PUERPERAL INFECTIONS

DEFINITION

Puerperal infection is an infection of the genital tract which occurs as a complication of

delivery is termed as Puerperal sepsis/Puerperal infection

CAUSATIVE ORGANISMS

• Doderlein bacillus (60-70%)

• Yeast like fungus –Candida albicans (25%)

• Staphylococcus albus or aureus

• Streptococcus –anaerobic

common

• Beta hemolyticus streptococcus

rare

• E.coli

• Clostridium welchii

INCIDENCE OF PUERPERAL INFECTIONS

• Puerperal infection morbidity affects 2 -10% of patient.5 -10 times

higher

in caesarean delivery.

• There is marked decline in puerperal infection due to:-

– Improved obstetric care

– Availability of wide antibiotic

COMMON PUERPERAL INFECTIONS

• Endo metritis

• Endo myometritis

• Endo parametritis

PREDISPOSING FACTORS

• Low host resistance

• Multiplication of organisms in the devitalized tissue usually starts the first two days

following delivery

• Introduction of organisms from outside

• Increased prevalence of organisms resistance to antibiotics

ANTENATAL FACTORS

• Malnutrition and anemia

• Preterm labor

• Premature rupture of membrane

• Prolonged rupture of membrane>18 hrs

• Chronic debilitating illness

INTANATAL FACTORS

• Repeated vaginal examination

• Traumatic operative delivery

• Dehydration and ketoacidosis during labour.

• Retained bits of placental tissue or membrane.

• Placenta praevia- placental site lying close to the vagina.

• Haemorrhage-antenatal or postnatal

• Caesarean delivery

MODE OF INFECTIONS

Puerperal infection is essentially a wound infection.

Placental sit lacerations of the genital tract or caesarean section wounds

may be infected.

PATHOLOGY

Puerperal infection is an wound infection.

The primary sites of the infection are:-

• Perineum

• Vagina

• Cervix

• Uterus

PERINUEM

Laceration of the perineum are likely to infected.

The wound edges become red and swollen.

There may be collection of purulent discharge resulting in complete

disruption of the wound.

VAGINA

• Vaginal laceration are infected directly or by extension from the perineal

infection.

• The mucosa is swollen and hyperaemic, resulting in necrosis

and sloughing.

CERVIX AND UTERUS

Cervix

• The cervical laceration become the site of infection

Uterus

• The uterus is most common site of infection

• Decidua is common site and infected first

• The infection usually manifests between 3rd and 6th day of delivery

SPREAD OF INFECTIONS

Pelvic cellulitis

• Infection of the pelvic peritoneum and levator ani muscles.

Salpingitis

• Infection of the fallopian tube and ovaries with the formation of Tubo

ovarian mass

Peritonitis

• Localised pelvic abscess

Thrombho-phelebitis

• Ovarian vein of one side is usually involved

• Uterine vein may also involved’Septicaemia and pyemia:-

• These may lead to endocarditis,pericarditis,

• Renal abscess, lung abscess, meningitis or artheritis.

Local infection-

• slight raise in temperature, generalised malaise and headache.

• Redness and the swelling of the local wound

• Pus formation and disruption of wound

Uterine infection(Mild)

• Pyrexia of variable degree and tachycardia.

• Red, copius and offensive lochia.

• Subinvoluted, tender and soft uterus.

Uterine infection(Severe infection)-

• Fever with chills and rigor

• Rapid pulse

• Scanty, odourless lochia

• subinvoluted uterus

SPREADING INFECTIONS

• Extra uterine spread is evident by presence of pelvic tenderness

• Tenderness on the fornix ( Parametritis )

• Bulging fluctuant mass in the pouch of Douglas(pelvic

abscess)

PARAMETRITIS

• Sustained rise in temperature (7th to 10th day)

• Constant pelvic pain

• Tenderness on either side of the hypogastrium

• Unilateral, tender mass felt on vaginal examination

• leukocytosis

PELVIC PERITONITIS

• Pyrexia with increased pulse rate

• Lower abdominal pain and tenderness

• Collection of the pus in pouch of Douglas

GENERALISED PERITONITIS

• High fever with rapid pulse

• Vomiting

• Abdominal pain

• Tender and distended abdomen

THROMBOPHELEBITIS

• swinging fever with chills and rigor

• Features of pyemia

SEPTICEMIA

• High temperature with rigor

• Rapid pulse

• Headache, insomnia or mental confusion

• Positive blood culture

• Sign/symptoms of infection in the lungs,meninges or joint

INVESTIGATIONS PRINCIPLES

1. To locate the site of infection

2. To identify the organisms

3. To assess the severity of the disease.

HISTORY ANTENATAL HISTORY

• History of Anemia

• Ante partum haemorrhage

• Presence of septic foci in teeth and gums and tonsils

• Debilitating disease like heart disease ,diabetes, tuberculosis and

urinary tract infection or malaria

INTRANATAL HISTORY

• Preterm labour.

• Duration of rupture of the membranes.

• Number of internal examination done outside and inside the hospital.

• Duration of labour.

• Method of delivery.

• Nature of intrauterine manipulation

POSTNATAL DETAILS

Nature of fever and associated symptoms with the site of

lesion.

BACTERIOLOGICAL STUDY

• Smear

• Culture and antibiotic sensitivity of purulent material

• High vaginal and cervical swabs

• Peritoneal fluids

• Blood culture

URINE

• Routine and microscopic examination

• Culture if infection is suspected

OTHER INVESTIGATIONS

• COMPLETE BLOOD COUNT

• ULTRASONOGRAPHY (For diagnosis of pelvic mass)

• Pelvic abscess

• Pelvic peritonitis

• Retained bits of placenta and/ or membrane

• OTHER SPECIFIC INVESTIGATIONS

• X – ray

• Blood for malaria parasite

PROPHYLAXIS OF PUERPERAL INFECTIONS ANTENATAL:

• Improvement of general condition

• Treatment of septic cocci

• Abstinence from sexual intercourse in the last two months

• Care about personal hygiene –bathing in dirty water to be avoided

• Avoiding contact with people having infection, such as cold, boils.

• Avoiding unnecessary vaginal examinations and douches in the later

months.

PROPHYLAXIS OF PUERPERAL INFECTIONS INTRANATAL:

• Staff attending on labor client should be free of infections.

• Full surgical asepsis to be taken while conducting delivery

• Women having respiratory tract infection or skin infection should be

admitted in single room or separate ward

• Membranes should be kept intact as long as possible and vaginal examination

should be restricted to minimum

INTRANATAL HISTORY

• Traumatic vaginal delivery and intrauterine manipulation should be preferably avoided.

If required should be done using fresh (sterile) gloves with liberal use of strong antiseptic solution.

• Laceration of the genital tract should be repaired promptly and meticulously with perfect

homeostasis

• Excessive blood loss during delivery should be replaced promptly by transfusion to improve the

general body resistance

• Prophylactic antibiotic must be administered in cases of premature rupture of membranes,

prolonged labor or following traumatic delivery.

PROPHYLAXIS OF PUERPERAL INFECTIONS POSTNATAL HISTORY:

• Take aseptic precautions while dressing the perineal wound

• Restriction of the visitor in the postpartum ward

• Mothers to be instructed to use sterile sanitary pads and to change them frequently

• Vulva and perineum to be cleaned with mild antiseptic solution following urination

and defecation

• Infected mothers and babies are to be isolated

TREATMENT NURSING CARE

• Isolation

• Adequate fluid and calorie is supplied if needed by IV infusion

• Anemia is corrected by oral Iron and if needed by blood transfusion

• Pain is relieved by adequate analgesia

• An indwelling catheter is used to relive any urine retention due to pelvic

abscess.

• Chart is maintained by recording vital signs, lochial discharge and fluid

intake and output

ANTIBIOTICS

• Ideal antibiotics regime should depend on the culture and sensitivity report.

• Gentamycin 2mg/kg IV loading dosed followed by 1.5 mg/kg IV Q8H

and

Amphicllin 1gm IV Q6H

or

Clindamycin 900mg IV Q8H should be started

• Or

Ceftaxime IV 1gm Q8H

• Metronidazole 0.5 IV Q8H to control anaerobic group

• Treatment should be for 7-10 days

SURGICAL TREATMENT

There is a very little role of major surgery in the treatment of puerperal

sepsis

PUERPERAL WOUND

The stitches of the perineal wound may have to be removed to facilitate

drainage of pus and relieve pain.

SEPTIC PELVIC THROMBOPHELEBITIS

Treated with IV Heparin for 7-10 days