What is the history, examination, and investigation findings for postpartum (after childbirth) infection?

From the Guidelines

Postpartum infections should be suspected in any woman presenting with symptoms such as uterine tenderness, lochia, or symptoms of inflammation, vaginal discharge or bleeding, perineal pain, or urinary symptoms after childbirth, and a thorough history, examination, and investigation should be undertaken to confirm the diagnosis and guide treatment. When evaluating a patient with suspected postpartum infection, a thorough history should be obtained, including delivery method, duration of labor, premature rupture of membranes, number of vaginal examinations, and any invasive procedures, as well as symptoms such as fever, abdominal pain, abnormal vaginal discharge with foul odor, wound pain or drainage, urinary symptoms, and breast pain or redness 1.

History

The history should include:

• Assessment of bowel and urinary function, including presence of faecal or urinary incontinence
• Assessment of uterine tenderness, lochia, or symptoms of inflammation
• Assessment of pelvic floor dysfunction
• Presence of vaginal discharge or bleeding
• Perineal pain and perineal hygiene
• Resumption of sexual intercourse and presence of dyspareunia

Examination

The physical examination should include:

• Vital signs, particularly temperature
• Abdominal examination for tenderness and uterine involution
• Inspection of any surgical wounds
• Pelvic examination to assess vaginal discharge and cervical motion tenderness
• Breast examination
• Assessment for perineal or anal sphincter injury, examination of perineal or vaginal tears, and healing of any perineal wound

Investigation

Laboratory investigations should include:

• Complete blood count
• C-reactive protein
• Blood cultures if febrile
• Urine analysis and culture
• Wound cultures if applicable
• Vaginal swabs Imaging may include pelvic ultrasound to evaluate for retained products of conception or abscess formation, and CT scan if deeper infections are suspected, as recommended in the latest guidelines 1. A thorough and prompt evaluation is essential to prevent serious complications like sepsis or thrombophlebitis, and to improve morbidity, mortality, and quality of life outcomes.

From the Research

History of Postpartum Infection

• Postpartum endometritis occurs when vaginal organisms invade the endometrial cavity during labor and birth, and is more common after cesarean section 2, 3, 4, 5.
• The condition warrants antibiotic treatment, with the combination of gentamicin and clindamycin being appropriate for treatment 2, 3, 4, 5.

Examination Findings

• Clinical predictors of postpartum endometritis have low sensitivity, but a Gram stain of the amniotic fluid may be helpful in identifying women who may benefit from therapeutic antibiotics 6.
• Incipient infection of the myometrium may explain why patients develop postpartum endometritis despite antibiotic prophylaxis 6.

Investigation Findings

• Broad-spectrum antimicrobial therapy is the mainstay of therapy for postpartum endometritis, with newer extended spectrum cephalosporins such as cefotetan and ceftizoxime being as effective as cefoxitin 6.
• Regimens with activity against penicillin-resistant anaerobic bacteria are better than those without, and once-daily dosing of gentamicin may be more effective than thrice-daily dosing 2, 3, 4, 5.
• Wound infection surveillance can decrease infection incidence rates by providing feedback to the operating surgeon, and abdominal wound infection is a common cause of antimicrobial failure in patients treated for post-cesarean endomyometritis 6.