Puerperal Pyrexia

The symptoms with which the mother presents may well provide some idea of the source of the infection or there may be many symptoms referring to more than one system, which will require a systematic method of determining the problem.

A full history should be taken, to include a full history of the delivery:

• When did the membranes rupture?
• Length of labour
• Instrumentation used
• Sutures required
• Was the placenta complete?
• Was there any bleeding during or after delivery?

• Take the patient's temperature
• Palpate the uterus to assess size and tenderness
• Assess any perineal wounds and lochia
• Examine the breasts
• Examine the chest for signs of infection
• Examine the abdomen
• Examine the legs for possible thromboses

• High vaginal swab
• Urine culture and microscopy
• Other swabs as felt necessary e.g. wound swabs, throat swabs
• Full blood count
• Blood culture
• Ultrasound scan may be required to assist diagnosis of retained products of conception

General measures

Ice packs may be helpful for pain from perineal wounds or mastitis.
Rest and adequate fluid intake is required, particularly for mothers who continue to breastfeed.

Pharmacological

When prescribing drugs, it is important to ascertain whether or not the mother is breastfeeding, as this may influence the choice of agent used:

• Analgesia may be required.
• Antibiotics should be commenced after taking specimens and should not be delayed until the results are available.
• A broad spectrum antibiotic with activity against Gram positive cocci, such as penicillin or erythromycin may be used in the first instance and amended when the results are available or if there is no response.
• More than one antibiotic may be needed in some instances e.g. if it is thought that anaerobes may be involved.
• If endometritis has been diagnosed, the patient should be referred to secondary care for inpatient intravenous treatment with clindamycin and gentamicin in the absence of contra-indications.⁸
• Intravenous agents may be required initially
• If the fever is prolonged then treatment with heparin should also be considered.⁹

Surgical

Surgical intervention may be required if it is thought that an abscess has formed, as in this case the fever will not settle until the abscess has been incised and drained.

The possible complications of the infection will depend on the site, although several complications such as septicaemia, pulmonary embolus, disseminated intravascular coagulation and pneumonia are common to all:

• Genital tract infection may lead to abscess formation, adhesions, peritonitis, haemorrhage and subsequent infertility if not treated early and aggressively.
• Urinary tract infection may progress to pyelonephritis and renal scarring if left untreated.
• Mastitis may lead to the formation of breast abscesses if treatment is not started early.

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

However, the possibility of septicaemia and lasting sequelae or even death are still good reasons to treat all cases of puerperal pyrexia early and aggressively.

• Scrupulous attention to hygiene should be used during all examinations and instrumentation during and after labour.
• Some centres advocate the use of prophylactic antibiotics during prolonged labour.²
• Catheterisation should be avoided where possible.
• Early mobilisation of delivered mothers will help to protect against venous thrombosis.
• New mothers should be helped to acquire the skills required for successful breastfeeding.¹⁰
• Perineal wounds should be cleaned and sutured as soon as possible after delivery.
• All blood losses and the completeness of the placenta should be recorded at all deliveries.