Puerperal infections

1. PUERPERAL INFECTIONS
Mrs.Jagadeeswari.J
M.Sc (N)

2. DEFINITION
Puerperal infection is an infection of the
genital tract which occurs as a complication
of delivery is termed as Puerperal sepsis
/Puerperal infection
-D.C.DUTTA

3. 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

4. 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

5. COMMON PUERPERAL
INFECTIONS
• Endometritis
• Endomyometritis
• Endoparametritis

6. 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

7. Cont..ANTENATAL FACTORS
• Malnutrition and anemia
• Preterm labor
• Premature rupture of membrane
• Prolonged rupture of
membrane>18 hrs
• Chronic debilitating illness

8. Cont..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

9. MODE OF INFECTIONS
Puerperal infection
is essentially a wound
infection. Placental site
lacerations of the genital
tract or caesarean
section wounds may be
infected.

10. PATHOLOGY
Puerperal infection is an
wound infection. The primary sites
of the infection are:-
• Perineum
• Vagina
• Cervix
• Uterus

11. 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.

12. VAGINA
• Vaginal laceration are infected
directly or by extension from the
perineal infection.
• The mucosa is swollen and
hyperaemic, resulting in necrosis
and sloughing.

13. 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

14. 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

15. CONT…
Thrombhophelebitis :-
• 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.

16. CLINCAL FEATURES
Local infection-
• slight raise in temperature,
generalised malaise and
headache.
• Redness and the swelling of
the local wound
• Pus formation and disruption
of wound

17. CONT..
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

18. 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)

19. 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

20. PELVIC PERITONITIS
• Pyrexia with increased pulse
rate
• Lower abdominal pain and
tenderness
• Collection of the pus in pouch
of Douglas

21. GENERALISED PERITONITIS
• High fever with rapid pulse
• Vomiting
• Abdominal pain
• Tender and distended
abdomen
THROMBOPHELEBITIS
• swinging fever with chills and
rigor
• Features of pyemia

22. 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

23. INVESTIGATIONS
PRINCIPLES
1. To locate the site of
infection
2. To identify the organisms
3. To assess the severity of
the disease.

24. 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.

25. 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.

26. POSTNATAL DETAILS
Nature of fever and
associated symptoms
with the site of lesion.

27. BACTERIOLOGICAL STUDY
• Smear
• Culture and antibiotic sensitivity
of purulent material
• High vaginal and cervical swabs
• Peritoneal fluids
• Blood culture

28. URINE
• Routine and microscopic
examination
• Culture if infection is
suspected

29. 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

30. 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.

31. 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

32. CONT..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.

33. 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

34. 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.

35. 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 IV Ceftaxime 1gm Q8H
• Metronidazole 0.5 IV Q8H to control
anaerobic group
• Treatment should be for 7-10 days

36. 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.

37. RETAINED UTERINE PRODUCTS
With a diameter of 3cm
or less may be disregarded
and left alone. Otherwise
surgical evacuation after
antibiotic coverage for 24hrs
should be done to avoid the
risk of septicemia.

38. SEPTIC PELVIC
THROMBOPHELEBITIS
Treated with
IV Heparin for 7-
10 days

39. PELVIC ABSCESS
Pelvic abscess
should be drained by
colpotomy under
ultrasound guidance.
Abscess above the
poupart’s ligaments should
be incised and the pus
drained

40. LAPROTOMY(Limited indication)
Maintenance of
electrolyte balance by
intravenous fluids along with
appropriate antibiotic therapy
usually control the Peritonitis.
However in unresponsive
Peritonitis laprotomy is
indicated .even if no palpable
pathology is found ,drainage
of pus may be effective.

41. HYSTERECTOMY
It is indicated in cases with
rupture or Perforation having
multiple abscess ,gangrene
infection , Ruptured Tubo-
Ovarian abscess should be
removed.

42. MANAGEMENT OF BACTERAEMIC
SEPTIC SHOCK
• Fluid and electrolyte balance (to
maintain CVP)
• Respiratory support (to maintain
arterial Po2 and Pco2)
• Circulatory support
• Infection control
• Surgical removal of septic foci
• Specific management(as
haemodialysis for renal failure)