Puerperal Sepsis: Causes, Symptoms, and Treatment

Introduction

Puerperal sepsis is a bacterial infection of the genital tract of the female following childbirth or miscarriage. It causes after the first 24 hours and within the first 42 days after delivery. It is also known as postpartum infection and child head or puerperal fever. Puerperal sepsis occurs when bacteria infect the uterus and surrounding areas after a female gives birth to a child. Puerperal sepsis occurs when a temperature of 38 degrees Celsius or higher occurs for more than two consecutive days, leaving the first postpartum day. According to World Health Organization (WHO), around five lakh women die due to childbirth problems, and 15 percent are associated with puerperal sepsis. The incidence is higher in cesarean delivery as compared to normal delivery. Puerperal sepsis is the most common cause of death not only in developing countries but also in developed countries. In middle and low-income countries, the burden of puerperal sepsis is more.

What Are the Types of Puerperal Sepsis?

Puerperal sepsis infections are described in three distinct areas where they may occur. These include:

• Endometritis (inflammation of the uterus lining).

• Endomyometritis (inflammation of the uterine muscle).

• Endoparametritis (also known as pelvic cellulitis) supports tissue around the uterus.

• The most common postpartum infection is endometritis. Once the lining of the uterus undergoes trauma and tear during childbirth. The damage can provide an entrance for infection to develop. Infection to the uterus muscle and the structure supporting the uterus may form at the incision site, such as in a cesarean section.

What Are the Causes of Puerperal Sepsis?

An entire uterus is considered sterile. The bacteria cause the infection by invading through damaged skin. The postpartum infection starts immediately after the mother's water breaks. The causal organisms include.

• Aerobic Bacteria: This includes Group A beta-hemolytic streptococcus, Group B beta-hemolytic streptococcus, and methicillin-resistant Staphylococcus aureus.

• Anaerobic Bacteria: This includes streptococcus (present in injurious labor and unskilled instrument delivery), fusobacteria, and clostridia (present in the lower bowel).

• Others: Streptococcus pyogenes, staphylococcus aureus (inhabitant of the skin and pustular eruptions), pseudomonas, klebsiella, and escherichia coli (present in the lower bowel).

What Is the Risk Factor of Puerperal Sepsis?

The risk of developing puerperal sepsis depends upon the method used to deliver the baby. The chance of puerperal sepsis is more common in cesarean delivery. Medical diseases such as diabetes, high blood pressure, and an impaired immune system may increase the chances of infection. The risk factors include

1. Antepartum (Prenatal) -

• Malnutrition (deficiency of excess nutrients).

• Anemia (low level of red blood cells).

• Preterm labor.

• Early rupture of membrane.

• Diabetes.

• Obesity.

2. Intrapartum (From the Onset of Labor Through the Delivery of the Placenta) -

• Cesarean delivery.

• Hemorrhage (bleeding from the blood vessels).

• Dehydration.

• Traumatic vaginal delivery.

• Retained pieces of the placental membrane.

• Prolonged rupture of membrane.

• The placenta site lies close to the vagina.

How Does Puerperal Sepsis Spread?

• The endometrium, vaginal wound, or perineal deep-cut wound are favorable sites for bacteria growth.

• The weakened tissue, blood clots, retained cotton swabs, and surgical trauma favor the growth of bacteria, multiplication, and spread of infection.

• It leads to metritis (inflammation of the uterus), endometritis (inflammation of the lining of the uterus), and parametritis (inflammation of the surrounding areas of the uterus).

What Are the Sign and Symptoms of Puerperal Sepsis?

Based on the location, the symptoms are described in three phases. These include.

1. Local or Wound Infection - The symptoms include:

• Rise in temperature.

• Headache.

• Generalized malaise (feeling of illness and discomfort).

• Redness and swelling of the local wound.

• Chills.

• Pus formation.

• Disruption of the wound.

2. Uterine Infection - The symptoms include:

• Rise in temperature to more than 100.4 degrees Fahrenheit.

• Rise in pulse rate (more than 90).

• Lochial discharge (vaginal discharge) becomes red and offensive.

• The uterus becomes tender.

3. Severe Infection - The symptoms include:

• The high rise of temperature.

• Chills.

• Rapid pulse rate.

• Breathlessness.

• Abdominal pain.

• Dysuria (painful urination).

How is Puerperal Sepsis Diagnosed?

The investigation includes:

1. History - The doctor will ask the patient about the previous delivery, fever, pain, and foul smelly vaginal discharge.

2. A Complete Blood Count Test (CBC) - It is done for white blood cells and hemoglobin estimation. A platelet count may indicate septicemia (bloodstream infection).

3. Vaginal and Endocervical Swabs - These are required for culture in aerobic and anaerobic media.

4. Urine Examination - It is done for routine and microscopic examination.

5. Pelvic Ultrasound - The test is used to locate any abscess in the pelvis and any retained pieces of the placenta.

6. Chest X-Ray - A chest X-ray is used to detect any lung pathology.

7. Blood Urea and Electrolyte - These tests are prescribed to detect renal failure.

How is Puerperal Sepsis Managed?

The management of puerperal sepsis can be done in three ways. It includes:

1. Medical Management - Ideal antibiotics are prescribed based on the culture and sensitivity report, including Gentamycin (1.5mg/kg/8 hourly) plus Clindamycin (900 mg/8 hourly), Metronidazole (500mg/12 hourly) plus Penicillin (5 million units / 6 hours), and Clindamycin plus Aztreonam (2gm/8 hours).

2. Surgical Management - The doctor will open and drain the infected episiotomy (a surgical cut made at the opening of the vagina during childbirth). Removal of the clot, damaged or necrotic tissue is done. A hysterectomy ( a surgical operation to remove part of the uterus) is done, followed by surgical evacuation (the amniotic fluid, placenta, and fetus are suctioned through a cannula).

3. Nursing Management - The nurse isolates the patient and administers adequate fluids to the patient. Anemia is to be corrected by giving iron supplements and a change in diet. A chart is maintained by the nurse for recording pulse, blood pressure, temperature, and respiratory rate. The wound is cleaned with a sitz bath several times daily. The doctor manages the abdominal wound in cesarean section by scrubbing the wound twice daily and closing the wound with a secondary suture.

How Can Puerperal Sepsis Be Prevented?

Puerperal sepsis can be prevented by following ways.

1. Antenatal - It includes:

• Improvement of the nutritional status to raise the hemoglobin level of pregnant women.

• Treatment of the septic cocci (treating the bacterial invasion to prevent further spread).

• Care about personal hygiene.

• Avoid contact with people having an infection.

• Avoiding unnecessary vaginal infections.

2. Intranatal - It includes:

• Aseptic precautions are to be taken while conducting delivery.

• Staff attending to labor women should be free from infection.

• The use of antibiotics during cesarean delivery will reduce the incidence of wound infection and urinary tract infection.

• Traumatic vaginal delivery must be avoided.

• Blood transfusion can be done in case of excessive bleeding.

3. Postpartum - It includes:

• Perineal wound dressing must be done under aseptic conditions.

• Sterile sanitary pads can be used.

• Visitors must be restricted in the postpartum ward.

• Infected mother and baby should be isolated.

• The vulva and perineum are to be cleaned with an antiseptic solution.

Conclusion

Puerperal sepsis results from infection infected during childbirth. An increase in the health facilities for labor, delivery care, proper monitoring, and checks leads to a decrease in the death rate of puerperal sepsis. Drug and technological development must be combined with an effective health system to decrease infection. The hospital staff must follow the proper labor and delivery care guidelines to reduce puerperal sepsis, in which hand hygiene and using sterile instruments are important to eliminate bacterial invasion.