History, Causes and Interventions of Puerperal Sepsis

Abstract
The purpose of the report is to understand what puerperal sepsis is and to raise awareness of the condition to expectant mothers, women that have miscarried, families and physicians. To understand the risks that is linked with the condition and to be able to spot signs and symptoms, as well as how to prevent further cases through aseptic techniques and principles and hand hygiene.

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The information that will be included is background information on the condition: what is it, how it came about, what treatment was used and what caused it. The report will include information on what are the symptoms, what causes it, who is at risk, how it can be diagnosed, how to treat it, what are the complications and how to prevent further cases from occurring.
The report will focus on national statistics for the UK. This will include statistics to show how the prevalence of puerperal sepsis within the UK has decreased from 1900’s to today through medical advances and research. The research used will be secondary: books, journals, and internet. Primary research will not be used as the report is based on facts and information that is already available through reports and medical advice.
Background/History
Puerperal sepsis is a term giving to an infection that affect expectant mothers and those who have recently delivered. Infections within pregnancy can be severe as the genital tract has an increased surface area. (Knight, M. 2015). (Awori, N. et al. 1999). The infection can affect the cavity and walls of the uterus, which can lead to pelvic abscesses. The pus can spread high into the pelvis or into the lower abdomen. Infection tends to spreads after long labour or severe bleeding due to haemorrhaging which can cause peritonitis, septicaemia or death. (Awori, N. et al. 1999).
Puerperal Sepsis formerly known as childbed fever or puerperal fever was a mystery; it killed those at the cruellest of moments. It was understood that wherever physicians went the disease became more prevalent, especially within hospitals. During the 1700’s it was believed women were delivered from the peril of childbirth, not deliver a child into the world. Physicians believed sepsis occurred when there was a failure to urinate, it then became known as ‘milk metastasis’ as the internal organs of those that had died looked like they were covered in milk, it was later identified as pus. (Burch, D. 2009).
It was believed that puerperal fever was caused by various environmental factors: sewage, poor ventilation, cold, mists, vague ‘putrid tendencies,’ not bacterium and infection control. During the late 1700’s, Alexander Gordon leading obstetrician studied childbed fever and came to the conclusion that the disease was spread by physicians, it was related to skin infections and the only treatment was bloodletting. Bloodletting was widely accepted as a cure, however physicians understood more needed to be done to stop the spread of sepsis. (Burch, D. 2009).
Causes
Puerperal sepsis is caused by bacterium being introduced into the genital tract and women that are in labour or giving birth are more susceptible due to large genital tract surface area. The genital and urinary tracts have warm, moist environments that bacteria need to multiple. The bacterium can enter the body through pelvic exams, trauma during labour or prolonged labour. During pelvic exams the bacterium is introduced into the genital tract by unclean hands during examinations or through the use of non-sterile instruments. (Nall, R. 2014). Bacteria that are known to cause a puerperal sepsis include:

Chlamydia
Clostridium tetani
Clostridium welchii
Escherichia coli (E.coli)
Gonococci
Staphylococci
Streptococci

(Nall, R. 2014).
Other causes of puerperal sepsis are mastitis, pyelonephritis, ruptured membranes, respiratory complication, first birth, poor socioeconomic status, caesarean delivery and superficial or deep-vein thrombosis. (Baring, N. 2013).
Symptoms
Symptoms for puerperal sepsis normally appear between 24 hours to 10 days after infection begins. If one or more symptoms are present, action should be taken and treat as appropriate. Women should be monitored closely for any of the following symptoms:

Fever – higher that 38⁰C or 100.4⁰F
Shivering and chills
Uterus does not return to normal size
Pain and discomfort in lower abdomen
Tenderness and pain in the uterus
Malaise
Discharge from the vagina – foul-smelling and containing pus
Pale and discoloured skin
Short of breath
Fatigued, difficult to rouse
Altered mental state
Edema
Flu like symptoms

(Nall, R. 2014) (Sepsis Alliance 2015).
Who is at Risk?
Any woman that is pregnant, has miscarried, aborted or delivered are at risk of sepsis but certain factors increase that risk. Women that are more susceptible are those that have liver disease, lupus a condition of the immune system, diabetes, congestive heart failure, are obese, first pregnancy, women that are under 25 or women that are over 40. Women over 40 are at risk of sepsis from infections due to placenta praevia and placenta abruption. Women that are underwent invasive procedures to become pregnant or invasive tests during pregnancy are more prone to infections that can lead to sepsis. (Sepsis Alliance 2015)
Diagnosis
Abnormal changes in the patient temperature, heart and breathing rate can indicate infection. The vagina and uterus will be checked for swelling and tenderness by abdominal and internal exams. Broad-spectrum antibiotics will be prescribed if sepsis is suspected to prevent the infection from spreading, long term damage to the body and death. Further tests will be carried out to determine the type of infection, where it is located and if bodily functions have been affected. These tests can include:

Blood and urine test
Wound swabs
Blood pressure checks
Ultrasound scan, X-rays or computerised tomography (CT) scan
Organ function tests – liver, kidney, heart
Lumbar puncture
Stool samples

(NHS Choices. 2014) (Nall, R. 2014)
Treatment
If sepsis is suspected broad-spectrum antibiotics will be given orally or intravenously to prevent infection spreading. When results from further testing have been received then a focused antibiotic is used to kill the bacterium. Anti-fever medication and cold compresses may be used to keep the fever under control. Oxygen may be given as levels in the blood can become low due to the body demand for oxygen. Intravenous fluids may be given to prevent dehydration and kidney failure, normally given within the first 48 hours after hospital admission. Sepsis can cause the blood pressure to drop; medication called vasopressors will be given to increase blood pressure allowing the patient condition to improve. Infection sites need to be keep clean and dry; pus to be drained away allowing infected tissue to repair and to prevent bacteria from entering. (Nall, R. 2014) (NHS Choices. 2014)
Complications
Sepsis can lead to serious complications and the damage can be irreversible. Complications for the women include:

Septicaemia
Septic shock
Peritonitis
Haemorrhaging
Pyelonephritis
Mastitis
Pulmonary embolism
Disseminated intravascular coagulation
Abscesses
Death
Compromise fertility

The foetus can be affected causing depressed Apgar scores, neonatal septicaemia, pneumonia and death. (Dharmaraj, D. Patriquin, G. 2012)
Willacy (2012) wrote that severe sepsis can cause acute organ dysfunction and has a mortality rate of 20-40%. If septic shock develops the mortality rate rises to around 60%.
Prevention
Following aseptic techniques and principles is very important. Correct cleaning practice of hospital and home environments need to be followed and use of sterile packs and equipment must be used to prevent contamination; these must only be used once then deposed of. (Johnson, R. Taylor, W. 2011. p. 80). Physicians must exercise the correct hand hygiene techniques (appendixes A) and use antiseptic soap, washes, alcohol-based rubs and sterile gloves. By doing this it reduces the risk of introducing bacterium into a sterile environment. (Johnson, R. Taylor, W. 2011. pp. 73-77). Protective clothing: aprons, shoes covers must be worn to prevent spread of infection and contamination from one situation to another, these to be deposed of after one use. Use of non-touch technique is important by ensuring sterile equipment does not touch with anything unsterile to prevent contamination and potential for infection. The use of an assistant to open packs and equipment can reduced the risk of cross contamination as it prevents touching anything non-sterile with sterile gloved hands. (Johnson, R. Taylor, W. 2011. pp. 80-82).
Analysis of Statistics
During the early 1900’s, just under 1.5% in 1000 births within the UK died from sepsis, greatly decreased on early years. Advances in medicine meant physicians were discovering asepsis was paramount in infection control. The introduction of carbolic spray in operating room, hand washing and rubber gloves were used to minimise contamination. Then in 1920, face masks were introduced into obstetrics to prevent contamination through body fluids. (Chamberlain, G. 2006).
In the last hundred years there has been a significant drop in puerperal sepsis. In 2003-5 0.85% of maternal deaths per 100,000 births were a direct cause of sepsis, which means asepsis was tackling infection. However in 2006-8 there was a rise to 1.13%, through lack of knowledge, not seeking advice when unwell and through infection control. Sepsis is now the leading cause of maternal death within UK above hypertension, thromboembolic disease and haemorrhage, where there has been a reduction in these. It has been noted that over recent years that it has been hard to achieve a reduction in the number of deaths within the UK due to bacterial infections, more needs to be done in order to prevent maternal deaths and these statistics rising further. (Sriskandan, S. 2011).
Conclusion
Puerperal sepsis is now the leading cause of maternal death, which means more medical research need to be undertaken in order to reduce the number of cases. Sepsis through pelvic exams, trauma during labour or prolonged labour needs to be evaluated and assessed on how using aseptic techniques and principles can reduce the risk of cross contamination and introducing bacterium into the genital tracts.
Over the last hundred years puerperal sepsis has declined significantly, however over recent years it has increased from lack of knowledge and infection control. The UK is a developed country and should have infection control and aseptic techniques and principles at the forefront of medical practice.
Recommendations
After miscarriages, during last trimester and during delivery broad-spectrum antibiotic should be given orally or intravenously to expectant mothers to provide the body with a barrier towards infections, this could reduce the number of cases sepsis.
More training and awareness of sepsis and aseptic principles should be provided to physicians, to ensure understanding and they are being diligent in regards to infection control.
Expectant mother and families should receive education through antenatal classes to learn the signs and symptoms of sepsis and what to do if they suspect it. Symptoms can be confused with flu like symptoms and education should be given to seek help and advice off midwives, health visitors and other physicians.
References
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Baring, N. (2013) OBSTETRICS – Puerperal Infection. Available at: http://www.slideshare.net/nianbaring/obstetrics-puerperal-infection (Accessed: 23/04/2015).
Burch, D. (2009) When Childbirth Was Natural, and Deadly. Available at: http://www.livescience.com/3210-childbirth-natural-deadly.html (Accessed: 23/04/2015).
Chamberlain, G. (2006) ‘British maternal mortality in the 19th and early 20th centuries’ Journal of the Royal Society of Medicine. 99(11). 559-563. [Online]. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1633559/ (Accessed: 20/04/2015).
Dharmaraj, D. Patriquin, G. (2012) Puerperal Infection. Available at: http://www.sharinginhealth.ca/conditions_and_diseases/puerperal_infection.html (Accessed: 25/04/2015).
Johnson, R. Taylor, W. (2011) Skills for Midwifery Practice. 3rd edn. London: Churchill Livingstone Elsevier.
Knight, M. (2015) What is a life threatening complication in pregnancy and childbirth? Available at: http://ww.healthtalk.org/peoples-experiences/pregnancy-children/conditions-threaten-womens-lives-childbirth-pregnancy/what-life-threatening-complication-pregnancy-and-childbirth (Accessed: 12/04/2015).
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NHS Choices (2014) Sepsis – Diagnosis. Available at: http://www.nhs.uk/Conditions/Blood-poisoning/Pages/Diagnosis.aspx (Accessed: 25/04/2015).
Sepsis Alliance (2015) Sepsis. Available at: http://www.sepsisalliance.org/sepsis/symptoms/ (Accessed: 24/04/2015).
Sriskandan, S. (2011) ‘Severe peripartum sepsis’ Royal College of Physicians of Edinburgh, 41 339–46. [Online]. Available at: www.rcpe.ac.uk/sites/default/files/sriskandan.pdf (Accessed: 26/04/2015)
Willacy, H. (2012) Puerperal Pyrexia. Available at: http://www.patient.co.uk/doctor/Puerperal-Pyrexia.htm (Accessed: 25/04/2015).
World Health Organizations (2015) Clean Care is Safer Care. Available at: http://www.who.int/gpsc/clean_hands_protection/en/ (Accessed: 26/04/2015).
Bibliography
Awori, N. Bayley, A. Beasley, A. Boland, J. Crawford, M. Driessen, F. Foster, A. Graham, W. Hancock, B. Hancock, B. Hankins, G. Harrison, N. Kennedy, I. Kyambi, J. Nundy, S. Sheperd, J. Stewart, J. Warren, G. Wood, M. (1999) ‘Puerperal Sepsis,’ Primary Surgery, 1 [Online]. Available at: http://www.meb.uni-bonn.de/dtc/primsurg/docbook/html/x1831.html (Accessed: 20/04/2015).
Baring, N. (2013) OBSTETRICS – Puerperal Infection. Available at: http://www.slideshare.net/nianbaring/obstetrics-puerperal-infection (Accessed: 23/04/2015).
Burch, D. (2009) When Childbirth Was Natural, and Deadly. Available at: http://www.livescience.com/3210-childbirth-natural-deadly.html (Accessed: 23/04/2015).
Chamberlain, G. (2006) ‘British maternal mortality in the 19th and early 20th centuries’ Journal of the Royal Society of Medicine. 99(11). 559-563. [Online]. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1633559/ (Accessed: 20/04/2015).
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Glossary
Apgar scores – designed to quickly evaluate a newborn’s physical condition.
Asepsis – the absence of sepsis or infection.
Disseminated intravascular coagulation (DIC) – is a serious disorder in which the proteins that control blood clotting becomeover active.
Malaise – is a feeling of general discomfort or uneasiness; normally first indication of infection of other disease.
Mastitis – is the inflammation of breast tissue.
Peritonitis – is the inflammation of the thin layer of tissue that lines the inside of the abdomen called the peritoneum.
Placenta abruption – part of the placenta comes away from the uterus wall),
Placenta praevia – all or part of the placenta covers the cervix.
Pulmonary embolism – is a blockage in the artery that transports blood to the lungs.
Pyelonephritis – inflammation of the substance of the kidney as a result of bacterial infection.
Septicemia – is known as bacteremia or blood poisoning. Septicemia occurs when a bacterial infection enters the bloodstream.
Appendixes
Appendixes A – Hand washing techniques (WHO. 2015)