INTRODUCTION

Puerperal sepsis is serious form of septicemia contracted by women during or soon after child birth or Miscarriage. The first recorded epidemic of puerperal fever occurred at the Hotel-Dieude Paris in 1646. Hospitals through out Europe and America consistently reported death rates of 20% to 25% . During 18th and 19th centuries, it was the single most common cause of maternal mortality, accounting for about half of all deaths related to child birth and second only to tuberculosis in killing women of child bearing age. Introduction of antisepsis technique of hand washing, introduction of carbolic acid invention of germ theory in 18 century reduced maternal mortality from 18% to 3% After the importance of antiseptic techniques became widely under stood in the 20th century along with the mid century introduction of new antibiotics, death rate greatly reduced due to sepsis in developed word. So for things have remained same in developing countries for last 160 years. In 2008 WHO (World health organization) stated that puerperal sepsis is the second leading cause of maternal mortality in developing countries.

PEUPERAL SEPSIS
An infection of the genital tract which occurs as a complication of delivery is termed puerperal sepsis. Vaginal flora : The vaginal flora in late pregnancy and at the onset of labour consist of the following organisms 1) Doderleins bacillius 60-70%, 2) Yeast like fungus with increased prevalence of Candidia albicans 25%, Staphylococcus albus or aureus, 4) Streptococcus- anaerobic common, beta hemolytics rare, 5) Ecoli and bacteroides group. These organisms remain dormant and are harmless during delivery conducted in aseptic condition, inspite of the fact that 1) the cervico vaginal mucus membrane is damaged to a variable extent even in normal delivery. 2)T he uterine surface too, specially the placental site, is converted in t o an open wound by the cleavage of the deciduas which takes place during the third stage of labour and 3) the blood clot present at the placental site are excellent media for the growth of the bacteria. Predisposing factors Antepartum factors malnutrition, anemia, preterm labour, premature rupture of membranes, chronic debilitating illness, and prolonged rupture of membranes > 18 hours. Intra partum factor-repeated vaginal examination, prolonged rupture of membranes, dehydration and keta acidosis, during labor, traumatic operative delivery, haemorrhage, retained bits of placental tissue, placenta praevia, caesarean delivery Micro organism responsible for puerperal sepsis Aerobic- streptococcus haemolytic group A, streptococcus group B

Anaerobic- anaerobic streptococcus,[ bactreoids, fragilis ,bivius,fusobacterium] and clostridia Mode of infection Causes of infection may be endogenous were organism are present in genital tract before delivery. Infection may be autogenous were organism present elsewhere [skin ,throat] in the body and migrate to the genital organs by blood stream or by the patient herself infection may be exogenous where infection is contracted from sources outside the patient PATHOLOGY The primary sites of infection are: (1) Perineum 2) Vagina 3) cervix 4) uterus. The infection is either localized to the site or spread to distant sites. The laceration on the perineum, vagina and cervix are often infected by the organism due to the presence of blood clot or dead space. The wounds become red, swollen and there is associated sangopurulent discharge. There may be the disruption of the wound if repaired before control of infection. Diabetes, obesity, low nutritional status are the other high risk factors for wound infection. Perineum: Lacerations on the perineum, whether repaired or not, are likely to be infected by organisms of low virulence like staphylococcus aureus or anaerobic streptococcus. The wound edges become red and swollen. There may be the collections of sangopurelent discharge or pus which result in complete disruption of the wound. Vagina: The vaginal lacerations are infected directly or by extension from the perineal infection. The mucosa is swollen and hyperemic, resulting in necrosis and sloughing. On occasions, a retained and forgotten plug may be left inside the vagina leading to offensive vaginal discharge. Cervix: The cervical infection is quite common as the cervix is commonly lacerated and it is also the common site, for the pathogenic organism to harbour. Uterus: Endomyometritis- The incidence varies from 1-3% following vaginal delivery and about 10% following caesarean section. It is commonly polymicrobial. The deciduas especially over the placental site are primarily affected. The risk factors for endometritis are, retained products of conception, caesarean section, chorioamnionitis, prolonged rupture of the membrane, preterm labour and repeated vaginal examination in labour. SPREAD IF INFECTION Pelvic cellulites is due to spread of infection to the pelvic cellular tissues by direct or lymphatic or by haematogenous route Salphingitis Septic pelvic thronbophlebitis Septicemia and septic shock

CLINICAL FEATURES Local infection-there is a slight rise of temperature generalized malice or head ache. The local wound become red and swollen, pus may form which leads to destruction of wound Uterine infection Mild- there is rise in temperature in pulse rate, lochial discharging become offensive and copious,the uterus is subinvoluted and tender Severe- high temperature , rapid pulse, lochia may be scanty and odorless , uterus may be subinvoluted tender and soft, wound infection[ perineum vagina and cervix] Spreading infection Parametritis, pelvic peritonitis, general peritonitis thrombophlebitis septicemia bacterimia DIAGNOSIS History Antenatal history, history of anemia, antipartum haemerrage,present of septic foci in teeth gums mouth tonsils in debilitating disease like heart disease tuberculosis and UTI or malaria should be enquired Intranatal history regarding preterm labour , duration of rupture of membrane, number of examination done in and outside the hospital, duration of labour, method of delivery, nature of intrauterine manipulation if any Postnatal detail including nature of fever associated symptom Investigation include high vaginal and entocervical swab for culture in aerobic and anaerobic media and sensitivity test to antibiotic Clean catch midstream urine for analysis and culture including sensitivity test

Blood for total and differential white cell count, hemoglobin estimation low platelet count may indicate septicemia or DIC . thick blood smear also examined for malarial parasites Blood culture if fever associated chills and rigor

Pelvic ultra sound to detect in retained bits or conception within the uterus to locate any abscess within the pelvis , collecting sample from the pelvis for cultural sensitivity color flow Doppler study to detect Venus thrombosis X ray chest should be taken in case of suspected pulmonary Kochs lesions and also to detect lung pathology like lung collapse or atlectalis

Treatment
Isolation of the patient Anemia is corrected by oral iron intake Pain is relieved by adequate analgesia An indwelling catheter is used if urinary retention TPR chart and I/O chart Antibiotics should depend upon the culture and sensitivity test. Gentamicin 2 mg/ kg iv loading dose followed by 1.5 mg /kg iv every 8 hours., ampicillin or clindamicin should be started.

Surgical treatment
Perineal wound the stitches of the perineal wound should be removed to facilitate drainage pus or drainage. Apply hot compress with antibiotic solution followed by application of antiseptic ointment or power. Retained uterine products with a diameter of 3 cm or less may be disregarded and left alone. Otherwise surgical evacuation after antibiotic coverage for 24 hours should be done to avoid the risk of septicemia. Cases with septic pelvic thrombophlebitis are treated with iv heparin for 7-10 days. Pelvic abscess should be drained by colpotomy under ultrasound guidance. CONCLUSION Puerperal sepsis is still a major cause of maternal morbidity and mortality. Almost all predisposing factors leading to sepsis and maternal mortality are preventable. It needs proper implementation of protocols for antenatal, intranatal and post natal care, continuing perinatal education programs for midwives, TBAs and doctors for proper management during labour, aseptic measures, prophylactic antibiotics, proper hand washing, avoiding unnecessary repeated vaginal examinations, prolonged labour, observing partogrames, avoiding unnecessary interventions in premature/pre-labour rupture of membranes proper and timely referrals to health facility.

BIBLIOGAPHY
# Diane. M. Fraser, Margaret. A. Cooper. Myles text books for midwives. 14th edition. Churchil living stone; 2003 # Diane. M. Frasher. Margaret A. Cooper. Mylws text book for midwives 15th publication 2009 edition. Elsever

# D.C Dutta, Text book of gynecology. 6th edition. New central book agency (p) LTD. Culcutta 2006

# Kamini. A. Raw, Text book of midwifery and obstetrics for nurses. Elsever publication 2011 # Michael. D. Benson. OB/ GYN Mentior edition J P Brothers medical publishers New delhi # Neville.F. Hacker, Joseph C Cambone, Calvin. J. Hobel. Essential of obstetrics and gynecology, Elsever publications # Richa Saxena, Bedside obstetrics and gynacologyf first edition. Jaypee brothers 2010 Shirish N Daffary, Sudip Chakravarti. 2nd edition. Manual pf obstetricus. Lseveier publications # Sudha Salhan. Text book of obstetrics. 1st edition Jaypee brothers medical publishers. New Delhi