Department of Reproductive Health and Research (RHR), World Health Organization
Sexually transmitted and other reproductive tract infections
A guide to essential practice
Management of STIs/RTIs
Infection following childbirth
Postpartum endometritis and puerperal sepsis
Postpartum endometritis (uterine infection) and puerperal sepsis are common causes of maternal morbidity and mortality respectively and are largely preventable with good antenatal care, delivery practices and postpartum care. When care is delayed or inadequate, however, infection can progress quickly to generalized sepsis, which can result in infertility, chronic disability and even death.
Postpartum endometritis is commonly caused by gonococci, chlamydia, anaerobic bacteria, Gram-negative facultative bacteria, and streptococci. In developed countries, most postpartum infections are related to caesarean section. Elsewhere, postpartum endometritis more often follows vaginal delivery. Early postpartum endometritis occurs within the first 48 hours, and late infection between 3 days and 6 weeks following delivery. Aggressive treatment should be given for all postpartum infections (for complete management, see Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice, Geneva, World Health Organization, 2003).
Women with signs of infection immediately postpartum should be stabilized, given a first dose of antibiotics intravenously (or intramuscularly) and referred urgently to hospital.
Flowchart 8 outlines the management of women presenting with fever between 24 hours and 6 weeks postpartum.
Activities to prevent postpartum infection include prevention and detection of STI/RTI during pregnancy (Chapter 2 and Chapter 3) and good delivery practice. See the WHO publications: Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice, Geneva, World Health Organization, 2003 or Managing complications in pregnancy and childbirth: a guide for midwives and doctors, Geneva, World Health Organization, 2000 for guidelines on prevention and comprehensive management of postpartum complications.
Treatment table 11. Antibiotic regimens for treatment of infection following miscarriage, induced abortion or delivery (septic abortion, postpartum endometritis)
a. Patients taking metronidazole should be counselled to avoid alcohol.
b. The use of quinolones should take into consideration the patterns of Neisseria gonorrhoeae resistance, such as in the WHO South-East Asia and Western Pacific Regions.
a. Erythromycin estolate is contraindicated in pregnancy because of drug-related hepatotoxicity; only erythromycin base or erythromycin ethylsuccinate should be used. Note that oral erythromycin alone has been shown to decrease preterm birth in women with preterm, prelabour rupture of membranes in Europe (where gonorrhoea is uncommon). Since gonorrhoea is resistant to erythromycin in many areas, addition of cefixime or ceftriaxone is recommended where gonorrhoea is common.
b. Patients taking metronidazole should be counselled to avoid alcohol.
Infections of the male and female reproductive tract and their consequences:
Preventing STIs/RTIs and their complications
STI/RTI education and counselling
Promoting prevention of STI/RTI and use of services
STI/RTI Assessment during Routine Family Planning Visits
STI/RTI Assessment in pregnancy, childbirth and the postpartum period
Management of symptomatic STIs/RTIs
STI/RTI complications related to pregnancy, miscarriage, induced abortion, and the postpartum period
Annex 1. Clinical skills needed for STI/RTI
Annex 2. Disinfection and universal precautions
Annex 3. Laboratory tests for RTI
Annex 4. Medications