Puerperal Infection: A Risk After Childbirth

Puerperal infection (or maternal sepsis) is a polymicrobial infection and occurs in the mother during puerperium, that is, a few days after delivery. The World Health Organization (WHO) estimates that for every 1,000 births, 11 women suffer from infections that can cause them to die.

The reason for a puerperal infection is that commensal bacterial colonies or symbionts from the vaginal canal infiltrate internal tissues and spread as a result of physiological stress during childbirth. If you want to learn more about this serious medical condition, read on.

Symptoms of puerperal infection

Puerperal infection was common years ago. However, thanks to the effective use of antibiotics and the disinfection of the material during childbirth, this condition is becoming increasingly rare in high-income countries. Some of its symptoms include the following:

• Chills and a feeling of general malaise.
• Pain in the lower abdomen.
• Foul-smelling vaginal discharge.
• Vaginal bleeding.
• Dizziness and fainting.

As indicated in the MSD manual, all of these clinical signs usually occur with severe fever (24-48 hours postpartum), headache and anorexia. In more severe cases, tachycardia, leukocytosis (increased number of white blood cells in the blood), and swelling of the pelvic walls may also occur.

Possible complications

An uncontrolled puerperal infection can cause microorganisms to colonize the blood and multiply in other organs. This is called bacteremia, which is a serious and life-threatening condition.

Blood poisoning is usually the immune response (also uncontrolled) to the systemic infection. This then leads to septic shock, which causes death in 40% of cases.

Causes of puerperal infection

Infection occurs when bacteria from the vaginal canal take advantage of the opportunity to infiltrate the mother’s postpartum wounds. They are usually polymicrobial, meaning that there are several species present. These include the following:

• Gram-positive cocci: Group B Streptococci, Group A Streptococci (GAS), Staphylococcus epidermidis, and Enterococcus species.
• Anaerobes: grow without oxygen, such as strains of the genera Bacteroides and Prevotella.

• Gram-negative bacteria: Gardnerella vaginalis, Escherichia coli, Klebsiella pneumoniae and Proteus mirabilis.

Bacteria can penetrate surgical instruments during childbirth and enter the deep tissues of the mother during the procedure. Alternatively, the causative agent may have entered the body normally (mouth-to-nose), but it takes advantage of the weakened immune status to multiply.

A third option, the most common, is for bacteria present in the vaginal canal to enter internal tissues through wounds created during childbirth.

Prevalence and Risk Factors

As studies on the PubMed portal indicate, in high-income countries there are only 0.1 to 0.6 cases of puerperal infection per 1,000 births. Worldwide, estimates are much higher, at 11 per 1,000.

The chance of suffering from this condition also depends a lot on the method of delivery. The statistics are as follows:

• Vaginal deliveries: incidence of 1 to 3%.
• Planned cesarean section: 5 to 15%.
• Unplanned caesarean section: 15 to 20%.

This does not mean that an unplanned cesarean section will cause a puerperal infection 1 in 5 times. Using broad-spectrum antibiotics prevents overgrowth of bacterial colonies even before severe clinical symptoms appear.

Risk factors include:

• Prolonged delivery.
• Complicated cesarean sections.
• Postpartum hemorrhage.
• Bacterial vaginosis.
• Young mother age.
• Retention of placental fragments in the uterus.

Diagnosis

In general, it is a diagnosis by exclusion. After the first 24 hours after delivery, doctors should suspect a puerperal infection if there is no apparent cause for a fever above 38ºC in the mother lasting 2 days.

After other pathologies have been ruled out, doctors will perform blood and urine cultures to find out how far the bacteria have come. At the same time, the analysis of cervical samples is not common, as doctors assume that they are contaminated with microorganisms.

Treatment of puerperal infection

Treatment of puerperal infection is based on the intravenous injection of broad spectrum antibiotics. These drugs are usually clindamycin plus gentamicin, with or without ampicillin. As shown by scientific studies (Spanish link), the intravenous approach is recommended until the woman has not had a fever for 48 consecutive hours.

For tissue debris in the uterus, a curettage is used to remove the debris from the uterus. This prevents the bacteria from multiplying again once the course of antibiotics is completed.

Preventing or minimizing predisposing factors for infection is essential. According to the NSW Government Health portal, good hygiene during this delicate period is essential for the well-being of the mother. Some of the tips to follow are as follows:

• Daily showers, to keep the perineum clean.
• Clean and dry the perineal area so that bacteria from the rectum cannot spread to the vaginal area.
• Don’t use tampons until a healthcare professional tells you to.

• Wash your hands with soap for at least 15 seconds before coming into contact with instruments used in the perineal area.

Puerperal infection is a geographic problem

Today, a puerperal infection is a disease that is rarely a cause for concern. If medical professionals see a risk that this could happen, they turn to preventive antibiotics, reducing the chance by 75%.

Unfortunately, not all geographic areas can say the same thing. In countries with fewer public health structures, the mortality of new mothers increases dramatically, as the lack of resources means that uncontrolled infection is much more common.