Case 18 · Obstetrics
Puerperal sepsis
Five days after a prolonged home birth, a young mother arrives drowsy, febrile and hypotensive with foul-smelling lochia. Run the hour-1 sepsis bundle, choose antibiotics that cover the likely organisms and suit breastfeeding, find the source, and evacuate retained placental tissue at the right time.
About this case
What you will practise
Learning objectives
- Recognise septic shock in a woman after childbirth.
- Deliver the hour-1 sepsis bundle: lactate, cultures, antibiotics, fluid and vasopressors.
- Choose antibiotics that cover streptococci, Gram-negatives and anaerobes and are compatible with breastfeeding.
- Look for the source in the uterus, and consider the breasts, wound, urine and legs.
- Time the evacuation of infected retained tissue under antibiotic cover.
- Think about the baby and arrange the right level of care.
Key decisions this case tests
- Which antibiotics, and how quickly?
- How much fluid before noradrenaline?
- Where is the infection coming from?
- When to evacuate the uterus, and when not to operate?
- ICU or ward?
Reference basis
- WHO. Managing complications in pregnancy and childbirth, 2nd ed. (2017): fever after childbirth.
- RCOG Green-top Guideline No. 64b: Bacterial sepsis following pregnancy (2012).
- Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock 2021.
- Empirical antibiotics should follow the local antibiogram (for example, ICMR treatment guidelines).
Content version 1.0 · November 2026 · clinical review pending. See the Clinical content policy.
Before you start
The physiology is a simplified teaching model: bacterial burden, the response to antibiotics, fluid and vasopressors, and the timing of source control are timed for learning, not prediction. Doses follow the cited guidelines but have not yet been signed off by a clinician.
Visle is for education only and is not medical advice. Fever, foul-smelling bleeding or feeling very unwell after childbirth needs urgent care in hospital.
Ready for another emergency?
Case 17 is a woman with a previous caesarean, 16 hours into a labour that will not progress.