Clinical overview
The puerperium — the six weeks from delivery of the placenta to involution of the genital tract — is the most lethal period of the maternity continuum in South Africa, and yet the most clinically neglected. The woman has "delivered safely", goes home (often within hours of a normal vaginal birth), and re-presents days later, frequently to a level-1 clinic, with a complaint that the junior practitioner is tempted to under-read. Sepsis, venous thromboembolism (VTE), and the postpartum psychiatric emergencies kill in this window, and they kill because their early signals are mistaken for the normal discomforts of the early puerperium. The Saving Mothers (NCCEMD) reports repeatedly identify the puerperium as a phase where substandard care — late recognition, late referral, no senior review — converts a survivable complication into a maternal death.
This objective is a HOTS objective: you are asked to appraise — to weigh risk factors, presentation, diagnosis and management together and decide what matters. The exam will not reward a list; it will reward a registrar who can take a woman 8 days postpartum with a fever, a tender breast, a swollen calf and a flat affect, and triage which of those is the emergency. The discipline is to treat every puerperal presentation as guilty until proven innocent: fever is sepsis until excluded, breathlessness is pulmonary embolism until excluded, and a mother who says she might harm her baby is a psychiatric emergency, not a "low mood" to be reviewed next week. Build on the baseline of the normal-puerperium before reading this — you cannot recognise the abnormal without owning the normal involution timeline, lochia pattern and physiological observations.
Figure J3.1 — Red-flag triage dashboard for puerperal presentations, prioritising sepsis, VTE/PE, psychiatric emergency and lactation infection within the 42-day puerperal clock.
Core knowledge
Puerperal sepsis
Maternal sepsis is infection of the genital tract (or any source) occurring between rupture of membranes/delivery and 42 days postpartum, with a systemic inflammatory response. In South Africa, non-pregnancy-related infections (overwhelmingly HIV-associated) plus pregnancy-related sepsis remain leading causes of maternal death per Saving Mothers/NCCEMD, and the immunosuppressed parturient (advanced HIV, low CD4, TB co-infection) presents atypically and deteriorates fast.
The genital-tract source is usually endometritis — ascending polymicrobial infection (group A and B streptococci, E. coli, anaerobes, Staphylococcus aureus; group A Streptococcus pyogenes causes the most fulminant, rapidly fatal puerperal sepsis). Risk factors: caesarean delivery (the single largest), prolonged rupture of membranes, prolonged labour, repeated vaginal examinations, retained products of conception, manual removal of placenta, operative vaginal birth, anaemia, diabetes, and immunosuppression. Non-genital sources that masquerade as puerperal sepsis must be actively sought: mastitis/breast abscess, urinary tract/pyelonephritis, wound (caesarean or perineal) infection, chest (including TB and COVID-class respiratory infection), and septic pelvic thrombophlebitis.
The danger of sepsis is that the classic febrile picture is unreliable: a septic woman may be normo- or hypothermic, and tachycardia or tachypnoea may be the only early sign. Standard teaching is that a sustained maternal tachycardia (>90–100/min) or tachypnoea is a red flag that outranks the temperature.
Venous thromboembolism
Pregnancy and the puerperium are prothrombotic (Virchow's triad: venous stasis, hypercoagulability of pregnancy, endothelial injury at delivery). The postpartum period carries the highest per-day risk of VTE of the whole maternity continuum, concentrated in the first weeks after birth. Deep vein thrombosis (DVT) in pregnancy is left-sided in the great majority (the gravid uterus and right iliac artery compress the left iliac vein) and is more often ilio-femoral/proximal, which both raises embolic risk and confounds the inexperienced who expect calf disease. Pulmonary embolism (PE) is a direct, fast cause of puerperal maternal death.
Risk factors stratify the patient: caesarean (especially emergency), age >35, obesity (BMI ≥30), parity ≥3, immobility, pre-eclampsia, postpartum haemorrhage/transfusion, sepsis, varicose veins, smoking, previous VTE, and known thrombophilia. RCOG Green-top Guideline 37a (risk and prophylaxis) and 37b (acute management) frame the assessment; the principle is a postnatal VTE risk-factor score that drives the duration of low-molecular-weight heparin (LMWH) thromboprophylaxis.
Breast complications
Engorgement (bilateral, days 3–5, physiological), mastitis (a tender, erythematous, wedge-shaped segment with fever and flu-like malaise, usually 2nd–3rd week, commonest organism Staph. aureus, classically from milk stasis ± a cracked nipple) and breast abscess (a fluctuant, pointing collection where mastitis has not resolved) form a continuum. Importantly, mastitis is not an automatic indication to stop breastfeeding — continued drainage of the affected breast is part of the treatment. See infant-feeding for the lactation physiology that underpins this.
Postpartum psychiatric conditions
Three distinct entities, of very different severity:
- "Baby blues" — transient tearfulness/lability peaking around day 3–5, affecting roughly half of mothers, self-limiting within ~2 weeks. Needs reassurance, not treatment.
- Postnatal (postpartum) depression — a depressive episode, typically with onset in the first weeks to months; persistent low mood, anhedonia, guilt, poor sleep beyond the baby's needs, and crucially thoughts of self-harm or of harming the infant.
- Postpartum psychosis — a psychiatric emergency, classically abrupt onset within the first 1–2 weeks, with delusions, hallucinations, confusion and grossly disordered behaviour; carries a real risk of suicide and infanticide and mandates urgent psychiatric admission. There is a strong association with bipolar disorder.
In the SA context, screening overlaps heavily with the burden addressed in gbv-mental-health-pregnancy: poverty, intimate-partner violence, HIV diagnosis and lack of social support all amplify risk.
Assessment
The structured puerperal review
Take the history with the puerperal clock in mind — day postpartum, mode of delivery, and what is abnormal for that day. Ask about fever/rigors, lochia (amount, smell, "heavier than a period" or offensive), abdominal/pelvic pain, the wound (caesarean or perineal), urinary symptoms, the breasts, calf pain/swelling, breathlessness or pleuritic chest pain, and — explicitly and without euphemism — mood, sleep, thoughts of self-harm and any thoughts of harming the baby.
Examine systematically: full vital signs including respiratory rate and oxygen saturation (the most under-recorded and most predictive observations), temperature, abdomen (uterine involution and tenderness, caesarean wound), perineum, legs (calf circumference, tenderness, oedema), and breasts. Use a Modified Early Obstetric Warning Score (MEOWS / MEOWC chart) — the SA Maternity Guideline embeds early-warning observation charting precisely to catch the deteriorating puerperal woman before collapse.
Sepsis work-up
If sepsis is suspected, the drill is the "Sepsis Six" within one hour, adapted to obstetrics: take blood cultures (and a lactate), measure urine output, then give high-flow oxygen, IV broad-spectrum antibiotics, and IV fluids. Investigations: FBC with differential, CRP, U&E, LFTs, lactate, blood cultures, MSU, high vaginal/endocervical swabs, wound swab, and pelvic ultrasound for retained products or a collection. In SA, always know the HIV status and CD4/viral load — advanced immunosuppression broadens the differential (TB, cryptococcus, atypical organisms) and worsens prognosis. A rising lactate and oliguria signal septic shock and the need for level-2/3 care.
Suspected VTE
DVT: assess and image — compression duplex ultrasound of the leg is first-line. If negative but clinical suspicion persists, repeat in ~1 week or proceed to further imaging for iliac vein disease. PE: do not rely on D-dimer in the puerperium — it is physiologically raised and not validated to exclude VTE in pregnancy/postpartum. Standard teaching is to obtain an ECG and chest X-ray (which also screens for an alternative diagnosis), then definitive imaging — CTPA or V/Q (ventilation–perfusion) scan — discussing the radiation/breast-dose trade-off. Critically: if VTE is clinically suspected, start therapeutic LMWH immediately and do not wait for imaging, unless anticoagulation is strongly contraindicated.
Breast and psychiatric assessment
For breast complications, differentiate engorgement from mastitis from abscess clinically; ultrasound confirms (and can guide aspiration of) an abscess. Send breast milk/pus for culture if not responding. For mood, screen actively — the Edinburgh Postnatal Depression Scale (EPDS) is the widely used tool — and treat any thought of self-harm or harm to the baby, or any psychotic feature, as an emergency requiring same-day psychiatric assessment.
Management
Puerperal sepsis — the emergency drill
PUERPERAL SEPSIS IS AN EMERGENCY. The "Sepsis Six" must be completed within ONE HOUR.
- Take blood cultures (+ lactate, FBC, U&E, CRP).
- Take a urine output measurement (catheterise; aim to monitor hourly).
- Give high-flow oxygen to keep saturations ≥94%.
- Give IV broad-spectrum antibiotics — do not delay for results.
- Give IV fluid resuscitation (balanced crystalloid) for hypotension/raised lactate.
- Escalate — senior obstetrician + early discussion with anaesthetics/ICU; refer up a level of care.
Empirical antibiotics should follow local NDoH/EML and facility antimicrobial policy — broad-spectrum cover for gram-positives, gram-negatives and anaerobes (standard teaching is a regimen along the lines of a penicillin/cephalosporin + aminoglycoside + metronidazole, or an EML-listed equivalent; confirm the exact agents and doses against the current SA Standard Treatment Guidelines/EML, as these are updated and locally adapted). Add source control: evacuate retained products (cautiously — the infected, soft postpartum uterus perforates easily; senior-led), drain a wound or pelvic collection, and de-roof/aspirate a breast abscess. In suspected invasive group A streptococcal sepsis, add clindamycin for its antitoxin effect (standard teaching) and consider immunoglobulin in fulminant disease — but anchor specifics to the guideline. Hand-hygiene and standard infection prevention are not footnotes: group A strep is often hospital-/carrier-acquired.
If septic shock develops, this becomes a critical-care problem — link to shock-management and resuscitation-in-pregnancy for the resuscitation framework, and refer to a regional/tertiary unit with ICU.
Venous thromboembolism
For confirmed or strongly suspected acute VTE, give therapeutic-dose LMWH (weight-based; the SA EML and RCOG GTG 37b give the dosing) and continue. Treatment is maintained for the remainder of the puerperium and typically for at least 3 months total and until at least 6 weeks postpartum, whichever is longer (standard teaching/RCOG — confirm duration against the guideline for the individual case). LMWH is the agent of choice postpartum and is compatible with breastfeeding; warfarin is also safe in breastfeeding if oral anticoagulation is chosen, whereas direct oral anticoagulants (DOACs) are generally avoided in breastfeeding. Massive PE with haemodynamic collapse is a peri-arrest emergency — escalate immediately to senior obstetric, anaesthetic and critical-care teams; thrombolysis is a senior, multidisciplinary decision.
For prophylaxis, assess every postnatal woman against an RCOG GTG 37a-style risk score and give LMWH thromboprophylaxis for the indicated duration (commonly extended — e.g. ~6 weeks postpartum — for high-risk women such as those with previous VTE, thrombophilia, or after caesarean with additional risk factors), alongside early mobilisation, hydration and graduated compression where indicated. The SA Maternity Guideline integrates VTE risk assessment into routine postnatal care.
Breast complications
Mastitis: continue breastfeeding/expressing from the affected breast (effective milk drainage is therapeutic), analgesia (paracetamol/NSAID), warm compresses, and antibiotics covering Staph. aureus (an EML-listed anti-staphylococcal agent, e.g. cloxacillin/flucloxacillin, for a standard course — verify the agent and duration against the SA EML). Failure to improve in 48 hours, or a fluctuant mass, suggests abscess → ultrasound-guided needle aspiration (often repeated) or incision and drainage plus antibiotics; breastfeeding usually continues. Counsel on technique to prevent recurrence; involve lactation support. Reassure that this rarely necessitates weaning.
Postpartum psychiatric conditions
- Baby blues: reassurance, support, safety-net to return if symptoms persist beyond two weeks.
- Postnatal depression: assess severity and risk; psychological therapy for mild–moderate; consider an antidepressant for moderate–severe (SSRIs are generally first-line and most are compatible with breastfeeding — confirm the agent against current prescribing guidance); mobilise social support and community mental-health services.
- Postpartum psychosis: a psychiatric emergency — urgent same-day psychiatric assessment and almost always admission, ideally to a setting that can keep mother and baby together with appropriate supervision. Assess suicide and infanticide risk explicitly; never discharge a psychotic mother with her baby on the strength of reassurance alone.
In every psychiatric presentation, ask directly about thoughts of harming the self or the baby — this single question changes the disposition from outpatient to emergency.
Red flags / pitfalls
- Treating fever as benign. Any puerperal fever, offensive lochia, or sustained tachycardia/tachypnoea is sepsis until excluded — and the septic woman may be afebrile or hypothermic. Respiratory rate and saturations are the most under-recorded, most predictive observations; chart a MEOWS.
- Using D-dimer to exclude PE postpartum. It is physiologically raised and not validated — image instead, and start LMWH on clinical suspicion without waiting for imaging.
- Forgetting that puerperal DVT is usually left-sided and ilio-femoral. Normal-looking calf does not exclude proximal disease; image the iliac veins if suspicion is high.
- Discharging too early in SA reality. A woman who goes home hours after delivery and lives far from care must be safety-netted with explicit return advice; the puerperium is where Saving Mothers finds late recognition and late referral.
- Missing the immunosuppressed presentation. Advanced HIV/TB broadens the sepsis differential and accelerates deterioration; know the HIV status and CD4.
- Perforating the infected uterus. Evacuation of retained products in sepsis is senior-led and gentle — the soft, infected postpartum uterus is friable.
- Stopping breastfeeding for mastitis. The opposite is correct — drainage is treatment; weaning worsens stasis.
- Under-reading the psychiatric mother. Failing to ask explicitly about harm to self/baby; treating postpartum psychosis as "blues"; sending a psychotic mother home with her infant. This is an emergency.
- Anchoring on the genital tract. Always look for the non-genital sepsis source — breast, urine, wound, chest/TB, septic pelvic thrombophlebitis (consider when fever persists despite antibiotics and no collection is found).
Evidence anchors
- National Integrated Maternal and Perinatal Care Guideline (NDoH, 2024), SA NDoH — the SA source of truth for postnatal care, early-warning observation charting (MEOWS/MEOWC), VTE risk assessment, sepsis management and referral pathways across levels of care.
- Saving Mothers / NCCEMD (latest triennium) — identifies pregnancy-related sepsis, non-pregnancy-related (HIV-associated) infection, and VTE among leading causes of maternal death in SA; repeatedly flags late recognition/late referral in the puerperium as avoidable.
- RCOG Green-top Guideline No. 64 — Maternal sepsis — recognition (including the unreliable temperature), Sepsis-Six within one hour, source control.
- RCOG Green-top Guideline No. 37a — Reducing the risk of VTE in pregnancy and the puerperium (risk-factor scoring and thromboprophylaxis) and No. 37b — Acute management of thrombosis and embolism (imaging strategy, therapeutic LMWH, duration).
- RCOG Green-top Guideline No. 56 — Maternal Collapse in Pregnancy and the Puerperium — for massive PE and septic collapse.
- SA Essential Medicines List / Standard Treatment Guidelines (current edition) — confirm the exact empirical antibiotic regimen, anti-staphylococcal agent and LMWH dosing against the current EML.
- SA National HIV / ART Consolidated Guidelines (2023) and SAHCS 2023 Adult ART Guidelines — relevant to the immunosuppressed septic puerperal patient (TLD first-line ART).
Notes on uncertainty (for the editor): specific antibiotic agents/doses for puerperal sepsis and mastitis, the precise LMWH therapeutic and prophylactic doses, the exact minimum treatment duration for VTE (~3 months and ≥6 weeks postpartum), the precise prophylaxis duration (~6 weeks for high-risk), the EPDS as the named screening tool, the addition of clindamycin/immunoglobulin in invasive GAS, and the day-of-onset windows for the psychiatric conditions are written as standard teaching and deliberately hedged — none should ship with a fabricated citation, and all should be reconciled against the current SA EML/STG and RCOG GTG 37a/37b/64 before publication.