Puerperal sepsis: Causes, Symptoms, Treatment and Prevention

Puerperal sepsis is an infection of the genital tract that occurs at any time between the rupture of membranes in labour and 42 day following delivery or abortion threatens the well-being of both mother and child in postpartum period. This is may be caused by endogenous bacteria or exogenous bacteria.

What is puerperal sepsis?

Puerperal sepsis is an infection of the genital tract during the first 6–8weeks of delivery or abortion.  Pyrexia in puerperium is often caused by postpartum sepsis or extragenital causes like pyelonephritis, mastitis, and pneumonia. In some developed countries, puerperal pyrexia is a notifiable case if the temperature gets to 37.7oC within 14 days.

Signs and symptoms of postpartum infection

  • Pelvic pain
  • Fever 38.50C or more
  • Abnormal odour or foul- smelling vaginal discharge
  • Delay in the rate of reduction of the size of the uterus.(subinvolution).

Causes of puerperal sepsis

In considering the causes of postpartum sepsis, the midwife should ponder of these three factors:

  • The infecting microbes/organisms
  • The source of the infection
  • The risk factors

The organisms causing puerperal sepsis

The microbes responsible for puerperal sepsis are under four groups:

  • Streptococcus pyrogenes: The patient may be infected with Streptococcus pyrogenes from the respiratory tract of her care provider.
  • Escherichia Coli (E.Coli): The patient may get infected with these microbes from her own perineum and gastrointestinal tract.
  • Staphylococcus pyrogenes: The patient is infected with Staphylococcus pyrogenes from the throat or skin lesions (e.g. boils and septic fingers) of care providers or from bed clothes.
  •  Anaerobic streptococci and other anaerobic microbes such as Clostridium tetani or welchii.

Anaerobic streptococci from the patient’s bowel can infect her.  Infection with Clostridium tetani or welchii can occur due to taking delivery in unhygienic environment or use of rusty, unsterile instruments.

Puerperal sepsis

Risk/predisposing factors to genital tract infection/postpartum infection

  • Prolonged labour, with repeated vaginal examination during the course of labour is a direct cause of infection in puerperium.
  • Anaemic, malnourished and debilitated patients: These patients are prone to develop puerperal infection than those who are well-nourished and healthy.
  • Extensive lacerations of the perineum, vagina and cervix are crucial risk factor of infection especially if the lacerations are not properly sutured in time.
  • Patients who are untreated or poorly treated for antepartum haemorrhage and/ or postpartum haemorrhage have reduced immunity to withstand infection.
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For better understanding these risk factors for puerperal sepsis include:

  • Poor hygiene
  • Poor aseptic technique
  • Manipulations in birth canal
  • Presence of dead tissue in the birth canal due to IUFD (intrauterine foetal death)
  • Retained fragments of placenta or membranes
  • Shedding of dead tissue from vaginal wall following obstructed labour.
  • Insertion of unsterile hand, instrument or packing
  • Traditional practices should also be examined
  • Pre-existing anaemia and malnutrition
  • Prolonged of obstructed labour
  • Prolonged rupture of membrane
  • Frequent vaginal examinations
  • Caesarean section and other operative deliveries
  • Unrepaired vaginal or cervical lacerations
  • Pre-existing sexually transmitted disease
  • Post-partum haemorrhage
  • Not being immunized against tetanus.

 Common sites of puerperal infection

Women are vulnerable to infection because the placental site is large, warm, dark moist, rich to grow microorganisms very quickly. 

During delivery, traumatized tissue or tear in the vagina or perineal area is susceptible to infection.

Types of puerperal infection

Genital tract Infections or postpartum infections are grouped into:

  • Localized: This infection results in local sepsis of the perineum, vagina, uterus, oviducts and ovaries. An unstitched or poorly stitched vaginal and perineal laceration can become infected, thereby contributing to postpartum infection
  • Widespread: This is an infection that extends beyond the uterus and spread into the pelvic cellular tissues, lymphatics and pelvic veins but not entering the general or systemic circulation.
  • Infection that spread into the peritoneum, resulting in peritonitis.
  • The infections that are blood-borne, resulting in septicaemia.

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The source of postpartum infection

The source of the infection may be attributed to:

  • Autogenous
  • Endogenous
  • Exogenous
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Autogenous source of postpartum infection

In this case, the source of the infection is from the patient’s respiratory tract. Septic foci in her body can also be a source of infection.

Endogenous source of postpartum infection

This is often from microbes already present in the patient’s vagina and bowel. These organisms are non-pathogenic in normal conditions but they become virulent and pathogenic if there is laceration of the birth canal.

Exogenous source of postpartum infection

Organisms from the patient’s respiratory tract and septic foci of the patient’s care provider, the dust in the air of maternity wall from blankets, sheets, and so on are the main sources of this infection. 

Unfortunately, most of hospital staff (doctors, nurses and midwives) harbour staphylococci and streptococci in their respiratory tract and would readily infect their patients if proper precautions are not taken. Infections gotten from hospital are called nosocomial infections

How to manage postpartum infection

  1. Isolation and Barrier nursing of the woman: Nurse the woman in a separate room, use  gloves only when attending her keep one set of equipment, dishes and other utensils for the use of this woman, wash hands carefully before  and after attending this woman.
  2. Administration of high doses of antibiotics / Broad spectrum: This would eradicate the causative bacteria of the postnatal infection.
  3. Give supportive medications:  These may include antimalarial therapy and haematinics. Patients infected with Clostridium tetani or welchii should be treated with anti-tetanus serum and anti-gasgangrene serum.
  4. Give plenty of fluids: This helps correct or prevent dehydration and also lowers the fever. In severe cases, it is necessary to give IV fluids at first. Copious fluid intake (e.g. water, fruit juice, milk, and beverage) and adequate nutrition is essential to regenerate maternal system.
  5. Ruling out Retained placental fragments: Suspect this if the uterus is soft and bulky, if lochia are excessive and contain blood clots, it can be a sign of puerperal sepsis. The woman should be referred to a facility that has the equipment and health care personnel trained to perform curettage.
  6. Providing skilled nursing care: Careful attention to the comfort of the woman. It is important for the woman to rest, monitor uterine size, measure intake and out pout, keep accurate recurs, prevent spread of infection and cross infection .Accurate observation, recording and reporting. Ensure proper charting of fluid intake and urinary output.
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Prevention of puerperal sepsis

The following tips would be of great help to prevent postpartum infection:

  • Anaemia and other conditions that reduce the patient’s immunity should be properly treated during antenatal visits.
  • All septic foci in the patient such as sore throat, infected tonsils or teeth should be well-treated during pregnancy.
  • Prolonged and debilitating labour and traumatic deliveries should be prevented.
  • Nose and throat swabs of all the doctors and midwives should be thoroughly examined bacteriologically and all those harbouring haemolytic streptococci or staphylococci should be properly treated with correct antibiotics and suspended from attending to patients until these microbes are totally eliminated from their respiratory tract.
  • All health care providers should wear masks, and observe strict aseptic and antiseptic techniques such as wearing sterile gowns and gloves, scrubbing of hands, use of antiseptic lotions and lubricants) during vaginal examination or while taking deliveries.
  • Provision of respectful and evidence-based care and eliminate unnecessary procedures capable of causing infections
  • Dust in the labour and lying-in wards should be meticulously cleaned and avoided.
  • Isolation and barrier nursing of infected patients and infants is highly beneficial