a much lower incidence of childbed fever than those giving birth
in the doctor's maternity ward. His investigation discovered that
washing hands with an antiseptic, in this case a calcium chloride
solution, before a delivery reduced childbed fever fatalities by
90%. Publication of his findings was not well received by the
medical profession. The idea conflicted both with the existing medical
concepts and with the image doctors had of themselves. The scorn
and ridicule of doctors was so extreme that Semmelweis moved from
Vienna and was eventually committed to a mental asylum where he
Semmelweis was not the only doctor ignored after sounding a warning
about this issue: in Treatise on the Epidemic of Puerperal Fever
(1795), ex-naval surgeon and Aberdonian obstetrician Alexander Gordon
warned that the disease was transmitted from one case to another by
midwives and doctors. Gordon wrote, "It is a disagreeable declaration
for me to mention, that I myself was the means of carrying the
infection to a great number of women."
Thomas Watson, Professor of Medicine at King's College Hospital,
London, wrote in 1842: "Wherever puerperal fever is rife, or when a
practitioner has attended any one instance of it, he should use most
diligent ablution." Watson recommended handwashing with chlorine
solution and changes of clothing for obstetric attendants "to prevent
the practitioner becoming a vehicle of contagion and death between one
patient and another."
Prevention via hygienic measures
Ignaz Semmelweis, discoverer of some of the causes of puerperal fever
Oliver Wendell Holmes Sr.
Oliver Wendell Holmes Sr. published The Contagiousness of
Puerperal Fever and controversially concluded that puerperal fever
was frequently carried from patient to patient by physicians and
nurses; he suggested that clean clothing and avoidance of autopsies by
those aiding birth would prevent the spread of puerperal fever.
Holmes quoted Dr. James Blundell as stating, "... in my own
family, I had rather that those I esteemed the most should be
delivered unaided, in a stable, by the mangerside, than that they
should receive the best help, in the fairest apartment, but exposed to
the vapors of this pitiless disease."
Holmes' conclusions were ridiculed by many contemporaries, including
Charles Delucena Meigs, a well-known obstetrician, who stated,
"Doctors are gentlemen, and gentlemen's hands are clean." Richard
Gordon states that Holmes' exhortations "outraged obstetricians,
particularly in Philadelphia". In those days, "surgeons operated
in blood-stiffened frock coats - the stiffer the coat, the prouder the
busy surgeon", "pus was as inseparable from surgery as blood", and
"Cleanliness was next to prudishness". He quotes Sir Frederick Treves
on that era: "There was no object in being clean ... Indeed,
cleanliness was out of place. It was considered to be finicking and
affected. An executioner might as well manicure his nails before
chopping off a head".
Ignaz Semmelweis was appointed assistant lecturer in the
First Obstetric Division of the
Vienna General Hospital
Vienna General Hospital (Allgemeines
Krankenhaus), where medical students received their training. Working
without knowledge of Holmes' essay, Semmelweis noticed his ward's 16%
mortality rate from fever was substantially higher than the 2%
mortality rate in the Second Division, where midwifery students were
trained. Semmelweis also noticed that puerperal fever was rare in
women who gave birth before arriving at the hospital. Semmelweis noted
that doctors in First Division performed autopsies each morning on
women who had died the previous day, but the midwives were not
required or allowed to perform such autopsies. He made the connection
between the autopsies and puerperal fever after a colleague, Jakob
Kolletschka, died of septicaemia after accidentally cutting his hand
while performing an autopsy.
Semmelweis began experimenting with various cleansing agents and, from
May 1847, ordered all doctors and students working in the First
Division wash their hands in chlorinated lime solution before starting
ward work, and later before each vaginal examination. The mortality
rate from puerperal fever in the division fell from 18% in May 1847 to
less than 3% in June–November of the same year. While his
results were extraordinary, he was treated with skepticism and
ridicule (see Response to Semmelweis).
He did the same work in St. Rochus hospital in Pest, Hungary, and
published his findings in 1860, but his discovery was again
Leonard Colebrook showed
Prontosil was effective against
haemolytic streptococcus and hence a cure for puerperal fever.
See also: List of women who died in childbirth
Elizabeth of York, the mother of Henry VIII of England, died of
puerperal fever one week after giving birth to a daughter. Other
famous victims include author Jean Webster, English queens Jane
Katherine Parr (both wives of Henry VIII), housekeeping
authority Isabella Beeton, famous French natural philosopher Émilie
du Châtelet and Mary Wollstonecraft, author of Vindication of the
Rights of Woman and mother of
Frankenstein author Mary Shelley.
Suzanne Barnard, mother of philosopher Jean-Jacques Rousseau,
contracted childbed fever after giving birth to him, and died nine
days later. Her infant son was also in perilous health following the
birth; the adult Rousseau later wrote that "I came into the world with
so few signs of life that little hope was entertained of preserving
me". He was nursed back to health by an aunt. African-American
Phillis Wheatley (1753–84) died of puerperal fever. In Charles
Dickens' novel A Christmas Carol, it is implied that both Scrooge's
mother and younger sister perished from this condition, explaining the
character's animosity towards his nephew Fred and also his poor
relationship with his own father.
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V · T · D
Pathology of pregnancy, childbirth and the puerperium (O, 630–679)
Oedema, proteinuria and
related to pregnancy
Acute fatty liver of pregnancy
Intrahepatic cholestasis of pregnancy
Integumentary system /
dermatoses of pregnancy
Intrahepatic cholestasis of pregnancy
Pruritic folliculitis of pregnancy
Pruritic urticarial papules and plaques of pregnancy
Pruritic urticarial papules and plaques of pregnancy (PUPPP)
Maternal care related to the
fetus and amniotic cavity
Braxton Hicks contractions
chorion / amnion
Amniotic band syndrome
Premature rupture of membranes
Twin-to-twin transfusion syndrome
Amniotic fluid embolism
Pain management during childbirth
Umbilical cord prolapse
Low milk supply
Diastasis symphysis pubis
Systemic lupus erythematosus