Other causes of puerperal fever include breast engorgement; infections of the urinary tract, of perineal lacerations, and of episiotomy or abdominal incisions; and respiratory complications ater cesarean delivery (Nlaharaj, 2007). Approximately 15 percent of women who do not breastfeed develop postpartum fever from breast engorgement. As discussed in Chapter 36 (p. 659), the incidence of fever is lower in breastfeeding women. "Breast fever" rarely exceeds 39°C in the irst few postpartum days and usually lasts <24 hours. Urinary inections are uncommon post partum because of the normal diuresis encountered then. Acute pyelonephritis has a variable clinical picture. The irst sign of renal infection may be fever, followed later by costovertebral angle ten derness, nausea, and vomiting. Atelectasis following abdominal delivery is caused by hypoventilation and is best prevented by gery. Fever associated with atelectasis is thought to stem from normal flora that proliferate distal to obstructing mucus plugs.
Postpartum uterine infection or puerperal sepsis has been called variously endometritis, endomyometritis, and endoparametritis. Because infection involves not only the decidua but also the myometrium and parametrial tissues, we prefer the inclusive term metritis with pelvic celulitis.
The route of delivery is the single most signiicant risk factor for the development of uterine infection (Burrows, 2004; Koroukian, 2004). In the French Confidential Enquiry on Maternal Deaths, Deneux-haraux and coworkers (2006) cited a nearly 25-fold increased infection-related mortality rate with cesarean versus vaginal delivery. Rehospitalization rates for wound complications and metritis were increased significantly in women undergoing a planned primary cesarean delivery compared with those having a planned vaginal birth (Declercq, 2007).
Women delivered vaginally at Parkland Hospital have a Ito 2-percent incidence of metritis. For women at high risk for infection because of membrane rupture, prolonged labor, and multiple cervical examinations, the frequency of metritis after vaginal delivery is 5 to 6 percent. If intrapartum chorioamnionitis is present, the risk of persistent uterine infection increases to 13 percent (Maberry, 1991). These igures are similar to those reported from a cohort of more than 11r5,000 women by the Maternal Fetal Medicine Units Network in whom the overall pelvic infection rate approximated 5 percent (Grobman, 2015).
Because of the significant morbidity following hysterotomy, single-dose perioperative antimicrobial prophylxis is recommended for all women undergoing cesarean delivery (American College of Obstetricians and Gynecologists, 2016b). Antimicrobial prophylaxis has done more to decrease the incidence and severity of postcesarean delivery infections than any other intervention in the past 30 years. Such practices decrease the puerperal pelvic infection risk by 65 to 75 percent (Smaill, 2010).
he magnitude of the risk is exemplified from earlier reports that predate antimicrobial prophylaxis. Cunningham and associates (1978) described an overall incidence of 50 percent in all women undergoing cesarean delivery at Parland Hospital. Important risk factors for infection following surgery included prolonged labor, membrane rupture, multiple cervical examinations, and internal fetal monitoring. Women with all these factors who were not given perioperative prophylaxis had a 90-percent serious postcesarean delivery pelvic infection rate (DePalma, 1982).
It is generally accepted that pelvic infection is more frequent in women of lower socioeconomic status (Maharaj, 2007).