Puerperal sepsis

Puerperal sepsis

Puerperal sepsis is an infective condition in the mother following childbirth. It is the third most common cause of maternal death worldwide as a result of child birth after haemorrhage and abortion. According to World Health Organization (WHO) estimates puerperal sepsis accounts for 15% of the 500000 maternal deaths annually. In low and middle income countries puerperal infections are the sixth leading cause of disease burden in women during their reproductive years. Puerperal sepsis can cause long-term health problems such as chronic pelvic inflammatory disease (PID) and infertility in females.

Puerperal sepsis was defined as infection of the genital tract occurring at any time between the onset of rupture of membranes or labour, and the 42^nd day postpartum in which two or more of the following are present:

• Fever (oral temperature 38.5°C/101.3°F or higher on any occasion).
• Pelvic pain.
• Abnormal vaginal discharge, e.g. presence of pus.
• Abnormal smell/foul odour of discharge.
• Delay in the rate of reduction of the size of the uterus (involution).

(A puerperal infection is a more general term than puerperal sepsis and includes not only infections due to puerperal sepsis, but also all extra-genital infections and incidental infections-WHO).

Sample Registration System (SRS), India estimated that 16% and 11% maternal deaths in the year 1998 (survey of causes of death) and 2001-03(special survey of deaths) respectively were due to puerperal sepsis. In a population based study in rural Maharashtra puerperal sepsis was the second major cause of maternal mortality (13.2%) after postpartum haemorrhage.

( Maternal mortality-The death of a woman while pregnant, or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management (from direct or indirect obstetric death), but not from accidental or incidental causes).

Puerperal sepsis is preventable with provision of adequate antenatal care, referral and timely treatment of complications of pregnancy, promoting institutional delivery and postnatal care.   

References-

apps.who.int/iris/bitstream/10665/44145/6/9789241546669_6_

www.who.int/healthinfo/statistics/bod_maternalsepsis.pdf

planningcommission.nic.in/aboutus/committee/strgrp/stgp_fmlywel/sgfw

www.bettercaretogether.org/sites/default/files/resources/Hussein%20%

www.cghr.org/wordpress/wp-content/uploads/RGI-CGHR-Maternal-Mortality-in-India

www.healthline.com/health/puerperal-infection#Overview1

www.rcog.org.uk/globalassets/documents/guidelines/gtg_64b.

Puerperal sepsis was defined as infection of the genital tract occurring at any time between the onset of rupture of membranes or labour, and the 42nd day postpartum in which two or more of the following symptoms and signs may be present-

• fever (temperature of 38°C or more) with chills and general malaise,
• lower abdominal pain,
• tenderness lower abdomen,
• Delay in the rate of reduction of the size of the uterus (involution)(<2cm/day during first eight days)
• Purulent foul-smelling lochia,
•  light vaginal bleeding, shock

References-

apps.who.int/iris/bitstream/10665/44145/6/9789241546669_6_eng.pdf

www.royalberkshire.nhs.uk/Downloads/GPs/GP%20proto

www.who.int/healthinfo/statistics/bod_maternalsepsis.pdf

Puerperal sepsis is bacterial infection of the genital tract which occurs after the birth of a baby. Some of the most common bacteria causing puerperal sepsis are streptococci, staphylococci, escherichia coli (E.coli), clostridium tetani, clostridium welchii, chlamydia and gonococci (bacteria which cause sexually transmitted diseases). More than one type of bacteria may be involved in puerperal sepsis. Bacteria may be either nosocomial, endogenous or exogenous.

Nosocomial infections are acquired in hospitals or other health facilities and may come from the hospital environment or from the patient's own flora.

Endogenous bacteria- These bacteria are normally present in the vagina and rectum without causing any disease (e.g. some types of streptococci and staphylococci, E.coli, clostridium welchii). Endogenous bacteria can be transmitted from vagina to uterus;

• during pelvic examinations and use of instruments,
• following obstructed labour due to tissue damage and,
• prolonged ruptured of membrane because microorganisms can enter the uterus.

Exogenous bacteria-These bacteria are introduced into the vagina from the outside by unclean hands and unsterile instruments, sexually transmitted infections, foreign substances inserted in to vagina. Tetanus bacilli were particularly prevalent in rural areas. India has eliminated maternal and neonatal tetanus by routine immunization coverage and promotion of institutional/clean delivery/clean cord practices and effective surveillance system.

Risk factors-Some women are more vulnerable to puerperal sepsis, including-

• Prolonged/obstructed  labour,
• multiple vaginal examinations in labour (more than five),
• premature ruptured membranes,
• caesarean section (CS),
• obstetrical manoeuvres,
• post-partum haemorrhage,
• pre-existing sexually transmitted infections,
• unrepaired cervical lacerations, or large vaginal lacerations,
• unhygienic practices during labour,
• prolonged retention of dead fetus, retained fragments of placenta or membranes,
• obesity,
• low socio-economic status,
• poor nutrition,
• primiparity,
• anaemia, diabetes.

Community factors-

• Delivery by an untrained birth attendant,
• lack of transportation,
• long distance from a woman’s house to the health facility,
• cultural factors which may delay care-seeking behaviour,
•  low status of women which contributes to their poor health in general,
•  lack of knowledge of symptoms and sings of puerperal sepsis, and
• availability of postnatal care.

References- 

apps.who.int/iris/bitstream/10665/44145/6/9789241546669_6_eng.pdf

www.royalberkshire.nhs.uk/Downloads/GPs/GP%20protocols%20and%20guidelines/Maternity%20Guidelines%20and%20Policies/Postnatal/Postpartum%20infection_V4.0_GL893.pdf

www.who.int/healthinfo/statistics/bod_maternalsepsis.pdf

pib.nic.in/newsite/PrintRelease.aspx?relid=147093

General history and clinical examination of women after child birth are important steps in assessing the post partum complications. Vital signs such as temperature, pulse, respiration, blood pressure, and examination of breast, abdomen, perineum, legs; lochia (discharge after child birth) should be examined carefully.

Various diseases causing fever in puerperium (six weeks period after childbirth) should be excluded; such as-

• Urinary tract infection (acute pyelonephritis),
• wound infection (e.g. scar of caesarean section),
• mastitis or breast abscess,
• thrombophlebitis or deep vein thrombosis,
• respiratory tract infections,
• other medical conditions, such as malaria, typhoid fever, human immunodeficiency virus infection (HIV)

Laboratory investigation-  

• Complete blood count,
• Urinalysis, with culture and sensitivity tests,
• Electrolytes estimation,
• Cervical or uterine cultures,
• Blood culture, if sepsis is suspected,
• Coagulation studies-In pelvic thrombosis, deep vein thrombosis, pulmonary embolism, or invasive treatment (eg, surgical procedure) is being considered,
• Pelvic ultrasonography may be helpful in detecting retained products of conception, pelvic abscess, or infected hematoma,
• Contrast-enhanced CT or MRI are useful in establishing the diagnosis of septic pelvic thrombosis

References-

emedicine.medscape.com/article/796892-differential

www.healthline.com/health/puerperal-infection#Riskfactors4

apps.who.int/iris/bitstream/10665/44145/6/9789241546669_6_eng.pdf

The objective of management in puerperal sepsis is to make an early diagnosis, treat, prevent complications, and consequently to improve quality of life.

Isolation and barrier nursing care-Basic principle of care in puerperal sepsis cases is preventing the spread of infection to other women and their babies by providing isolation and barrier nursing care.

Administration of antibiotics- A combination of antibiotics is given until the woman is fever-free for 48 hours. If fever is still present 72 hours after starting the antibiotic regime, the doctor will re-evaluate the woman and her treatment. Referral to a higher level health facility may be necessary.

Tetanus toxoid- If there is uncertainty about tetanus vaccination, it should be given.

Plenty of fluids- Fluids are given to correct or prevent dehydration and help to lower the fever. In severe cases, it is necessary to give intravenous fluids at first. If the woman is conscious and no operative procedure is required in the next few hours, she may also be given oral fluids.

Ruling out retained placental fragments- Retained placental fragments can be a cause of puerperal sepsis. Digital exploration of the uterus to remove clots and large pieces of placental tissue will be required if retained placental pieces are suspected.

Care of the newborn- Unless the mother is very ill, the newborn can safely stay with her. However, precautions are necessary to prevent the infection passing from the mother to the newborn. Careful observation of the newborn is essential to recognize early signs of infection.

References-

apps.who.int/iris/bitstream/10665/44145/6/9789241546669_6_eng.pdf

www.gfmer.ch/SRH-Course-2010/national-guidelines/pdf/Management-

Puerperal sepsis may be localized in the perineum, vagina, cervix or uterus. In severe cases, it can extend beyond the uterus to involve the fallopian tubes and ovaries, to the pelvic cellular tissue causing parametritis, to the pelvic peritoneum, causing peritonitis and into the blood stream causing septicaemia.

Pelvic inflammatory disease and infertility may be delayed complications of the puerperal sepsis.

References-

apps.who.int/iris/bitstream/10665/44145/6/9789241546669_6_eng.pdf

www.healthline.com/health/puerperal-infection#Diagnosis5

Identification of risk factors, universal precautions for prevention of infection, and identification of symptoms and signs at early stage can significantly control and prevent puerperal sepsis.

Antenatal care- During routine antenatal care health care provider can recognize various risk factors and respond appropriately. Diagnosis and treatment of anaemia, diabetes mellitius, sexually transmitted infections; assessment with proper planning of certain conditions such as feto-pelvic disproportion can reduce the incidence of puerperal sepsis.

Intrapartum care- Supervised hospital delivery should be encouraged in order to prevent puerperal sepsis.

• To minimize the risk of maternal infection health care provider should maintain infection free environment.
•  Prevention of prolonged labour by the use of partograph is an essential element of intrapartum care, (aim is to deliver a woman within 18 hours of onset of labour).
• Conditions such as prolonged rupture of foetal membranes (rupture of membranes more than 12 hours), retained placenta early diagnosis and management is required, (For woman at term, aim is to deliver within 24 hours of rupture of membrane).

Post partum management- Infection after childbirth can be eliminated if good hygiene is practiced and if early signs of infection are recognized and treated in timely manner complications can be prevented. Regular observations of all vital signs (including temperature, pulse rate, blood pressure and respiratory rate) should be recorded on an obstetric warning score chart. All women who are unwell during the puerperium require regular and frequent observations.

Special emphasis should be given to the role of ASHA (Accredited Social Health Activist) and ANM (Auxillary nurse midwife) in promoting safe motherhood in the community by helping individuals, families and other community members to understand and contribute to safe motherhood.

References-

www.who.int/mediacentre/factsheets/fs348/en/

apps.who.int/iris/bitstream/10665/59429/1/WHO_