Post Partum Infection

Endometritis
• Ascending polymicrobial infection
– Usually normal vaginal flora or enteric bacteria

• Primary cause of postpartum infection

– 1-3% vaginal births
– 5-15% scheduled C-sections
– 30-35% C-section after extended period of labor
• May receive prophylactic antibiotics
• <2% develop life-threatening complications
 ETIOLOGY
• Endometritis is an ascending polymicrobial infection

• The most common organisms are divided into 4 groups:

• aerobic gram-negative bacilli
• anaerobic gram-negative bacilli
• aerobic streptococci
• anaerobic gram-positive cocci.

• Specifically, Escherichia coli, Klebsiella pneumoniae, and

Proteus species are the most frequently identified organisms.
• The infection is variously
known as endometritis;
endoparametritis; or simply,
metritis.

• Endometritis complicates 1-3%

of all vaginal deliveries and 5-
15% of scheduled cesarean
deliveries.

The incidence of endometritis in patients who undergo cesarean

delivery after an extended period of labor is 30-35% and falls to
15-20% if the patient receives prophylactic antibiotics.
 Endometritis
Risk factors:
• C-section • Multiple vaginal exams
• Young age • Placement of intrauterine
• Low SES catheter
• Prolonged labor • Preexisting infection
• Prolonged rupture of • Twin delivery
membranes • Manual removal of the
placenta
 Endometritis
Clinical presentation Exam findings
• Fever • Fever
• Chills • Tachycardia
• Lower abdominal pain • Fundal tenderness
• Malodorous lochia
• Increased vaginal Treatment
bleeding
• Antibiotics
• Anorexia
• Malaise
 Urinary Tract Infection
• Bacterial inflammation of the bladder or
urethra

• 3-34% of patients
– Symptomatic infection in ~2%
 Urinary Tract Infection
Risk factors
• C-section • Preeclampsia
• Forceps delivery • Eclampsia
• Vacuum delivery • Epidural anesthesia
• Tocolysis • Bladder catheterization
• Induction of labor • Length of hospital stay
• Maternal renal disease • Previous UTI during
pregnancy
 Urinary Tract Infection
Clinical Presentation Exam Findings
• Urinary • Stable vitals
frequency/urgency • Afebrile
• Dysuria • Suprapubic tenderness
• Hematuria
• Suprapubic or lower
Treatment
abdominal pain
• antibiotics
OR…
• No symptoms at all
 Mastitis
• Inflammation of the mammary gland
• Milk stasis & cracked nipples contribute to the
influx of skin flora

• 2.5-3% in the USA

– Neglected, resistant or recurrent infections can
lead to the development of an abscess (5-11%)
 Mastitis
Treatment
Clinical Presentation • Moist heat
• Fever
• Massage
• Chills
• Fluids
• Myalgias
• Rest
• Warmth, swelling and breast
• Proper positioning of the
tenderness
infant during nursing
• Nursing or manual expression
Exam Findings of milk
• Area of the breast that is • Analgesics
warm, red, and tender
• Antibiotics
 Wound Infection
Perineum Abdominal incision
(episiotomy or laceration) (C-section)
• 3-4 days postpartum • Postoperative day 4
• rare • 3-15%
• prophylactic antibiotics
– 2%
 Wound Infection
Perineum Abdominal incision
Risk Factors: • Risk factors:
– Infected lochia – Diabetes
– Fecal contamination – Hypertension
– Poor hygiene – Obesity
– Corticosteroid treatment
– Immunosuppression
– Anemia
– Prolonged labor
– Prolonged rupture of
membranes
– Prolonged operating time
– Abdominal twin delivery
– Excessive blood loss
 Wound Infection
Clinical Presentation Diagnosis
• Erythema
Perineal Infection:
• Induration
• Pain
• Warmth
• Malodorous discharge
• Tenderness
• Vulvar edema
• Purulent drainage
• With or without fever
Abdominal Infection
• Persistent fever
(despite antibiotics)
 TREATMENT: Perineal infections
• Treatment of perineal infections includes
symptomatic relief with NSAIDs, local
anesthetic spray, and sitz baths. Identified
abscesses must be drained, and broad-
spectrum antibiotics may be initiated.
 TREATMENT: Abdominal wound infections
• These infections are treated with drainage and inspection of the
fascia to ensure that it is intact.

• Antibiotics may be used if the patient is afebrile.

• Most patients respond quickly to the antibiotic once the wound is

drained. Antibiotics are generally continued until the patient has
been afebrile for 24-48 hours.

• Patients do not require long-term antibiotics unless cellulitis has

developed.

• Studies have shown that closed suction drainage or suturing of the

subcutaneous fat decreases the incidence of wound infection when
the subcutaneous tissue is greater than 2 cm in depth
• In emergency cesarean deliveries, use of prophylactic
cefazolin has been shown to reduce the rate of postpartum
endometritis and wound infection.

• Other studies have demonstrated that

ampicillin/sulbactam, cefazolin, and cefotetan are all
acceptable choices for single-dose antibiotic prophylaxis.

• Controversy still exists with regard to the need for

prophylactic antibiotics during elective deliveries