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Puerperal complications include many of those encountered during pregnancy, but there are some that are more common at this time. Typical of these is puerperal pelvic infection—a well-known killer of postpartum women. Other infections include mastitis and breast abscesses. Thromboembolism during the short 6-week puerperium is as frequent as during all 40 antepartum weeks.
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Traditionally, the term puerperal infection describes any bacterial infection of the genital tract after delivery. These infections as well as preeclampsia and obstetrical hemorrhage form the lethal triad of maternal death causes before and during the 20th century. Fortunately, because of effective antimicrobials, maternal mortality from infection has become uncommon. Berg and associates (2010) reported results from the Pregnancy Mortality Surveillance System, which contained 4693 pregnancy-related maternal deaths in the United States from 1998 through 2005. Infection caused 10.7 percent of pregnancy-related deaths and was the fifth leading cause. In a similar analysis of the North Carolina population from 1991 through 1999, Berg and colleagues (2005) reported that 40 percent of infection-related maternal deaths were preventable.
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A number of factors can cause fever—a temperature of 38.0°C (100.4°F) or higher—in the puerperium. Most persistent fevers after childbirth are caused by genital tract infection. Using this conservative definition of fever, Filker and Monif (1979) reported that only about 20 percent of women febrile within the first 24 hours after giving birth vaginally were subsequently diagnosed with pelvic infection. This was in contrast to 70 percent of those undergoing cesarean delivery. It must be emphasized that spiking fevers of 39°C or higher that develop within the first 24 hours postpartum may be associated with virulent pelvic infection caused by group A streptococcus and is discussed on Uterine Infection.
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Other causes of puerperal fever include breast engorgement, urinary infections, episiotomy and abdominal incisions, perineal lacerations, and respiratory complications after cesarean delivery (Maharaj, 2007). Approximately 15 percent of women who do not breast feed develop postpartum fever from breast engorgement. As discussed in Chapter 36 (Maternal Care During the Puerperium), the incidence of fever is lower in breast-feeding women. “Breast fever” rarely exceeds 39°C in the first few postpartum days and usually lasts < 24 hours. Urinary infections are uncommon postpartum because of the normal diuresis encountered then. That said, acute pyelonephritis has a variable clinical picture. The first sign of renal infection may be fever, followed later by costovertebral angle tenderness, nausea, and vomiting. Atelectasis following abdominal delivery is caused by hypoventilation and is best prevented by coughing and deep breathing on a fixed schedule following surgery. Fever associated with atelectasis is thought to follow infection by normal flora that proliferate distal to obstructing mucus plugs.
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Postpartum uterine infection or puerperal sepsis has been called variously endometritis, endomyometritis, and endoparametritis. Because ...