Fever and infection are common complications in the puerperium and range from mild rises in temperature (for example, in the context of lactation), wound infections, urinary tract infections, and mastitis to a severe, sometimes septic course due to endomyometritis.

1. PRACTICE TEACHING
ON
DISORDER OF PUERPERIUM
DR.ANJALATCHI MUTHUKUMARAN
VICE PRINCIPAL
ERA COLLEGE OF NURSING

2. GENERAL OBJECTIVE:
After completion of the topic, the students will be able
to gain knowledge about disorders of puerperium and
they can apply their knowledge in clinical area also.

3. SPECIFIC OBJECTIVES: after the completion of
the lesson plan the students will be able to
 Introduction of puerperium, types of puerperium and disorder of
puerperium
 Puerperal pyrexia definition, causes, risk factors, pathogenesis
investigations and management
 Puerperal sepsis definition, causes, investigations and management
 Sub-involution, causes, sign and symptoms, management
 Urinary complications in puerperium and treatments
 Breast complications, its types and treatment of breast complications.

4. INTRODUCTION OF PUERPERIUM
Following the birth of a baby, placenta and
membranes, the newly birthed mother enters a
period of physical and emotional/psychological
recuperation.
Skin to skin contact is advocated immediately
following birth and during the postnatal period as
there is clear evidence of benefit to the mother and
baby.

5. Definition of normal Puerperium
 Puerperium is the period following childbirth
during which the body tissues, especially the
pelvic organs revert back approximately to the
prepregnant state both anatomically and
physiologically.
 Involution: involution is the process whereby the
genital organs revert back approximately to the
state as they were before pregnancy.
 The women is termed as a puerpera.

6. Duration: puerperium begins as soon as placenta is
expelled and lasts for approximately 6 weeks
where the uterus becomes regressed almost to the
nonpregnant size.
The period is divided into:
 Immediate- within 24 hours
 Early- up to 7 days
 Remote- up to 6 weeks.
• Similar changes occurs following abortion but takes a
shorter period for the involution to complete.
• Fourth trimester is the term from delivery until
complete physiological involution and psychological
adjustment.

7. DISORDERS OF PUERPERIUM

8. PUERPERAL PYREXIA
Definition: A rise of temperature reaching100.4°F
(38°C) or more (measured orally) on two separate
occasions at 24 hours apart (excluding first 24
hours) within first 10 days
following delivery is called
puerperal pyrexia.
In some countries,
Postabortal fever is also
included.

9. CAUSES OF PUERPERAL PYREXIA
 Puerperal sepsis
 Breast abscess
 Pulmonary infection:
pneumonia
 Recrudescence of
malaria or pulmonary
tuberculosis.
 Urinary complication.
 Others: pharyngitis,
gastroenteritis.

10. INVESTIGATION OF PUERPERAL PYREXIA
 A case of puerperal pyrexia is considered to be
due to genital sepsis unless proved otherwise.
 History: Antenatal, intranatal and postnatal history
of any high risk factor for infection like anemia,
prolonged rupture of membranes or prolonged
labor are to be taken.
 Clinical examination includes thorough general,
physical and systemic examinations. Abdominal and
pelvic examinations are done to note the
involution of genital organs and locate the specific
site of infection. Legs should be examined for
thrombophlebitis or thrombosis.

11.  Investigations include:
1. High vaginal and endocervical swabs for
culture in aerobic and anaerobic media
and sensitivity test to antibiotics.
2. “Clean catch” midstream specimen of urine
for analysis and culture including sensitivity test.
3. Blood for total and differential white cell
count, hemoglobin estimation. A low platelet
count may indicate septicemia or DIC. Thick blood film
should be examined for malarial parasites.
4. Blood culture, if fever is associated with chills and
rigor. Other specific investigations as per the clinical
condition are needed.

12. (5). Pelvic ultrasound is helpful—(i) to detect any
retained bits of conception within the uterus, (ii) to
locate any abscess within the pelvis, (iii) to collect
samples (pus or fluid) from the pelvis for culture and
sensitivity, and (iv) for color flow Doppler study to
detect venous thrombosis. Use of CT and MRI is needed
especially when diagnosis is in doubt or there is pelvic
vein thrombosis.
(6). X-ray chest (CXR) should be taken in cases with
suspected pulmonary Koch’s lesion and also to detect
any lung pathology like collapse and atelectasis
(following inhalation anesthesia).
(7). Blood urea and electrolytes may be done in a
selected case to have a baseline record in the event
that renal failure develops later in the course of the
disease or laparotomy is needed.

13. Treatment
Treatment of puerperal infection usually
begins with I.V. infusion of broad spectrum
antibiotics and is continue for 48 hours
after fever is resolved.
Supportive care.
Symptomatic treatment.

14. Prevention
 Avoid the risk factors.
 Keep the episiotomy site clean.
 Careful attention to antiseptic procedures during
childbirth is the basic underpinning of preventing
infection. With some procedures, such as cesarean
section, a doctor may administer prophylactic
antibiotics as a preemptive strike against infectious
bacteria.

15. PUERPERAL SEPSIS (Syn: puerperal infection)
Definition: An infection of the genital tract which
occurs as a complication of delivery is termed
puerperal sepsis.
Definition: the infection of the
genital tract occurring at labour
or within 42 days of the postpartum period called
puerperal sepsis. - WHO
• Puerperal pyrexia is considered
to be due to genital tract infection
unless proved otherwise.

16.  There has been marked decline in puerperal
sepsis during the past few years due to:
(1) improved obstetric care
(2) availability of wider range of antibiotics.
 Puerperal sepsis is commonly due to:
(i) endometritis, (ii) endomyometritis
(iii) endoparametritis or a combination of all these
when it is called pelvic cellulitis.

17. Predisposing factors of puerperal sepsis
Antepartum Intrapartum
• Malnutrition
• Anemia
• Preterm labor
• Early rupture of membrane – PROM
• Precipitate delivery
• Immunocompromised diseases-
AIDS
• Diabetes
• Obesity
• Organisms of normal vaginal flora.
• Repeated vaginal examinations
• Dehydration
• Ketoacidosis during labor
• Traumatic vaginal delivery
• APH OR PPH
• Retained bits of placental tissue or
membranes
• Prolonged labor
• Obstructed labor
• Caesarean section or instrumental
delivery.

18. Organisms of normal vaginal flora
Vaginal flora: The vaginal flora in late pregnancy and at
the onset of labor consists of the following organisms:
• Doderlein’s bacillus (60–70%)
• Yeast-like fungus with increased prevalence of
Candida albicans (25%)
• Staphylococcus albus or aureus
• Streptococcus—anaerobic common; beta-hemolytic
• Escherichia coli and Bacteroides group
• Clostridium welchii on occasion
These organisms remain dormant and are harmless
during normal delivery conducted in aseptic condition.

19. Microorganisms responsible for puerperal
sepsis
 Aerobic
—Group A beta-hemolytic Streptococcus (GAS)
—Group B beta-hemolytic Streptococcus (GBS) is a significant
-Methicillin-resistant S. aureus (MRSA) causes severe infection.
 Anaerobic—Streptococcus, Peptococcus, Bacteroides
(fragilis, bivius), Fusobacteria, Mobiluncus and Clostridia.
 Others—Staphylococcus pyogenes, S. aureus, E. coli,
Klebsiella, Pseudomonas, Proteus, Chlamydia.
Most of the infections in the genital tract are polymicrobial
with a mixture of aerobic and anaerobic organisms.

20. Mode of infection
Puerperal sepsis is essentially a wound infection.
Placental site (being a raw surface), lacerations
of the genital tract or cesarean section wounds
may be infected in the following ways:
Source of infection:
Endogenous where organisms are present in the
genital tract before delivery. E.g. streptococcus.
Exogenous where infection is contracted from
sources outside the patient (from hospital or
attendants). E.g. Beta hemolytic Streptococcus,
E. coli, Staphylococcus.

21.  Autogenous where organisms present elsewhere (skin,
throat) in the body and migrate to the genital organs by
bloodstream or by the patient herself. E.g. Beta
hemolytic Streptococcus, E. coli, Staphylococcus are
important.
 Pathology: The primary sites of infection are: (1)
perineum, (2) vagina, (3) cervix, (4) uterus. The
infection is either localized to the site or spreads to
distant sites. The lacerations on the perineum, vagina
and the cervix are often infected by the organisms due
to the presence of blood clots or dead space. The
wounds become red, swollen and there is associated
seropurulent discharge. There may be disruption of the
wound if repaired before control of infection.

22. Pathogenesis
Endometrium (placental implantation site), cervical lacerated
wound, vaginal wound or perineal lacerated wound are the
favorable sites for bacterial growth and multiplication.
The devitalized tissue, blood clots, foreign body (retained
cotton swabs) and surgical trauma favour Polymicrobial growth,
proliferation and spread of infection.
This ultimately leads to metritis, Parametritis, endomyometritis
and/ or cellulitis. Puerperal sepsis is commonly due to – (I)
Endometritis (II) endomyometritis (III) endoparametritis or a
combination of all these when it is called pelvic cellulitis.

23. Sign and symptoms
based on severity and area its divided into:
 Local infection
 Uterine infection
 Spreading infection
Local infection (Wound infection): (1) There is
slight rise of temperature, generalized malaise or
headache, (2) The local wound becomes red and
swollen, (3) Pus may form which leads to disruption
of the wound. When severe (acute), there is high
rise of temperature with chills and rigor.

24. Rise temperature Generalized malaise Headache

25. Uterine infection
 Mild—(1) There is rise in temperature (>100.4°F)
and pulse rate (>90), (2) Lochial discharge becomes
offensive and copious, (3) The uterus is
subinvoluted and tender.
 Severe—(1) The onset is acute with high rise of
temperature, often with chills and rigor, (2) Pulse
rate is rapid, out of proportion to temperature, (3)
Often there is breathlessness, coughs, abdominal
pain and dysuria, (4) Lochia may be scanty and
odorless, (5) Uterus may be subinvoluted, tender
and softer. There may be associated wound
infection (perineum, vagina or the cervix).

26. Spreading infection (extrauterine
spread) is evident by presence of pelvic
tenderness (pelvic peritonitis),
tenderness on the fornix (parametritis),
bulging fluctuant mass in the pouch of
Douglas (pelvic abscess).

27. Complications
 Pelvic tenderness
 Pelvic peritonitis
 General peritonitis
 Tenderness on the fornix
 Endometritis, endomyometritis, endoparametritis
 Bulging fluctuant mass in the pouch of Douglas
 Pelvic abscess
 Phlebitis, thrombophlebitis
 Bacteremia, endotoxic or septic shock
 Septicemia

28. Septicemia may leads to:
• Streptococcal pharyngitis
• Rheumatic fever
• Rheumatic heart disease
• Scarlet fever
• Erysipealas cellulitis
• Necrotizing fascilitis
• Streptococcal toxic shock syndrome

29. Diagnostic evaluation
General principles in investigations are:
• To locate the site of infection
• To identify the organisms
• To assess the severity of the disease.
Investigation of puerperal pyrexia includes:
• History
• Clinical examinations
• Lab findings and investigations

30. Prophylaxis
 Puerperal sepsis is to a great extent preventable
provided certain measures are undertaken before,
during, and following labor.
 Antenatal prophylaxis includes improvement of
nutritional status (to raise hemoglobin level) of the
pregnant woman and eradication of any septic focus
(skin, throat, tonsils) in the body.
 Intranatal prophylaxis includes—(a) Full surgical
asepsis during delivery, (b) Screening for Group B
Streptococcus in a high risk patient. Prophylactic use
of antibiotic is not recommended as a routine, (c)
Prophylactic use of antibiotic at the time of cesarean
section has significantly reduced the incidence of
wound infection, endometritis, urinary tract infection
and other serious infections.

31. Postpartum prophylaxis includes aseptic
precautions for at least 1 week, following
delivery until the open wounds in the
uterus, perineum, and vagina are healed
up. Too many visitors are restricted.
Sterilized sanitary pads are to be used.
Infected babies and mothers should be in
isolated room.

32. Treatment
Medical management
Surgical management
Nursing management

33. General care:
 Isolation of the patient is preferred especially when
hemolytic Streptococcus is obtained on culture
 Adequate fluid and calorie are maintained by
intravenous infusion
 Anemia is corrected by oral iron or if needed by
blood transfusion
 An indwelling catheter is used to relieve any urine
retention due to pelvic abscess. It also helps to
record urinary output
 A chart is maintained by recording pulse, respiration,
temperature, lochial discharge, and fluid intake and
output.

34. Medical management
Antibiotics: Ideal antibiotic regimen should depend on the culture and
sensitivity report.
 Gentamicin (2 mg/kg IV loading dose, followed by 1.5 mg/kg IV
every 8 hours) +clindamycin (900 mg IV every 8 hours) should be
started.
 Metronidazole (500mg/12 hrs.) + Penicillin (5 million units/6 hrs.)
to control the anaerobic group.
 Clindamycin + Aztreonam (2 gm./8 hrs.)
 Ampicillin (2 gm./6 hrs.) + Gentamycin
 Antibiotics regimens- a combination of either piperacillin-
tazobactam or carbapenem.
 Women's with MRSA (Methicillin-resistant S. aureus) infection should
be treated with Vancomycin or teicoplanin.
 The treatment is continued until the infection is controlled for at
least 7–10 days.

35. Surgical management
Stitches of the perineal wound
Surgical evacuation
Colpotomy
Laparotomy
Hysterectomy

36. Nursing management
 Isolate to the patient
 Adequate fluid and calorie
 Correcting anemia
 Indwelling catheter
 A chart is maintained by recording temperature, pulse,
respiration, lochial discharge and fluid intake and output
 Ensure that wound is cleaned with siz bath several times a
day and is dressed with an antiseptic ointment
 Dehiscence of episiotomy or abdominal wound following
cesarean section is managed by scrubbing the wound twice
daily, debridement of all necrotic tissue and then closing the
wound with secondary suture.

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