6b puerp sepsis 13sept2011

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Puerperal Sepsis
Maternal Health Division
Ministry of Health & Family Welfare
Government of India
BEMoC - Presentation 6 (b)
Session 6b

PUERPERAL SEPSIS
Government of India
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Objectives
 Define puerperal sepsis
 Acquire skills to diagnose , manage and refer
cases of puerperal sepsis

PUERPERAL SEPSIS
Government of India
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Puerperal Sepsis
Definition:
Puerperal sepsis is an infection of the genital tract at any
time between the onset of rupture of membranes or labour
and the 42nd day following delivery or abortion in which any
two or more of the following signs and symptoms are
present:
 Fever of >100.4 Fahrenheit (>38.5 ºC)
 Abnormal, Foul smelling vaginal discharge
 Lower abdominal pain
 Subinvoluted uterus which is tender

PUERPERAL SEPSIS
Government of India
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How Puerperal Sepsis Occurs ?
 Occurs due to colonization of the genital tract by
microorganisms
 Organisms can be introduced from within (infection
of endogenous origin), or from outside (infection of
exogenous origin).
• Endogenous Infections: bacteria living within
vagina brought into uterus by pelvic
examination, instruments, dead tissue.
Microorganisms ascend into the uterus during
premature & PROM.
• Exogenous Infections: introduced from
outside by unclean hands, unsterile
instruments, Foreign substances & sexual
activity

PUERPERAL SEPSIS
Government of India
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How Puerperal Sepsis Occurs ?
 Intrapartum:
• due to PROM & can cause Chorioamnionitis
 Extrapartum:
• may be localized or
• can spread and lead to parametritis,
peritonitis, septicaemia & DIC

PUERPERAL SEPSIS
Government of India
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Risk Factors for Puerperal Sepsis
Patient-related
 Poor patient hygiene
 Pre-existing anaemia &
malnutrition
 Pre-existing sexually
transmitted infections
(STIs)/RTIs
 Not immunized against
tetanus
 Pre-existing diabetes
Related to delivery
 Failure to follow Asepsis
 Frequent vaginal examinations
 Manipulations high in the birth canal
 Dead tissue in the birth canal
 PROM
 Prolonged/obstructed labour
 C- section/ Instrumental delivery
 Unrepaired vaginal/cervical
lacerations
 PPH

PUERPERAL SEPSIS
Government of India
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Risk Factors For Puerperal Sepsis – Contd...
Related to health service delivery
 Delivery by untrained persons
 Lack of asepsis during delivery
 Lack of routine postpartum care
 Inadequate monitoring of the temperature during prolonged
labour and after delivery
 Non-availability of proper antibiotics
 Inadequate management with appropriate antibiotics in a
case in whom puerperal sepsis has set in
 Further operative intervention in a case where puerperal
sepsis has set in

PUERPERAL SEPSIS
Government of India
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Causes of Fever in Puerperium
Infectious
 Localized infection of vaginal/cervical laceration or
episiotomy
 Infection of a laceration or episiotomy which has spread
to the underlying soft tissue
 Ischiorectal abscess
 Endometritis
 Salpingitis
 Parametritis
 Generalized peritonitis
 Septic thrombophlebitis
 Cystitis
 Acute Pyelonephritis

PUERPERAL SEPSIS
Government of India
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Causes of Fever in Puerperium: Infectious –
Contd...
 Tubo-ovarian abscess;
 Broad ligament abscess;
 Abscess in the pouch of Douglas
 Abscesses at other sites in the abdomen or chest
 Septicaemia
 Septic shock
 Breast infection such as mastitis or, at a later stage, breast
abscess
 UTI
 Malaria
 Wound infection
 Thromboembolic disorders (superficial thrombophlebitis &
DVT)

PUERPERAL SEPSIS
Government of India
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Non – Infectious
 Dehydration
 Tissue trauma
 Reaction to foetal proteins
 Breast engorgement

PUERPERAL SEPSIS
Government of India
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Most common causes are
 Endometritis
 Breast engorgement, mastitis, breast abscess
 Urinary tract infection
 Leg vein thrombosis
 Non obstetric causes

PUERPERAL SEPSIS
Government of India
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Features of Puerperal Sepsis
 High grade fever
 Tachycardia, hypotension
 Excessive or foul smelling discharge
 Persistent lower abdominal pain
 On abdominal examination, uterus feels soft,
tender and subinvoluted
 On per speculum examination, foul smelling
purulent discharge is seen which may be
blood stained.

PUERPERAL SEPSIS
Government of India
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Management of Puerperal Fever
 Detailed history regarding onset, severity and
associated symptoms
 Complete physical examination including general,
systemic and local examination
 Manage according to the underlying cause
 Blood & urine for routine & microscopic investigation
 Encourage increased oral fluid intake
 Cold sponging to help decrease temperature
 Antibiotics
 Treat the cause
 Refer if required

PUERPERAL SEPSIS
Government of India
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Management of Puerperal Sepsis
If the general condition of the woman is non toxic i.e., low
grade fever & pulse not rapid, give her a combination of
oral antibiotics
• Ampicillin 500 mg. QDS PLUS
• Tab Metronidazole 400mg. TDS PLUS
• Inj Gentamicin 80 mg. TDS
 Rule out presence of retained placental bits
 Monitor vitals every 2 hrly.
 Watch for 24 hrs
 If vital signs improving, then complete the course of
Antibiotic

PUERPERAL SEPSIS
Government of India
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Management of puerperal sepsis
If fever persists after 72 hours of initiating
antibiotics:
 Re-evaluate and consider other causes of fever
 Consider if antibiotic cover sufficient; and
 REFER to FRU

PUERPERAL SEPSIS
Government of India
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If the general condition of the woman is toxic i.e.,
with high grade fever & rapid pulse
 Start her on intravenous fluids and
 Give her the first dose of IV antibiotics:
• Ampicillin 1 gm IV PLUS
• Tab Metronidazole 500mg PLUS
• Inj Gentamicin 80 mg IM
 Rule out presence of retained placental bits
 Refer the woman to FRU immediately

PUERPERAL SEPSIS
Government of India
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PUERPERAL SEPSIS
Government of India
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Prevention
 Puerperal sepsis is to a great extent preventable;
 Measures to be taken in
• Antenatal Period:
 Improve Hb level to > 11 gms %
 Treat any septic focus (skin, throat etc.)
• Intranatal Period:
 Asepsis during delivery
• Postpartum Period:
 Maintain perineal hygiene
 Use of clean sanitary pad

PUERPERAL SEPSIS
Government of India
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Key Messages
 Puerperal sepsis is important cause of
maternal mortality and morbidity
 It is, to a great extent, preventable
 Early detection and treatment helps complete
recovery
 Serious cases require referral

6b puerp sepsis 13sept2011

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