PUERPERAL 

SEPSIS
 DEFINITION
• Puerperal sepsis is an infection of the uterus, usually caused by bacteria
due to unsterile techniques during delivery. 
• Puerperal sepsis is a puerperal infection of genital tract during the first 6
weeks of delivery or abortion. 
• It rises as a result of invasion, incubation and multiplication of an
organism and does not therefore normally occur until 24 hours of
delivery . 
PUERPERAL PYREXIA
• A rise of temperature reaching 100°F (38°C) or more at 24 hours apart
(excluding first 24 hours) within first days following delivery is called
puerperal pyrexia. 

• Postpartum fever (PPF) or puerperal fever is defined as a continuous

high an oral temperature of ≥38°C for any two days in the first 10 days
postpartum. 
COMMON INFECTION
Endometritis 
Wound infections
Urinary tract infections (cystitis, pyelonephritis)
Septic pelvic thrombophlebitis
Mastitis 
 Causes
1. The infecting organism
2. The source of infection
3. The pre-disposing factor

4. The infecting organism : The organism responsible for puerperal sepsis

are the following:
 Aerobic: - Staphylococcus pyogenes, Escherichia coli, klebsiella,
pseudomonas, streptococcus, staphylococcus aureus.
 Anaerobic:- Anaerobic streptococcus, bacteriodes, clostridium welchii,
clostridium tetani.
2. The source of infection:- Puerperal sepsis is essentially a wound
infection. Placental site, laceration of the genital tract, a caesarean
sections wound may be infected in the following ways.
a. Endogenous source:- This is usually from organism already present
on patients vagina and bowel. The organism is non- pathogenic in
normal condition. They may become virulent and pathogenic if
there is laceration of the birth canal.
b. Exogenous:- Organism from the respiratory tract and septic foci of
the patients attendant. The dust in the air of the ward , from
blanket sheets etc are the main source of infection in this variety.
The majority of the hospital staff(nurses and doctor) carry
staphylococci and streptococci in the respiratory tract and will
readily infect their patient, if adequate precautions are not taken.
c. Autogenous:- The source of infection in this course is from the
patient usually from her respiratory tract, septic foci may also be a
source of infection. Puerperal infection caused by this organism is
mostly likely occur in women who have had a difficult forceps
delivery or emergency caesarean section and those who are
debilitated and anemic.
3. The predisposing factors:-
 Antepartum factors
• Malnutrition and anemia
• Alcoholism and drugs abuse
• Sexual intercourse during late pregnancy
• Immunosuppressive condition

 Intrapartum factors:-
• Repeated vaginal examination
• Traumatic/operative delivery
• Bladder catheterization
• Episiotomy or lacerations
• Hematoma formation
PATHOGENESIS
PATHOGENESIS

• Puerperal infection following vaginal delivery primarily involves

the placental implantation site, cervical lacerated wound, vaginal
wound or perineal wound. These are the favourable sides for the
bacterial growth and multiplication.
• Uterine infection following caesarean delivery is that of an infected
surgical incision.
• Bacteria that colonize the cervix and vagina gain access to amniotic
fluid during labour, and post partum.
• They invade devitalized tissue, blood clots, foreign body and
surgical infection, polymicrobial growth, proliferation and spread of
infection.
TYPES PUERPERAL SEPSIS

1. Localized infection
2. Uterine infection
3. Spread to peritoneum, peritonitis
4. Septicemia
CLINICAL FEATURES
 CLINICAL FEATURES
1. Localized Infection
 Slight rise in temperature .
 Malaise
 Headache
 tachycardia
 Local wound become red & swollen(PRISH)
 Pain & tenderness over lower abdomen
 Pus may form
2.UTERINE INFECTION

 Mild uterine infection

 Pyrexia (>100.4 degree F ) with rise in pulse rate (>90b/m)
 Lochia become offensive, copious & often red
 Uterus is tender & softer than usual
 SEVERE UTERINE INFECTION

 High rise in temperature with often chills & rigors

 Pulse rate rapid
 Lochia may be scanty & colorless
 Subinvolution of uterus
3.SPREAD OF INFECTION

a) Spread to femoral vein , iliac vein , inferior vena cava , fallopian

tube , ovary
 Patient look ill.
 Fever
 Tachycardia
 Lower abdominal pain
 Pain & tenderness in calf muscles
b) Peritonitis
 Rise temperature
 Rapid pulse
 Tender abdomen
 Vomiting
c)Septicemia
 This may occur in 48 hours of
delivery
 High fever ( 39.5- 40.5 degree
celsius )
 Tachycardia ( > 120/m)
 Abdominal pain absent
 Joint pain
 Pt. look ill
PREVENTION
1.ANTENATAL:-
1. Detect and eradicate the septic focus especially located in the
teeth,gums,tonsils,middle ears etc.
2. Maintain and immprove the health status of the patients especially to raise Hb level,
prevent eclampsia, early treatment of any abnormalities.
3. Vaginal examination during pregnancy espesially in the last months should be kept
in a minimum and should be carried out with strict surgical.
4. Intercourse should be avoided during the last two months to prevent introduction of
organisms like streptococcus.
5. The patient should avoid contact with persons suffering from infections disease.
6. The patient should take care of personal hygiene.
2. INTRANATAL:-
1. The nurse doctor and other personnel entering into labour room should wear mask ,gown, and cap to
prevent the infection of personnel spread to labour room.
2. The delivery should be conducted taking full surgical asepsis.
3. Use sterilized equipment with control dates.
4. The patients is instructed not to touch the vulva during labour.
5. Membranes should be kept preserved as long as possible. Vagina examination should be restricted to
minimum during labour which increases the chances of introducing organisms from the rectum and
vagina into the uterus.
6. After placenta delivery explore the vagina to determine if there are any pieces of membranes or blot
clots retained in uterus.
7. Laceration of the genital tract should be repaired promptly and meticulously with perfect
homeostasis taking due aseptic precaution.
8 . Excessive blood loss during delivery should be replaced promptly
by blood transfusion to improve the general body.
9. Prophylactic antibiotics in case of premature rupture of the
membranes having prolonged Labour of following traumatic delivery.
3.POST NATAL:-
1. Aseptic precaution should be taken for at least one week following delivery until
the open wound in the uterus and the genital tract injury.if any are healed up.
2. Nurse should take aspectic precaution and wear mask while giving perinatal care.
3. Restrict too much visitors in ward.
4. Sterilised sanitary pad should be used and changed frequently to prevent lochia
to decompose and became offensive on the pad.
5. Clean the vulval area with antiseptic solution after urination and defecation.
6. Infected babies and mothers should be in isolated room.
7. Advice to avoid sexual intercourse for 4-6 weeks after delivery.
DIAGNOSTIC EVALUATION
DIAGNOSTIC EVALUATION

• History to find risk factor of peurperal infection.

(antenatal history, Intranatal history, postnatal
details).

• Clinical examination.
• Test/ Investigation
- High vaginal and endocervical swabs for culture in
anaerobic and aerobic media and sensitivity to antibiotics.
- Specimen of urine for urinalysis and culture including
sensitivity test.
-Blood test for total and differential white cell count.
- Blood culture, if fever is associated with chills and rigor.
- Pelvic ultrasound is helpful to detect any retained bits of
conception within uterus.
- Use of CT and MRI are needed specially when diagnosis
is in doubt or there is pelvic vein thrombosis.
MANAGEMENT OF PUERPERAL INFECTIONS
A) GENERAL MANAGEMENT

Isolation of patient is prefered especially when hemolytic streptococcus is obtained on culture.

• Pharmacological Management
A combination of antibiotics is given until the women is fever free for 48 hours and following
regime is recommended:
- Ampicilline 2g IV every 6 hours
- Gentamicin 5mg/kg body weight IV every 24 hours
- Metronidazole 500mg IV every 8 hours
If the fever is still, 72 hrs after starting the antibiotic regime, refer to higher facility.
Tetanus toxoid if there is possibility that the woman was exposed to tetanus.
• Giving plenty of fluids
• Rulling out retained placenta fragments
• Anemia is corrected by oral iron and if needed by BT
• Pain is relieved by adequate analgesic
• Provide skilled midwifery care
• Care of newborns
SURGICAL MANAGEMENT
• The stitches of the perineal wound may have to be removee to
facilitate drainage of pus and relieve pain
• The wound is to be dressed with mild antiseptic solution. After
infection is controlled secondary suture may be given.
• Retained uterine producta must be evacuated.
• Septic pelvic thrombophlebitis is treated with IV heparin fir 7-10
days
• Pelvic abscess should be drained by colpotomy under ultrasound
guidance
• Laparotomy is indicated in unresponsive peritonitis
• Hysterectomy is indicated in case with rupture or perporation
having multiple abscess, gangrenous uterus or gas gangrene
infection.
NURSING MANAGEMENT
 ASSESSMENT

• Elevation in temperature to 38’C ( 100’F) or above with chills.

• Foul with lochia.
• Abdominal tenderness and pelvic pain.
• Pain and burning on urination.
• Tachycardia.
• Increase white blood cells.
• Presence of predisposing factors.
• Traumatic birth,prolonged difficult labour.
• Dehydration, excessive vaginal discharge.
• Prolonged rupture of membranes
• Anaemia
• Hemorrhage
• Retained placental fragments.
• Mother frustrated due to extreme fatigue.
• May appear uncooperative and not interested.
NURSING DIAGNOSIS
• Risk for injury.
• Knowledge deficit.
• Interupted breast feed .
• Fluid deficit.
• Impaired gas exchange.
• Bodily image disturbances.
PLANNING

• Provide teaching regarding hygienic measures.

• Administer treatment specific to Infection .
• provide opportunities to express feelings.
• Provide education to self care.
IMPLEMENTATION
• Assess vital signs every 2-4 hours .
• Obtain culture’s blood and urine sample.
• Evaluate pain and lochia.
• Provide Routine postnatal care.
• Use meticulous had washing techniqu and also teach to other.
• Provide warm sitz baths hot compress application or heat lamp exposure.
• Provide reassurance and support.
• Isolate women as indicated.
EVALUATION
• Ensure that women:-
• Demonstres hand washing and verbalise understanding of hygienic
measures.
• Cotinue ordered medications to full recovery.
• Verbalizes feelings and incresae ability to cope.
• Verbalizes understanding of self care measures to treat and prevent
infection and increase comforts.
COMPLICATIONS

• Peritonitis
• Septicaemia
• Abscesses or pockets of pus
• Pelvic thrombophlebitis or blood clots in the pelvic veins.
REFERENCE
• Awasthi M. S. (2074) “Essential textbook of midwifery nursing”, 1 st edition,
samikshya publication pvt, Ltd., page no. 79-81
• Subedi D. (2018) “ Textbook of midwifery nursing 3, postpartum care”, 1 st
edition, tara books and stationary.
• Tuitui R. (2014) “Manual of Midwifery 3”, 10 th edition, vidyarthi pustak
bhandar.