Puerperal Fever in Hospital Settings

Puerperal fever, also known as postpartum infection or childbed fever, occurs when bacteria infects the female reproductive tract shortly after childbirth, miscarriage or abortion. It is typically caused by the streptococcal bacteria, although there are other agents of infection. Puerperal fever was once the single greatest cause of maternal mortality in the 18th and 19th centuries, afflicting 6 to 9 women per 1000 deliveries and claiming the lives of 2 to 3 women when the condition advanced to peritonitis or septicemia. These numbers were greatly inflated during times of epidemics. Approximately half of all childbirth-related deaths were caused by puerperal fever, with tuberculosis coming in at a close second. Prior to the advances of modern medicine, "childbed fever" incited great fear in pregnant women and prompted them to seek greater provisions of care than what traditional midwives could offer. At the time, because it advanced spread of the disease, hospitals were often a more hazardous place for the mother than her own home. A poor understanding of causation led to a relative prevalence of the disease prior to the 20th century.

11.8 million postpartum infections occurred throughout the world in 2015, although the developed world sees an incidence of just one to two percent of uterine infections in vaginal deliveries. While 34,000 deaths occurred from postpartum infections in 1990, this figure dropped to 17,900 by 2015. It currently accounts for 10% of pregnancy related deaths. Its name comes from the Latin "puer," meaning child, and "parere" meaning birth.

The most common types of puerperal infections are endometritis, myometritis, and parametritis - which are uterine lining infection, uterine muscle infection and infection of the surrounding area respectively.

Causes of Puerperal Fever

A woman becomes vulnerable to a number of infections immediately after childbirth. Infection may take hold in the placental site within the first ten days of delivery; fever becomes a concern if lasting more than 24 hours.

The most common form of puerperal infection occurs on the interior surface of the uterus, following its separation of the placenta. Infection causing pathogens like the streptococcal bacteria can successfully invade any laceration within the mother's genital tract. Invasion of the bloodstream (sepsis) may occur, causing inflammation of the woman's connective tissue. As with many diseases, the severity of infection will depend on the virulence of the pathogen and the host/mother's natural immunity.

Staphylococci, which may live on the skin and inhabit common pimples, is commonly behind infection, although there are other culprit bacteria. Any present anaerobic streptococci in the area may flourish after an unskilled delivery leading to injurious labor.

In c-Section deliveries, the site of incision could be infected if proper techniques are not followed, such as the administration of precautionary antibiotics and sterilization of tools used in the method of delivery.

Causative bacteria include:

  • E.coli
  • Strep
  • tetanus
  • C. welchii.

Causative conditions include:

  • endometritis
  • urinary tract infection
  • pneumonia/atelectasis
  • wound infection
  • septic pelvic thrombophlebitis.

Symptoms of Puerperal Fever

Symptoms will vary based on the type of postpartum infection, if one should take hold:

  • fever greater than 38.0 °C (100.4 °F)
  • chills
  • malaise
  • lower abdominal pain
  • possibly bad smelling vaginal discharge
  • difficulty urinating or painful urination, the sensation of needing to urinate often
  • Swelling, discharge, warmth or redness at the incision site (if any).

Treatment for Puerperal Fever

Experiments in the 1920s and 30s led physicians to the conclusion that sulfonamides aided in the fight against childbed fever. Antibiotics are commonly used today both as a precursory measure and for established infections. Antimicrobial treatment is administered in most cases, with a combination of aminoglycoside and clindamycin, or alternately aminoglycoside and metronidazole. The type of antibiotics used will likely depend on the severity of the infection.

Endometritis, if mild, can be treated with oral antimicrobials such as doxycycline and clindamycin. If wound infection occurs, drainage or debridement may be required in addition to broad spectrum antibiotics.

Risk Factors for Puerperal Fever

Mothers who deliver by C-section are generally at a greater risk for developing a postpartum infection. In anticipation of such complications, these mothers are given a precursory dose of antibiotics.

Abortions performed in unhygienic surroundings may put the mother at far greater risk of developing puerperal fever. Unique risk factors exist for each of the causative conditions associated with puerperal fever. On Postpartum Day 0, the mother could be at risk for developing atelectasis (lung collapse) if she has undergone general anesthesia, was a heavy smoker or has obstructive lung disease. Between postpartum days 1 and 2, the mother could potentially develop a urinary tract infection, risk factors for which include untreated bacteriuria multiple catheterizations during labor or multiple vaginal examinations during labor. On postpartum days 2 and 3, the mother is at risk for endometritis ( the most common cause of puerperal fever). The risk factors of endometritis include prolonged labor, emergency cesarean section, prolonged membrane rupture, and multiple vaginal examinations during labor. On postpartum days 4 and 5, mothers who underwent a c-section, experienced prolonged membrane rupture, prolonged labor, and multiple vaginal examinations during labor are at a greater risk of wound infection. On postpartum days 5 and 6, septic pelvic thrombophlebitis could take hold of the mother; the risk factors of this include prolonged labor, emergency c-section, prolonged membrane rupture, and diffuse difficult vaginal childbirth 

Prevention of Puerperal Fever

Preventing postpartum infection is critical to the health of both mother and baby. There are a number of situationally-specific recommendations for the prevention of puerperal fever, some of which may be taken on by the mother herself or her healthcare provider. Above all, conducting all birthing or abortion procedures in a hygienic environment with sanitized equipment and hands is the chief means of preventing infection.

During the heyday of puerperal fever in the 18th and 19th centuries, a contemporary was amusingly quoted saying "There was no object in being clean ... Indeed, cleanliness was out of place. It was considered to be finicking and affected." Experimentation with cleansing agents began 1847, with a German physician requiring his medical students and staff to wash their hands in chlorinated lime solution prior to performing vaginal examinations. Mortality from puerperal fever fell from 18% to 3% that same year.

It is recommended:

  • for the provider
    • to administer antibiotics to women with group B Streptococcus (GBS) colonization
    • to administer prophylaxis when the mother undergoes manual removal of the placenta - although prophylaxis in not recommended in cases of uncomplicated vaginal births
    • to cleanse the vagina with povidone-iodine prior to performing a c-section
  • for the mother
    • to not shave the pubic area prior to birth
    • to not use vaginal douches before or after giving birth
    • to use sanitary pads in lieu of tampons.

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