Puerperal sepsis is a potential complication during postpartum due to infections. It is one of the leading causes of postpartum mortality in the world. Postpartum infections, also known as childbed fever and puerperal fever, are any bacterial infections of the female reproductive tract following childbirth.
Puerperal Sepsis Definition:-
What is the meaning of puerperal sepsis?
Puerperal sepsis is an infection of the genital tract at any time between the onset of rupture of membranes or labour and the 42nd day following delivery or abortion in which any two or more of the following signs and symptoms are present:
- Fever of 38.5 ºC or higher, measured orally on any one occasion;
- Abnormal vaginal discharge;
- The abnormal smell, foul odour of the vaginal discharge;
- Pelvic pain;
- Delay in the rate of reduction of the size of the uterus (sub involution of the uterus; <2 cm/day).
Objectives:-
At the end of the session, the trainee will be able to :
- Define puerperal sepsis.
- Acquire skills for diagnosis & management of puerperal sepsis.
Skills to be acquired by the participants-
Defining puerperal sepsis as two or more of the following signs/symptoms:-
1. Fever > 100.4ºF
2. Foul smelling vaginal discharge
3. Lower abdominal pain
4. Sub involuted, soft and tender uterus.
Management of a case of P. sepsis by parenteral/oral antibiotics:-
1. Ampicillin
2. Gentamicin
3. Metronidazole
- Do not improve or are toxic (high-grade fever and pulse>100/minute) to a higher facility
- Prevention is better than cure. Deliveries by skilled personnel in the aseptic environment following all clears would prevent cases of P. Sepsis
How puerperal sepsis occurs:-
What causes puerperal sepsis?
Puerperal sepsis occurs due to colonization of the genital tract by microorganisms. These organisms can be introduced from within (infection of endogenous origin), or from outside (infection of exogenous origin).
Endogenous infections are caused by bacteria that normally live in the vagina and rectum without causing harm (commensals). These bacteria can become harmful if:
- They are brought into the uterus by the examining finger or by instruments during pelvic examinations
- There are bruised lacerated or dead tissue
- They ascend into the uterus during premature and prolonged rupture of the membranes.
- Exogenous infections are introduced into the vagina from outside the body, by:
- Unclean hands and unsterile instruments.
- Foreign substances introduced into the vagina, e.g. herbs oils, etc. during an illegal and unsafe abortion.
- By sexual activity.
- Puerperal sepsis can occur both intrapartum and postpartum.
- During the intrapartum period, due to PROM, the bacteria ascend and can cause chorioamnionitis. This is a very serious condition and can endanger the life of both the mother and the baby.
- During the postpartum period, puerperal sepsis may be localized to the perineum, vagina, cervix, or uterus; or it can spread and also infect the fallopian tubes, the ovaries, etc.
- It can lead to parametritis, peritonitis, and even septicemia. It can result in complications such as DIC and can be rapidly fatal for the woman.
Why puerperal sepsis occurs?
Women are vulnerable to infection during the puerperium due to the large, raw placental site that is warm, dark, and moist. It has a rich blood supply.
The site is not far from the outside environment and the rectum. These factors make it very easy for bacteria to enter and colonize the genital tract.
The scars in the cervix, vagina, and/or perineum which may have occurred during the birthing process make the genital tract even more susceptible to infection, and for the infection to spread to the underlying tissues.
The most common site of infection in puerperal sepsis is the placental site in the uterus. Other sites of infection are tears of the cervix, vagina, perineum, and the site of episiotomy.
Risk factors for puerperal sepsis-
Patient-related risk factors:-
- Poor patient hygiene
- Pre-existing anemia and malnutrition
- Pre-existing sexually transmitted infections (STIs)/RTIs
- Not immunized against tetanus
- Pre-existing diabetes
Risk factors related to the delivery process and interventions:-
- Failure to follow aseptic techniques
- Frequent vaginal examinations
- Manipulations high in the birth canal
- Presence of dead tissue in the birth canal (due to IUD, retained placental fragments or fragments of membranes, necrosis of tissue due to prolonged labour, etc.)
- PROM
- Prolonged/obstructed labour
- Caesarean section or other assisted deliver (forceps, ventouse)
- Unrepaired vaginal/cervical laceration
- PPH
Risk factors related to health service delivery:-
- Delivery by untrained persons
- Lack of asepsis during delivery
- Lack of routine postpartum care
- Inadequate monitoring of the temperature during prolonged labour and after delivery
- Non-availability of proper antibiotics
- Inadequate management with appropriate antibiotics in a case in whom puerperal sepsis has set in
- Further operative intervention in a case where puerperal sepsis has set in
Causes of fever in the puerperium:-
What are the causes of puerperal pyrexia?
Infectious causes:-
1. Puerperal sepsis, depending on how far it has spread, may present as:
- Localized infection of a vaginal/cervical laceration or episiotomy;
- Infection of a laceration or episiotomy which has spread to the underlying soft tissue, e.g. ischiorectal abscess;
- Infection of the uterine lining-endometritis;
- Infection of the fallopian tubes-salpingitis;
- Parametritis;
- Generalized peritonitis;
- Septic thrombophlebitis;
- Tubo-ovarian abscess;
- Broad ligament abscess;
- Abscess in the pouch of Douglas (peritoneal abscess);
- Abscesses at other sites in the abdomen or chest;
- Septicaemia (an infection that has entered the bloodstream and is a very serious condition);
- Septic shock (may complicate septicaemia).
2. Breast infection such as mastitis or, at a later stage, breast abscess
3. UTI
4. Wound infection (e.g. of the caesarean section incision)
5. Thromboembolic disorders, including superficial thrombophlebitis and deep vein thrombosis, sometimes give rise to fever and tachycardia.
Non-infectious causes:-
A low-grade fever is very common in the postpartum period, especially in the first 24 hours. The causes include dehydration, tissue trauma, reaction to foetal proteins, and breast engorgement.
Although fever occurring in the first 24 hours after delivery has generally been regarded as being unrelated to infection, a temperature of 38.5ºC or higher within the first 24 hours should alert you to the possibility of puerperal sepsis developing in the patient.
Management of puerperal sepsis:-
The basic principles of infection control should be followed to prevent the spread of infection to other women and their babies.
Women will die of puerperal sepsis and septicemia if appropriate antibiotic therapy is not given early enough. The aim of starting antibiotic therapy immediately is to manage/treat the current infection and to stop it from spreading further.
Antibiotics:-
Give the first dose of the following regimen of antibiotics and refer the woman to an FRU as soon as possible:
- If the woman is not very sick (e.g. there is no fever or it is low grade, the pulse is not very high, and the consciousness is normal), you may start the woman on: Cap. Ampicillin 1 g stat orally PLUS Tab. Metronidazole 400 mg orally PLUS Inj. Gentamicin 80 mg IM.
- If the woman is very sick (e.g. she has a very high fever, a rapid pulse, appears confused), more than one microorganism is usually involved. A combination of antibiotics that provide as broad a coverage as possible should be given, preferably through the parenteral route. A useful regime is:Inj. Ampicillin 1 g IV stat PLUS Metronidazole 400 mg IV, PLUS Inj. Gentamicin 80 mg IM.
Give plenty of fluids:-
The aim of this is to correct or prevent dehydration and to help bring down the fever. In severe cases (e.g. if the woman is in shock or is in a confused, delirious state), it is necessary to give IV fluids immediately.
If the woman is conscious and there is no indication that a general anesthetic may be needed in the next few hours, she should also be given oral fluids.
In mild cases, a simple increase in oral fluid intake is sufficient.
Rule out the presence of retained placental fragments:-
Retained placental fragments can be a cause of puerperal sepsis. Suspect this if the uterus is soft and bulky and if the lochia is excessive and contains blood clots. Refer the woman to an FRU that has the equipment and health care personnel trained to perform curettage.
Refer to an FRU:-
Refer the woman as soon as possible to an FRU after initiating the required treatment. It is important to write a full description of the treatment offered in the referral card. Ask the ANM in charge of the area to follow up the condition of the woman after she is discharged from the FRU.
Tetanus toxoid:-
If there is a possibility that the woman was exposed to tetanus (if, for example, cow dung, mud, or herbs were inserted into the vagina), and there is uncertainty about her vaccination history, then give her TT.
A case of tetanus needs management that will not be possible in a PHC setting. Hence, the woman must be urgently referred to an FRU.
Provide skilled nursing care:-
This requires careful attention. Nursing staff must be instructed to ensure the following:
- Advise the woman to take bed rest;
- Monitor vital signs (temperature, pulse, BP, RR);
- Measure intake and output of fluids;
- Keep an accurate record of the medicines given;
- Prevent the spread of infection and cross-infection
Principles of Management of Puerperal Sepsis:-
Recommended Antibiotic to Mother:-
| Not very Sick Mother | Very Sick Mother |
| Ampicillin 1 gm -6 hourly oral | Ampicillin 1 gm 6hrly Intravenous |
| Metronidazole 400mg – 8 hourly oral | Metronidazole 500mg -IV 8 hourly |
| Gentamycin 80 mg, BD Intra Muscularly | Gentamycin 80 mg, BD Intra Muscularly |
If mother is well enough to take oral medicine, administer drugs orally only
SUMMARY/KEY POINTS:-
What are the complications of puerperal sepsis?
- Puerperal sepsis is one of the leading causes of maternal deaths
- Puerperal sepsis is to a great extent preventable
- Antibiotics should be given to the woman only if they are indicated
- At the periphery, ANM should identify the indications for antibiotics and give the first dose before referral
EXERCISE/QUESTION BANK FOR PARTICIPANTS:-
Q.1. Define Puerperal sepsis
Q.2. How Puerperal sepsis occurs.
Q.3.What are the risk factors for puerperal sepsis
Q.4. What are the causes of fever in the puerperium.
Q.5.Write in brief about management of puerperal sepsis