{{Short description|Infection following childbirth}}
{{CS1 config|name-list-style=vanc}}
{{Infobox medical condition (new)
| name = Postpartum infections
| image = Streptococcus pyogenes.jpg
| caption = ''[[Streptococcus pyogenes]]'' (red-stained spheres) is responsible for many cases of severe puerperal fever.
| synonyms = Puerperal fever, childbed fever, maternal sepsis, maternal infection, puerperal infections
| field = [[Obstetrics]]
| symptoms = Fever, lower abdominal pain, bad-smelling vaginal discharge<ref name=W2014/>
| complications = 
| onset = 
| duration = 
| causes = Typically multiple types of bacteria<ref name=W2014/>
| risks = [[Caesarean section]], [[premature rupture of membranes]], [[prolonged labour]], [[malnutrition]], [[diabetes]]<ref name=W2014/><ref name=WHOBook2015/>
| diagnosis = 
| differential = 
| prevention = 
| treatment = [[Antibiotics]]<ref name=W2014/>
| medication = 
| prognosis = 
| frequency = 11.8 million<!-- incidence table --><ref name=GBD2015Pre/>
| deaths = 17,900<ref name=GBD2015De/>
}}

<!-- Definition and symptoms -->
'''Postpartum infections''', also known as '''childbed fever''' and '''puerperal fever''', are any bacterial [[infection]]s of the [[female reproductive tract]] following [[childbirth]] or [[miscarriage]].<ref name=W2014/> Signs and symptoms usually include a [[fever]] greater than {{convert|38.0|C|F}}, chills, lower abdominal pain, and possibly odorous [[vaginal discharge]].<ref name=W2014>{{cite book|title=Williams Obstetrics|date=2014|publisher=McGraw-Hill Professional|isbn=978-0-07-179893-8|pages=Chapter 37|edition=24th|chapter=37}}</ref> It usually occurs after the first 24 hours and within the first ten days following delivery.<ref name=Hir2014>{{cite book|author1=Hiralal Konar|title=DC Dutta's Textbook of Obstetrics|date=2014|publisher=JP Medical Ltd|isbn=978-93-5152-067-2|page=432|url=https://books.google.com/books?id=LU2VAwAAQBAJ&pg=PA432|url-status=live|archive-url=https://web.archive.org/web/20151208041911/https://books.google.ca/books?id=LU2VAwAAQBAJ&pg=PA432|archive-date=2015-12-08}}</ref>

<!--Causes and diagnosis-->
The most common infection is that of the [[uterus]] and surrounding tissues known as '''puerperal sepsis''', '''postpartum metritis''', or '''postpartum endometritis'''.<ref name=W2014/><ref name=Hac2015>{{cite book |title=Hacker & Moore's essentials of obstetrics and gynecology |date=2015 |publisher=Elsevier Canada |isbn=978-1-4557-7558-3 |pages=276–290 |edition=6 |chapter=Cover of Hacker & Moore's Essentials of Obstetrics and Gynecology}}</ref> Risk factors include [[caesarean section]] (C-section), the presence of certain bacteria such as [[group B streptococcus]] in the vagina, [[premature rupture of membranes]], multiple [[vaginal exam]]s, manual removal of the [[placenta]], and [[prolonged labour]] among others.<ref name=W2014/><ref name=WHOBook2015>{{cite book|title=WHO recommendations for prevention and treatment of maternal peripartum infections|date=2015|publisher=World Health Organization|isbn=978-92-4-154936-3|pmid=26598777|page=1|url=http://apps.who.int/iris/bitstream/10665/186171/1/9789241549363_eng.pdf|url-status=live|archive-url=https://web.archive.org/web/20160207091250/http://apps.who.int/iris/bitstream/10665/186171/1/9789241549363_eng.pdf|archive-date=2016-02-07}}</ref> Most infections involve a number of types of bacteria.<ref name=W2014/> Diagnosis is rarely helped by [[microbiological culture|culturing]] of the vagina or blood.<ref name=W2014/> In those who do not improve, [[medical imaging]] may be required.<ref name=W2014/> Other causes of fever following delivery include [[breast engorgement]], [[urinary tract infection]]s, infections of an abdominal incision or an [[episiotomy]], and [[atelectasis]].<ref name=W2014/><ref name=WHOBook2015/>

<!--Prevention and treatment-->
Due to the risks following caesarean section, it is recommended that all women receive a preventive dose of [[antibiotic]]s such as [[ampicillin]] around the time of surgery.<ref name=W2014/> Treatment of established infections is with antibiotics, with most people improving in two to three days.<ref name=W2014/> In those with mild disease, oral antibiotics may be used; otherwise, [[intravenous]] antibiotics are recommended.<ref name=W2014/> Common antibiotics include a combination of ampicillin and [[gentamicin]] following vaginal delivery or [[clindamycin]] and gentamicin in those who have had a C-section.<ref name=W2014/> In those who are not improving with appropriate treatment, other complications such as an [[abscess]] should be considered.<ref name=W2014/>

<!--Epidemiology and history-->
In 2015, about 11.8&nbsp;million maternal infections occurred.<ref name=GBD2015Pre>{{cite journal|author=((GBD 2015 Disease and Injury Incidence and Prevalence Collaborators)) |title=Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015.|journal=Lancet|date=8 October 2016|volume=388|issue=10053|pages=1545–1602|pmid=27733282|doi=10.1016/S0140-6736(16)31678-6|pmc=5055577}}</ref> In the developed world about 1% to 2% develop uterine infections following [[vaginal delivery]].<ref name=W2014/> This increases to 5% to 13% among those who have more difficult deliveries and 50% with C-sections before the use of preventive antibiotics.<ref name=W2014/> In 2015, these infections resulted in 17,900 deaths down from 34,000 deaths in 1990.<ref name=GBD2015De>{{cite journal|author=((GBD 2015 Mortality and Causes of Death Collaborators)) |title=Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015.|journal=Lancet|date=8 October 2016|volume=388|issue=10053|pages=1459–1544|pmid=27733281|doi=10.1016/s0140-6736(16)31012-1|pmc=5388903}}</ref><ref name=GDB2013>{{cite journal|author=((GBD 2013 Mortality and Causes of Death Collaborators)) |title=Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013.|journal=Lancet|date=17 December 2014|pmid=25530442|doi=10.1016/S0140-6736(14)61682-2|pmc=4340604|volume=385|issue=9963|pages=117–171}}</ref> They are the cause of about 10% of deaths around the time of pregnancy.<ref name=WHOBook2015/> The first known descriptions of the condition date back to at least the 5th century BCE in the writings of [[Hippocrates]].<ref>{{cite book|last1=Walvekar|first1=Vandana|title=Manual of perinatal infections|date=2005|publisher=Jaypee Bros.|location=New Delhi|isbn=978-81-8061-472-9|page=153|url=https://books.google.com/books?id=DIOmY2ROeVAC&pg=PA152|url-status=live|archive-url=https://web.archive.org/web/20160304220030/https://books.google.ca/books?id=DIOmY2ROeVAC&pg=PA152|archive-date=2016-03-04}}</ref> These infections were a very common cause of death around the time of childbirth starting in at least the 18th century until the 1930s when antibiotics were introduced.<ref>{{cite book|last1=Magner|first1=Lois N.|title=A history of medicine|date=1992|publisher=Dekker|location=New York|isbn=978-0-8247-8673-1|pages=[https://archive.org/details/historyofmedicin0000magn/page/257 257]–258|url=https://archive.org/details/historyofmedicin0000magn|url-access=registration}}</ref> In 1847, Hungarian physician [[Ignaz Semmelweiss]] decreased death from the disease in the First Obstetrical Clinic of Vienna from nearly 20% to 2% through the use of [[handwashing]] with [[calcium hypochlorite]].<ref>{{cite journal|last1=Anderson|first1=BL|title=Puerperal group A streptococcal infection: beyond Semmelweis.|journal=Obstetrics and Gynecology|date=April 2014|volume=123|issue=4|pages=874–882|pmid=24785617|doi=10.1097/aog.0000000000000175|doi-access=|s2cid=24685091 }}</ref><ref>{{cite journal|last1=Ataman|first1=AD|last2=Vatanoğlu-Lutz|first2=EE|last3=Yıldırım|first3=G|title=Medicine in stamps-Ignaz Semmelweis and Puerperal Fever.|journal=Journal of the Turkish German Gynecological Association|date=2013|volume=14|issue=1|pages=35–9|pmid=24592068|doi=10.5152/jtgga.2013.08|pmc=3881728}}</ref>

==Signs and symptoms==
Signs and symptoms usually include a [[fever]] greater than {{convert|38.0|C|F}}, chills, low abdominal pain, and possibly bad-smelling vaginal discharge.<ref name=W2014/> It usually occurs after the first 24 hours and within the first ten days following delivery.<ref name=Hir2014/>

==Causes==
After childbirth, the [[female reproductive system|female genital tract]] has a large bare surface, which is prone to infection. Infection may be limited to the cavity and wall of the [[uterus]], or it may spread beyond to cause [[sepsis]] or other illnesses, especially when resistance has been lowered by long labour or severe bleeding. Puerperal infection is most common on the raw surface of the interior of the uterus after separation of the [[placenta]] (afterbirth), but [[pathogenic]] organisms may also affect [[lacerations]] of any part of the genital tract. By whatever portal, they can invade the [[bloodstream]] and [[lymph system]] to cause [[sepsis]], [[cellulitis]] (inflammation of connective tissue), and pelvic or generalized [[peritonitis]] (inflammation of the abdominal lining). The severity of the illness depends on the [[virulence]] of the infecting organism, the resistance of the invaded tissues, and the general health of the woman. Organisms commonly producing this infection are ''[[Streptococcus pyogenes]]''; [[staphylococci]] (inhabitants of the skin and of [[pimples]], [[carbuncle (pathology)|carbuncle]]s, and many other [[pustular]] eruptions); the [[Peptostreptococcus|anaerobic streptococci]], which flourish in devitalized tissues such as may be present after long and injurious labour and unskilled instrumental delivery; ''[[Escherichia coli]]''<ref>{{cite web |url=https://emedicine.medscape.com/article/796892-overview |title=Postpartum Infections |author=Andy W Wong |website=Medscape |date=2024-03-27 |access-date=2025-03-14}}</ref> and ''[[Clostridium perfringens]]'' (inhabitants of the lower bowel); and ''[[Clostridium tetani]]''.<ref>{{cite journal |title=Determinants of puerperal sepsis among postpartum women: a case–control study in East Shoa Zone public hospitals, Central Ethiopia |author=Befekadu Tesfaye Oyato |journal=BMJ Open |date=2024-06-20 |volume=14 |issue=6 |article-number=e083230 |doi=10.1136/bmjopen-2023-083230  |doi-access=free|pmid=38908838 |pmc=11328626 }}</ref>

===Risk factors===
Causes (listed in order of decreasing frequency) include: [[endometritis]], [[urinary tract infection]], [[pneumonia]]/[[atelectasis]], [[wound infection]], and [[septic pelvic thrombophlebitis]]. Sepsis risk factors for each condition are listed in order of the [[postpartum]] day (PPD) on which the condition generally occurs.{{cn|date=April 2023}}
* PPD 0: [[atelectasis]] risk factors include [[general anesthesia]], [[cigarette smoking]], and [[obstructive lung disease]].
* PPD 1–2: urinary tract infection risk factors include multiple [[catheterization]] during labor, multiple [[vaginal examination]]s during labor, and untreated [[bacteriuria]].
* PPD 2–3: endometritis ( the most common cause ) risk factors include emergency cesarean section, prolonged membrane rupture, prolonged labor, and multiple vaginal examinations during labor.
* PPD 4–5: wound infection risk factors include emergency [[cesarean section]], prolonged [[membrane rupture]], prolonged labor, and multiple vaginal examinations during labor.
* PPD 5–6: septic pelvic thrombophlebitis risk factors include emergency cesarean section, prolonged membrane rupture, prolonged labor, and diffuse difficult vaginal childbirth.
* PPD 7–21: [[mastitis]] risk factors include nipple trauma from [[breastfeeding]].

== Diagnosis ==
Puerperal fever is diagnosed with:
* A temperature rise above {{convert|38|C|F|1|abbr=on}} maintained over 24 hours or recurring during the period from the end of the first to the end of the 10th day after childbirth or abortion. (ICD-10)
* Oral temperature of {{convert|38|C|F|1|abbr=on}} or more on any two of the first ten days postpartum. (USJCMW)<ref name="gfmer.ch">[http://www.gfmer.ch/Medical_education_En/PGC_RH_2004/Pdf/Chisembele_Puerperal_sepsis.pdf The Global Incidence of Puerperal Sepsis Protocol for a Systematic Review<!-- Bot generated title -->] {{webarchive|url=https://web.archive.org/web/20081217023721/http://www.gfmer.ch/Medical_education_En/PGC_RH_2004/Pdf/Chisembele_Puerperal_sepsis.pdf |date=2008-12-17 }}</ref>

Puerperal fever  (from the Latin ''puer'', ''male child (boy)''), is no longer favored as a diagnostic category. Instead, contemporary terminology specifies:<ref>Carter (2005):98</ref>
# the specific target of infection: [[endometritis]] (inflammation of the inner lining of the uterus), [[metrophlebitis]] (inflammation of the veins of the uterus), and [[peritonitis]] (inflammation of the membrane lining of the abdomen).
# the severity of the infection: less serious [[infection]] (contained multiplication of microbes) or possibly life-threatening [[sepsis]] (uncontrolled and uncontained multiplication of microbes throughout the bloodstream).

[[Endometritis]] is a polymicrobial infection.  It frequently includes organisms such as ''[[Ureaplasma]]'', ''[[Streptococcus]]'', ''[[Mycoplasma]]'', and ''[[Bacteroides]]'', and may also include organisms such as ''[[Gardnerella]]'', ''[[Chlamydia (bacterium)|Chlamydia]]'', ''[[Lactobacillus]]'', ''[[Escherichia]]'', and ''[[Staphylococcus]]''.<ref>{{cite journal | url=http://journals.lww.com/greenjournal/abstract/1990/04000/bacteriologic_findings_of_post_cesarean.12.aspx | title=Bacteriologic Findings of Post-Cesarian Endometritis in Adolescents | first=AB | last=Berenson | journal=Obstetrics and Gynecology | date=April 1990 | volume=75 | pages=627–629 | pmid=2314783 | issue=4 | url-status=live | archive-url=https://web.archive.org/web/20131103084443/http://journals.lww.com/greenjournal/abstract/1990/04000/bacteriologic_findings_of_post_cesarean.12.aspx | archive-date=2013-11-03 }}</ref>

===Differential diagnosis===
Several other conditions can cause fevers following delivery, including: [[urinary tract infections]], [[breast engorgement]], [[atelectasis]], and surgical incisions, among others.<ref name=W2014/>

==Management==
Antibiotics have been used to prevent and treat these infections; however, the misuse of antibiotics is a serious problem for global health.<ref name=WHOBook2015/> It is recommended that guidelines be followed that outline when it is appropriate to give antibiotics and which antibiotics are most effective.<ref name=WHOBook2015/>

[[Atelectasis]]: mild to moderate fever, no changes or mild rales on chest [[auscultation]].<ref>{{cite web |url=https://www.lecturio.com/concepts/atelectasis/| title=Atelectasis|website=The Lecturio Medical Concept Library |access-date= 7 July 2021}}</ref>

Management: pulmonary exercises, ambulation (deep breathing and walking).

[[Urinary tract infection]]: high fever, malaise, [[costovertebral angle tenderness|costovertebral]] tenderness, positive urine culture.<ref>{{cite web|title=Urinary Tract Infection|url=https://www.cdc.gov/getsmart/community/for-patients/common-illnesses/uti.html|website=[[Centers for Disease Control and Prevention]] (CDC)|access-date=7 July 2021|date=17 April 2015|url-status=live|archive-url=https://web.archive.org/web/20160222034940/http://www.cdc.gov/getsmart/community/for-patients/common-illnesses/uti.html|archive-date=22 February 2016}}</ref>

Management: antibiotics as per culture sensitivity (cephalosporin).

[[Endometritis]]: moderate fever, exquisite uterine tenderness, minimal abdominal findings.<ref>{{cite book |last1=Crum |first1=Christopher P. |last2=Lee |first2=Kenneth R. |last3=Nucci |first3=Marisa R. |title=Diagnostic Gynecologic and Obstetric Pathology E-Book |date=2011 |publisher=Elsevier Health Sciences |isbn=978-1-4557-0895-6 |page=430 |url=https://books.google.com/books?id=d91mO9WYtPYC&pg=PA430 |language=en}}</ref>

Management: multiple agent IV antibiotics to cover polymicrobial organisms: clindamycin, gentamicin, and addition of ampicillin if no response, no cultures are necessary.

[[Wound infection]]: persistent spiking fever despite antibiotics, wound [[erythema]] or fluctuance, wound drainage.<ref>[http://medical-dictionary.thefreedictionary.com/infection Definition of "infection" from several medical dictionaries] – Retrieved on 2021-07-07</ref>

Management: antibiotics for cellulitis, open and drain wound, saline-soaked packing twice a day, secondary closure.

[[Septic pelvic thrombophlebitis]]: persistent wide fever swings despite antibiotics, usually normal abdominal or pelvic exams.<ref>{{Cite book|title=Blueprint Obstetrics and Gynecology|last=Callaghan|first=Tamara}}</ref>

Management: IV heparin for 7–10 days at rates sufficient to prolong the PTT to double the baseline values.

[[Mastitis]]: unilateral, localized erythema, [[edema]], tenderness.<ref>{{cite journal | vauthors = Berens PD | title = Breast Pain: Engorgement, Nipple Pain, and Mastitis | journal = Clinical Obstetrics and Gynecology | volume = 58 | issue = 4 | pages = 902–14 | date = December 2015 | pmid = 26512442 | doi = 10.1097/GRF.0000000000000153 | s2cid = 13006527 | url = https://semanticscholar.org/paper/a3f96251efd59a92f82ed618dda1fea955027fbe }}</ref>

Management: antibiotics for cellulitis, open and drain the abscess if present.

==Epidemiology==
The number of cases of puerperal sepsis per year shows wide variations among published literature—this may be related to different definitions, recordings etc.<ref name="gfmer.ch"/> Globally, bacterial infections are the cause of 10% of [[maternal death]]s—this is more common in low income countries but is also a direct cause of maternal deaths in high-income countries.<ref name=WHOBook2015/><ref>{{cite web|url=http://apps.who.int/iris/bitstream/10665/186171/1/9789241549363_eng.pdf?ua=1|title=WHO recommendations for prevention and treatment of maternal peripartum infections|url-status=live|archive-url=https://web.archive.org/web/20160306061338/http://apps.who.int/iris/bitstream/10665/186171/1/9789241549363_eng.pdf?ua=1|archive-date=2016-03-06}}</ref>

In the United States, puerperal infections are believed to occur in between 1% and 8% of all births. About three die from puerperal sepsis for every 100,000 births. The single most important risk factor is [[caesarean section]].<ref>{{cite book |last1=Carter |first1=K. Codell |last2=Carter |first2=Barbara R. |title=Childbed fever. A scientific biography of Ignaz Semmelweis |publisher=Transaction Publishers |date= 2005 |isbn=978-1-4128-0467-7|page=100}}</ref> The number of maternal deaths in the United States is about 13 in 100,000. They make up about 11% of pregnancy-related deaths in the United States.<ref name=W2014/>

In the United Kingdom from 1985 to 2005, the number of ''direct'' deaths associated with genital tract sepsis per 100,000 pregnancies was 0.40–0.85.<ref>{{cite book|url=http://www.cemach.org.uk/getattachment/8f5c1ed8-fdf3-489b-a182-e53955bec07b/Saving-Mothers--Lives-2003–2005_full.aspx|title=Saving Mothers' Lives: Reviewing maternal deaths to make motherhood safer – 2003–2005. The Seventh Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom|publisher=CEMACH|year=2007|isbn=978-0-9533536-8-2|editor-last=Lewis|editor-first=Gwyneth|editor-link=Gwyneth Lewis (scientist)|page=97}}{{dead link|date=March 2018|bot=InternetArchiveBot|fix-attempted=yes}}</ref> In 2003–2005, genital tract sepsis accounted for 14% of direct causes of maternal death.<ref>[http://www.cemach.org.uk/Publications/CEMACH-Publications/Maternal-and-Perinatal-Health.aspx CEMACH: Saving Mothers' Lives 2003–2005] {{webarchive|url=https://web.archive.org/web/20080521093900/http://www.cemach.org.uk/Publications/CEMACH-Publications/Maternal-and-Perinatal-Health.aspx |date=2008-05-21 }}</ref>

Puerperal infections in the 18th and 19th centuries affected, on average, 6 to 9 women in every 1,000 births, killing two to three of them with peritonitis or sepsis. It was the single most common cause of maternal mortality, accounting for about half of all deaths related to [[childbirth]], and was second only to [[tuberculosis]] in killing women of childbearing age. A rough estimate is that about 250,000–500,000 died from puerperal fever in the 18th and 19th centuries in England and Wales alone.<ref>{{cite book |last=Loudon |first=Irvine |author-link=Irvine Loudon |title=The Tragedy of Childbed Fever |publisher=Oxford University Press, USA |date=9 March 2000 |page=6 |url=http://fds.oup.com/www.oup.co.uk/pdf/0-19-820499-X.pdf |isbn=978-0-19-820499-2 |archive-url=https://web.archive.org/web/20120211075531/http://fds.oup.com/www.oup.co.uk/pdf/0-19-820499-X.pdf |archive-date=11 February 2012 }}</ref>

== History ==
Although it had been recognized from as early as the time of the [[Hippocratic corpus]] that women in childbed were prone to fevers, the distinct name "puerperal fever" appears in historical records only from the early 18th century.<ref>The debate about when this term first emerged is presented by Irvine Loudon, The Tragedy of Childbed Fever, Oxford University Press, 2000, p. 8.</ref>

The death rate for women giving birth decreased in the 20th century in [[developed countries]]. The decline may be partly attributed to improved environmental conditions, better [[obstetrical]] care, and the use of [[antibiotics]]. Another reason appears to be a lessening of the virulence or invasiveness of Streptococcus pyogenes. That organism is also the cause of [[scarlet fever]], which declined over the same period but has seen a rise in the last decade worldwide, especially in Asia, with smaller outbreaks in the US and Canada. The UK reported 12,906 cases between September 2015 and April 2016, which is the largest outbreak since 1969.<ref>{{Cite journal|last1=Basetti|first1=S.|last2=Hodgson|first2=J.|last3=Rawson|first3=T. M.|last4=Majeed|first4=A.|date=2017-08-11|title=Scarlet fever: a guide for general practitioners|journal=London Journal of Primary Care|volume=9|issue=5|pages=77–79|doi=10.1080/17571472.2017.1365677|issn=1757-1472|pmc=5649319|pmid=29081840}}</ref>

==="The Doctor's Plague"===
[[Image:Yearly mortality rates 1784-1849.png|thumb|right|300px|In his 1861 book, [[Ignaz Semmelweis]] presented evidence to demonstrate that the advent of [[pathological anatomy]] in Vienna in 1823 (vertical line) was correlated to the incidence of fatal childbed fever there. Onset of [[chlorine]] handwash in 1847 marked by vertical line. Rates for the Dublin maternity hospital, which had no pathological anatomy, are shown for comparison ([[Historical mortality rates of puerperal fever#Yearly mortality rates for birth giving women 1784-1849|view rates]]). His efforts were futile, however.]]

From the 17th century through to the mid-to-late 19th century, the majority of childbed fever cases were caused by the doctors themselves. With no knowledge of [[microorganism|germs]], doctors did not believe hand washing was needed.<ref>{{cite web |url=https://www.npr.org/sections/health-shots/2015/01/12/375663920/the-doctor-who-championed-hand-washing-and-saved-women-s-lives |title=The doctor who championed hand-washing and saved women's lives |author=Rebecca Davis |website=[[National Public Radio]]|date=2015-01-12 |access-date=2025-03-14}}</ref>

Hospitals for childbirth became common in the 17th century in many European cities. These "lying-in" hospitals were established at a time when there was no knowledge of [[antisepsis]] or [[epidemiology]], and women were subjected to crowding, frequent vaginal examinations, and the use of contaminated instruments, dressings, and bedding. It was common for a doctor to deliver one baby after another, without washing his hands or changing clothes between patients.{{cn|date=April 2023}}

The first recorded epidemic of puerperal fever occurred at the [[Hôtel-Dieu de Paris]] in 1646. Hospitals throughout Europe and America consistently reported death rates between 20% and 25% of all women giving birth, punctuated by intermittent epidemics with up to 100% fatalities of women giving birth in childbirth wards.<ref>Loudon I. "Deaths in childbed from the eighteenth century to 1935". ''Med History'' 1986; 30: 1–41</ref>

In the early 19th century, [[Ignaz Semmelweis]] noticed that women giving birth at home had a much lower incidence of childbed fever than those giving birth in a [[maternity ward]]. His investigation discovered that washing hands before a delivery with a [[calcium hypochlorite]] solution reduced childbed fever fatalities by 90%.<ref>{{cite journal | url=http://www.med.mcgill.ca/mjm/issues/v01n01/fever.html | title=The Childbed Fever Mystery and the Meaning of Medical Journalism | last=Caplan | first=Caralee E. | journal=McGill Journal of Medicine | year=1995 | volume=1 | issue=1 | archive-url=https://web.archive.org/web/20120707205101/http://www.med.mcgill.ca/mjm/issues/v01n01/fever.html | archive-date=2012-07-07 }}</ref> His findings were not well received by the medical profession, because they conflicted both with existing medical concepts, and with the image doctors had of themselves.<ref name="Ignaz Semmelweis ">{{cite journal |vauthors = Wyklicky H, Skopec M |title=Ignaz Philipp Semmelweis, the prophet of bacteriology |journal=Infect Control |volume=4 |issue=5 |pages=367–370 |year=1983 |pmid=6354955 |doi=10.1017/S0195941700059762 |s2cid=25830725 }}</ref> The scorn and ridicule of doctors was so extreme that Semmelweis moved from Vienna and, following a breakdown, eventually died in a mental asylum.<ref name="childbed fever">{{cite journal | url=http://www.mja.com.au/public/issues/177_11_021202/dec10354_fm.html | title="The contagiousness of childbed fever": a short history of puerperal sepsis and its treatment | first=Caroline M | last=De Costa | journal=The Medical Journal of Australia | date=Nov 2002 | volume=177 | pages=668–671 | pmid=12463995 | issue=11–12 | url-status=live | archive-url=https://web.archive.org/web/20061203030203/http://www.mja.com.au/public/issues/177_11_021202/dec10354_fm.html | archive-date=2006-12-03 | doi=10.5694/j.1326-5377.2002.tb05004.x | s2cid=12164328 | url-access=subscription }}</ref>

Semmelweis was not the only doctor ignored after sounding a warning about the problem. In his ''Treatise on the Epidemic of Puerperal Fever'' (1795), ex-naval surgeon and [[Aberdeen|Aberdonian]] obstetrician [[Alexander Gordon (physician)|Alexander Gordon]] (1752–1799) warned that the disease was transmitted from one case to another by midwives and doctors.  Gordon wrote, "It is a disagreeable declaration for me to mention, that I myself was the means of carrying the infection to a great number of women."<ref>{{cite book |last1=Gordon |first1=Alexander |title=A Treatise on the Epidemic Puerperal Fever of Aberdeen |date=1795 |publisher=G.G. and J. Robinson |location=London, England |pages=[https://archive.org/details/treatiseonepidem00gord/page/63 63]–64 |url=https://archive.org/details/treatiseonepidem00gord}}  On  p. 63, Gordon recognized that puerperal fever was infectious: "But this disease seized such women only, as were visited, or delivered, by a practitioner, or taken care of by a nurse, who had previously attended patients affected with the disease. In short, I had evident proofs of its infectious nature, and that the infection was as readily communicated as that of smallpox, or measles, and operated more speedily than any other infection, with which I am acquainted."  From p. 64:  "It is a disagreeable declaration for me to mention, that I myself was the means of carrying the infection to a great number of women."</ref><ref name="Dr Alexander Gordon">{{cite web|url=http://www.general-anaesthesia.com/images/ignaz-semmelweis.html |title=Treatise on the Epidemic of Puerperal Fever |publisher=www.general-anaesthesia.com |access-date=September 15, 2011 |archive-url=https://web.archive.org/web/20080720005441/http://www.general-anaesthesia.com/images/ignaz-semmelweis.html |archive-date=July 20, 2008 }}</ref>

In 1842, [[Sir Thomas Watson, 1st Baronet|Thomas Watson]] (1792–1882), a professor of medicine at [[King's College Hospital]], London, wrote: "Wherever puerperal fever is rife, or when a practitioner has attended any one instance of it, he should use most diligent [[hygiene|ablution]]." Watson recommended [[handwashing]] with [[chlorine]] solution and changes of clothing for obstetric attendants "to prevent the practitioner becoming a vehicle of contagion and death between one patient and another."<ref>{{cite journal |last1=Watson |title=Lectures on the principles and practice of physic: Diseases of the abdomen |journal=The London Medical Gazette |date=February 18, 1842 |volume=29 |pages=801–808 |url=https://babel.hathitrust.org/cgi/pt?id=mdp.39015018029671&view=1up&seq=811}}  [https://babel.hathitrust.org/cgi/pt?id=mdp.39015018029671&view=1up&seq=816 From p. 806]: "Whenever puerperal fever is rife, or when a practitioner has attended any one example of it, he should use most diligent ablution; he should even wash his hands with some disinfecting fluid, a weak solution of chlorine for instance: he should avoid going in the same dress to any other of his midwifery patients: in short, he should take all those precautions which, when the danger is understood, common sense will suggest, against his clothes or his body becoming a vehicle of contagion and death between one patient and another."</ref><ref>[http://www.mja.com.au/public/issues/177_11_021202/dec10354_fm.html#i1067496 ''The Medical Journal of Australia.''"The contagiousness of childbed fever: a short history of puerperal sepsis and its treatment"] {{webarchive|url=https://web.archive.org/web/20061203030203/http://www.mja.com.au/public/issues/177_11_021202/dec10354_fm.html |date=2006-12-03 }}</ref>

===Hygienic measures===
In 1843, [[Oliver Wendell Holmes Sr.]] published ''The Contagiousness of Puerperal Fever'' and controversially concluded that puerperal fever was frequently carried from patient to patient by physicians and nurses. He suggested that clean clothing and avoidance of autopsies by those aiding birth would prevent the spread of the disease.<ref>{{cite journal |last1=Holmes |first1=Oliver W. |title=On the contagiousness of puerperal fever |journal=The New England Quarterly Journal of Medicine |date=1842–1843 |volume=1 |pages=503–530 |url=https://babel.hathitrust.org/cgi/pt?id=mdp.39015059415961&view=1up&seq=513}}</ref><ref name="bartleby.com">[http://www.bartleby.com/38/5/1.html Oliver Wendell Holmes: ''The Contagiousness of Puerperal Fever''] {{webarchive|url=https://web.archive.org/web/20070203165344/http://www.bartleby.com/38/5/1.html |date=2007-02-03 }}</ref> Holmes quoted Dr. James Blundell as stating, "...&nbsp;in my own family, I had rather that those I esteemed the most should be delivered unaided, in a stable, by the mangerside, than that they should receive the best help, in the fairest apartment, but exposed to the vapors of this pitiless disease."<ref>(Holmes, 1842–1843), [https://babel.hathitrust.org/cgi/pt?id=mdp.39015059415961&view=1up&seq=520 p. 510.]</ref>

Holmes' conclusions were ridiculed by many contemporaries, including [[Charles Delucena Meigs]], a well-known obstetrician, who stated, "Doctors are gentlemen, and gentlemen's hands are clean."<ref>{{cite book |last1=Meigs |first1=Charles Delucena |title=On the Nature, Signs, and Treatment of Childbed Fevers: In a Series of Letters Addressed to the Students of His Class |date=1854 |publisher=Blanchard and Lea |location=Philadelphia, Pennsylvania|page=[https://archive.org/details/onnaturesignstre1854meig/page/104 104] |url=https://archive.org/details/onnaturesignstre1854meig}}  From p. 104:  Speaking of a physician in Philadelphia, Pennsylvania, Meigs said: "He is a gentlemen who is scrupulously careful of his personal appearance, …  But a gentleman's hands are clean."</ref> Richard Gordon states that Holmes' exhortations "outraged obstetricians, particularly in Philadelphia".<ref name="GordononMotherhood">{{cite book| title=Great Medical Disasters| last= Gordon|first= Richard | author-link=Richard Gordon (English author)|chapter=Disastrous Motherhood: Tales from the Vienna Wards | year= 1983| publisher= Hutchinson & Co.| location= London |pages=43–46 [43]}}</ref> In those days, "surgeons operated in blood-stiffened frock coats—the stiffer the coat, the prouder the busy surgeon", "pus was as inseparable from surgery as blood", and "cleanliness was next to prudishness". He quotes [[Sir Frederick Treves, 1st Baronet|Sir Frederick Treves]] on that era: "There was no object in being clean.  Indeed, cleanliness was out of place.  It was considered to be finicking and affected.  An executioner might as well manicure his nails before chopping off a head."<ref>{{cite book |last1=Treves |first1=Frederick |title=The Elephant Man and Other Reminiscences |date=1923 |publisher=Cassell and Company, Ltd. |location=London, England |pages=[https://archive.org/details/elephantmanother00trevuoft/page/56 56]–57 |url=https://archive.org/details/elephantmanother00trevuoft |chapter=Ch. 2: The Old Receiving Room}}</ref><ref name="GordononMotherhood44">Gordon, Richard (1983) p. 44</ref>

In 1844, [[Ignaz Semmelweis]] was appointed assistant lecturer in the First Obstetric Division of the [[Vienna General Hospital]] (Allgemeines Krankenhaus), where medical students received their training. Working without knowledge of Holmes' essay, Semmelweis noticed his ward's 16% mortality rate from fever was substantially higher than the 2% mortality rate in the Second Division, where midwifery students were trained. Semmelweis also noticed that puerperal fever was rare in women who gave birth before arriving at the hospital. Semmelweis noted that doctors in the First Division performed autopsies each morning on women who had died the previous day, but the midwives were not required or allowed to perform such autopsies. He made the connection between autopsies and puerperal fever after a colleague, [[Jakob Kolletschka]], died of sepsis after a student accidentally cut his hand while performing an autopsy.{{cn|date=April 2023}}

Semmelweis began experimenting with various cleansing agents and, from May 1847, ordered all doctors and students working in the First Division to wash their hands in chlorinated lime solution before starting ward work and later ordered this before each vaginal examination. The mortality rate from puerperal fever in the division fell from 18% in May 1847 to less than 3% in June–November of the same year.<ref name="raju">{{cite journal |last=Raju |first=T. N. |title=Ignác Semmelweis and the etiology of fetal and neonatal sepsis |journal=Journal of Perinatology |year=1999 |volume=19 |issue=4 |pages=307–310 |pmid=10685244|doi=10.1038/sj.jp.7200155 |doi-access= |s2cid=29047987 }}</ref>  While his results were extraordinary, he was treated with skepticism and ridicule (see [[Contemporary reaction to Ignaz Semmelweis|Response to Semmelweis]]).

He did the same work in St. Rochus hospital in [[Pest, Hungary]], and published his findings in 1860, but his discovery was again ignored.<ref name="colyer">Christa Colyer.[http://www.sciencecases.org/childbed_fever/childbed_fever.asp "Childbed fever: a nineteenth-century mystery,"] {{webarchive|url=https://web.archive.org/web/20090416054052/http://www.sciencecases.org/childbed_fever/childbed_fever.asp |date=2009-04-16 }} National Center for Case Study Teaching in Science, December 8, 1999 (revised October 27, 2003).</ref>

In 1935, [[Leonard Colebrook]] showed [[Prontosil]] was effective against [[Haemolysis|haemolytic]] [[streptococcus]] and hence a cure for puerperal fever.<ref>Colebrook, L; Kenny, M (June 6, 1936). "Treatment of Human Puerperal Infections, and of Experimental Infections in Mice, with Prontosil".''Lancet''  '''227'''(1): 1279–1286.</ref><ref>{{cite book|url= https://books.google.com/books?id=zbIuXxpoRXMC&q=fireguards+act+1952&pg=PA54|title=Wound care nursing|author1=Sue Bale |author2=Vanessa Jones |page=54|access-date=2009-08-05 | isbn=978-0-7234-3344-6 | year=2006 | publisher=Elsevier Health Sciences}}</ref>

===Notable cases===
{{See also|List of women who died in childbirth}}

Elite status was no protection against postpartum infections, as the deaths of several English queens attest. [[Elizabeth of York]], queen consort of [[Henry VII of England|Henry VII]], died of puerperal fever one week after giving birth to a daughter, who also died. Her son [[Henry VIII]] had two wives who died this way, [[Jane Seymour]]{{cn|date=April 2023}} and [[Catherine Parr]].<ref>{{cite web |url=https://www.telegraph.co.uk/travel/destinations/europe/united-kingdom/england/cotswolds/articles/Sudeley-Castle-the-curious-life-and-death-of-Katherine-Parr/ |title=Sudeley Castle: the curious life and death of Katherine Parr |author=Sophie Campbell |website=The Telegraph |date=2012-08-14 |access-date=2025-03-14}}</ref>

Suzanne Barnard, mother of philosopher [[Jean-Jacques Rousseau]], contracted childbed fever after giving birth to him and died nine days later. Her infant son was also in perilous health following the birth; the adult Rousseau later wrote that "I came into the world with so few signs of life that little hope was entertained of preserving me". He was nursed back to health by an aunt.<ref>Quoted from [[Will Durant]]'s "The Age of Rousseau".{{full citation needed|date=November 2012}}</ref> French natural philosopher [[Émilie du Châtelet]] died in 1749. [[Mary Wollstonecraft]], author of ''[[Vindication of the Rights of Woman]]'', died ten days after giving birth to [[Mary Shelley|her second daughter]], who grew up to write ''[[Frankenstein]]''. Other notables include African-American poet [[Phillis Wheatley]] (1784), British housekeeping authority [[Isabella Beeton]] (1865),<ref>{{cite ODNB|last=Beetham|first=Margaret|title=Beeton, Samuel Orchart (1831–1877)|url=http://www.oxforddnb.com/view/article/45481|access-date=23 November 2015|doi=10.1093/ref:odnb/45481|year=2004}}</ref><ref>{{cite book|last=Hughes|first=Kathryn|author-link=Kathryn Hughes|title=The Short Life and Long Times of Mrs Beeton|url=https://books.google.com/books?id=p5NvuLMB3tYC&pg=PP1|year=2006|publisher=HarperCollins Publishers|location=London|isbn=978-0-7524-6122-9}}</ref> and American author [[Jean Webster]] in 1916 died of puerperal fever.{{cn|date=July 2022}}

In [[Charles Dickens]]' novella ''[[A Christmas Carol]]'', it is implied that both [[Ebenezer Scrooge|Scrooge's]] mother and younger sister perished from this condition, explaining the character's animosity towards his nephew Fred and also his poor relationship with his own father.{{citation needed|date=August 2015}}

==See also==
* [[Postpartum confinement]], a traditional practice after childbirth

== References ==
{{Reflist}}

== Further reading ==
* {{cite journal |vauthors=Chaim W, Burstein E |title=Postpartum infection treatments: a review |journal=Expert Opinion on Pharmacotherapy |volume=4 |issue=8 |pages=1297–313 |date=August 2003  |pmid=12877638 |doi=10.1517/14656566.4.8.1297 |s2cid=26781321 |type=review}}
* {{cite journal |vauthors=Calhoun BC, Brost B |title=Emergency management of sudden puerperal fever |journal=Obstetrics and Gynecology Clinics of North America |volume=22 |issue=2 |pages=357–67 |date=June 1995  |doi=10.1016/S0889-8545(21)00185-6 |pmid=7651676 |type=review}}
* {{cite journal |author=French L |title=Prevention and treatment of postpartum endometritis |journal=Current Women's Health Reports |volume=3 |issue=4 |pages=274–9 |date=August 2003  |pmid=12844449 |type=review}}

{{Medical condition classification and resources
 | DiseasesDB      =
 | ICD10           = {{ICD10|O|85||o|85}}
 | ICD9            = {{ICD9|672}}
 | ICDO            =
 | OMIM            =
 | MedlinePlus     =
 | eMedicineSubj   = article
 | eMedicineTopic  = 796892
 | MeshID          = D011645
}}
{{Pathology of pregnancy, childbirth and the puerperium}}
{{Authority control}}

[[Category:Health issues in pregnancy]]
[[Category:Infectious diseases]]
[[Category:Maternal health]]
[[Category:Pathology of pregnancy, childbirth and the puerperium]]
[[Category:Wikipedia medicine articles ready to translate]]
[[Category:Women's health]]