The puerperium
Louise C Kenny, Jenny E Myers in Obstetrics, 2017
A mixed flora with low virulence normally colonizes the vagina. Puerperal infection is usually polymicrobial and involves contaminants from the bowel that colonize the perineum and lower genital tract. The organisms most commonly associated with puerperal genital infection are listed in the box below. Following delivery, natural barriers to infection are temporarily removed and therefore organisms with a pathogenic potential can ascend from the lower genital tract into the uterine cavity. Placental separation exposes a large raw area equivalent to an open wound, and retained products of conception and blood clots within the uterus can provide an excellent culture medium for infection. Furthermore, vaginal delivery is almost invariably associated with lacerations of the genital tract (uterus, cervix and vagina). Although these lacerations may not need surgical repair, they can become a focus for infection similar to iatrogenic wounds, such as caesarean section and episiotomy.
Prelabor rupture of the membranes
Hung N. Winn, Frank A. Chervenak, Roberto Romero in Clinical Maternal-Fetal Medicine Online, 2021
Clinical investigators have compared expectant management with steroid administration for 48 hours followed by delivery. However, induction of delivery immediately after steroid administration is associated with an increased risk of RDS and, therefore, is best avoided (261). The 1994 National Institutes of Health Consensus Conference recommended the use of corticosteroids in pregnancies complicated by preterm PROM with expected delivery between 24 and 30 to 32 weeks of gestation (234). This recommendation was based largely on data suggesting that the incidence of IVH was lower in neonates exposed to corticosteroids (234). The modest increased risk of puerperal infection is considered easy to manage. A meta-analysis comparing the outcome of treatment with antibiotics and steroids versus antibiotics without steroids found that steroid administration diminished the beneficial effects of antibiotics in reducing the rate of chorioamnionitis, endometritis, neonatal sepsis, and IVH (262).
The bodily processes of childbirth
Adrian Wilson in The Making of Man-Midwifery, 2018
Childbirth is liable not only to obstruction, but also to a variety of complications; these can conveniently be divided into minor and major types. The minor complications included fainting, vomiting, and tearing of the perineum. Although distressing for the mother, these were not very common and seem not to have led to serious difficulty. It is also worth observing that fistulae, which are today a widespread and serious problem in parts of Africa, seem to have been uncommon in early-modern England.10 The two major complications, attested by a variety of sources, were “flooding” (what is now called haemorrhage) and convulsions or “fits” (today known as eclampsia). Flooding was usually caused by the separation of the placenta during late pregnancy or at the onset of labour. Probably about half of these dangerous occurrences arose from the placenta being implanted near the cervix of the uterus (a condition recognized only towards the end of our period, and known today as “placenta praevia”). This was extremely serious, leading swiftly to the death of both mother and child unless a speedy delivery was enforced. Convulsions, while less often fatal, were nevertheless dangerous. A third cause of death, the most dangerous condition of all, was puerperal fever, which arose not during birth but after it. Its incidence is very difficult to assess because it was only recognized at the end of our period. Very probably it was this condition that Willughby described as “scouring” or “looseness”, that is, diarrhoea — another telling instance of the historical mutability of observation categories.11 The risk of puerperal infection was certainly increased by difficulty in the birth itself, especially by prolonged obstructed labour.
A review of post-caesarean infectious morbidity: how to prevent and treat
Published in Journal of Obstetrics and Gynaecology, 2018
Rebecca C. Pierson, Nicole P. Scott, Kristin E. Briscoe, David M. Haas
Puerperal infection is a significant cause of morbidity and mortality in postpartum women worldwide (Kassebaum et al. 2014). Puerperal infection increases length of hospital stay and healthcare costs. One of the major risk factors for postpartum infection is caesarean delivery (CD). Post-caesarean infection can be separated into two sub-groups: surgical site infection (SSI) and endometritis. Surgical site infection refers to infection of the skin and subcutaneous tissue at the location of the incision. Endometritis or endomyometritis refers to infection of the uterine corpus, endometrium and myometrium. According to a large retrospective study in the United States, the cost per patient of readmission and treatment for SSI and endometritis was $3529 USD and $3956 USD, respectively (Olsen et al. 2010). In addition to healthcare costs, there is the potential for impact on initiation and continuation of breastfeeding. In 2012, approximately 22.9 million CDs were performed worldwide (Molina et al. 2015); it is imperative to understand the disease process and prevention and management strategies.
Microbiology and clinical outcomes of puerperal sepsis: a prospective cohort study
Published in Journal of Obstetrics and Gynaecology, 2018
Rumbidzai Majangara, Muchabayiwa Francis Gidiri, Zvavahera Mike Chirenje
The majority of women managed for puerperal sepsis at Parirenyatwa and Harare Hospitals had delivered at a hospital (78.1%), by caesarean section (57.6%). Overall, caesarean section rate in Zimbabwe is 6%, and for Harare alone is 8.4% (Zimbabwe National Statistics Agency and ICF International 2016). Based on total annual deliveries for Parirenyatwa Hospital and half of Harare city in 2016, 48% of women delivered in hospital while 52% delivered in the city clinics and the institutional caesarean section rate was 36% (MF. Gidiri, personal communication). The high incidence of caesarean section among women with puerperal sepsis is consistent with findings of other investigators who noted that caesarean delivery increases the risk of puerperal infection 5- to 20-fold, compared to vaginal delivery (Conroy et al. 2012). The higher rate of hospital delivery among these women also raises concerns that some women may have had nosocomial infections.
Pregnancy outcomes of adolescent primigravida and risk of pregnancy-induced hypertension: a hospital-based study in Southern Thailand
Published in Journal of Obstetrics and Gynaecology, 2019
Thanawut La-Orpipat, Chitkasaem Suwanrath
Our findings add to previously published literature, in the context of developing countries in Southeast Asia, as it demonstrates the higher rates of adverse maternal and foetal outcomes in adolescent pregnancy. Rate of maternal death was higher, with different causes of death from a previous study (Chen et al. 2007), and an increased risk of PIH in both younger (≤15 years) and older (16–19 years) adolescents. Rates of infection during pregnancy and the postpartum period, such as urinary tract infection, chorioamnionitis and puerperal infection were also increased in adolescents which were not frequently analysed in previous literature. Confirmation of earlier studies in lower rate of caesarean deliveries was reported and we also found decreased rates of diabetes mellitus, chronic hypertension, placenta praevia and CPD. Our study additionally demonstrated the effect of inadequate antenatal care for adolescents, which revealed higher rates of adverse maternal and foetal outcomes. Importantly, students were common in this group. It implies the consequences of unplanned pregnancy coupled with a limitation in accessing to health care.
Related Knowledge Centers
- Childbirth
- Fever
- Streptococcus Agalactiae
- Miscarriage
- Infection
- Uterus
- Vaginal Discharge
- Female Reproductive System
- Caesarean Section
- Prelabor Rupture of Membranes