Pyrexia in Labour

Question 1

A 29-year-old woman develops a temperature of 38.5OC two days after delivery. How would you assess and manage?

Answer 1

Impression
With the onset of a fever in the postpartum period, I am concerned about postpartum infection. In particular, I am concerned about complications of sepsis and subsequent shock. Would also want to consider other non-infectious differentials such as thyroid disease, or medications side effect.

Common postpartum infections

• endometritis
• perineal and wound infections
• mastitis
• other (UTI, LRTI, meningitis, etc)

Goals of management

• conduct A to E in initial setting to assess HD status, and ensure safety of both mother and baby
• comprehensive Hx/Ex/Ix and blood cultures, assess for source of infection and appropriately treat
• manage with supportive and definitive measures including empirical antibiotics and antipyretics

Question 2

Postpartum infection - Initial assessment

Answer 2

Postpartum infection - Assessment:

• Take A to E approach to assess HD status
• if unstable, call for senior O&G help, potentially transfer to ED.

A - likely normal
B - likely normal
C - 
D
E
F
G

Question 3

Postpartum infection - History

Answer 3

History:

• sx: fevers, rigors, onset, tachycardia/palpitation, pain and SOCRATES, how is baby? (pelvic pain, etc), urinary symptoms, respiratory symptoms, any rashes. Where any of these symptoms present during/prior to labour?
• HPI: details of birth/labour: any tears, complications (PROM/PPROM), c-section vs NVD, sutures required
• any positive findings on routine antenatal screening (GBS positive, TORCH etc), any treatments administered for this?

Question 4

Post-partum infection - Examination

Answer 4

Examination:

• General appearance + vital signs (HR, BP, Temp)
• Inspection of vagina and any wounds associated with delivery for signs of infection (erythema, pus, weeping, tenderness)
• systems review for evidence of systemic illness
• newborn check and examination for evidence of infection/sepsis
• breast examination for mastitis/abscess formation

Question 5

Post-partum infection - Investigations

Answer 5

Investigations:
Key/diagnostic: septic screen:
o urine/sputum/stool MCS
o blood cultures
o CXR
- Bedside: urinalysis, sputum sample, ECG, vital signs
- Bloods: FBC, UEC, LFT, CRP/ESR, Blood culture collection
- Imaging: CXR, nil other indicated initially

Question 6

Post-partum infection - Management

Answer 6

Management
If evidence of sepsis on assessment would initiate management using sepsis pathway local protocol;
- fluids
- empirical antibiotics - piptaz, consider Vanc if high risk of MRSA
- would arrange ID consult for further input into management, ongoing review with O&G
- paeds for any infection in the newborn

Wound infections

• drainage, debridement, irrigation
• empirical antibiotics

Mastitis
- empirical antibiotics