Fever after childbirth

 

 

PROBLEM

• A woman has a fever (temperature 38°C or more) occurring more than 24 hours after delivery.

GENERAL MANAGEMENT

• Encourage bed rest.

• Ensure adequate hydration by mouth or IV.

• Use a fan or tepid sponge to help decrease temperature.

• If shock is suspected, immediately begin treatment. Even if signs of shock are not present, keep shock in mind as you evaluate the woman further because her status may worsen rapidly. If shock develops, it is important to begin treatment immediately.

DIAGNOSIS

TABLE S-14    Diagnosis of fever after childbirth 

Presenting Symptom and Other Symptoms and Signs Typically Present Symptoms and Signs Sometimes Present Probable Diagnosis 
• Fever/chills
• Lower abdominal pain
• Purulent, foul-smelling lochia
• Tender uterus		 • Lighta vaginal bleeding
• Shock
 		 Metritis
a Light bleeding: takes longer than 5 minutes for a clean pad or cloth to be soaked.
• Lower abdominal pain and distension
• Persistent spiking fever/chills
• Tender uterus		 • Poor response to antibiotics
• Swelling in adnexa or pouch of Douglas
• Pus obtained upon culdocentesis 		 Pelvic abscess
• Low-grade fever/chills
• Lower abdominal pain
• Absent bowel sounds		 • Rebound tenderness
• Abdominal distension
• Anorexia
• Nausea/vomiting
• Shock		 Peritonitis
• Breast pain and tenderness
• 3–5 days after delivery		 • Hard enlarged breasts
• Both breasts affected		 Breast engorgement
• Breast pain and tenderness
• Reddened, wedge-shaped area on breast
• 3–4 weeks after delivery		 • Inflammation preceded by engorgement
• Usually only one breast affected		 Mastitis
• Firm, very tender breast
• Overlying erythema		 • Fluctuant swelling in breast
• Draining pus		 Breast abscess
• Unusually tender wound with bloody or serous discharge • Slight erythema extending beyond edge of incision Wound abscess, wound seroma or wound haematoma
• Painful and tender wound
• Erythema and oedema beyond edge of incision		 • Hardened wound
• Purulent discharge
• Reddened area around wound		 Wound cellulitis
• Dysuria
• Increased frequency and urgency of urination		 • Retropubic/suprapubic pain
• Abdominal pain		 Cystitis
• Dysuria
• Spiking fever/chills
• Increased frequency and urgency of urination
• Abdominal pain		 • Retropubic/suprapubic pain
• Loin pain/tenderness
• Tenderness in rib cage
• Anorexia
• Nausea/vomiting		 Acute pyelonephritis
• Spiking fever despite antibiotics • Calf muscle tenderness Deep vein thrombosis a
a Give heparin infusion
• Fever
• Difficulty in breathing
• Cough with expectoration 
• Chest pain		 • Consolidation
• Congested throat
• Rapid breathing
• Rhonchi/rales		 Pneumonia
• Fever
• Decreased breath sounds		 • Typically occurs postoperative Atelectasis b
b Encourage ambulation and deep breathing. Antibiotics are not necessary.
• Fever
• Chills/rigors
• Headache
• Muscle/joint pain		 • Enlarged spleen Uncomplicated malaria
• Symptoms and signs of uncomplicated malaria
• Coma
• Anaemia		 • Convulsions
• Jaundice		 Severe/complicated malaria
• Fever
• Headache
• Dry cough
• Malaise
• Anorexia
• Enlarged spleen		 • Confusion
• Stupor		 Typhoid c
c Give ampicillin 1 g by mouth four times per day OR amoxicillin 1 g by mouth three times per day for 14 days. Alternative therapy will depend on local sensitivity patterns
• Fever
• Malaise
• Anorexia
• Nausea
• Dark urine and pale stool
• Jaundice
• Enlarged liver		 • Muscle/joint pain
• Urticaria
• Enlarged spleen		 Hepatitis d
d Provide supportive therapy and observe.

MANAGEMENT

METRITIS

Metritis is infection of the uterus after delivery and is a major cause of maternal death. Delayed or inadequate treatment of metritis may result in pelvic abscess, peritonitis, septic shock, deep vein thrombosis, pulmonary embolism, chronic pelvic infection with recurrent pelvic pain and dyspareunia, tubal blockage and infertility.

• Transfuse as necessary. Use packed cells, if available.

• Give a combination of antibiotics until the woman is fever-free for 48 hours:

- ampicillin 2 g IV every 6 hours; 

- PLUS gentamicin 5 mg/kg body weight IV every 24 hours; 

- PLUS metronidazole 500 mg IV every 8 hours;

- If fever is still present 72 hours after initiating antibiotics, re-evaluate and revise diagnosis. 

Note: Oral antibiotics are not necessary after stopping IV antibiotics. 

• If retained placental fragments are suspected, perform a digital exploration of the uterus to remove clots and large pieces. Use ovum forceps or a large curette if required. 

• If there is no improvement with conservative measures and there are signs of general peritonitis (fever, rebound tenderness, abdominal pain), perform a laparotomy to drain thepus.

• If the uterus is necrotic and septic, perform subtotal hysterectomy.


PELVIC ABSCESS

• Give a combination of antibiotics before draining the abscess and continue until the woman is fever-free for 48 hours:

- ampicillin 2 g IV every 6 hours; 

- PLUS gentamicin 5 mg/kg body weight IV every 24 hours;

- PLUS metronidazole 500 mg IV every 8 hours.

• If the abscess is fluctuant in the cul-de-sac, drain the pus through the cul-de-sac. If the spiking fever continues, perform a laparotomy.


PERITONITIS

• Provide nasogastric suction.

• Infuse IV fluids.

• Give a combination of antibiotics until the woman is fever-free for 48 hours:

- ampicillin 2 g IV every 6 hours; 

- PLUS gentamicin 5 mg/kg body weight IV every 24 hours;

- PLUS metronidazole 500 mg IV every 8 hours.

• If necessary, perform laparotomy for peritoneal lavage (wash-out).


BREAST ENGORGEMENT

Breast engorgement is an exaggeration of the lymphatic and venous engorgement that occurs prior to lactation. It is not the result of overdistension of the breast with milk.

BREASTFEEDING

• If the woman is breastfeeding and the baby is not able to suckle, encourage the woman to express milk by hand or with a pump.

• If the woman is breastfeeding and the baby is able to suckle:

- Encourage the woman to breastfeed more frequently, using both breasts at each feeding;

- Show the woman how to hold the baby and help it attach;

- Relief measures before feeding may include:

- Apply warm compresses to the breasts just before breastfeeding, or encourage the woman to take a warm shower;

- Massage the woman’s neck and back;

- Have the woman express some milk manually prior to breastfeeding and wet the nipple area to help the baby latch on properly and easily;

- Relief measures after feeding may include:

- Support breasts with a binder or brassiere;

- Apply cold compress to the breasts between feedings to reduce swelling and pain;

- Give paracetamol 500 mg by mouth as needed;

- Follow up 3 days after initiating management to ensure response.
 

NOT BREASTFEEDING

• If the woman is not breastfeeding:

- Support breasts with a binder or brassiere;

- Apply cold compresses to the breasts to reduce swelling and pain;

- Avoid massaging or applying heat to the breasts;

- Avoid stimulating the nipples;

- Give paracetamol 500 mg by mouth as needed;

- Follow up 3 days after initiating management to ensure response. 


BREAST INFECTION

MASTITIS

• Treat with antibiotics:

- cloxacillin 500 mg by mouth four times per day for 10 days; 

- OR erythromycin 250 mg by mouth three times per day for 10 days.

• Encourage the woman to:

- continue breastfeeding;

- support breasts with a binder or brassiere;

- apply cold compresses to the breasts between feedings to reduce swelling and pain.

• Give paracetamol 500 mg by mouth as needed. 

• Follow up 3 days after initiating management to ensure response.

BREAST ABSCESS

• Treat with antibiotics:

- cloxacillin 500 mg by mouth four times per day for 10 days; 

- OR erythromycin 250 mg by mouth three times per day for 10 days.

• Drain the abscess:

- General anaesthesia (e.g. ketamine) is usually required;

- Make the incision radially extending from near the alveolar margin towards the periphery of the breast to avoid injury to the milk ducts;

- Wearing high-level disinfected gloves, use a finger or tissue forceps to break up the pockets of pus;

- Loosely pack the cavity with gauze;

- Remove the gauze pack after 24 hours and replace with a smaller gauze pack. 

• If there is still pus in the cavity, place a small gauze pack in the cavity and bring the edge out through the wound as a wick to facilitate drainage of any remaining pus. 

• Encourage the woman to:

- continue breastfeeding even when there is collection of pus;

- support breasts with a binder or brassiere;

- apply cold compresses to the breasts between feedings to reduce swelling and pain.

• Give paracetamol 500 mg by mouth as needed. 

• Follow up 3 days after initiating management to ensure response.


INFECTION OF PERINEAL AND ABDOMINAL WOUNDS

WOUND ABSCESS, WOUND SEROMA AND WOUND HAEMATOMA

• If there is pus or fluid, open and drain the wound.

• Remove infected skin or subcutaneous sutures and debride the wound. Do not remove fascial sutures.

• If there is an abscess without cellulitis, antibiotics are not required. 

• Place a damp dressing in the wound and have the woman return to change the dressing every 24 hours.

• Advise the woman on the need for good hygiene and to wear clean pads or cloths that she changes often.

WOUND CELLULITIS AND NECROTIZING FASCIITIS

• If there is fluid or pus, open and drain the wound.

• Remove infected skin or subcutaneous sutures and debride the wound. Do not remove fascial sutures.

• If infection is superficial and does not involve deep tissues, monitor for development of an abscess and give a combination of antibiotics:

- ampicillin 500 mg by mouth four times per day for 5 days;

- PLUS metronidazole 400 mg by mouth three times per day for 5 days.

• If the infection is deep, involves muscles and is causing necrosis (necrotizing fasciitis), give a combination of antibiotics until necrotic tissue has been removed and the woman is fever-free for 48 hours:

- penicillin G 2 million units IV every 6 hours;

- PLUS gentamicin 5 mg/kg body weight IV every 24 hours;

- PLUS metronidazole 500 mg IV every 8 hours;

- Once the woman is fever-free for 48 hours, give:

- ampicillin 500 mg by mouth four times per day for 5 days; 

- PLUS metronidazole 400 mg by mouth three times per day for 5 days. 

Note: Necrotizing fasciitis requires wide surgical debridement. Perform secondary closure 2–4 weeks later, depending on resolution of infection.

• If the woman has a severe infection or necrotizing fasciitis, admit her to the hospital for management and change wound dressing twice daily.