Fever and Poor Feeding on Day 2 After Home Birth
A 30-year-old G3P2 arrives at a health center 36 hours after a home birth assisted by a traditional birth attendant. The placenta was complete, but she has had fever and chills since last night. Her temperature is 38.4°C, pulse 112, blood pressure 100/60, and respiratory rate 22. The uterus is tender and palpable 2 cm above the umbilicus, lochia is foul-smelling, and the perineum has a small healing tear. She says she has passed only a little urine since delivery. Her term baby breastfed once, but now feeds poorly, feels cool, and has a respiratory rate of 62 with mild chest indrawing. The health center has oral amoxicillin, oral metronidazole, and paracetamol, but no IV antibiotics, incubator, or laboratory. The referral hospital is 90 minutes away and the family has no cash. The mother asks for medicine to take home because she must care for her other children.
1. What is your leading diagnosis for the mother and baby, and what findings support it? What other assessments would you do?
Read the worked answer
The mother most likely has puerperal sepsis, probably endometritis, after a home birth. The supporting findings are fever of 38.4°C, tachycardia of 112, tender uterus enlarged to 2 cm above the umbilicus, foul-smelling lochia, and reduced urine output. The baby has danger signs of possible neonatal sepsis and hypothermia: poor feeding, cool skin, respiratory rate of 62, and mild chest indrawing. I would assess the mother for shock with mental status, capillary refill, blood pressure, and urine output, examine the breasts and perineum, and check for retained placental tissue or peritonitis. For the baby I would check temperature, heart rate, breathing, colour, tone, feeding, umbilical stump, and jaundice, and check glucose if a glucometer is available. Malaria or dengue can cause fever in Cambodia, but the foul lochia and tender uterus make sepsis the priority.
2. What immediate management and referral decision would you make with the available resources?
Read the worked answer
Both mother and baby need referral; this is not a case for oral antibiotics at home. Because the health center has no IV antibiotics, I would give the first doses of oral amoxicillin and metronidazole according to national protocol, give paracetamol for fever, start IV fluids if supplies and skill allow, and monitor vital signs and urine output. I would not do uterine evacuation or give oxytocin at the health center. I would call the referral hospital, explain the fever, tender uterus, foul lochia, and the baby's poor feeding and chest indrawing, and arrange urgent transfer with the mother and baby together. I would involve the health center chief and VHSG to access the Health Equity Fund, write a referral note with all observations and treatments, and document that the family was advised not to take medicine home and delay care.
3. What newborn care and feeding support would you provide before and during transfer?
Read the worked answer
Before transfer I would dry the baby, place him skin-to-skin with the mother if she is stable and he is not distressed, cover both with a warm blanket and put a hat on the baby, and check the temperature frequently. If skin-to-skin is not possible because of the mother's condition, I would use a clean warm wrap and a radiant warmer. I would not feed the baby by bottle; if he can swallow, I would give expressed breast milk by cup or spoon, and if he cannot feed I would refer immediately and not force oral fluids. I would teach the mother hand hygiene before feeding and explain the danger signs: poor feeding, cold body, fast breathing, chest indrawing, yellow palms, or convulsions. Keeping mother and baby together during transfer supports breastfeeding and reduces separation, but the baby must be kept warm and monitored throughout.