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One cannot fail to be impressed with the very large proportion of patients whose troubles have originated from febrile affections during the puerperium, which in many cases were clearly due to the neglect of aseptic precautions on the part of the obstetrician or midwife.
—J. Whitridge Williams (1903)
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Although the woman who recently gave birth is susceptible to several potentially serious complications, pelvic infection continues to be the most important source of maternal morbidity and mortality. Other infections include mastitis and breast abscesses. That said, puerperal complications include many of those encountered during pregnancy. For example, as discussed in Chapter 52 (Pathophysiology), venous thromboembolism during the short 6-week puerperium is as frequent as during all 40 antepartum weeks. Other puerperal issues and care are discussed in Chapter 36.
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PUERPERAL PELVIC INFECTION
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Traditionally, the term puerperal infection describes any bacterial infection of the genital tract after delivery. These infections as well as preeclampsia and obstetrical hemorrhage formed the lethal triad of maternal death causes before and during the 20th century. Fortunately, because of effective antimicrobials, maternal mortality from infection has become uncommon. Creanga and associates (2017) reported results from the Pregnancy Mortality Surveillance System, which contained 2009 pregnancy-related maternal deaths in the United States from 2011 through 2013. Infection caused 12.7 percent of pregnancy-related deaths and was the second leading cause. In a similar analysis of the North Carolina population from 1991 through 1999, Berg and colleagues (2005) reported that 40 percent of infection-related maternal deaths were preventable.
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Several infective and noninfective factors can cause puerperal fever—a temperature of 38.0°C (100.4°F) or higher. Most persistent fevers after childbirth are caused by genital tract infection. Using this conservative definition of fever, Filker and Monif (1979) reported that only about 20 percent of women febrile within the first 24 hours after vaginal delivery were subsequently diagnosed with pelvic infection. This was in contrast to 70 percent of those after cesarean delivery. It must be emphasized that spiking fevers of 39°C or higher that develop within the first 24 hours postpartum may be associated with virulent pelvic infection caused by group A streptococcus, discussed in Uterine Infection.
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Other causes of puerperal fever include breast engorgement; infections of the urinary tract, of perineal lacerations, and of episiotomy or abdominal incisions; and respiratory complications after cesarean delivery (Maharaj, 2007). Approximately 15 percent of women who do not breastfeed develop postpartum fever from breast engorgement. As discussed in Chapter 36 (Hospital Care), the incidence of fever is lower in breastfeeding women. “Breast fever” rarely exceeds 39°C in the first few postpartum days and usually lasts <24 hours. Urinary infections are uncommon postpartum because of the normal diuresis encountered then. Acute pyelonephritis has a variable clinical picture. The first sign of renal infection may be fever, followed later by costovertebral angle tenderness, ...