Introduction

Even in the 21st century, approximately 60,000 women die of regnancy related causes each year, the majority of these occurring in developing countries. In UK, sepsis in the puerperium remains an important cause of maternal death. Sepsis from Group A betahaemolytic streptococci (GAS) was responsible for 13 maternal death between 2006-200. (www.patient.com.uk/doctor/puerperal pyrexia)

OBJECTIVE
1. Review the current evidence for the normal parameters of womens health after childbirth. 2. Explore the role of the midwife in the assessment of womens postpartum health and psychosocial need.

Puerperal pyrexia
Definition
Puerperal pyrexia means a temperature of 38:C, maintained for or recurring within 24 hours, within 21 day (14 days in England) of childbirth or abortion. (by Obstetrics illustrated-Kevin P. Hanretty)

Definition
Puerperal pyrexia/fever a rise in temperature in the puerperium.This is poorly defined in the textbooks but is assumed to be based on the definition of pyrexia which is a rise above the normal body temperature of 37.2:C. Where pyrexia is used as a clinical sign of importance, the elevation in temperature is generally taken as being 38:C and above. (by Diane M. Fraser and Margaret A.CooperMyles Midwives)

Aetiology
Specific causes of puerperal pyrexia: Urinary Tract Infection :-Frequency, dysuria,haematuria. -Rigor from pyelonephritis. -95% caused by Esherichia coli, Proteus and Klebsiella.

 Genital Tract Infection:-Tender bulky uterus. -Prolonged bleeding/pink or discoloured lochia. -Painful inflamed perineum.

 Mastitis:- Painful, hard, red breast abscess. -Nipple trauma and cellulitis.

Postoperative infection following Caesarean section:-Painful, red suture line. -Deep tenderness on palpation.

 Deep Venous Thrombosis:-Painful -Swollen calf.

Signs and symtoms: Fever - great than or equal to 38:C Tachycardi - 90beats/minute Breathlessness - respiratory rate 20 breaths/ minute. Abdominal or chest pain. Diarrhoea and / or vomiting.

Signs and symtoms: Headache . Loss appetite. General malaise Vaginal examination- Vulva/vagina infected wounds, pus inflamed and induration around wound. Uterus sub-involuted, pain on movement of uterus, adnexal tenderness.

Postnatal Care
A full history should be taken, to include a full history of the delivery: When did the membranes rupture? Length of labour. Instrumentation used. Sutures required. Was the placenta complete? Was there any bleeding during or after delivery?

Examination
Taken the patient temperature. Palpate the uterus to assess size and tenderness. Assess any perineal wounds and lochia. Examine the breasts. Examine the chest for signs of infection. Examine the abdomen. Examine the legs for possible thromboses.

Investigations
Urine FEME - Bacteriuria. FBC Septic work out Urine, HVS ( high vagina swabs),Blood culture. Other swabs as felt necessary- wound swabs, throat swabs. Ultrasound scan- For retain products of conception. Chest x-ray

Management/Treatment
Management involve detail history for risk factors for infection, detail physical examination and appropriate intervention may be necessary.
IV Drip: Correct dehydration/for stabilization of patient. Antibiotics: depend on organism, analgesics for pain,vitamin supplements. Surgery: -Infected episiotomies,stitches removed to drain out pus -Abscess-drained -Retained tissues in the uterus-ERPOC should be performed after iv antibiotics coverage. Good nourishing diet. Optimum perineal care. Thromboprophylaxis if indicated. Depend on severity of infection ICU care.

CASE
A 28-year-old primigravid underwent a cesarean section secondary to having a breech presentation and rupture of membranes at 36 weeks gestation. The cesarean section was uncomplicated, but on postpartum day two the patient was having fever (38.5C) and uterine tenderness. A diagnosis of postpartum endometritis was made and the infection was treated with Mefoxine 1 g IV Q8H.

 After 24 hours of antibiotics, the patient presented pain in the right lower abdomen and loin, and her WBC count was 12000/mm3. She continued to spike fevers . Abd:soft,flat, tenderness on the right abdomen,no rebound-tenderness, Mcburneys point (+/-),Murphys sign(-), kindey region percussion (-). Urinalysis was unremarkable On postpartum day four, the patients condition was no improvement after antibiotic treatment, and an abdominal CT scan was obtained. A right ovarian vein thrombosis was noted on the imaging. IMP: ovarian vein thrombophlebitis

 The patient started therapeutic enoxaparin(clexane). After 48 hours of anticoagulation, the patient was afebrile and asymptomatic. The patient was discharged home after being anticoagulated with warfarin and after 6 weeks a CT scan was repeated. The right ovarian thrombosis was not present in the images and warfarin was discontinued

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

Prevention
Scrupulous attention to hygiene should be used during all examinations and use of instrumentation during and after labour. Some center advocate the use of prophylactic antibiotics during prolonged labour. Catheterisation should be avoided where possible.

Prevention
Early mobilisation of delivered mother will help to protect against venous thrombosis. New mothers should be helped to acquire the skills required for successful breastfeeding. All blood losses and the completeness of the placenta should be recorded at all deliveries.

Complications
Genital tract infection may lead to abcess formation, adhesions,peritonitis,haemorrhage and subsequent infertility if not treated early and aggressively. Urinary tract infection may progress to pyelonephritis and renal scarring if left untreated. Mastitis may lead to the formation of breast abcesses if treatment is not started early.

Conclusion