Fever after delivery
Obstetrics
Postpartum ward or the emergency department in the six weeks after birth
The first question
What day, what route of delivery, and where is the source?
Two patients: the gestational age and the maternal stability first, then the fetal status.
- 01
Sepsis screen
Vital signs, lactate if unwell; maternal sepsis is a leading cause of death and progresses fast.
- 02
Source by system
Uterus (endometritis), wound, breast, urine, chest, legs, and the ones that hide: retained products, pelvic abscess, septic pelvic thrombophlebitis.
- 03
Treat
Cultures then broad-spectrum antibiotics; source control (evacuation, drainage) where needed.
Where it is
Each opens the structure on the 3D pelvis.
History that discriminates
- Day postpartum, mode of delivery, length of labour and rupture, instrumentation, manual removal
- Lochia: volume, odour
- Breast pain, feeding
- Wound, perineal pain
- Urinary symptoms, catheterisation
- Leg pain, dyspnoea, chest pain
- GBS status, intrapartum fever
Examination that discriminates
- Full vital signs, mental state
- Uterus: tenderness, size, lochia
- Wound or perineum
- Breasts
- Calves, chest
- Speculum and bimanual if endometritis or retained products are suspected
Investigations
- CBC, CRP, lactate, blood cultures, urine culture
- Wound or lochia swabs
- Pelvic ultrasound for retained products or collection
- Chest imaging or leg Doppler by symptoms
- CT for persistent fever despite antibiotics (abscess, septic thrombophlebitis)
The differential
| Diagnosis | Favours | Against | Urgency |
|---|---|---|---|
| Endometritis | Day 2 to 5, uterine tenderness, foul lochia, caesarean, long labour | Non-tender uterus | urgent |
| Wound infection | Day 4 to 7, erythema, discharge, dehiscence | Clean wound | urgent |
| Mastitis or abscess | Week 2 to 3, a red painful wedge, fluctuance | Normal breasts | urgent |
| Urinary infection or pyelonephritis | Catheter, dysuria, flank pain | Normal urine | urgent |
| Retained products | Heavy bleeding with fever, open os, ultrasound collection | Empty uterus | urgent |
| Venous thromboembolism | Leg swelling, dyspnoea, pleuritic pain, low-grade fever | Normal legs and chest | emergent |
| Necrotising fasciitis | Pain out of proportion at a wound or perineum, crepitus, rapid deterioration | Mild wound findings | emergent |
Pitfalls this pathway refuses
- Treating a fever as mastitis without examining the uterus and wound
- Missing sepsis because the white count is 'normal for pregnancy'
- Forgetting VTE in a febrile postpartum patient