History
The history and course of the delivery is important in the evaluation of postpartum patients. Obtain the following information:
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Ascertain if the delivery was vaginal or cesarean.
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Ascertain if premature rupture of the membranes occurred.
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Determine if the patient had any prenatal care.
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Determine if the patient was diagnosed or treated for any infections during pregnancy or during the antepartum period.
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Assess the patient's symptoms.
Features of postpartum infection vary depending on the source and may include the following:
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Flank pain, dysuria, and frequency of UTIs
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Erythema and drainage from the surgical incision or episiotomy site, in cases of postsurgical wound infections
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Respiratory symptoms, such as cough, pleuritic chest pain, or dyspnea, in cases of respiratory infection or septic pulmonary embolus
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Fever and chills
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Abdominal pain
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Foul-smelling lochia
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Breast engorgement in cases of mastitis
Physical Examination
Focus the physical examination on identifying the source of fever and infection. A complete physical examination, including pelvic and breast examinations, is necessary. Potential findings are discussed below.
Endometritis
Endometritis may be characterized by lower abdominal tenderness on one or both sides of the abdomen, adnexal and parametrial tenderness elicited with bimanual examination, and temperature elevation (most commonly >38.3°C).
Some women have foul-smelling lochia without other evidence of infection. Some infections, most notably caused by group A beta-hemolytic streptococci, are frequently associated with scanty, odorless lochia.
Wound infections
Patients with wound infections, or episiotomy infections, have erythema, edema, tenderness out of proportion to expected postpartum pain, and discharge from the wound or episiotomy site.
Drainage from wound site should be differentiated from normal postpartum lochia and foul-smelling lochia, which may be suggestive of endometritis.
Mastitis
Patients with mastitis have very tender, engorged, erythematous breasts. Infection frequently is unilateral.
Urinary tract infections
Patients with pyelonephritis or UTIs may have costovertebral angle tenderness, suprapubic tenderness, and an elevated temperature.
Respiratory tract infections
Evaluate for tachypnea, rales, crackles, rhonchi, and consolidation.
Septic pelvic thrombophlebitis
Patients with septic pelvic thrombophlebitis, although rare, may have palpable pelvic veins. These patients also have tachycardia that is out of proportion to the fever.
