Postpartum Endometritis: Symptoms, Causes & Treatment

What Is Postpartum Endometritis?

Postpartum endometritis is a bacterial infection of the uterine lining (endometrium) that develops after childbirth. It occurs when bacteria enter the uterus through the vagina and infect the wound left by the detached placenta. This condition is also called puerperal endometritis or metritis.

After delivery, the uterus undergoes significant changes as it begins the process of involution—returning to its pre-pregnancy size. When the placenta separates from the uterine wall, it leaves behind a wound approximately the size of a dinner plate. This wound site, along with any trauma to the cervix or vaginal tissues during delivery, creates potential entry points for bacterial infection.

The postpartum uterus is particularly vulnerable to infection for several reasons. The cervix remains dilated for some time after delivery, making it easier for bacteria from the vagina to ascend into the uterus. Additionally, the presence of blood, amniotic fluid, and tissue debris provides an ideal environment for bacterial growth. The physical trauma of childbirth also temporarily weakens the natural immune defenses of the reproductive tract.

Postpartum endometritis represents a spectrum of infection severity. In its mildest form, the infection may be limited to the superficial layers of the endometrium. More severe cases can involve deeper layers of the uterine wall (endomyometritis) or spread beyond the uterus to affect the surrounding pelvic tissues (parametritis). Understanding this condition is crucial because prompt recognition and treatment can prevent serious complications including sepsis.

How Common Is Postpartum Endometritis?

The incidence of postpartum endometritis varies significantly based on the mode of delivery and the presence of risk factors. Following vaginal delivery, approximately 1-3% of women develop endometritis. However, after cesarean delivery, the rate increases dramatically to 5-15%, making it one of the most significant complications associated with surgical birth.

Without prophylactic antibiotics given at the time of cesarean section, the rate of postpartum endometritis can reach as high as 30-40% in high-risk populations. The introduction of routine perioperative antibiotics has been one of the most important advances in reducing this complication, decreasing the incidence by approximately 60-70%.

The Role of Bacteria in Postpartum Infection

Postpartum endometritis is typically a polymicrobial infection, meaning it involves multiple types of bacteria working together. The most common organisms responsible include a mix of aerobic bacteria (which require oxygen) and anaerobic bacteria (which thrive without oxygen). Common aerobic bacteria include group B streptococcus, Escherichia coli, and Enterococcus species. Anaerobic bacteria frequently involved include Bacteroides, Peptostreptococcus, and Prevotella species.

These bacteria are often part of the normal vaginal flora that become pathogenic when they gain access to the normally sterile uterine cavity. Some cases of postpartum endometritis are also associated with sexually transmitted organisms such as Chlamydia trachomatis and Neisseria gonorrhoeae, particularly in women who did not receive prenatal screening and treatment for these infections.

What Are the Symptoms of Postpartum Endometritis?

The hallmark symptoms of postpartum endometritis include fever over 38°C (100.4°F), lower abdominal pain resembling severe menstrual cramps, uterine tenderness when pressed, and foul-smelling vaginal discharge (lochia). Additional symptoms may include headache, fatigue, rapid heartbeat, and general malaise.

The symptoms of postpartum endometritis typically develop within the first 1-10 days after delivery, with most cases occurring within the first 5 days. The timing of symptom onset can provide clues about the causative organisms. Early-onset endometritis (within 48 hours of delivery) is often associated with more virulent bacteria, while late-onset cases may involve different organisms or result from retained placental tissue.

Understanding the full range of symptoms is important because early recognition leads to earlier treatment and better outcomes. While fever is the most consistent finding, the complete clinical picture often includes multiple symptoms that together point toward uterine infection.

Fever and Systemic Symptoms

Fever is the most common and often the first symptom of postpartum endometritis. A temperature of 38°C (100.4°F) or higher on any two of the first 10 days postpartum (excluding the first 24 hours) should raise suspicion for infection. The fever may be accompanied by chills, sweating, and a general feeling of being unwell.

Many women with postpartum endometritis experience systemic symptoms beyond fever. These can include persistent headache, extreme fatigue that goes beyond the expected tiredness of new motherhood, loss of appetite, and a rapid heart rate (tachycardia). Some women describe a general sense that something is wrong, even before other symptoms become apparent.

Abdominal Pain and Uterine Tenderness

Lower abdominal pain is another cardinal symptom of postpartum endometritis. This pain is often described as feeling like severe menstrual cramps or afterpains that are more intense than expected. The pain typically occurs in the lower central abdomen, corresponding to the location of the uterus.

When the abdomen is examined, the uterus is tender to palpation. This uterine tenderness is a key diagnostic finding that helps distinguish endometritis from other causes of postpartum fever. The uterus may also feel softer than expected (subinvolution), suggesting that the normal process of uterine shrinkage has been delayed by the infection.

Changes in Vaginal Discharge

Lochia—the vaginal discharge that occurs after childbirth—normally has a distinctive but not unpleasant odor. In women with postpartum endometritis, the lochia typically becomes foul-smelling, sometimes described as having a strong, offensive, or putrid odor. This change in smell reflects the presence of bacteria and their metabolic byproducts.

The appearance of the lochia may also change, becoming more purulent (containing pus) or taking on an abnormal color. However, it can be difficult to distinguish abnormal from normal lochia based on appearance alone, which is why the odor change is often a more reliable indicator. It's important to note that normal lochia does have some odor, so the key finding is a strong, unusually foul smell.

When Should You Seek Medical Care?

Seek immediate medical care if you develop fever over 38°C (100.4°F) after the first 24 hours postpartum, severe lower abdominal pain, foul-smelling vaginal discharge, or feel generally unwell with chills and fatigue. Call emergency services if you experience very high fever, severe abdominal pain, difficulty breathing, or feel like you might faint.

Recognizing when to seek medical care is crucial because postpartum endometritis can progress rapidly if left untreated. The consequences of delayed treatment can include the spread of infection to the bloodstream (sepsis), formation of pelvic abscesses, and development of infected blood clots in the pelvic veins (septic pelvic thrombophlebitis).

New mothers face a particular challenge in recognizing infection symptoms because the postpartum period naturally involves some discomfort, fatigue, and vaginal discharge. Learning to distinguish normal postpartum changes from warning signs of infection can be lifesaving.

Warning Signs That Require Same-Day Medical Attention

Contact your healthcare provider, a maternity unit, or an urgent care clinic immediately if you experience any of the following symptoms:

• Fever of 38°C (100.4°F) or higher at any time after the first 24 hours postpartum
• Lower abdominal pain that feels like severe menstrual cramps
• Uterine tenderness when you press on your lower abdomen
• Foul-smelling vaginal discharge
• Persistent headache and feeling generally unwell
• Extreme fatigue beyond what's normal for new mothers

What Causes Postpartum Endometritis?

Postpartum endometritis is caused by bacteria entering and infecting the uterus after delivery. The wound left when the placenta detaches creates an ideal site for infection. Risk factors include cesarean delivery (5-20 times higher risk), prolonged labor, prolonged rupture of membranes, multiple vaginal examinations, retained placental tissue, and significant blood loss.

Understanding the causes and risk factors for postpartum endometritis helps explain why some women develop this condition while others do not. The infection results from an interplay between bacterial exposure and factors that compromise the uterus's natural defenses.

The placenta attaches to the uterine wall through a rich network of blood vessels. When the placenta separates after delivery, it leaves behind a wound that is exposed to bacteria present in the vagina and cervix. Under normal circumstances, the body's immune system and the normal involution of the uterus prevent these bacteria from causing infection. However, when risk factors are present, the balance shifts in favor of bacterial growth and infection.

Major Risk Factors

Cesarean Delivery: This is the single most important risk factor for postpartum endometritis. Women who deliver by cesarean section have a 5-20 times higher risk of developing uterine infection compared to those who deliver vaginally. The surgical incision creates additional sites for bacterial entry, and the procedure involves greater manipulation of the uterus. Emergency cesarean sections carry higher risk than planned procedures, likely due to the additional factors that led to the emergency.

Prolonged Labor: Extended labor increases the risk of postpartum endometritis through several mechanisms. The longer duration allows more time for bacteria to ascend from the vagina to the uterus. It also leads to more vaginal examinations and potentially greater trauma to the birth canal. For first-time mothers, labor lasting more than 15 hours is considered prolonged, while for women who have given birth before, the threshold is approximately 11 hours.

Prolonged Rupture of Membranes: When the amniotic sac breaks (water breaking), the protective barrier between the outside environment and the uterus is removed. If more than 18 hours pass between membrane rupture and delivery, the risk of infection increases substantially. The longer the membranes are ruptured, the more time bacteria have to reach the uterus.

Multiple Vaginal Examinations: Each vaginal examination during labor has the potential to introduce bacteria from the vagina and external environment into the upper reproductive tract. While examinations are often necessary to monitor labor progress, the cumulative effect of multiple examinations increases infection risk.

Additional Risk Factors

• Retained placental tissue: Pieces of placenta or membranes left in the uterus provide a growth medium for bacteria
• Manual removal of placenta: When the placenta must be manually extracted, there is increased risk of tissue trauma and bacterial introduction
• Significant blood loss: Heavy bleeding during delivery can impair the immune system's ability to fight infection
• Assisted delivery: Use of vacuum extraction (ventouse) or forceps increases risk
• Internal fetal monitoring: Placement of internal monitors creates potential entry points for bacteria
• Chorioamnionitis: Infection of the amniotic membranes during pregnancy significantly increases postpartum infection risk
• Bacterial vaginosis: Disruption of normal vaginal flora before delivery increases risk
• Group B streptococcus colonization: Carries higher risk especially without adequate intrapartum antibiotics

How Can You Prevent Postpartum Endometritis?

You can help prevent postpartum endometritis by avoiding baths while you have lochia (showers are fine), using condoms during intercourse, avoiding tampons and menstrual cups, and monitoring for warning signs. Medical prevention includes prophylactic antibiotics before cesarean delivery, which reduces infection risk by 60-70%.

While not all cases of postpartum endometritis can be prevented, there are both medical interventions and personal hygiene measures that can significantly reduce the risk. Understanding these preventive strategies empowers new mothers to take an active role in protecting their health during the vulnerable postpartum period.

Personal Prevention Measures

Several simple hygiene practices can help reduce the risk of introducing bacteria into the healing uterus:

• Avoid baths while you have lochia: Submerging in bath water can allow bacteria to enter the vagina and ascend to the uterus. Showers are safe and recommended for hygiene.
• Use condoms during intercourse: If you resume sexual activity while you still have vaginal discharge, using condoms helps prevent introduction of bacteria.
• Avoid internal menstrual products: Do not use tampons or menstrual cups while you have lochia. Use external pads instead.
• Practice good hand hygiene: Wash hands thoroughly before and after using the bathroom or changing pads.
• Change pads frequently: Regular pad changes reduce bacterial growth.

Medical Prevention

Healthcare providers implement several evidence-based strategies to prevent postpartum endometritis. The most important of these is the administration of prophylactic antibiotics before cesarean delivery. A single dose of a broad-spectrum antibiotic given within 60 minutes of surgical incision has been shown to reduce the rate of postpartum endometritis by 60-70%.

Other medical preventive measures include minimizing the number of vaginal examinations during labor, using sterile technique for all procedures, and ensuring complete delivery of the placenta and membranes. Screening for and treating infections like bacterial vaginosis and group B streptococcus before delivery also helps reduce postpartum infection risk.

How Is Postpartum Endometritis Diagnosed?

Postpartum endometritis is primarily diagnosed through clinical evaluation including temperature measurement, pelvic examination to assess uterine tenderness and lochia, blood tests showing elevated white blood cells and inflammatory markers, and sometimes ultrasound to check for retained placental tissue. Endometrial cultures may be taken but treatment typically begins before results return.

The diagnosis of postpartum endometritis is largely clinical, based on the presence of characteristic symptoms and physical examination findings. Laboratory tests and imaging studies play a supporting role in confirming the diagnosis and identifying any underlying factors that may need specific treatment.

Clinical Examination

When you arrive at the hospital or clinic with suspected postpartum endometritis, the healthcare provider will perform a comprehensive evaluation. This typically includes:

• Temperature measurement: Confirming the presence and degree of fever
• Pelvic examination: Assessing uterine tenderness, size, and the character of lochia including its odor
• Vital signs: Checking heart rate, blood pressure, and respiratory rate to assess for signs of systemic illness
• Abdominal examination: Evaluating for tenderness, distension, or other concerning findings

Laboratory Tests

Blood tests help confirm the diagnosis and assess the severity of infection. Common tests include:

• Complete blood count (CBC): Typically shows elevated white blood cell count indicating infection
• C-reactive protein (CRP): An inflammatory marker that is elevated in infection
• Blood cultures: May be obtained if there is concern for sepsis
• Urinalysis and urine culture: To rule out urinary tract infection as a cause of fever

Imaging Studies

Ultrasound examination may be performed to evaluate for retained products of conception (placental or membrane tissue) that could be contributing to the infection. The ultrasound can also assess the uterine size and identify any fluid collections or abscesses.

How Is Postpartum Endometritis Treated?

Postpartum endometritis is treated with intravenous broad-spectrum antibiotics, typically a combination of clindamycin and gentamicin. Most women require hospitalization for 1-3 days for IV antibiotics, then continue with oral antibiotics at home. Fever-reducing medication is given as needed, and rest is essential. If retained placental tissue is present, surgical removal may be necessary.

The treatment of postpartum endometritis centers on eliminating the bacterial infection through appropriate antibiotic therapy. Because the condition involves multiple types of bacteria, broad-spectrum antibiotics that cover both aerobic and anaerobic organisms are required. Prompt initiation of treatment is essential to prevent progression to more serious complications.

Antibiotic Therapy

The standard first-line treatment for postpartum endometritis consists of intravenous antibiotics, most commonly a combination of clindamycin and gentamicin. This combination provides excellent coverage against the polymicrobial bacteria typically responsible for the infection. Alternative regimens may include ampicillin-sulbactam, piperacillin-tazobactam, or other broad-spectrum combinations.

Intravenous antibiotics are continued until the patient has been without fever for 24-48 hours and shows clinical improvement, which typically occurs within 2-3 days of starting treatment. At this point, many patients can be discharged to complete a course of oral antibiotics at home, although some protocols do not require additional oral antibiotics after successful IV treatment.

Hospital Care

Most women with postpartum endometritis require hospitalization for initial treatment. During the hospital stay:

• Intravenous antibiotics are administered, typically for 1-3 days
• Fever-reducing medication (such as paracetamol/acetaminophen) is given for comfort
• Intravenous fluids may be administered if needed for hydration
• Pain management is provided as necessary
• Vital signs are monitored regularly to track response to treatment

During hospitalization, your baby can typically stay with you, and a partner or support person can often remain as well. Breastfeeding can continue in most cases, as the antibiotics commonly used are considered compatible with nursing.

Treatment for Retained Tissue

If ultrasound reveals retained placental tissue or membranes, additional treatment may be needed. Medication to help the uterus contract (uterotonics) may help expel small amounts of retained tissue. For larger amounts of retained tissue, surgical removal through a procedure called dilation and curettage (D&C) may be necessary. This is performed under anesthesia and involves gently removing the retained tissue from the uterine cavity.

What Is the Recovery Process Like?

With appropriate antibiotic treatment, most women with postpartum endometritis begin feeling significantly better within 48-72 hours. Complete recovery typically takes 1-2 weeks. Hospital stays usually last 1-3 days, followed by rest at home. The condition rarely affects future fertility when treated promptly.

The prognosis for postpartum endometritis is excellent when the condition is recognized and treated promptly. The vast majority of women make a full recovery without long-term consequences. Understanding what to expect during recovery can help manage expectations and identify any problems that may arise.

Timeline of Recovery

Most women notice improvement in their symptoms within 48-72 hours of starting intravenous antibiotic treatment. Fever typically resolves first, followed by gradual improvement in abdominal pain and uterine tenderness. The malaise and fatigue associated with infection also begin to lift as the bacteria are eliminated.

After discharge from the hospital (typically after 1-3 days), continued rest at home is important. Normal activities can be gradually resumed as symptoms improve, but it's important to listen to your body and not push too hard too soon. Complete recovery, with resolution of all symptoms and return of normal energy levels, generally takes 1-2 weeks.

Impact on Future Fertility

One of the most common concerns for women who develop postpartum endometritis is whether the infection will affect their ability to have more children. The reassuring news is that when treated promptly and appropriately, postpartum endometritis rarely has any impact on future fertility. The uterine lining heals completely after the infection resolves, and the reproductive organs return to normal function.

However, if endometritis is complicated by pelvic abscess formation or the infection spreads to involve the fallopian tubes (salpingitis), there may be some risk of scarring that could affect fertility. This is another important reason why early recognition and treatment of the infection is so important.

What Are the Potential Complications?

If left untreated, postpartum endometritis can spread beyond the uterus and lead to serious complications including sepsis (blood infection), pelvic abscess, and septic pelvic thrombophlebitis (infected blood clots). These severe complications are rare when treatment is initiated promptly but can be life-threatening.

While most cases of postpartum endometritis respond well to antibiotic treatment, it's important to understand the potential complications that can occur if the infection is not treated or does not respond to initial therapy. This knowledge underscores the importance of seeking care promptly when warning signs appear.

Spread of Infection

Untreated endometritis can spread beyond the uterine lining to involve the deeper muscle layers of the uterus (myometrium), the tissues surrounding the uterus (parametrium), and even the peritoneal cavity (peritonitis). As the infection spreads, symptoms become more severe, with higher fevers, more intense pain, and greater systemic illness.

Sepsis

Sepsis occurs when bacteria enter the bloodstream and trigger a systemic inflammatory response. This is a life-threatening condition that requires intensive medical care. Symptoms of sepsis include very high fever, rapid heart rate, rapid breathing, confusion, and low blood pressure. If you develop these symptoms, emergency medical care is essential.

Pelvic Abscess

In some cases, the infection can lead to the formation of a pelvic abscess—a collection of pus in the pelvic cavity. Abscesses may require drainage in addition to antibiotic therapy and can prolong the recovery process.

Septic Pelvic Thrombophlebitis

This rare but serious complication involves the formation of infected blood clots in the pelvic veins. It typically presents as persistent fever despite adequate antibiotic treatment and may require anticoagulation therapy in addition to antibiotics.