Puerperal Fever/Sepsis

Infection of the female internal genital tract within 6 weeks of childbirth. Signs and symptoms usually occur after 24
hours, although the disease may manifest earlier in settings of prolonged rupture of membranes and prolonged labour without prophylactic antibiotics.


  • Ascending infection from contamination during delivery or abortion
  • Bacteria include: Staphylococcus aureus and Gram negative bacteria from the gut, e.g. Escherichia coli,
    Bacteroides, Streptococcus pyogenes, clostridium spp, chlamydia, gonococci
  • In peurperal sepsis, multiple organisms are likely

Clinical features

  • Persistent fever >38°C
  • Chills and general malaise
  • Pain in the lower abdomen
  • Persistent bloody/pus discharge (lochia) from genital tract, which may have an unpleasant smell
  • Tenderness on palpating the uterus
  • Uterine sub-involution

Risk factors

  • Anaemia, malnutrition in pregnancy
  • Prolonged labour, prolonged rupture of membranes
  • Frequent vaginal exams
  • Traumatic delivery (instrumental deliveries, tears)
  • Retained placenta

Differential diagnosis

  • Other causes of fever after childbirth, e.g. malaria, UTI, DVT, wound sepsis, mastitis/breast abscess, RTI


  • Blood: CBC, C&S, BS for malaria parasites / RDT
  • Lochia: swab for C&S
  • Urine: For protein, sugar, microscopy, C&S


Puerperal fever carries a high risk of sepsis with a high mortality, and needs immediate attention

Parenteral antibiotic therapy

  • Ampicillin 500 mg IV or IM every 6 hours
  • Plus gentamicin 5-7 mg/kg IV or IM daily in 2 divided doses (every 12 hours)
  • Plus metronidazole 500 mg IV every 8 hours for at least 3 doses
  • Alternative
    • Clindamycin 150 mg IV/IM every 6 hours + gentamicin as above

Supportive/additional therapy

  • Give IV fluids
  • Give analgesics
  • If anaemic, transfuse with blood
  • Look for retained products and evacuate uterus if necessary


  • Use of clean delivery kits and ensuring clean deliveries, proper hygiene
  • Prophylactic antibiotic when indicated (prolonged labour and premature rupture of membranes, manual removal of placenta)