Childbirth postpartum infections

• If woman unwell and/or febrile in first 6 weeks after childbirth — examine carefully
• Sepsis can be subtle in onset and women may deteriorate rapidly

Common sites of infection

Can be more than 1 type of infection

• Uterus — endometritis is the most common cause of postnatal infection
• Urinary tract
• Breast — mastitis
• Wound — perineal or abdominal
• Chest

Ask

• Breastfeeding issues
• Symptoms of chest infection
• Bowel or urine problems
• Vaginal bleeding
• Other symptoms not related to pregnancy (eg sore throat, influenza)

Check

• U/A
• Head-to-toe exam — with attention to
• Breasts — tenderness, red areas, lumps in breast or axilla 
• Lungs — observe and listen to breathing 
• Abdominal assessment — check wound if caesarean 
• Perineum — sores, episiotomy, tears, offensive discharge, heavy bleeding
• Signs of deep vein thrombosis or pulmonary embolism

Do

• If signs of infection — see appropriate protocol
• Uterus infection (endometritis) — most common cause of postnatal infection
• Abdominal and perineal wound infections
• Urinary tract
• Breast — mastitis
• Wound — perineal or abdominal
• Chest
• Medical consult — for antibiotic choice based on regional sensitivities
  
• Consider blood cultures

Uterus infection (endometritis)

Problems

• May be heavy vaginal bleeding
• Sepsis — bacteria infecting the uterus enters bloodstream
• If woman is or starts bleeding heavily — see Secondary postpartum haemorrhage straight away

Causes

• Retained products (part of placenta or membranes left inside uterus)
• Infection in vagina (eg STI, GBS)
• Infection introduced during or after birth (eg caesarean section, forceps, manual removal, perineal tear)

Look — in file notes

• Date and type of birth
• Did placenta and membranes appeared complete, perineal trauma (eg tears), other complications
• Did woman have high temp after birth
• Last vaginal swab results
• If STI in pregnancy — were woman and partner/s treated
• Perinatal infection in baby

Ask

• Pain — where, what type, when did it start
• Vaginal loss — how much, has it increased, colour, any clots, has bleeding stopped since birth
• Vaginal discharge — brown, offensive smell
• If has had sex since birth, was there any pain
• Any other symptoms — may complain of
• Feeling unwell, no energy
• Fever, chills
• Nausea, vomiting, poor appetite
• Difficulty breathing, chest pain, abdominal pain, pain in legs

Check

• Head-to-toe exam — with attention to
• Uterus — feel for height of fundus, tenderness, bulkiness, firm or soft, if central or to one side
• Vaginal loss — how much, colour, smell, any clots — put pad between woman’s legs. Change pad each time you check. If bleeding — save and weigh all pads — 1g increase = 1mL loss
• Speculum exam, if skilled — cervix open or closed
• Bimanual exam, if skilled — tenderness, masses, size of uterus, is cervix painful when moved
• Full STI check

Do

• Medical consult about sending to hospital
• Need to send to hospital if
• Very unwell and/or signs of sepsis 
• Severe abdominal pain
• Bleeding heavily and/or in shock
• Possible retained products
• Vomiting up medicines
• Nobody to help look after her and her baby
• Diagnosis uncertain

If sending to hospital

• Put in IV cannula — largest possible, insert 2 if time
  
• Take blood cultures before starting antibiotics — send in with woman
• Start normal saline 1L at 125mL/hr
• Medical consult about antibiotics. Give straight away
  
• Ceftriaxone IM/IV — adult 1g, single dose

AND azithromycin oral — adult 1g, single dose

AND metronidazole IV — adult 500mg, single dose

• If delay in sending to hospital of more than 24 hours and directed to by doctor — give gentamicin IV once a day — doses
• If allergy to penicillin — medical consult

• While waiting for evacuation
• Give pain relief if needed
• Do not let woman eat or drink anything — may need operation
• Encourage to continue to breastfeed baby, if possible
• Continue observations until evacuation

If woman staying in community

• Medical consult about antibiotics
• Give azithromycin oral — adult 1g, single dose  AND ceftriaxone IM — adult 500mg, single dose mixed with lidocaine (lignocaine) 1%
• Next day give amoxicillin-clavulanic acid oral — adult 875+125mg, twice a day (bd) for 10 days
• Day 8 give azithromycin oral — adult 1g single dose
• If allergy to penicillin — medical consult
• Give pain relief if needed
• Assess daily for 5 days (or until antibiotics finished) — make sure there is support and help at home
• Tell woman to come back to clinic straight away if fever, vomiting, pain, heavy bleeding
• If woman not improving after 1–2 days of treatment — medical consult. May need to go to hospital
• Check swab and urine results
• If positive STI — see Pelvic inflammatory disease for follow-up
• Remember to treat partner/s

Abdominal and perineal wound infections

Do

• Wound swab, MC&S
• Medical consult about
• Removing any stitches
• Antibiotics — give amoxicillin-clavulanic acid oral — adult 875+125mg, twice a day (bd) for 5 days
  
• If allergy — medical consult
• Give pain relief if needed
• Assess daily, clean and dress wound until healed
• If perineal wound — keep area as clean and dry as possible
• Encourage perineal hygiene — shower or wash perineal area twice a day. Change pads often

Follow-up

• If wound not improving after 1–2 days of treatment — medical consult