Diagnostic reasoning case · WHO maternal health: PCPNC and MCPC

Fever after childbirth

Infection after childbirth is one of the main causes of maternal death, and it kills through sepsis: an infection that starts to make the organs fail. The first hour at the health centre, and how quickly she reaches hospital, decide the outcome.

  • Setting: Health centre 2 hours by road from the district hospital, in a malaria area
  • For midwives, nurses, clinical officers and doctors at first-level facilities
  • Reviewed October 2026

The presentation

Esther, 30, gave birth at home 5 days ago to her second baby after a labour that her mother says 'lasted two nights'. The waters broke the day before the birth. Since yesterday she has had fever, shivering and pain low in the abdomen, and the discharge smells bad. She is weak and was brought on a motorbike. The baby is with her.

Taken at triage.
SignValue
Temperature39.2 °C
Pulse124 per minute
Blood pressure92/58 mmHg
Breathing rate26 per minute
Conscious level (AVPU)Alert, slow to answer

Tests at hand: Malaria rapid diagnostic test (RDT) · Haemoglobin (Hb) · Urine dipstick · Blood glucose (finger-prick) · HIV rapid test

Starting differential
  • Uterine infection (postpartum endometritis) Must not missStill possible
  • Maternal sepsis or septic shock Must not missStill possible
  • Retained placental fragmentsStill possible
  • Kidney infectionStill possible
  • Mastitis or breast abscessStill possible
  • Malaria Must not missStill possible
  • Perineal or wound infectionStill possible
  • Deep vein thrombosis or pulmonary embolism Must not missLess likely

Work through it

Read each question and decide your own answer first. Then open the model answer and see how the differential changes.

  1. Step 1 of 6 · Look

    Make a rapid evaluation. Is Esther in shock, and does she have signs that the infection is affecting her organs?

    Model answer

    Check airway, breathing, circulation, consciousness, blood loss, skin colour and temperature.

    • Shock: fast, weak pulse of 110 or more and systolic BP below 90 mmHg; other signs are pallor, cold clammy skin, breathing 30 or more, anxiety or confusion, little urine.
    • Maternal sepsis is organ dysfunction caused by infection in pregnancy, after abortion or after birth. Signs that organs are struggling include a fast pulse, low blood pressure, fast breathing, an altered mental state and reduced urine.

    Her pulse is 124, BP 92/58, breathing 26, and she is slow to answer. She is not yet in shock by definition, but she has fever with several signs of organ dysfunction: treat this as possible maternal sepsis. Keep shock in mind: she can get worse quickly. Insert an IV line now.

    Do not wait to find the source before acting. Start fluids and antibiotics in the first hour, and arrange transport while you do.
    Differential now
    • Maternal sepsis or septic shock Must not missLeading (moved up)
    • Uterine infection (postpartum endometritis) Must not missStill possible
    • Retained placental fragmentsStill possible
    • Kidney infectionStill possible
    • Mastitis or breast abscessStill possible
    • Malaria Must not missStill possible
    • Perineal or wound infectionStill possible
    • Deep vein thrombosis or pulmonary embolism Must not missLess likely
  2. Step 2 of 6 · Ask

    What do you ask to find the source of the fever?

    Model answer
    • The birth: where, how long the labour, how long the waters had been broken, was the placenta complete, any tear or stitches, any hands or instruments inside the vagina?
    • Bleeding: how much now; is it increasing?
    • Lochia: smell, colour, amount.
    • Lower abdominal pain; burning or frequent urine; loin pain.
    • Breasts: pain, redness, a hard lump.
    • Cough, breathlessness, chest pain; pain or swelling in a calf.
    • Headache, stiff neck; recent malaria; HIV status.
    • The baby: feeding, fever, cold, breathing, cord.

    The placenta came out 'in pieces' after an hour. A neighbour pushed on her abdomen. Bleeding has been moderate, more than she expected by now, and dark. The lochia smells bad. Low abdominal pain, worse when she moves. No urinary symptoms, breasts soft, no cough or calf pain, no neck pain. HIV negative in pregnancy. The baby is breastfeeding.

    Differential now
    • Uterine infection (postpartum endometritis) Must not missLeading (moved up)
    • Maternal sepsis or septic shock Must not missLeading
    • Retained placental fragmentsLeading (moved up)
    • Malaria Must not missStill possible
    • Perineal or wound infectionStill possible
    • Kidney infectionLess likely (moved down)
    • Mastitis or breast abscessLess likely (moved down)
    • Deep vein thrombosis or pulmonary embolism Must not missSet aside for now (moved down)
  3. Step 3 of 6 · Look

    What do you examine, and what does each finding suggest?

    Model answer
    • Lower abdomen: a tender uterus, and whether it is well contracted (endometritis, retained fragments); rebound tenderness or a swollen, silent abdomen (peritonitis); a tender mass (pelvic abscess).
    • Lochia: amount and smell.
    • Perineum: tear or episiotomy red, swollen, discharging pus.
    • Breasts: wedge-shaped red tender area (mastitis), a fluctuant lump (abscess).
    • Loins: tenderness (kidney infection). Calves: swelling, redness, tenderness. Chest: crackles.
    • Neck stiffness; pallor; jaundice.

    The uterus is large for day 5, soft and very tender. Purulent, foul-smelling lochia, more than expected. No rebound tenderness; bowel sounds present. Perineum: a small healing tear, no pus. Breasts soft. Loins not tender. Calves normal. Chest clear. Neck supple. Pale.

    Differential now
    • Uterine infection (postpartum endometritis) Must not missLeading
    • Maternal sepsis or septic shock Must not missLeading
    • Retained placental fragmentsLeading
    • Malaria Must not missStill possible
    • Kidney infectionSet aside for now (moved down)
    • Mastitis or breast abscessSet aside for now (moved down)
    • Deep vein thrombosis or pulmonary embolism Must not missSet aside for now
    • Perineal or wound infectionSet aside for now (moved down)
  4. Step 4 of 6 · Test

    Which tests do you do, and do any of them change what you do in the next hour?

    Model answer
    • Malaria RDT: malaria is a cause of postpartum fever in malaria areas, and can coexist with another infection.
    • Haemoglobin: she is pale and may have bled; severe anaemia changes the speed of fluids and the need for transfusion.
    • Urine dipstick: supports or excludes a urinary source.
    • Glucose: she is slow to answer.
    • HIV: her result is from early pregnancy; offer a retest per national policy, but not before treatment.

    Results: RDT negative. Hb 8.6 g/dL. Urine: no nitrites, no leucocytes. Glucose 5.4 mmol/L. None delays the treatment.

    Differential now
    • Uterine infection (postpartum endometritis) Must not missLeading
    • Maternal sepsis or septic shock Must not missLeading
    • Retained placental fragmentsLeading
    • Kidney infectionSet aside for now
    • Mastitis or breast abscessSet aside for now
    • Malaria Must not missSet aside for now (moved down)
    • Deep vein thrombosis or pulmonary embolism Must not missSet aside for now
    • Perineal or wound infectionSet aside for now
  5. Step 5 of 6 · Do

    Classify her, and give the emergency treatment before transfer.

    Model answer

    Fever above 38 °C with a tender uterus, foul-smelling and profuse lochia, a poorly contracted uterus and weakness: uterine infection (postpartum endometritis), probably with retained fragments, and signs of maternal sepsis.

    • IV fluids, given rapidly, while you watch the pulse, BP, breathing and lungs (slow down if breathing becomes difficult). Measure urine output.
    • First doses of IM or IV antibiotics: for uterine infection the PCPNC table gives three: ampicillin 2 g IV or IM (then 1 g every 6 hours), gentamicin 80 mg IM (every 8 hours) and metronidazole 500 mg IV (every 8 hours; not IM). Use your national protocol if it differs.
    • Paracetamol 500 to 1000 mg for the fever.
    • Refer urgently: she needs continued IV antibiotics, removal of retained fragments, and blood if needed.
    Differential now
    • Uterine infection (postpartum endometritis) Must not missLeading
    • Maternal sepsis or septic shock Must not missLeading
    • Retained placental fragmentsLeading
    • Kidney infectionSet aside for now
    • Mastitis or breast abscessSet aside for now
    • Malaria Must not missSet aside for now
    • Deep vein thrombosis or pulmonary embolism Must not missSet aside for now
    • Perineal or wound infectionSet aside for now
  6. Step 6 of 6 · Do

    What about the baby, and how do you organise the transfer?

    Model answer
    • Assess the baby now: not feeding well, convulsions, breathing 60 or more, severe chest indrawing, temperature 38 °C or more or below 35.5 °C, moving only when stimulated. A sick baby needs his own pre-referral treatment.
    • The baby goes with her; breastfeeding continues.
    • A health worker or trained companion travels with her; keep the IV running.
    • Referral note: the birth history (long labour, waters broken a day before, placenta in pieces), vital signs and their times, the time and dose of each antibiotic, fluids given, Hb.
    • Call ahead so the hospital is ready.

    You have an infection in the womb, and it is making you very weak. I have started the medicines and the drip. You need the hospital now to clean the womb and continue the treatment. Your baby comes with you, and you can keep feeding him.

Must-not-miss conditions

ConditionCluesWhat to do at first-level care
Maternal sepsis and septic shockFever (or low temperature) after birth with fast pulse, low BP, fast breathing, confusion or little urine.IV fluids, first doses of IM/IV antibiotics, urgent transfer; reassess often.
Pelvic abscess or peritonitisSpiking fever despite antibiotics; lower abdominal pain and swelling; rebound tenderness, a swollen silent abdomen, vomiting.IV fluids, ampicillin, gentamicin and metronidazole; urgent transfer for surgery.
Severe malariaFever with convulsions, jaundice, coma or severe anaemia in a malaria area; positive test.Pre-referral artesunate; urgent transfer.
Deep vein thrombosis or pulmonary embolismPainful swollen calf; sudden breathlessness, pleuritic chest pain, fast breathing.Oxygen if available; urgent transfer for anticoagulation.
Secondary postpartum haemorrhageHeavy or increasing bleeding more than 24 hours after birth, often with uterine infection.Uterine massage, oxytocin, IV fluids, antibiotics; urgent transfer.

Decision at first-level care

Esther has postpartum uterine infection, probably with retained placental fragments, after a prolonged labour with prolonged rupture of membranes, and signs of maternal sepsis (fast pulse, borderline BP, fast breathing, slow mentation). Rapid IV fluids, first doses of ampicillin, gentamicin and metronidazole, and urgent transfer with her baby.

Source: WHO Pregnancy, childbirth, postpartum and newborn care (PCPNC, 2015); WHO Managing complications in pregnancy and childbirth (2017); WHO Statement on maternal sepsis (2017).

Treat here
  • Burning on urination without fever or loin pain: oral antibiotic for lower urinary infection, more fluids, follow-up in 2 days.
  • Fever with a positive malaria test and no danger sign: oral antimalarial, follow-up in 2 days.
  • Breast engorgement or mild mastitis with no sign of sepsis: frequent feeding, good attachment, review.
Observe and review
  • A raised temperature with no source, no organ dysfunction and normal vital signs: repeat the temperature and vital signs, and decide again within hours.
Refer (urgently, now)This patient
  • Fever above 38 °C with a tender uterus, foul-smelling or profuse lochia, or lower abdominal pain: urgently, after first doses.
  • Fever with stiff neck or lethargy (very severe febrile disease).
  • Fever with kidney infection signs (loin pain, spiking fever).
  • Any sign of shock or organ dysfunction.

Key learning points

  • Fever of 38 °C or more after the first day following birth needs a search for the source and a check for sepsis.
  • Maternal sepsis is organ dysfunction from infection: look for a fast pulse, low BP, fast breathing, confusion and little urine.
  • A tender uterus with foul-smelling lochia after a long labour or prolonged rupture of membranes is uterine infection until proved otherwise.
  • Start IV fluids and the first doses of antibiotics before transfer; do not wait for test results.
  • Assess the baby too, and send the baby with the mother.

Sources

  1. World Health Organization. Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice, 3rd edition. 2015. Postpartum fever classification (uterine infection, upper and lower urinary infection, very severe febrile disease, malaria); IV line and rapid fluids; IM/IV antibiotics table (ampicillin, gentamicin, metronidazole doses); urgent referral; follow-up in 2 days.
  2. World Health Organization. Managing complications in pregnancy and childbirth: a guide for midwives and doctors, 2nd edition. 2017. Fever after childbirth (38 °C or more after 24 hours); rapid evaluation; shock definition; Table S-18 differential (endometritis, pelvic abscess, peritonitis, mastitis, breast abscess, wound infection, urinary infection, DVT, pulmonary embolism, pneumonia, malaria); endometritis as a major cause of maternal death; paracetamol dose; hospital antibiotics and retained fragments.
  3. World Health Organization. Statement on maternal sepsis. 2017 (WHO/RHR/17.02). Definition of maternal sepsis; clinical signs of organ dysfunction.
  4. World Health Organization. WHO recommendations for management of serious bacterial infections in infants aged 0–59 days. 2024. The seven danger signs in the newborn.
Adapted from WHO guidance; not endorsed by WHO. This page paraphrases and adapts the WHO publications listed under Sources, which are licensed CC BY-NC-SA 3.0 IGO; the adapted text is shared under the same licence for non-commercial education. Reasoning GP is not affiliated with WHO or any other organisation named here. Use it alongside your national guidelines, essential medicines list and formulary, and your clinical judgement. Doses are given only where they come from a WHO source; otherwise follow your national guideline or formulary.