Puerperial sepsis

Definition

A puerperal infection, or puerperal sepsis, is a condition that

occurs when a new mom experiences an infection related to
giving birth. Puerperal infections are the sixth-leading cause
of death among new mothers, according to the World Health
Organization (WHO).
 After childbirth a patient's genital tract has a large bare surface, which
can become infected. Infection may be limited to the cavity and wall of
her uterus, or it may spread beyond to cause peritonitis (6.2),
septicaemia, and death, especially when her resistance has been lowered
by a long labour or severe bleeding. If she is more fortunate, her
infection may be walled off by her gut and omentum. She may have a
pelvic abscess with pus in her pouch of Douglas, or she may have pus
high in her pelvis or in her lower abdomen.
types of postpartum infections

endometritis: an infection of the uterine lining

myometritis: an infection of the uterine muscle
parametritis: an infection of the areas around the uterus
 Symptoms and signs

 fever
 pain in the lower abdomen or pelvis caused by a swollen uterus
 foul-smelling vaginal discharge
 pale skin, which can be a sign of large volume blood loss
 chills
 feelings of discomfort or illness
 headache
 loss of appetite
 increased heart rate
 If sepsis is localized, only her lower abdomen is distended, she has guarding in
both her iliac fossae, and an ill-defined tender mass arising from her pelvis. She
may have hyperactive bowel sounds. Vaginally, she shows signs of recent
childbirth or abortion, and may have infected lacerations. Her cervix is open and
tender, painful on movement, and may be drawn up behind her symphysis. Her
pouch of Douglas may be thickened or swollen, but you cannot feel a fluctuant
mass vaginally. Her uterus and appendages form a mass which is difficult to
define because of their tenderness.
  Ifsepsis is generalized, she is weak, with anorexia, fever (perhaps with rigors), a
rapid thready pulse, a low blood pressure and generalized abdominal pain. Her
abdomen is uniformly distended, tympanitic, silent, and acutely tender. She may
have a visible mass extending up to her umbilicus; you may have to pass a
catheter to make sure that it is not merely a distended bladder. She cannot walk.
She may have diarrhoea until peritonitis causes ileus and this causes constipation
and vomiting.
 Risk factors

 anemia
 obesity
 bacterial vaginosis, a sexually transmitted infection
 multiple vaginal exams during labor
 monitoring the fetus internally
 prolonged labor
 delay between amniotic sac rupture and delivery
 colonization of the vaginal tract with Group B streptococcus bacteria
 having remains of the placenta in the uterus after delivery
 excessive bleeding after delivery
 young age
 low socioeconomic group
occurence

 1 to 3 percent in normal vaginal deliveries

 5 to 15 percent in scheduled cesarean deliveries performed before labor begins
 15 to 20 percent in non-scheduled cesarean deliveries performed after labor begins
investigations

 High vaginal swab.

 Urine culture and microscopy.
 Other swabs as felt necessary - eg, wound swabs, throat swabs.
 FBC.
 Blood culture x 2.
 Ultrasound scan may be required to assist diagnosis of retained products of conception.
 Sputum culture if indicated.
Prevention of sepsis

• Strict adherence to established antiseptic and sterilisation procedures such as:

 Cleaning hands immediately prior to delivery,
 Cleaning perineum,
 Cleaning delivery surface,
 Sterilised surgical instruments,
 Clean cord tie and clean cord care,
 Use of a prepacked sterilised delivery kits.
• Institutionalizing all deliveries.
• Restricting vaginal examinations to minimum in
 premature and prolonged rupture of membranes (PPROM). Refer guideline on Preterm Rupture of Membranes
prevention cont’d

•Prevention of prolonged labour by maintaing the partogram in all patients who are in labour and intervention at
the action line and early maternal transfer when indicated.
•Strict adherence to sterile procedures at every vaginal examination in women in labour.
•Strict adherence to sterile procedures especially when performing an emergency Caesarean Section and/or any
other operative procedures such as, removal of retained placenta or retained products of conception.
•Ensuring sterility in the operating room. (Grade X)
•Ensuring sterility in the labour room. (Grade X)
•Encourage-voiding urine during labour thereby avoiding unnecessary catheterization.
•Avoid unnecessary episiotomy.
•Use soap, water and effective antiseptics
Complications

 Complications are rare. But they can develop if the infection isn’t diagnosed and treated quickly. Possible
complications include:
 abscesses, or pockets of pus
 peritonitis, or an inflammation of the abdominal lining
 pelvic thrombophlebitis, or blood clots in the pelvic veins
 pulmonary embolism, a condition in which a blood clot blocks an artery in the lungs.
 sepsis or septic shock, a condition in that occurs when bacteria get into the bloodstream and cause dangerous
inflammation
 Management

 RESUSCITATE HER, if necessary.

 GIVE HER ANTIBIOTICS: chloramphenicol and metronidazole. Or, ampicillin 500 mg 6-hourly for 7 days, and
metronidazole. If she is very ill, she must have metronidazole either intravenously, or as suppositories, or tablets rectally
(2.7). Too little chloramphenicol will be excreted in her breast milk to harm her baby. Or, give her gentamicin, or
kanamycin.
 MONITOR HER daily for signs of the spread of infection.
 MANAGE HER like this:
 If she continues to bleed, she may have retained pieces of placenta. This is a common cause of puerperal sepsis, which will
not resolve until her uterus is empty. Give her antibiotics and curette her 24 hours later with great care! Use the largest
curette which will be less likely to perforate her uterus. Curetting a large, soft, infected uterus is dangerous.
 If her uterus is enlarged and tender, with a closed cervix as the result of scarring or carcinoma, it may be full of pus
(pyometra, 32-21). This can occur 2 weeks or more after delivery. Drain her cervix with Hegar's dilators, 10 Ch is usually
enough.
 If she has a definite swelling at one side of her uterus, she has parametritis.
 If she has generalized peritonitis without any localizing signs, surgery may be required; make a muscle splitting
incision as for appendectomy in an iliac fossa. Open her peritoneum, sweep gently with your finger, and insert a
sump sucker. Up to a litre of thin pus will probably escape. If you enter an abscess cavity, gently free any adhesions
and open up all loculi. Wash out her peritoneum, and then instil tetracycline 1 g in a litre of saline.
 If her fever recurs after initial improvement, there is more pus somewhere which must be drained, either through the
same incision or another one. If you fail to drain a subphrenic abscess, she will die.
 If she recovers from the acute episode, but is left with a mass, she may eventually need a need a full laparotomy,
with the separation of adhesions and the removal of a tubo- ovarian mass. Refer her if you can.