Puerperal Complications
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Direct answer
The puerperium — six weeks after delivery — is watched for fever, bleeding, breast problems, thrombosis and psychological collapse. Puerperal pyrexia is 38 degrees Celsius or more within 14 days of delivery, and puerperal sepsis (a leading cause of India's maternal deaths) is genital tract infection, most often endomyometritis after caesarean or retained products, presenting with fever, foul lochia, uterine tenderness and subinvolution; treatment is broad-spectrum intravenous antibiotics (clindamycin plus gentamicin, or co-amoxiclav with anaerobic cover) and evacuation of retained tissue. The rest of the list: secondary postpartum haemorrhage (bleeding from 24 hours to 12 weeks, usually retained products or endometritis — ultrasound, antibiotics, evacuation), mastitis and breast abscess, urinary retention and infection, venous thromboembolism (highest for three weeks postpartum), subinvolution, and postpartum depression or psychosis — the last a psychiatric emergency in the first two weeks.
What you must remember
- Definitions: puerperal pyrexia 38 degrees Celsius or more in the first 14 days; puerperal sepsis — genital tract infection with systemic signs, per WHO, a top-five direct cause of maternal mortality in India.
- Sepsis source map: endomyometritis (commonest, especially post-caesarean), wound infection, urinary tract, breast and thrombosis; caesarean multiplies endometritis risk several-fold over vaginal birth.
- Endometritis treatment: intravenous clindamycin 900 mg every 8 hours plus gentamicin 5 mg/kg once daily, or co-amoxiclav with anaerobic cover — most fevers defervesce within 48-72 hours; retained products are evacuated after cover.
- Secondary postpartum haemorrhage: bleeding from 24 hours to 12 weeks; causes — retained products (commonest), endometritis, subinvolution of the placental site; management — antibiotics, ultrasound, evacuation (medical with misoprostol or surgical).
- Mastitis versus abscess: mastitis — localised pain, redness, fever; continue breastfeeding plus anti-staphylococcal antibiotics; abscess — fluctuant mass needing aspiration or drainage, feeding maintained from the other side.
- Thromboembolism: hypercoagulability peaks in the puerperium; leg swelling or breathlessness demands urgent imaging (compression ultrasound or CT angiography) with therapeutic heparin; prophylactic enoxaparin 40 mg daily continues up to six weeks in high-risk women.
- Urinary complications: postpartum retention (check voiding within six hours; epidural and instrumental delivery are risks), urinary tract infection, and stress incontinence managed with pelvic floor exercises first.
- Mental health: blues (days 3-10, self-limiting, support only), postpartum depression (Edinburgh scale screening; SSRI plus psychological therapy), postpartum psychosis (delusions within two weeks — a psychiatric emergency, admission with the baby).
Chasing a fever day by day
Day 3 after a caesarean: temperature 38.6 degrees Celsius. The systematic pass — breasts (engorged, no localisation), wound (clean), chest (clear), urine (negative), lochia (foul, uterus tender and bulky): endomyometritis. Intravenous clindamycin plus gentamicin, fluids; defervescence by 48 hours confirms it retrospectively, and fever persisting beyond 72 hours widens the search to pelvic thrombophlebitis, abscess and resistant organisms.
Day 10, another woman: heavy bleeding with clots and fever after a home delivery. Secondary postpartum haemorrhage with retained products — intravenous antibiotics, ultrasound showing echogenic material, evacuation after cover (or misoprostol where surgery is unavailable and bleeding not torrential). The specimen goes for histology; contraception is planned before discharge. Day 12 in a third: a lactating mother with rigors and a tender, wedge-shaped breast area — mastitis, flucloxacillin while feeding continues; a fluctuant swelling by day 16 means an abscess, drained under ultrasound guidance.
The fourth thread: at the six-week visit a mother reports not sleeping though the baby sleeps, weeping, intrusive thoughts of harm. That is not blues — blues resolve by two weeks; the Edinburgh scale scores high and she starts sertraline (safe in breastfeeding) with referral, while any delusional content would trigger immediate admission for puerperal psychosis.
How the exam frames it
Questions hang on definitions and first steps: the 38-degree threshold (within 14 days), the commonest cause of secondary postpartum haemorrhage (retained products), the endometritis drug pair (clindamycin plus gentamicin), and the triage of postpartum mental illness (blues self-limiting, depression by scale, psychosis an emergency). The timing discrimination — fever day 1-2 (atelectasis or normal post-caesarean spike) versus day 3-5 (endometritis, wound) versus day 5-10 (breast, urinary, thrombosis) — is the pattern-recognition reward. The Indian anchor is maternal death review, where sepsis sits among the leading causes, making "preventable with clean delivery practices and early antibiotics" the programme answer.
Frequently asked questions
What defines puerperal pyrexia and puerperal sepsis?
Pyrexia is 38 degrees Celsius or more within 14 days of birth; sepsis is genital tract infection with systemic features — a leading direct cause of maternal death in India.
What is the commonest cause of secondary postpartum haemorrhage?
Retained products of conception with or without endometritis — antibiotics first, then ultrasound-guided evacuation.
Which antibiotic combination treats puerperal endometritis?
Intravenous clindamycin 900 mg every 8 hours plus once-daily gentamicin, or co-amoxiclav with anaerobic cover, until afebrile for 24-48 hours.
How are the postpartum blues distinguished from depression?
Blues peak around days 3-5 and resolve within two weeks; depression persists beyond two weeks with impairment, screened by the Edinburgh scale and treated with therapy and SSRIs.
Why is the puerperium a high-risk period for venous thromboembolism?
Hypercoagulability peaks around delivery and persists about six weeks, so high-risk women receive prophylactic heparin postpartum and suspicious symptoms are investigated urgently.