Puerperal Sepsis-Pyrexia and Hemorrhage

Major disorders or life-threatening condition of puerperium

Puerperium abnormalities often manifest in the second and third weeks, while they can frequently be noticed as early as six weeks into the puerperium stage. The following are typical puerperium complications:

• puerperal sepsis
  Infection of the vaginal tract within the first six weeks after giving birth is known as puerperal sepsis. Since it results from an organism's invasion, incubation, and multiplication, it often doesn't rise until 24 hours or longer after delivery. Unless otherwise demonstrated, genital tract infection is thought to be the cause of puerperal pyrexia.
• Puerperal pyrexia
  Puerperal pyrexia is defined as an increase in temperature of 100°F or higher on two distinct occasions, separated by 24 hours, during the first few days after delivery. In various regions of the world, it is an obvious condition.

Puerperal sepsis, UTI, breast problems, laboratory wound infection, intercurrent infections, thrombophlebitis, TB, and reasons of unknown origin are among the factors that contribute to puerperal pyrexia.

Causes

When thinking about the root of puerperal sepsis. The following things should be considered by the midwives.

• The infecting organism.
• The source of infection.
• The predisposing factor.

• The infecting organism
  The bacteria that cause puerperal sepsis are as follows:
  • Aerobic
    •  Examples of staphylococcus pathogens include Escherichia coli, klebsiella, pseudomonas, non-hemolytic streptococcus, and staphylococcus aureus.
  • Anaerobic
    • Clostridium welchii, bacteroids, and Clostridium tetani are examples of anaerobic streptococci.
• The source of infections
  • Endogenous sources
    • This typically results from an organism already existing in the patient's bowel and vagina. In healthy conditions, the organism is not harmful. If there is a laceration in the birth canal, they could become pathogenic and virulent.
  • Exogenous
    • organisms from the patient's attendant's septic foci and respiratory tract. The primary source of infection is dust from blankets, sheets, and other items in the ward's air. If proper precautions are not taken, the majority of hospital staff members who have Staphylococcus and streptococci in their respiratory tracts will easily infect their patients.
  • Autogenous
    • In this case, the patient's respiratory tract is typically the source of infection; however, septic foci can also be a source of infection.
• The predisposing factor
  The pathogenicity of the vaginal flora may be influenced by certain factors
  • Condition lowering the resistance-general or local.
  • Condition favoring multiplication and increased the virulence of the organisms.

Introduction of organisms from outside

• increased incidence of bacteria resistant to chemotherapy and antibiotics.
  • Antepartum factors
    • malnutrition and anemia.
    • pre-eclampsia
    • premature rupture of the membrane
    • chronic debilitating illness
    • sexual intercourse during late pregnancy.
    • Intrapartum factors
    • introduction of sepsis into the upper genital tract during internal examination especially after rupture of the membrane or during manipulative delivery.
    • dehydration and ketoacidosis during labour.
    • traumatic operative delivery.
    • hemorrhage-APH and PPH
    • retained bits of placental tissue and membrane.
    • prolonged Previa: placental site lying close to the vagina.
    • extensive lacerations of the perineum, vagina and cervix are important predisposing factors especially if the laceration are not stitched on time.

Types of puerperal sepsis

• Localized infection
  • There is a slight rise in temperature, generalized malaise or a headache.
  • The local wound becomes red and swollen.
  • Tachycardia, pain, and tenderness over the lower abdomen.
  • Pus may form which lead to disruption of the wound.
• Uterine infection
  • There is pyrexia of variable degree with a proportionate rise in pulse rate.
  • Lochia discharge becomes offensive, copious and often red.
  • The uterus is sub involuted, tender and softer than usual.
  • In severe cases, the onset is acute with high rise of temperature often with chills and rigors.
• Spread of infection
  a.spread of the femoral vein, iliac vein, inferior vena cava, fallopian tube,thrombophlebitis of the calf muscle and also pain on dorsiflexion.
• Peritonitis
• Septicemia
  • this may occur within 48 hours of delivery.
  • high fever
  • delirium
  • usually abdomen pain may be absent
  • joint pain
  • patient look very ill and toxic.

Prevention

Puerperal sepsis is to a great extent preventable. The Certain measure should undertake before, during and following labour.

• Antenatal
  • Detect and eradicate the septic focus especially located in the teeth, gums, tonsils,middle ears etc.
  • Maintain and improve the health status of the patient especially to raise Hb level, prevent eclampsia, early treatment of any abnormalities.
  • Vaginal examination during pregnancy especially in the last months should be kept to a minimum and should be carried out with strict surgical asepsis.
  • Intercourse should be avoided during the last two months to prevent introduction of organisms like streptococcus.
  • The patient should avoid contact with persons suffering from infectious diseases.
  • The patient should take care of personal hygiene.
• Intra-natal
  • The nurse ,doctor and other personnel entering into labour toom should wear mask, gown and cap to prevent infection.
  • The delivery should be conducted taking full surgical asepsis.
  • Membrane should be kept preserved as long as possible.
  • Well management on every step of labour which prevents possibility of infection.
  • Avoid prolonged labour to prevent exhaustion to the mother.
  • Traumatic vaginal delivery should be avoided but if required maintain strict surgical asepsis.
  • Dust should be avoided in the labour room.
  • Laceration of genital tract should be repaired promptly and meticulously with perfect homeostasis taking due aseptic precautions.
  • Excessive blood loss during delivery should be replaced promptly by blood transfusion to improve the general body resistance.
• Postnatal period
  • Aseptic precautions 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.
  • Nurse should take aseptic precaution and wear mask while giving perineal care.
  • Restrict too much visitors inward.
  • Sterilized sanitary pad should be used and change frequently to prevent lochia to decompose and become offensive on the pad.
  • Clean the vulval area with antiseptic solution after each urination and defecation.
  • Isolation ad well as barrier nursing measures for infected patients and infants is imperative.
  • Advice to avoid sexual intercourse for 4-6 weeks after delivery.

Management

• General
  • As soon as the patient is diagnosed puerperal sepsis, she should keep in separate room and care her in isolation room.
  • Use tepid sponge to help to decrease temperature.
  • Articles used to care the mother should be kept separately.
  • Identity the cause of fever and manage accordingly.
  • Midwives must wear gown, mask while caring the mother.
  • The patient's food or diet must be nutritious and digestible.
  • Encourage for adequate fluid intake.
  • Maintain the personal hygiene of patient by providing perineal care and encouraging to maintain oral hygiene.
  • Advice mother to empty the bladder frequently.
  • Intake and output chart should be maintained.
  • Monitor vital signs.
  • Fundal height and lochia should be checked daily.
• Specific treatment and urine.
• Send blood, urine and vaginal swabs for culture and sensitivity test then give antibiotics according to the result of CS. The most commonly used antibiotics are ;
  • Inj Ampicillin 2gm IV 6 hourly or inj cefotaxime 1 gm 8 hourly.
  • Inj. Gentamycin 5mg/kg/body weight daily 12 hourly.
  • Inj. Metronidazole 500mg/8 hourly IV.

The treatment should be continued until the infection is controlled for at least 10 days.

• Surgical treatment
  • I and D of abscess and perineal wound.