Postpartum fever is defined as:
- 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 first 24 postpartum hours are different because low-grade fever during this period is common and typically resolves spontaneously, especially after uncomplicated vaginal deliveries.
Clinically, it would be inappropriate to wait until a fever is present for > 24 hours before acting; in almost all cases, patients should be evaluated in person with an appropriate diagnostic workup and treatment initiated immediately.
- 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 than in vaginal births
Most etiologies share common risk factors, which include:
- History of C-section or operative vaginal delivery (e.g., vacuum extraction)
- Emergency C-section
- 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:
- Bacterial vaginosis
- STIs (e.g., Chlamydia trachomatis)
- Factors associated with poor wound healing:
- Poorly controlled diabetes mellitus
- Immunodeficiency disorders (e.g., HIV)
- Unhygienic birth conditions
Etiology and Pathophysiology
The most common etiologies of postpartum fever are:
- Infection of the surgical site or perineal lacerations
- Mastitis/breast abscess
- Urinary tract infection (UTI), especially pyelonephritis
- Respiratory causes:
- Aspiration pneumonia
- Pulmonary embolism
- Thrombotic causes:
- Septic pelvic thrombophlebitis
- Deep vein thrombosis
- 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, pulmonary embolism
- Walking*: septic pelvic thrombophlebitis and/or deep vein thrombosis (DVT)
- Wonder drugs*: drug fever
* Also part of the 5 Ws mnemonic to remember the causes of postoperative fever in all surgical patients.
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 aerobes and anaerobes
- 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
Clinical presentation of postpartum fever depends on the underlying etiology, which will determine when the fever develops and other associated symptoms.
|Etiology||Days postpartum||Associated symptoms|
|Wound and perineal infections||4–7|
|Septic pelvic thrombophlebitis||3–5|
|Clostridium difficile infection||Varies|
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
- Ask questions to elicit information about risk factors and symptoms that may help rule in or out the etiologies discussed above.
- Assess and monitor patient’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
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:
- 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).
- Cultures (with antibiotic sensitivity testing):
- Urine cultures
- Wound cultures
- Blood cultures
- If sepsis is suspected: inflammatory markers (e.g., lactate)
- If retained products of conception are suspected:
- 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
- Doppler imaging with ultrasound
- If aspiration pneumonia is suspected: chest X-ray
Management and Prevention
Management of postpartum fever depends on the cause.
General supportive measures
- 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.
- Breastfeeding can and should be safely continued in almost all cases.
- Treated with IV antibiotics until afebrile for 24–48 hours
- Preferred IV regimen: aminoglycoside (typically gentamicin) + clindamycin
- Alternative IV regimen: aminoglycoside + metronidazole
- Ampicillin should be added in patients colonized by group B Streptococcus (GBS).
- Drainage, debridement, and irrigation
- Administration of broad-spectrum antibiotics (often requires coverage for MRSA)
- 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)
- Penicillinase-resistant antibiotics such as cephalexin, dicloxacillin or cloxacillin, or clindamycin
- 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 → patients should continue breastfeeding
- Ice packs to relieve inflammation
- Nipple shields can be used during breastfeeding to prevent nipple cracking.
Urinary tract infection
- 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
- Administration of broad-spectrum antibiotics
- Ampicillin + gentamicin + clindamycin is a common regimen.
- Administration of anticoagulants, often low-molecular-weight heparin (e.g., Lovenox)
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
- Vaginal cleansing with a povidone–iodine solution in the operating room before C-section in patients 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
Complications and Prognosis
- Abscess formation
- Adhesions/scar tissue formation (which may lead to future pain and/or fertility issues)
- Pulmonary embolism
- Early intervention results in complete recovery with no complications for the vast majority of patients.
- Patients 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.
- Pamela Berens. (2021). Overview of postpartum period: disorders and complications. UpToDate. Retrieved June 23, 2021, from https://www.uptodate.com/contents/overview-of-the-postpartum-period-disorders-and-complications
- K. T. Chen. (2020). Postpartum endometritis. In Varss, V.A. (Ed.) UpToDate. Retrieved June 23, 2021, from https://www.uptodate.com/contents/postpartum-endometritis
- Noreen Iftikhar, Carolyn Kay. (2021). What to do if you have a fever after pregnancy. Healthline. https://www.healthline.com/health/pregnancy/postpartum-fever#prevention
- Michael Moore. (2013). Postpartum fever. Medscape. Retrieved June 23, 2021, from https://www.medscape.com/viewarticle/804263
- Julie S. Moldenhauer. (2020). Postpartum care. MSD Manual Professional version. https://www.msdmanuals.com/professional/gynecology-and-obstetrics/postpartum-care-and-associated-disorders/postpartum-care
- Andy W. Wong, Adam J. Rosh. (2019). Postpartum infections. Medscape. Retrieved June 23, 2021, from https://emedicine.medscape.com/article/796892-overview