Postpartum Fever (Clinical)

Postpartum fever is a common and often preventable complication that occurs

within the 1st 10 postpartum days. The most common etiology is an infection of
the uterine lining known as endometritis. Other common etiologies include
surgical or perineal wound infections and mastitis. In addition to the fever, other
presenting symptoms depend on the etiology. The diagnosis is made based on
the clinical history and presentation, with additional laboratory tests (such as
cultures) to help confirm the diagnosis and guide management. Management of
postpartum fever typically involves antibiotics to treat infectious etiologies, and
early intervention is important to prevent complications such as sepsis.
Last updated: April 21, 2023

Overview
● Postpartum fever is defined by the US Joint Commission on Maternal Welfare as:[1,6]
○ An oral temperature of ≥ 38℃ (≥ 100.4℉) on any 2 of the 1st 10 postpartum days,
excluding the 1st 24 hours
○ An oral temperature of ≥ 38.7℃ (101.6℉) within the 1st 24 postpartum hours
● The 1st 24 postpartum hours are different because low-grade fever during this period is
common and typically resolves spontaneously, especially after uncomplicated vaginal
deliveries.[2]
● Despite the formal definition for postpartum fever beyond the first 24 hours, clinically, it
would be inappropriate to wait until a fever is present for > 24 hours before acting; in
almost all cases, individuals should be evaluated in person with an appropriate
diagnostic workup, and treatment should be initiated immediately.

Epidemiology[9,12]
● Postpartum fever is a complication that occurs in 5%–7% of postpartum women.
● Endometritis (uterine infection) is the most common cause.
● The majority of cases occur > 2 days after birth.
● Higher incidence in cesarean deliveries (CDs) than in vaginal births

Risk factors[2,4,7]
Most etiologies share common risk factors, which include:

● History of CD or operative vaginal delivery (e.g., vacuum extraction)

 ● Emergency CD
● Prelabor rupture of membranes (PROM) or premature PROM (PPROM)
● Prolonged rupture of membranes
● Prolonged labor
● Multiple or repeated vaginal examinations
● Retained products of conception
● Manual removal of the placenta
● Recent or untreated infections at the time of delivery, for example:
○ Chorioamnionitis
○ Bacteriuria
○ Bacterial vaginosis
○ STIs (e.g., Chlamydia trachomatis)
● Factors associated with poor wound healing:
○ Poorly controlled diabetes mellitus
○ Anemia
○ Smoking
○ Obesity
○ Immunodeficiency disorders (e.g., HIV)
● Unhygienic birth conditions
REPORT MISTAKE

Etiology and Pathophysiology

Etiology[2,4,7,9,12]
The most common etiologies of

postpartum fever are:

● Endometritis
● Infection of the surgical site or perineal lacerations
● Mastitis/breast abscess
● Urinary tract infection (UTI), especially pyelonephritis
● Respiratory causes:
○ Atelectasis
○ Aspiration pneumonia
● Thrombotic causes:
○ Septic pelvic thrombophlebitis
○ Deep vein thrombosis (DVT)/pulmonary embolism (PE)
● Complications of neuraxial anesthesia (rare):
○ Bacterial or chemical meningitis
○ Epidural abscess
● Clostridium difficile infection
● Drug fever (a diagnosis of exclusion)

To remember the primary causes of

postpartum fever, think of the 7 Ws:
● Wound*: surgical or perineal laceration wound infection
● Womb: endometritis
● Woobies: mastitis
● Water*: UTI
● Wind*: atelectasis, aspiration pneumonia
● Walking*: DVT/PE and/or septic pelvic thrombophlebitis
● Wonder drugs*: drug fever

* Also part of the 5

Ws mnemonic to remember the causes of postoperative fever in all individuals who have
undergone surgery.
Pathophysiology[4,7,12]
The pathophysiology of

postpartum fever is dependent on the etiology.

● Infections, including endometritis and wound/perineal infections, are typically caused by
skin and vaginal flora; therefore, infections:
○ Are polymicrobial
○ Contain both aerobic and anaerobic bacteria
● Mastitis is caused by oral flora in the infant, often introduced via nipple trauma that
occurred during breastfeeding.
● UTIs typically result when vaginal flora are introduced into the bladder during frequent or
prolonged catheterization during labor (more common with epidural use).
● Postpartum infections can develop into sepsis if not treated early.
● Bacteremia → endothelial injury → inflammation, which can lead to:
○ Organ failure, including AKIs and ARDS
○ Hypotension and septic shock
○ Death
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Clinical Presentation
Clinical presentation of

postpartum fever depends on the underlying etiology, which will determine when the fever
develops and other associated symptoms.[2,4,12]
Etiology Days Associated symptoms
postpartu
m

Endometritis 1–10 ● Fever with chills

● Uterine tenderness on exam (typically
significant)
● Tachycardia associated with fever
● Lower midline abdominal pain
● Heavier than expected vaginal bleeding

Wound and 4–7 ● Erythematous, edematous tissue

perineal ● Purulent exudate
● Severe local pain at the site of infection
infections
(abdominal or vaginal)
● Foul-smelling vaginal discharge

Septic pelvic 3–5 ● Low-grade, intermittent fever that does

thrombophlebitis not resolve with medication
● Pelvic pain
● Painful, swollen calf is possible.

Mastitis 7–21 ● Fevers are often high.

● Firm, red, inflamed, and tender breast
(unilateral)
● Red streaks on the breast
● A tender fluctuant mass in case of an
abscess
● Myalgia
● Chills
● Malaise
 Meningitis 0–1 ● Recent history of neuraxial anesthesia
(e.g., epidural)
● Back and/or neck pain
● Neurologic changes, which may include
weakness, sensory loss, gait
disturbances, bladder dysfunction

UTI: 1–2 ● Dysuria

pyelonephritis ● Urinary urgency and frequency
● Lower back and/or flank pain
● Suprapubic pain
● Nausea and/or vomiting
● Note: Fever is typically absent if infection
is confined to the bladder; fever develops
as pyelonephritis develops.

Clostridium Varies ● Diarrhea (10–15 episodes/day)

difficile infection ● Low-grade fever
● Abdominal pain/cramping
● Recent antibiotic exposure

Drug fever Varies ● Fever that coincides with administration

of a drug and disappears with
discontinuation
● Typically develops about 1 week after
initiating the drug (though could be hours
to months)
● Rashes are possible.

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Diagnosis
Postpartum fever is frequently a clinical diagnosis based on the presentation and risk factors
discussed above, with labs and imaging used to support/confirm the diagnosis.
History and exam checklist
 ● Ask questions to elicit information about risk factors and symptoms that may help rule in
or out the etiologies discussed above.
● Assess and monitor an individual’s vital signs (BP, temperature, respiratory rate, and
heart rate) to immediately identify sepsis if it is present or develops.
● Assess the uterus for:
○ Significant tenderness: suggests endometritis
○ Abnormally bulky: suggests retained products of conception, which may be
becoming infected
● Assess perineal and/or surgical wounds.
● Check for abnormal vaginal discharge.
● Examine the breasts for signs of mastitis or abscess.
● Examine the chest/lungs and legs for signs of infection and/or thrombosis.

Laboratory and imaging[4,12]

Based on findings from the history and exam, lab and imaging studies may be
appropriate to help support the diagnosis and guide treatment. These studies
include:

● CBC:
○ Rising WBC counts and a “left shift” suggest infection.
○ Note: General leukocytosis is common and normal in postpartum women with
average WBC counts 10,000–16,000/µL.
● Urinalysis
● Cultures (with antibiotic sensitivity testing):
○ Urine cultures
○ Wound cultures
○ Blood cultures (if there is a concern for sepsis)
● If sepsis is suspected: inflammatory markers (e.g., lactate)
● If retained products of conception are suspected as a source of uterine infection:
○ Pelvic ultrasonography
○ Note: Pelvic ultrasonography is generally not indicated in cases of routine
endometritis, as findings overlap with normal postpartum changes.
● If thrombosis is suspected:
○ Coagulation studies
■ Note: Postpartum, D-dimer levels are almost always elevated > 500
ng/mL (standard cutoff in nonpregnant individuals), especially after a CD,
returning to normal around 4‒5 weeks postpartum; thus, diagnostic utility
is limited.[5]
○ Doppler imaging with ultrasound
● If aspiration pneumonia is suspected: chest X-ray
REPORT MISTAKE
Management and Prevention
Management of

postpartum fever depends on the cause, and recommendations may vary based on practice
location. The following information is based on US recommendations.
General supportive measures[4,10,12]
● Adequate rest, nutrition, and fluid intake
● Pain control with analgesics
● Regular monitoring of symptoms
● Pay attention to treatment effects on breastfeeding:
○ Choose antibiotics that are safe in lactation. These include:
■ Most penicillins and cephalosporins
■ Gentamicin
■ Clindamycin
○ Some common antibiotics should generally avoided during breastfeeding,
including:
■ Fluoroquinolones
■ Trimethoprim–sulfamethoxazole (infants < 2 months)
■ Metronidazole
○ Breastfeeding can and should be safely continued in almost all cases.

Endometritis
● Treated with IV antibiotics until afebrile for 24‒48 hours[8]
● Imaging is performed if symptoms persist for > 72 hours after antibiotic therapy.
● Regimens:
○ Without group B Streptococcus (GBS) colonization: clindamycin + gentamicin[8]
■ Gentamicin:
■ 5 mg/kg IV every 24 hours (preferred) OR
■ 1.5 mg/kg IV every 8 hours
■ Clindamycin 900 mg every 8 hours
○ With GBS colonization: clindamycin + gentamicin + ampicillin:[3]
■ Typical dosing of ampicillin: 2 g IV every 6 hours
■ Ampicillin is added with GBS owing to significant clindamycin resistance
○ Alternative regimen (with or without GBS): ampicillin–sulbactam 3 g IV every 6
hours[9]
● Individuals typically do not require any additional (i.e., oral) antibiotics.[8]

Wound infections
● Drainage, debridement, and irrigation:[2]
○ Obtain a sample of infected fluid for culture prior to drainage.
○ Requires opening the wound
● Administration of broad-spectrum antibiotics (often requires coverage for MRSA):[11]
 ○ Given to treat cellulitis surrounding the incision/wound and/or when systemic
signs of infection are present (e.g., fever)
■ Note: Systemic antibiotics are typically not indicated for routine surgical
wound infections without fever or surrounding cellulitis
○ Multiple potentially effective regimens
○ Should cover:
■ Gram-positive skin flora (especially for infections appearing in the 1st
24‒48 hours, which are typically due to group A or group B β-hemolytic
Streptococcus)
■ Gram-negative bacteria
■ Anaerobic species (from cervicovaginal flora)
○ Examples of some recommended regimens per the Infectious Diseases Society
of America (IDSA):
■ Infected abdominal skin incision with low concern for MRSA: dicloxacillin
500 mg PO 4 times daily
■ Infected abdominal skin incision with higher concern for MRSA:
piperacillin–tazobactam 3.375 g IV every 6 hours
■ Fever within the 1st 96 hours (more likely due to β-hemolytic
Streptococcus species): penicillin 2‒4 million units every 4‒6 hours IV +
clindamycin 600‒900 mg every 8 hours IV
■ Fever > 4 days after operation (more likely due to Staphylococcus or
cervicovaginal flora):
■ Clindamycin 300‒400 mg PO 4 times daily
■ Ceftriaxone 1 g daily + metronidazole 500 mg every 8 hours
● Keep wounds clean.
● Vaginal cleansing with povidone–iodine in cases of infected perineal wounds
● Fiber-rich diet to decrease straining with bowel movements (straining puts pressure on
surgical sutures, causing pain and ↑ risk of dehiscence)

Mastitis
● Penicillinase-resistant antibiotics such as cephalexin, dicloxacillin or cloxacillin, or
clindamycin (e.g., dicloxacillin 500 mg PO 4 times daily)[11]
● Frequent and effective milk removal:
○ Milk stasis ↑ infection, so milk needs to keep flowing.
○ Organisms came from infant’s oral flora, so infant is not at risk for infection →
woman should continue breastfeeding
● Ice packs to relieve inflammation
● Nipple shields can be used during breastfeeding to prevent nipple cracking.

Urinary tract infection[12]

● Simple cystitis (rarely presents with fever) should be treated with oral antibiotics, typically
with penicillins.
● The following should generally be avoided in breastfeeding mothers with infants < 1
month old:
 ○ Nitrofurantoin (↑ risk of hemolytic anemia in the infant)
○ Trimethoprim–sulfamethoxazole (↑ risk of kernicterus)
● In cases of pyelonephritis, IV antibiotics are typically required.

Septic pelvic phlebitis[12]

● Administration of broad-spectrum antibiotics
● Ampicillin + gentamicin + clindamycin is a common regimen.
● Administration of anticoagulants, often low-molecular-weight heparin (e.g., enoxaparin)

Prevention[4,7,12]
Postpartum fever is often a preventable complication. The preventive measures to be taken are:
● Aseptic technique should be used in all procedures, if possible, especially:
○ Bladder catheterization
○ Neuraxial anesthesia
○ Surgery (cesarean delivery)
● Appropriate use of prophylactic antibiotics, for example:
○ Prior to cesarean delivery (typically cefazolin +/– azithromycin)
○ After manual extraction of the placenta
● Skin cleansing with an alcohol-based solution (e.g., chlorhexidine–alcohol)
● Vaginal cleansing with a povidone–iodine solution in the operating room before CD in
individuals with ruptured membranes
● Keep incisions clean
● Clean the vaginal area with water after using the restroom.
● Regular breastfeeding and/or pumping to prevent milk stasis
● Use of a nipple shield to prevent cracks in the nipples
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Complications and Prognosis

Complications[4,12]
● Sepsis
● Abscess formation
● Adhesions/scar tissue formation (which may lead to future pain and/or fertility issues)
● Pulmonary embolism
● DIC

Prognosis[4,12]
● Early intervention results in complete recovery with no complications for the vast majority
of individuals.
● Individuals should be monitored carefully, and aggressive treatment should be
administered in cases of progression to sepsis.
● Untreated postpartum fever or late intervention increases the chances of severe
complications.