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Women are susceptible to several potentially serious complications during the fourth trimester. Many of these conditions are encountered during pregnancy, and others are unique to the puerperium. Historically, infection was the most important source of postpartum maternal morbidity and mortality, since emphasized by the studies of Semmelweis and Lister (Kadar, 2021). Puerperal infections include pelvic infections, mastitis, and breast abscesses. Discussed in their respective chapters, cardiovascular disease (Chap. 52, p. 915), venous thromboembolism (Chap. 55, p. 980), and hemorrhage (Chap. 42, p. 731) currently are leading noninfectious puerperal complications (Callaghan, 2012; Creanga, 2017). However, the incidence of postpartum hospitalization due to sepsis is rising. Other puerperal issues and their management are discussed in Chapter 36.


Traditionally, the term puerperal infection describes any bacterial infection of the genital tract after delivery. Infection, preeclampsia, and obstetrical hemorrhage formed the lethal triad of maternal death causes before and during the 20th century. Fortunately, maternal mortality from puerperal infection is uncommon because of effective antibiotics. Creanga and associates (2017) reported results from the Pregnancy Mortality Surveillance System, which contained 4693 pregnancy-related maternal deaths in the United States from 2006 through 2010. Infection caused 13.6 percent of the deaths and was the second leading etiology. In an analysis of the North Carolina population, Berg and colleagues (2005) reported that 40 percent of infection-related maternal deaths were preventable.

Puerperal Fever

Several infective and noninfective factors cause puerperal fever defined by a temperature of 38.0°C (100.4°F) or higher. Using this conservative definition, Filker and Monif (1979) reported that only approximately 20 percent of women febrile within the first 24 hours after vaginal delivery were subsequently diagnosed with pelvic infection. This value was 70 percent in those undergoing cesarean delivery. Most persistent fevers after childbirth are caused by genital tract infection. Of note, spiking fevers ≥39°C within the first 24 hours postpartum may be associated with virulent pelvic infection caused by group A streptococcus (p. 651).

Other sources of puerperal fever include breast engorgement, urinary infections, episiotomy and abdominal incisions, perineal lacerations, and postcesarean respiratory complications. Approximately 15 percent of women who do not breastfeed develop fever from breast engorgement. “Breast fever” rarely exceeds 39°C in the first few postpartum days and usually lasts <24 hours. The incidence of fever is lower in breastfeeding women (Chap. 36, p. 642). Postpartum urinary infections are uncommon because of the normal diuresis. Acute pyelonephritis has a variable clinical picture. The first sign of renal infection may be fever, followed later by costovertebral angle tenderness, nausea, and vomiting. Atelectasis following general anesthesia for cesarean delivery is caused by hypoventilation and is best prevented by coughing and deep breathing on a fixed schedule following surgery. Fever with atelectasis is due to infection triggered by proliferation of normal flora distal to obstructing mucus ...

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