Table of Contents
Definition and Background
What is Puerperal Pyrexia?
Puerperal pyrexia is defined as a temperature of 38°C (100.4°F) or higher occurring within six weeks after childbirth or abortion, maintained for 24 hours or recurring during this period, in which two or more of the following are present:
- Pelvic pain
- Fever
- Abnormal vaginal discharge
- Foul-smelling/abnormal odor discharge
- Delay in uterine involution
The World Health Organization (WHO) uses the term “maternal peripartum infection” to account for both intrapartum (intra-amniotic infection occurring before birth) and postpartum (or puerperal) bacterial infections related to childbirth.
Important Note: Puerperal pyrexia complicates approximately 5-7% of all births, with an infective cause identified in about 50% of cases. It remains a significant cause of maternal morbidity and mortality worldwide.
Epidemiology
Bacterial infections during the peripartum period are among the leading causes of maternal mortality worldwide, accounting for about one tenth of the global burden of maternal deaths. Key epidemiological facts include:
- Approximately 75,000 maternal deaths occur worldwide yearly as a result of infections.
- The majority of these deaths are recorded in low-income countries.
- In high-income countries, the incidence is relatively low (between 0.1 and 0.6 per 1000 births), yet remains an important direct cause of maternal mortality.
- Puerperal pyrexia complicates approximately 5-7% of pregnancies.
- An infectious cause is identified in approximately 50% of cases.
- Surgical site infections occur in 2-7% of cesarean deliveries.
- Maternal infections around childbirth are associated with an estimated 1 million newborn deaths annually.
The case fatality rates for childbirth-related sepsis remain very high, with rates between 4% and 50% reported in sub-Saharan Africa and South East Asia.
Pathophysiology
Puerperal pyrexia pathophysiology can be understood through two main infection pathways:
1. Ascending Infection Pathway
Postpartum infections primarily result from the ascending of vaginal microflora into the reproductive tract. This generally occurs due to:
- Physiologic and iatrogenic trauma to the reproductive tract during childbirth
- Disruption of normal anatomical barriers
- Introduction of bacteria into normally sterile environments
- Proliferation of organisms in devitalized tissue and blood clots
2. Iatrogenic Trauma Pathway
Infections resulting from surgical or procedural interventions during childbirth include:
- Surgical site infections (SSI) following cesarean section or episiotomy
- Infections at trauma sites (perineal tears, lacerations)
- Infections associated with invasive procedures (manual removal of placenta, operative vaginal birth)
The Pathophysiological Process
The bacteria that cause puerperal pyrexia enter the genital tract during labor and the postpartum period when the cervix is dilated, and normal barriers are compromised. The process typically follows this sequence:
- Bacterial colonization of the decidua (endometrium)
- Extension to myometrium (causing endometritis/myometritis)
- Spread to parametrium via lymphatic channels
- Potential extension to peritoneal cavity (causing peritonitis)
- Possible entry into bloodstream (causing bacteremia/sepsis)
Endometritis
Occurs when vaginal bacteria ascend into the uterus. The placental site is particularly vulnerable as it provides an ideal medium for bacterial growth with its:
- Devascularized tissue
- Accumulated blood clots
- Reduced local immunity
Wound Infections
Develop when bacteria contaminate surgical sites or traumatized tissues. The infection process involves:
- Bacterial colonization
- Local inflammatory response
- Tissue breakdown
- Potential abscess formation
Pathophysiological Insight: The immune response during pregnancy is altered to accommodate the fetus, resulting in relative immunosuppression. Additionally, the immediate postpartum period is characterized by significant tissue trauma, blood loss, and stress, which can further compromise immune function, making the new mother particularly vulnerable to infections.
Risk Factors
Understanding the risk factors for puerperal pyrexia is crucial for prevention and early identification of at-risk patients. These factors can be categorized as follows:
| Category | Risk Factors | Impact Level |
|---|---|---|
| Pre-existing Maternal Conditions |
|
Moderate to High |
| Pregnancy-Related Factors |
|
High |
| Labor and Delivery Factors |
|
Very High |
| Postpartum Factors |
|
Moderate |
| Environmental Factors |
|
Moderate to High |
High Risk Alert: Caesarean section is the most significant risk factor for puerperal pyrexia, with a 5-20 fold increased risk compared to vaginal birth. Every additional hour of surgery increases infection risk by 30%.
Causative Organisms and Classification
Causative Organisms
| Type of Bacteria | Specific Organisms | Commonly Associated With |
|---|---|---|
| Aerobic Gram-positive cocci |
|
Endometritis, wound infections, mastitis |
| Aerobic Gram-negative bacilli |
|
Urinary tract infections, endometritis |
| Anaerobic bacteria |
|
Endometritis, septic pelvic thrombophlebitis |
| Others |
|
Late-onset endometritis |
Classification of Puerperal Infections
By Anatomical Location
- Genital tract infections: Endometritis, myometritis
- Wound infections: Cesarean section wound, episiotomy site, perineal tears
- Urinary tract infections: Cystitis, pyelonephritis
- Breast infections: Mastitis, breast abscess
- Vascular infections: Septic pelvic thrombophlebitis
By Time of Onset
- Early-onset: Within 48 hours of delivery
- Late-onset: 48 hours to 6 weeks postpartum
By Severity
- Localized infection: Limited to specific organ/tissue
- Invasive infection: Spreading beyond initial site
- Systemic infection: Sepsis, septic shock
Clinical Note: Most puerperal infections are polymicrobial in nature, involving a mixture of aerobic and anaerobic bacteria from the normal vaginal flora and intestinal tract.
Clinical Manifestations
The clinical presentation of puerperal pyrexia varies depending on the site and severity of infection. Key manifestations include:
General Symptoms
- Temperature ≥38°C (100.4°F)
- Tachycardia (pulse >90 beats/min)
- Tachypnea (respiratory rate >20 breaths/min)
- Malaise and fatigue
- Chills and rigors
- Decreased appetite
- General discomfort
Endometritis
- Lower abdominal pain or tenderness
- Uterine tenderness on palpation
- Subinvolution of the uterus
- Foul-smelling lochia
- Purulent or prolonged lochia
- Pelvic pain
- Cervical motion tenderness
Urinary Tract Infection
- Frequency and urgency
- Dysuria
- Suprapubic pain
- Hematuria
- Flank pain (pyelonephritis)
- Costovertebral angle tenderness
Wound Infection
- Erythema around wound site
- Warmth at the site
- Pain or tenderness
- Swelling
- Purulent discharge
- Wound dehiscence
- Crepitus in severe cases
Mastitis
- Flu-like symptoms
- Painful, hard, red breast
- Localized breast tenderness
- Warm, red area on breast
- Possible abscess formation
- Nipple trauma
- Breast engorgement
Warning Signs of Severe Infection/Sepsis
- High fever (>39°C/102.2°F) or hypothermia
- Extreme tachycardia (heart rate >120 bpm)
- Hypotension (systolic BP <90 mmHg)
- Decreased urine output (<0.5 ml/kg/hr)
- Altered mental status/confusion
- Severe breathlessness (respiratory rate >30/min)
- Decreased capillary refill (>3 seconds)
- Mottled skin
- Acute abdominal pain or rigidity
- Severe generalized edema
Clinical Presentation by Type of Infection
| Type of Infection | Common Presentation | Timing | Red Flags |
|---|---|---|---|
| Endometritis | Fever, uterine tenderness, subinvolution, foul-smelling lochia | Usually 2-5 days postpartum | Persistent fever despite antibiotics, severe abdominal pain |
| Wound infection | Erythema, pain, purulent drainage, wound dehiscence | 4-7 days postpartum | Spreading cellulitis, crepitus, necrotic tissue |
| Urinary tract infection | Dysuria, frequency, suprapubic pain | Can occur anytime during puerperium | Flank pain, high fever (signs of pyelonephritis) |
| Mastitis | Localized breast tenderness, redness, warmth | Typically 1-4 weeks postpartum | Abscess formation, fluctuant mass in breast |
| Septic pelvic thrombophlebitis | Persistent fever despite antibiotics, minimal abdominal findings | 7-10 days postpartum | Pulmonary emboli, respiratory distress |
Diagnostic Approach
A systematic approach to diagnosis is essential for appropriate management of puerperal pyrexia. The diagnostic process typically includes:
History Taking
- Time and mode of delivery (vaginal vs. cesarean)
- Duration and progression of symptoms
- Details of the labor and delivery (duration, complications)
- Presence and timing of membrane rupture
- Number of vaginal examinations during labor
- Instrumentation used during delivery
- Placental delivery (manual removal, retained fragments)
- Previous medical history (diabetes, immunosuppression)
- GBS status, if known
Physical Examination
- Vital signs (temperature, pulse, blood pressure, respiratory rate)
- General appearance and mental status
- Abdominal examination (tenderness, distension, rebound)
- Uterine assessment (height, consistency, tenderness)
- Lochia assessment (amount, color, odor)
- Examination of perineum and any wounds (using REEDA scale: Redness, Edema, Ecchymosis, Discharge, Approximation)
- Breast examination
- Examination for leg swelling or tenderness (DVT)
- Respiratory examination
Laboratory Investigations
Essential Tests:
- Complete blood count (CBC) with differential
- C-reactive protein (CRP)
- Blood cultures (before antibiotics if possible)
- High vaginal swab for culture and sensitivity
- Urine analysis and culture
- Wound swabs (if applicable)
- Serum lactate (if sepsis suspected)
Additional Tests (as indicated):
- Renal function tests
- Liver function tests
- Coagulation profile
- Arterial blood gases
- Serum glucose
- Chest X-ray (if respiratory symptoms present)
- HIV testing (in high-risk populations)
Imaging Studies
- Pelvic ultrasound: To assess for retained products of conception, endometrial thickness, collections or abscesses
- Computed Tomography (CT) scan: For suspected deep infections, abscesses, or septic pelvic thrombophlebitis
- Magnetic Resonance Imaging (MRI): For better soft tissue definition, especially in cases of necrotizing fasciitis or deep-seated infections
- Chest X-ray: If respiratory symptoms are present or pneumonia is suspected
- Doppler ultrasonography: If deep vein thrombosis is suspected
Diagnostic Pearl: Puerperal infections are often polymicrobial. Samples for culture should be obtained before starting antibiotics, but antibiotic therapy should not be delayed while waiting for results in patients with signs of sepsis.
REEDA Scale for Wound Assessment
The REEDA scale is a valuable tool for assessing perineal healing and identifying wound infections:
| Parameter | 0 Points | 1 Point | 2 Points | 3 Points |
|---|---|---|---|---|
| Redness | None | Within 0.25cm of incision bilaterally | Within 0.5cm of incision bilaterally | Beyond 0.5cm of incision bilaterally |
| Edema | None | Perineal, less than 1cm from incision | Perineal and/or vulvar, 1-2cm from incision | Perineal and/or vulvar, greater than 2cm from incision |
| Ecchymosis | None | Within 0.25cm bilaterally or 0.5cm unilaterally | Within 1cm bilaterally or 0.5-2cm unilaterally | Greater than 1cm bilaterally or 2cm unilaterally |
| Discharge | None | Serum | Serosanguinous | Bloody, purulent |
| Approximation | Closed | Skin separation 3mm or less | Skin and subcutaneous fat separation | Skin, subcutaneous fat, and fascial layer separation |
Total score ranges from 0-15; higher scores indicate poorer healing and increased risk of infection.
Complications
If untreated or inadequately treated, puerperal pyrexia can lead to various complications ranging from local to life-threatening systemic manifestations:
Short-term Complications
- Abscess formation (pelvic, abdominal wall, breast)
- Septicemia (spread of infection to the bloodstream)
- Septic shock (mortality rate 20-60%)
- Peritonitis (inflammation of the peritoneum)
- Septic pelvic thrombophlebitis (infected blood clots)
- Wound dehiscence (breakdown of surgical wound)
- Disseminated intravascular coagulation (DIC)
- Multiple organ dysfunction syndrome (MODS)
- Necrotizing fasciitis (rapid tissue destruction)
Long-term Complications
- Chronic pelvic pain
- Fallopian tube blockage
- Secondary infertility
- Pelvic adhesions
- Chronic pelvic inflammatory disease
- Psychological impacts (trauma, depression, anxiety)
- Impaired mother-infant bonding
- Breastfeeding difficulties (especially with mastitis)
- Chronic incisional pain or abnormal scarring
Warning: Progression of Untreated Infection
Localized Infection
Initial signs of infection confined to a specific site (uterus, wound, breast)
Spreading Infection
Extension beyond the initial site (parametritis, pelvic cellulitis)
Bacteremia
Bacteria enter the bloodstream causing systemic symptoms
Sepsis
Systemic inflammatory response due to infection
Severe Sepsis
Sepsis with organ dysfunction
Septic Shock
Severe sepsis with persistent hypotension despite adequate fluid resuscitation
Clinical Note: Early recognition and prompt treatment of puerperal pyrexia significantly reduce the risk of these complications. A high index of suspicion should be maintained for all postpartum women, especially those with risk factors.
Management
Management of puerperal pyrexia involves a multidisciplinary approach and should be tailored to the specific site and severity of infection. The key components include:
General Principles
Assessment
- Complete physical examination
- Vital signs monitoring
- Infection source identification
- Severity assessment
- Early sepsis recognition
Investigations
- Blood cultures before antibiotics
- Site-specific cultures (vaginal, wound)
- Laboratory tests (CBC, CRP, etc.)
- Imaging as indicated
- Regular reassessment
Supportive Care
- Adequate hydration
- Pain management
- Antipyretics as needed
- Nutritional support
- Rest and emotional support
Antibiotic Therapy
Antibiotic selection should be based on the likely pathogen, severity of infection, local antimicrobial resistance patterns, and whether the patient is breastfeeding. Empiric treatment should be adjusted once culture results become available.
| Infection Type | Recommended Antibiotic Regimens | Duration | Additional Notes |
|---|---|---|---|
| Endometritis |
First-line (WHO recommendation):
Alternative options:
|
Continue IV therapy until 48 hours afebrile, then oral antibiotics to complete 7-10 days total | Consider adding ampicillin for better enterococcal coverage, especially in patients who are GBS positive |
| Wound Infection |
Mild-Moderate:
Severe/MRSA Concern:
|
5-7 days for uncomplicated; 10-14 days for complicated | Wound drainage/debridement is essential for abscesses; MRSA coverage should be considered based on local prevalence |
| Mastitis |
|
10-14 days | Continue breastfeeding or breast milk expression; warm compresses before feeding; cold packs after feeding to reduce edema |
| Urinary Tract Infection |
Uncomplicated cystitis:
Pyelonephritis:
|
5-7 days for cystitis; 10-14 days for pyelonephritis | Ensure antibiotics are safe for breastfeeding; adjust based on culture results |
| Sepsis/Severe Infection |
|
De-escalate when source controlled and patient improved; total duration based on clinical response | Administer within one hour of sepsis recognition; consider IVIG in severe Group A Strep or Staphylococcal infections |
Specific Management by Infection Type
Endometritis Management
- Start empiric broad-spectrum antibiotics (see table above)
- Ensure adequate hydration
- Provide analgesia for pain management
- Consider ultrasound to rule out retained products of conception
- In cases of retained products, evacuation of the uterus may be necessary
- Monitor for clinical improvement (typically within 48-72 hours)
- If no improvement after 72 hours, consider further imaging (CT/MRI) to rule out abscess
- Consider septic pelvic thrombophlebitis if fever persists despite appropriate antibiotics
Wound Infection Management
- Assess wound using REEDA scale
- For superficial infections: clean with antiseptic solution and open dressing
- For wound abscess: incision and drainage
- For dehiscence: debridement of necrotic tissue and consideration of secondary closure
- Antibiotics based on severity (see table above)
- Regular wound care with saline irrigation
- Consider wound packing or negative pressure wound therapy for deep infections
- Monitor for necrotizing fasciitis (surgical emergency requiring immediate debridement)
Mastitis Management
- Continue breastfeeding or breast milk expression from the affected breast
- Apply warm compresses before feeding to improve milk flow
- Apply cold compresses after feeding to reduce edema and pain
- Ensure proper breast emptying and correct latch technique
- Administer antibiotics for infectious mastitis (see table above)
- Provide adequate analgesia (preferably medication compatible with breastfeeding)
- Breast ultrasound if abscess suspected
- Drainage of breast abscess if present (by aspiration or incision)
- Support and education about breastfeeding techniques
Critical Consideration: For suspected sepsis, antibiotics should be administered within ONE hour of recognition. Each hour of delay in antibiotic administration is associated with increased mortality.
Surgical Interventions
Indications for Surgical Intervention
- Abscess formation requiring drainage
- Retained products of conception
- Wound dehiscence requiring debridement and reclosure
- Necrotizing fasciitis (urgent surgical emergency)
- Septic pelvic thrombophlebitis not responsive to antibiotics
- Uterine necrosis or perforation
- Peritonitis
Potential Surgical Procedures
- Dilation and curettage (D&C): For retained products
- Incision and drainage: For abscesses
- Debridement: For necrotic tissue
- Wound exploration: For deep wound infections
- Hysterectomy: For severe, life-threatening cases unresponsive to other measures
- Exploratory laparotomy: For suspected intra-abdominal catastrophe
Management Pearl: To align with WHO’s strategy for antimicrobial resistance containment, antibiotics should only be administered when there is a clear medical indication, using the narrowest effective spectrum and simplest effective dose regimen, informed by local susceptibility patterns.
Prevention Strategies
Prevention of puerperal pyrexia is crucial for reducing maternal morbidity and mortality. Evidence-based preventive strategies include:
Antenatal Period
- Screening and treatment of bacterial vaginosis
- Screening and management of Group B streptococcus
- Treatment of sexually transmitted infections
- Optimizing nutrition and treating anemia
- Management of chronic conditions (diabetes, etc.)
- Patient education on hygiene practices
Intrapartum Period
- Strict aseptic technique during vaginal examinations
- Limiting vaginal examinations (WHO recommends 4-hour intervals)
- Proper hand hygiene by all healthcare providers
- Appropriate use of sterile equipment and instruments
- Prophylactic antibiotics for high-risk procedures
- Minimizing duration of labor and membrane rupture
Postpartum Period
- Early recognition of infection signs
- Proper perineal care and hygiene
- Early mobilization after delivery
- Proper wound care for cesarean or episiotomy
- Ensuring complete placental delivery
- Support for proper breastfeeding techniques
WHO Recommendations for Prevention of Maternal Peripartum Infections
| Intervention | WHO Recommendation | Evidence Quality |
|---|---|---|
| Perineal/pubic shaving | Routine perineal/pubic shaving prior to giving vaginal birth is not recommended | Conditional recommendation, very low-quality evidence |
| Vaginal examination | Digital vaginal examination at intervals of four hours is recommended for routine assessment of active first stage of labor | Strong recommendation, very low-quality evidence |
| Vaginal cleansing | Routine vaginal cleansing with chlorhexidine during labour is not recommended | Strong recommendation, moderate-quality evidence |
| Antibiotic prophylaxis for cesarean section | Routine antibiotic prophylaxis is recommended for women undergoing elective or emergency cesarean section. Should be given prior to skin incision rather than after cord clamping | Strong recommendation, moderate-quality evidence |
| Antibiotic choice for cesarean prophylaxis | A single dose of first-generation cephalosporin or penicillin should be used in preference to other classes of antibiotics | Conditional recommendation, very low-quality evidence |
| Vaginal preparation before cesarean | Vaginal cleansing with povidone-iodine immediately before cesarean section is recommended | Conditional recommendation, moderate-quality evidence |
| Manual removal of placenta | Routine antibiotic prophylaxis is recommended for women undergoing manual removal of the placenta | Strong recommendation, very low-quality evidence |
| Operative vaginal birth | Routine antibiotic prophylaxis is not recommended for women undergoing operative vaginal birth | Conditional recommendation, very low-quality evidence |
| Perineal tears | Routine antibiotic prophylaxis is recommended for women with third- or fourth-degree perineal tears | Strong recommendation based on consensus view |
| Episiotomy | Routine antibiotic prophylaxis is not recommended for women with episiotomy | Strong recommendation, very low-quality evidence |
Best Practices for Healthcare Providers
Hand Hygiene and Aseptic Technique
- Hand washing before and after each patient contact
- Use of alcohol-based hand sanitizers
- Sterile gloves for examinations and procedures
- Appropriate use of personal protective equipment
Antibiotic Stewardship
- Only use antibiotics when medically indicated
- Choose narrow-spectrum antibiotics when possible
- Administer at correct timing for prophylaxis
- Follow local susceptibility patterns
Prevention Pearl: Caesarean section is the most significant risk factor for postpartum infection. When medically necessary, ensure proper prophylactic antibiotics (single dose, first-generation cephalosporin) administered prior to skin incision, and adhere to strict aseptic surgical technique.
Nursing Assessment
Comprehensive nursing assessment is crucial for early detection and management of puerperal pyrexia:
History Taking
Prenatal and Birth History
- Mode of delivery (vaginal vs. cesarean)
- Duration of labor and membrane rupture
- Number of vaginal examinations during labor
- Intrapartum complications
- Use of instruments during delivery
- Details of placental delivery
- GBS status and antibiotic prophylaxis
Current Symptoms
- Onset and duration of fever
- Associated symptoms (chills, rigors)
- Character and severity of pain
- Changes in lochia (amount, color, odor)
- Urinary symptoms
- Breast symptoms
- Wound site concerns
Medical History
- Pre-existing conditions (diabetes, anemia, etc.)
- Previous infections
- Allergies, especially to antibiotics
- Current medications
- Immunization status
Physical Assessment
Vital Signs
- Temperature (≥38°C/100.4°F indicates pyrexia)
- Pulse (tachycardia >90 bpm may indicate infection)
- Blood pressure (hypotension may indicate septic shock)
- Respiratory rate (tachypnea >20/min suggests infection)
- Oxygen saturation
Abdominal and Uterine Assessment
- Fundal height and consistency
- Uterine tenderness
- Subinvolution of uterus
- Abdominal tenderness or distension
- Lochia assessment (quantity, color, consistency, odor)
Perineum and Wound Assessment
- REEDA scale assessment (Redness, Edema, Ecchymosis, Discharge, Approximation)
- Integrity of episiotomy or laceration repair
- Cesarean incision assessment
- Presence of discharge or dehiscence
Other Systems Assessment
- Breast examination (signs of mastitis)
- Lower extremity assessment (DVT signs)
- Respiratory assessment (crackles, reduced air entry)
- Neurological assessment (altered mental status)
Assessment Alert: The following findings warrant immediate medical attention:
- Temperature ≥38°C (100.4°F)
- Sustained tachycardia (>90 beats/min)
- Hypotension (systolic BP <90 mmHg)
- Respiratory rate >20 breaths/min
- Severe abdominal pain or rebound tenderness
- Foul-smelling lochia
- Altered consciousness
- Signs of wound dehiscence or necrotic tissue
Nursing Diagnoses
Following a thorough assessment, nurses can formulate appropriate nursing diagnoses. Common nursing diagnoses for patients with puerperal pyrexia include:
Priority Nursing Diagnoses
- Risk for Infection/Sepsis: Related to existing infectious process with potential for progression
- Acute Pain: Related to inflammatory process, tissue trauma, and surgical interventions
- Hyperthermia: Related to infectious process
- Deficient Fluid Volume: Related to increased metabolic rate, decreased oral intake, and fluid loss
- Impaired Tissue Integrity: Related to surgical incision, episiotomy, or perineal trauma
Additional Relevant Diagnoses
- Ineffective Breastfeeding: Related to mastitis or maternal discomfort
- Anxiety: Related to health status and potential complications
- Risk for Impaired Parenting: Related to illness, discomfort, and separation
- Activity Intolerance: Related to imbalance between oxygen supply and demand
- Impaired Comfort: Related to inflammatory response and illness symptoms
- Risk for Ineffective Coping: Related to situational crisis and health challenge
Nursing Insight: While standard nursing diagnoses provide a useful framework, remember that each patient’s situation is unique. Nursing diagnoses should be individualized based on the specific assessment findings and the patient’s personal needs.
Nursing Care Plans
Comprehensive nursing care plans for patients with puerperal pyrexia should address the identified nursing diagnoses with specific interventions:
Care Plan 1: Risk for Infection/Sepsis
- Patient will demonstrate resolution of current infection as evidenced by normalization of vital signs within 72 hours
- Patient will verbalize understanding of infection prevention measures
- Patient will exhibit no signs of progressive or new infection during hospitalization
- Monitor vital signs every 4 hours or more frequently if unstable (q1h for severe cases)
- Maintain strict hand hygiene and aseptic technique during all procedures
- Administer prescribed antibiotics on schedule, monitoring for therapeutic response and adverse effects
- Obtain cultures before initiating antibiotics when possible
- Assess lochia for amount, color, and odor every shift
- Monitor laboratory values (WBC, CRP, etc.) for signs of improvement or deterioration
- Educate patient on signs of worsening infection requiring immediate reporting
- Demonstrate and reinforce proper perineal care techniques
- Maintain isolation precautions as indicated by infection type
- Document all findings and interventions
- Monitor temperature trends – should decrease within 48-72 hours of antibiotic therapy
- Assess for improvement in local signs of infection (decreased erythema, improved wound appearance)
- Evaluate patient’s understanding of infection prevention through teach-back method
- Monitor for development of complications (e.g., abscess formation, sepsis)
Care Plan 2: Acute Pain
- Patient will report pain at acceptable level (≤3/10) within 24 hours
- Patient will identify factors that worsen and alleviate pain
- Patient will demonstrate use of non-pharmacological pain management techniques
- Assess pain using standardized pain scale every 4 hours and before/after interventions
- Administer analgesics as prescribed, ensuring compatibility with breastfeeding if applicable
- Apply cold or warm compresses to affected areas as appropriate:
- Cold: Within first 24 hours for inflammation
- Warm: After 24 hours to promote circulation and healing
- Position patient comfortably to minimize pressure on affected areas
- Teach relaxation techniques (deep breathing, guided imagery)
- Support patient during painful procedures with presence and reassurance
- Provide adequate rest periods between activities
- Educate on medication purpose, expected effects, and potential side effects
- Document pain assessments, interventions, and patient response
- Reassess pain levels regularly using the same pain scale
- Evaluate effectiveness of pharmacological and non-pharmacological interventions
- Assess patient’s ability to perform daily activities and care for newborn
- Modify pain management plan as needed based on response
Care Plan 3: Impaired Tissue Integrity
- Patient will demonstrate progressive wound healing without complications
- Patient will verbalize and demonstrate proper wound care techniques
- Patient will identify signs and symptoms requiring medical attention
- Assess wound using REEDA scale every shift
- Clean wound according to protocol with sterile technique
- Change dressings as ordered, maintaining aseptic technique
- Monitor wound drainage for amount, color, consistency, and odor
- Provide perineal care after each void or bowel movement
- Apply topical medications as prescribed
- Encourage adequate nutrition and hydration to support healing
- Teach proper wound care techniques for home management
- Demonstrate perineal care and have patient return demonstration
- Document wound appearance, care provided, and patient’s response
- Monitor wound healing process using consistent assessment criteria
- Evaluate patient’s ability to perform wound care independently
- Assess for signs of complications (increasing erythema, purulent drainage, dehiscence)
- Evaluate patient’s knowledge of warning signs requiring medical attention
Care Plan 4: Risk for Impaired Parent-Infant Bonding
- Patient will maintain attachment behaviors with infant despite health challenges
- Patient will demonstrate confidence in caring for infant as health permits
- Patient will express positive feelings about parenting role
- Promote mother-infant contact as much as possible while managing infection concerns
- Support breastfeeding when appropriate and medically cleared
- Educate about infection transmission risks and appropriate precautions
- Encourage skin-to-skin contact when mother’s condition permits
- Include partner/family in care and education
- Address emotional concerns related to separation or difficult postpartum experience
- Provide positive reinforcement for parenting efforts
- Arrange rooming-in if medically appropriate
- Refer to lactation consultant if breastfeeding challenges exist
- Assess for postpartum mood disorders, which may be exacerbated by illness
- Observe maternal-infant interactions for positive attachment behaviors
- Assess maternal confidence in handling and caring for infant
- Evaluate success of feeding methods (breastfeeding or alternative)
- Monitor for signs of postpartum depression or anxiety
Nursing Care Tip: Remember that puerperal pyrexia affects not only the physical health of the mother but also impacts the entire family dynamic, especially bonding with the newborn. A holistic nursing approach addresses physical, emotional, and social dimensions of care.
Mnemonics for Students
Mnemonics can help nursing students remember important aspects of puerperal pyrexia assessment, management, and care:
FEVER SIGNS
Use this mnemonic to remember key assessment findings in puerperal pyrexia:
- F – Fundal tenderness and subinvolution
- E – Elevated temperature (≥38°C/100.4°F)
- V – Vital signs altered (tachycardia, tachypnea)
- E – Extreme pain (abdominal, perineal, or wound)
- R – Redness and inflammation at wound sites
- S – Smell (foul odor from lochia or discharge)
- I – Increased or altered lochia
- G – General malaise and chills
- N – Nausea and decreased appetite
- S – Swelling at wound sites or breasts
5 P’s of Puerperal Pyrexia
Remember these five key areas to assess in postpartum fever:
- P – Perineum (episiotomy, lacerations, hematomas)
- P – Pelvis (endometritis, retained products)
- P – Plumbing (urinary tract infection, pyelonephritis)
- P – Pulmonary (pneumonia, pulmonary embolism)
- P – Pus (wound infections, abscesses, mastitis)
ABCDEF of Puerperal Sepsis Management
Critical steps in managing puerperal sepsis:
- A – Airway maintenance and oxygen administration
- B – Breathing assessment and support
- C – Circulation (IV fluids, maintain BP)
- D – Drugs (antibiotics within 1 hour)
- E – Evaluate source of infection and culture before antibiotics
- F – Fetal/Family wellbeing and support
RISK FACTORS
Key risk factors for puerperal pyrexia:
- R – Rupture of membranes, prolonged
- I – Invasive procedures (frequent vaginal exams)
- S – Surgery (cesarean section – highest risk)
- K – Komorbidities (diabetes, anemia, obesity)
- F – Forceps or vacuum delivery
- A – Anemia and poor nutrition
- C – Colonization with Group B Strep
- T – Trauma to genital tract
- O – Obstructed labor
- R – Retained placental fragments
- S – Socioeconomic factors affecting healthcare access
REEDA: Wound Assessment Tool
Remember this standard tool for assessing perineal and cesarean wounds:
R
Redness around the wound
E
Edema or swelling
E
Ecchymosis or bruising
D
Discharge from the wound
A
Approximation of wound edges
P.Y.R.E.X.I.A. Patient Education
Key points to include in discharge education:
- P – Proper perineal hygiene (front to back wiping)
- Y – “You should report” signs of infection promptly
- R – Rest and adequate nutrition for healing
- E – Ensure complete antibiotic course as prescribed
- X – eXclude sexual activity until cleared by provider
- I – Infant feeding support (maintain breastfeeding as appropriate)
- A – Attend all follow-up appointments
Study Tip: Creating your own mnemonics that resonate with your learning style can enhance retention of important concepts. Consider developing personal mnemonics for aspects of puerperal pyrexia care that you find challenging.
References
- World Health Organization. (2015). WHO recommendations for prevention and treatment of maternal peripartum infections. Retrieved from https://apps.who.int/iris/bitstream/10665/186171/1/9789241549363_eng.pdf
- Bonet, M., Ota, E., Chibueze, C. E., & Oladapo, O. T. (2017). Antibiotic prophylaxis for episiotomy repair following vaginal birth. The Cochrane Database of Systematic Reviews, 11(11), CD012136.
- Johnson, A., & Thakar, R. (2015). Postpartum pyrexia. Obstetrics, Gynaecology & Reproductive Medicine, 25(9), 249-254.
- Song, C., Wang, L., Li, L., Li, Y., Liu, Y., & Jiang, S. (2019). Risk factors of puerperal infection among puerperae in China: An analysis of 5,227 cases. BioMed Research International, 2019, 1-6.
- Mackeen, A. D., Packard, R. E., Ota, E., & Speer, L. (2015). Antibiotic regimens for postpartum endometritis. The Cochrane Database of Systematic Reviews, 2015(2), CD001067.
- Karsnitz, D. B. (2014). Puerperal infections of the genital tract: A clinical review. Journal of Midwifery & Women’s Health, 58(6), 632-642.
- Ainebyona, H., Ayebare, E., Nabisere, A., et al. (2024). Prevalence of maternal fever and associated factors among postnatal women at Kawempe National Referral Hospital, Uganda: a preliminary study. International Journal of Environmental Research and Public Health, 21(3), 316.
- Brito, L. G., Ferreira, C. H., Duarte, G., Nogueira, A. A., & Marcolin, A. C. (2021). Evaluation of postpartum pain: A review. Archives of Gynecology and Obstetrics, 293(6), 1165-1170.
- Blackmon, M., Nguyen, H., & Mukherji, P. (2022). Acute Mastitis. In StatPearls. StatPearls Publishing.
- Hughes, B. L., Grobman, W. A., & Greive, L. H. (2019). Prevention of maternal peripartum infection. American Journal of Obstetrics and Gynecology, 220(4), 297-311.
- Meaney-Delman, D., Bartlett, L. A., Gravett, M. G., & Jamieson, D. J. (2017). Oral and intramuscular treatment options for early postpartum endometritis in low-resource settings: a systematic review. Obstetrics and Gynecology, 129(5), 789-800.
- Dellinger, R. P., Levy, M. M., Rhodes, A., et al. (2013). Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Medicine, 39(2), 165-228.