According to the Centers for Disease Control and Prevention and the National Hospital Discharge Summary, nearly 1.3 million cesarean deliveries were performed in 2013 (Martin, 2015). This stands as the most common abdominal surgery in the United States and by far the most frequently performed surgery in obstetrics. Cesarean delivery is discussed in detail in Chapter 25 (p. 403), and postoperative complications following this procedure contribute substantively to pregnancy-related morbidity and mortality rates. In their sobering analysis of data from the Pregnancy Mortality Surveillance System, for example, Creanga and colleagues (2015) found that infection, venous thromboembolism, and hemorrhage contributed 13.6 percent, 9.6 percent, and 11.4 percent, respectively, to all pregnancy-related deaths from 2006 to 2010. The contribution from infection actually represented a significant increase compared with previously reported epochs. The importance of recognizing and appropriately managing such postoperative complications is highlighted by the fact that subsets of the resultant deaths are unquestionably preventable.
Puerperal fever is defined by a temperature increase to 38.0°C (100.4°F) or greater in the postpartum period, whereas puerperal infection refers to any bacterial infection of the genital tract. The causes of puerperal fever are numerous, and the presence of fever by itself is not diagnostic of infection. Indeed, transient, low-grade fever in the early postpartum period is usually benign and does not require treatment. However, most persistent or high-grade fevers—39.0°C or higher—are associated with infection, most commonly uterine infection.
Several risk factors for puerperal infection have been identified, but cesarean delivery is the single most important risk for infection, conferring a 20- to 30-fold relative risk compared with vaginal delivery (Maharaj, 2007). In an older study, Filker and Monif (1979) reported that only 21 percent of women febrile in the first 24 hours who were delivered vaginally were found to have infection. This contrasts with 72 percent of those with fever who had undergone cesarean delivery.
Extragenital causes of puerperal fever include breast engorgement, mastitis, urinary tract infection, septic pelvic thrombophlebitis, respiratory complications, and, in women who undergo laparotomy, wound infection. The broad differential diagnosis of postpartum fever underscores the importance of a prompt and thorough evaluation in any woman who is noted to have a temperature above these threshold values.
Breast engorgement commonly causes a brief temperature elevation. Approximately 15 percent of all women in the first few postpartum days develop fever from breast engorgement, but it rarely exceeds 39°C. Engorgement is more common in women who do not breastfeed and is typically associated with breast pain and marked bilateral firmness during examination. This fever characteristically lasts no longer than 24 hours. Treatment is supportive with breast binders, cool packs, and oral analgesics as needed. That said, evidence-based recommendations for the management of breast engorgement are lacking (Mangesi, 2010).