Postpartum chills

Postpartum chills is a physiological response that occurs within two hours of childbirth. Postpartum chills appears as uncontrollable shivering, not really chills. Postpartum chills is seen in many women after delivery and can be unpleasant. It lasts for a short time. It doesn’t matter whether you had a caesarean section or a vaginal birth. And while it usually happens within a couple hours after you’ve had your baby, it can also occur toward the end of labor. You can also get postpartum chills even if the room you’re in is perfectly warm.

If you feel chills similar to those you have with the flu (an ache that you can almost feel in your bones), you may have a fever, and that could indicate an infection.

But if your teeth are chattering and you feel like you just stepped outdoors into sub-zero weather without a coat, that’s usually a sign of postpartum chills.

Either way, you should let your doctor or a nurse know so they can make sure you don’t have a fever. The presence of postpartum fever is generally accepted among clinicians as a sign of infection that must be determined and managed.

If you suffer from postpartum chills, you’ll usually be given extra blankets at the hospital to wrap up in. The most important thing is not to try and control the shivering. That’s especially true if you’ve had a C-section. Straining to stop the shivers can cause your incision to tear. Just try to relax as much as possible and ride it out. It’s not pleasant, but it does pass. It’s rare for postpartum chills to last longer than an hour after delivery.

The cause of postpartum chills isn’t fully understood, but it may relate to fluid or heat loss and hormonal changes in your body after you give birth.

Postpartum fever and chills

Postpartum fever is defined as a temperature greater than 100.4 °F (38 °C) on any 2 of the first 10 days following delivery exclusive of the first 24 hours ¹. The presence of postpartum fever is generally accepted among clinicians as a sign of infection that must be determined and managed.

Local spread of colonized bacteria is the most common cause for postpartum infection following vaginal delivery. Endometritis is the most common infection in the postpartum period. Other postpartum infections include (1) postsurgical wound infections, (2) perineal cellulitis, (3) mastitis, (4) respiratory complications from anesthesia, (5) retained products of conception, (6) urinary tract infections (UTIs), and (7) septic pelvic phlebitis. Wound infection is more common with cesarean delivery. A review study by Haas et al ² indicated that cleansing the vagina with a povidone-iodine or chlorhexidine solution immediately prior to cesarean delivery decreases the risk for postoperative endometritis.

In a study by Yokoe et al in 2001 ³, 5.5% of vaginal deliveries and 7.4% of cesarean deliveries resulted in a postpartum infection. The overall postpartum infection rate was 6.0%. Endometritis accounted for nearly half of the infections in patients following cesarean delivery (3.4% of cesarean deliveries). Mastitis and urinary tract infections together accounted for 5% of vaginal deliveries ³.

A study by Bauer et al ⁴ indicated that in the United States from 1998 to 2008, of approximately 45 million hospitalizations for delivery, sepsis was a complication in 1 out of every 3333 deliveries. The investigators also found that during the study period, the risk for severe sepsis (1:10,823 deliveries) and sepsis-related death (1:105,263 deliveries) increased.

The risk of postpartum urinary tract infection is increased in the African American, Native American, and Hispanic populations ⁵.

Postpartum fever and chills causes

Endometritis

The route of delivery is the single most important factor in the development of endometritis ⁶. The risk of endometritis increases dramatically after cesarean delivery ⁶. However, there is some evidence that hospital readmission for management of postpartum endometritis occurs more often in those who delivered vaginally ⁷.

Other risk factors include prolonged rupture of membranes, prolonged use of internal fetal monitoring, anemia, and lower socioeconomic status ⁶.

Perioperative antibiotics have greatly decreased the incidence of endometritis ⁶.

In most cases of endometritis, the bacteria responsible are those that normally reside in the bowel, vagina, perineum, and cervix.

The uterine cavity is usually sterile until the rupture of the amniotic sac. As a consequence of labor, delivery, and associated manipulations, anaerobic and aerobic bacteria can contaminate the uterus.

Wound infections

Most often, the etiologic organisms associated with perineal cellulitis and episiotomy site infections are Staphylococcus or Streptococcus species and gram-negative organisms, as in endometritis.

Vaginal secretions contain as many as 10 billion organisms per gram of fluid. Yet, infections develop in only 1% of patients who had vaginal tears or who underwent episiotomies.

Those who underwent cesarean delivery have a higher readmission rate for wound infection and complications than those who delivered vaginally ⁸.

Genital tract infections

Increased risk of genital tract infections is related to the duration of labor (ie prolonged labor increases risk of infection), use of internal monitoring devices, and number of vaginal examinations ⁹.

Genital tract infections are generally polymicrobial. Gram-positive cocci and Bacteroides and Clostridium species are the predominant anaerobic organisms involved. Escherichia coli and gram-positive cocci are commonly involved aerobes.

Mastitis

The most common organism reported in mastitis is Staphylococcus aureus. The organism usually comes from the breastfeeding infant’s mouth or throat.

Thrombosis may occur. Numerous factors cause pregnant and postpartum women to be more susceptible to thrombosis. Pregnancy is known to induce a hypercoagulable state secondary to increased levels of clotting factors. Also, venous stasis occurs in the pelvic veins during pregnancy.

Although relatively rare, septic pelvic thrombosis is occasionally observed in the postpartum patient, who might have fever.

Urinary tract infections

Bacteria most frequently found in urinary tract infections (UTIs) are normal bowel flora, including Escherichia coli (E coli) and Klebsiella, Proteus, and Enterobacter species.

Any form of invasive manipulation of the urethra (eg, Foley catheterization) increases the likelihood of a UTI.

General risk factors for postpartum infection

The following increase the risk for postpartum infections:

• History of cesarean delivery
• Premature rupture of membranes
• Frequent cervical examination. Sterile gloves should be used in examinations. Other than a history of cesarean delivery, this risk factor is most important in postpartum infection.
• Internal fetal monitoring
• Preexisting pelvic infection including bacterial vaginosis
• Diabetes
• Nutritional status
• Obesity

In the aforementioned study by Bauer et al. ⁴, of approximately 45 million hospitalizations for delivery between 1998 and 2008, medical conditions that were found to be independently associated with severe sepsis included congestive heart failure, chronic kidney disease, chronic liver disease, and systemic lupus erythematosus. An association with rescue cerclage was also found.

Postpartum infection symptoms

Features of postpartum infection vary depending on the source and may include the following:

• Flank pain, dysuria, and frequency of urinary tract infections (UTIs)
• Erythema and drainage from the surgical incision or episiotomy site, in cases of postsurgical wound infections
• Respiratory symptoms, such as cough, pleuritic chest pain, or dyspnea, in cases of respiratory infection or septic pulmonary embolus
• Fever and chills
• Abdominal pain
• Foul-smelling lochia
• Breast engorgement in cases of mastitis.

Physical examination

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 > 100.94 °F [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.

Postpartum fever and chills dianosis

Laboratory studies

Laboratory studies are directed at elucidating the severity of illness as well as the cause of the infection. Mild cases of mastitis usually do not require laboratory investigation. Wound infections and infections of the genital tract makes it more difficult to ascertain the extent of involvement.

Laboratory studies should include the following:

• Complete blood count (CBC)
• Electrolytes
• Blood cultures, if sepsis is suspected
• Urinalysis, with cultures and sensitivity tests
• Cervical or uterine cultures
• Wound cultures, if appropriate
• Lactate, if sepsis suspected
• Coagulation studies, if pelvic thrombosis, deep vein thrombosis, pulmonary embolism, or invasive treatment (eg, surgical procedure) is being considered.

Imaging studies

Pelvic ultrasonography may be helpful in detecting retained products of conception, pelvic abscess, or infected hematoma.

Contrast-enhanced CT or MRI are useful in establishing the diagnosis of septic pelvic thrombosis ¹⁰.

In some cases, a contrast-enhanced CT examination of the abdomen and pelvis may be helpful if concurrent concern is present for other non-pregnancy–related abdominal/pelvic sources of the infection (eg, appendicitis, colitis).

Postpartum fever and chills treatment

The most important aspect of prehospital care in a postpartum patient with a suspected infection is to ensure adequate fluid volume and to prevent sepsis and shock. Provide aggressive fluid management, begin cardiac monitoring, and administer oxygen.

Emergency Department care is focused on identifying the source of the infection, followed by appropriate antimicrobial therapy and referral.

Postpartum endometritis treatment

In most cases, initial antimicrobial treatment is a combination of an aminoglycoside and clindamycin. Alternatively, an aminoglycoside plus metronidazole with or without ampicillin may also be used ¹¹.

Mild cases of endometritis after vaginal delivery may be treated with oral antimicrobial agents (eg, doxycycline, clindamycin).

Moderate-to-severe cases, including those involving cesarean deliveries, should be treated with parenteral broad-spectrum antimicrobials.

A review of trials for antibiotic regimens for the treatment of endometritis by French and Smaill concluded that gentamicin in combination with clindamycin is appropriate for endometritis ¹². In an update of these findings, on the basis of a Cochrane review of 42 trials comprising more than 4200 patients, investigators confirmed combination therapy with gentamicin and clindamycin remains appropriate for treatment of endometritis ¹³. The researchers also noted that the use of additional oral therapy has not been proven to be beneficial.

In general, the patient’s condition rapidly improves after antibiotics are administered.

Wound infection or episiotomy infection treatment

Drainage, debridement, and irrigation may be required. Broad-spectrum antibiotics should be administered.

Mastitis treatment

The Academy of Breastfeeding Medicine recommends frequent and effective milk removal in managing mastitis (most important step) or fluid mobilization ¹⁴. Supportive measures include rest, adequate fluids, and nutrition ¹⁴. Also use local measures, such as ice packs, analgesics, and breast support ¹¹.

Administer a penicillinase-resistant antibiotic such as cephalexin, dicloxacillin or cloxacillin, or clindamycin in penicillin-allergic patients ¹¹.

The mother should be told to continue to breastfeed the baby ¹⁴. Continued breastfeeding prevents breast engorgement and subsequent pain.

If a breast abscess is present, or breastfeeding is not possible, a breast pump should be used in lactating women ¹¹.

Mastitis could lead to abscess formation, which may require surgical drainage.

UTI treatment

Administer fluids, if evidence of dehydration exists.

Appropriate antibiotics should be used. These typically are trimethoprim-sulfamethoxazole, nitrofurantoin, ciprofloxacin, levofloxacin, or ofloxacin ¹⁵.

The above antibiotics (including fluoroquinolones) for UTI are considered safe by the American Academy of Pediatrics for nursing infants, with no reported effects seen in infants who are breastfeeding ¹⁶.

Although the American Academy of Pediatrics considers fluoroquinolones to be safe for breastfeeding mothers, they also recommend that the safest drug should be prescribed ¹⁷. Fluoroquinolones are excreted in breast milk with unknown absorption by the infant. The potential for pediatric cartilage and joint damage were extrapolated from juvenile animal studies ¹⁸. For this reason, fluoroquinolones should not be first-line therapy and temporary discontinuation of breastfeeding should be considered ¹⁹.

Trimethoprim-sulfamethoxazole and nitrofurantoin are to be avoided in mothers with breastfeeding infants with G-6-PD deficiency ¹⁶.

When possible, the medication should be taken just after the patient has breastfed the infant to minimize drug exposure ¹⁷.

Fever and flank pain should raise suspicion for pyelonephritis, and inpatient hospital admission should be considered. Ampicillin and gentamicin may also be given to lactating mothers with no reported effects on breastfeeding infants ¹⁷.

Septic pelvic phlebitis treatment

Broad-spectrum antibiotics should be administered. Initial choice of antibiotics should cover gram-positive, gram-negative, and anaerobic organisms. Ampicillin and gentamicin with metronidazole or clindamycin is a common regimen ¹⁰.

Anticoagulation may be used, and it should be noted that there exists no universal guideline or recommendation for anticoagulation therapy in septic pelvic thrombosis. Initial bolus of 60 units/kg (4000 units maximum) followed by 12 units/kg/h (maximum of 1000 units/h) is recommended ⁶. The aPTT is monitored for 2-3 times the normal value ¹⁰.

Alternatively, low-molecular weight heparin may be used with a dose of 1 mg/kg ¹⁰.

Hospitalization

Patients with early postpartum endometritis especially after cesarean delivery should be admitted, as should any patient with suspected septic pelvic vein thrombosis. Postsurgical wound infections may also require inpatient management, particularly if there is extensive involvement of surrounding soft tissues, intractable pain, and fever.

Consultations

Obstetric consultation must be obtained in cases of endometritis, postsurgical wound infections and cellulitis, retained products of conception, and septic pelvic phlebitis. If an obstetrician/gynecologist is unavailable, seek consultation with a general surgeon.

Outpatient follow-up

All patients with a postpartum infection should undergo follow-up with an obstetrician.

Postpartum fever and chills prognosis

The prognosis for postpartum infections is good with prompt and appropriate therapy.

In most reviews, maternal death rates associated with infection range from 4-8%, or approximately 0.6 maternal deaths per 100,000 live births.

A pregnancy-related mortality surveillance by the Centers for Disease Control and Prevention indicated infection accounted for about 11.6% of all deaths following pregnancy that resulted in a live birth, stillbirth, or ectopic ²⁰.

Postpartum fever and chills complications

Complications include the following:

• Scarring
• Infertility
• Sepsis
• Septic shock
• Death

References

1. Adair FL. The American Committee of Maternal Welfare, Inc: The Chairman’s Address. Am J Obstet Gynecol. 1935. 30:868.
2. Haas DM, Morgan S, Contreras K, Enders S. Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections. Cochrane Database Syst Rev. 2018 Jul 17. 7:CD007892
3. Yokoe DS, Christiansen CL, Johnson R, Sandu KE, et al. Epidemiology of and Surveillance for Postpartum Infectious. Emerg Infect Dis. Sep-Oct 2001. 7(5):837-41.
4. Bauer ME, Bateman BT, Bauer ST, et al. Maternal sepsis mortality and morbidity during hospitalization for delivery: temporal trends and independent associations for severe sepsis. Anesth Analg. 2013 Oct. 117(4):944-50.
5. Schwartz MA, Wang CC, Eckert LO, Critchlow CW. Risk factors for urinary tract infection in the postpartum period. Am J Obstet Gynecol. 1999 Sep. 181(3):547-53.
6. Monif GR, Baker DA. Infectious Diseases in Obstetrics and Gynecology. 6th ed. Informa HealthCare; 2008.
7. Atterbury JL, Groome LJ, Baker SL, Ross EL, Hoff C. Hospital readmission for postpartum endometritis. J Matern Fetal Med. 1998 Sep-Oct. 7(5):250-4.
8. Newton ER, Prihoda TJ, Gibbs RS. A clinical and microbiologic analysis of risk factors for puerperal endometritis. Obstet Gynecol. 1990 Mar. 75(3 Pt 1):402-6.
9. Maharaj D. Puerperal Pyrexia: a review. Part II. Obstet Gynecol Surv. 2007 Jun. 62(6):400-6.
10. Garcia J, Aboujaoude R, Apuzzio J, Alvarez JR. Septic pelvic thrombophlebitis: diagnosis and management. Infect Dis Obstet Gynecol. 2006. 2006:15614.
11. Chaim W, Burstein E. Postpartum infection treatments: a review. Expert Opin Pharmacother. 2003 Aug. 4(8):1297-313.
12. French LM, Smaill FM. Antibiotic regimens for endometritis after delivery. Cochrane Database Syst Rev. Oct 2004. 18(4):CD001067
13. Mackeen AD, Packard RE, Ota E, Speer L. Antibiotic regimens for postpartum endometritis. Cochrane Database Syst Rev. 2015 Feb 2. 2:CD001067
14. Amir LH, Academy of Breastfeeding Medicine Protocol Committee. ABM clinical protocol #4: Mastitis, revised March 2014. Breastfeed Med. 2014 Jun. 9 (5):239-43.
15. Wagenlehner FM, Weidner W, Naber KG. An update on uncomplicated urinary tract infections in women. Curr Opin Urol. 2009 Jul. 19(4):368-74.
16. Kaiser J, McPherson V, Kaufman L, Huber T. Clinical inquiries. Which UTI therapies are safe and effective during breastfeeding?. J Fam Pract. 2007 Mar. 56(3):225-8.
17. [Guideline] American Academy of Pediatrics Committee on Drugs. Transfer of drugs and other chemicals into human milk. Pediatrics. 2001 Sep. 108(3):776-89.
18. Grady R. Safety profile of quinolone antibiotics in the pediatric population. Pediatr Infect Dis J. 2003 Dec. 22(12):1128-32.
19. Bar-Oz B, Bulkowstein M, Benyamini L, Greenberg R, Soriano I, Zimmerman D. Use of antibiotic and analgesic drugs during lactation. Drug Saf. 2003. 26(13):925-35.
20. Chang J, Elam-Evans LD, Berg CJ, Herndon J, Flowers L, Seed KA, et al. Pregnancy-related mortality surveillance–United States, 1991–1999. MMWR Surveill Summ. 2003 Feb 21. 52(2):1-8.