T3.2 Post-partum Sepsis & Endometritis – Comprehensive Bullet-Point Notes

Overview: Post-partum Sepsis / Endometritis

• Definition: Severe bacterial infection occurring after birth, most often originating in the uterine endometrium.
• Principal pathogen: Group A β-haemolytic Streptococcus (GAS, a.k.a. group A strep).
• Other possible organisms: \textit{E.coli},\ \textit{Staphylococcus aureus},\ \textit{Streptococcus pneumoniae},\ \text{MRSA} – however, GAS is the dominant culprit.
• Anatomical focus: Uterus = commonest site because it is an open, healing wound post-delivery.
• Epidemiology (NZ data cited): 9 pregnant women + 33 post-partum women admitted to ICU with sepsis in a single audit; maternal deaths documented.
• Time-frame of concern: Day 2 – Day 4 especially; early symptoms easily misattributed to “milk coming in.”

Pathophysiology & Route of Infection

• Birth leaves exposed decidua → easy portal of entry for bacteria.
• Micro-fragments of retained placenta/ cotyledons can remain despite a “complete looking” placenta → nidus for GAS growth.
• Ascending infection possible from lower genital tract, perineal trauma, C-section wound, breast infection, or community/family contacts with GAS (e.g., sore throat, cough).

Risk Factors

• Obstetric / surgical
– Caesarean section
– Perineal tears, episiotomy, haematoma
– Retained products of conception (even microscopic)
– Prolonged rupture of membranes
– Instrumental birth, uterine trauma
• Medical / maternal
– Diabetes mellitus
– Anaemia
– Immunosuppressive therapy or states
– Pre-eclampsia (possible link to placental fragments)
– Obesity
• Environmental / care factors
– Rural distance delaying review or transfer
– Early discharge without adequate re-assessment

Key Clinical Features & Red-Flag Symptoms

• Pyrexia: T \ge 38^{\circ}\text{C} (High risk of convulsions when T \ge 39^{\circ}\text{C})
• Tachycardia: sustained, often > 100 bpm
• Tachypnoea: earliest vital-sign change; rising RR precedes BP drop
• Rigors, chills, hot–cold swings
• Nausea / vomiting, feeling “flu-like,” generalized malaise
• Uterine pain, abdominal tenderness, delayed involution, offensive lochia odour
• Breast fullness + fever ≠ automatically lactogenesis II; must exclude sepsis
• Less common: rash (purpuric rash seen rarely), oliguria, hypotension (late), altered mental status, DVT / PE manifestations (dyspnoea, chest pain)

Assessment Protocol ("Full TOC TIC" exam)

• Immediate face-to-face assessment essential—telephone triage insufficient.
• Vital signs: T,\ HR,\ RR,\ BP,\ SpO_2,\ UO (low urine output = late sign)
• Physical examination
– Inspect uterus: fundal height, involution rate, tenderness
– Perineum/ lacerations/ surgical wounds/ epidural site for erythema, discharge
– Breast exam for mastitis but remember systemic signs may be uterine
– Chest auscultation (rule out pneumonia, PE)
• History: Onset, risk factors, procedures (amniocentesis, ROM duration), medications, community GAS exposure.
• Documentation: Precise times, findings, communications.

Initial Management & Referral

• Low threshold for transfer to obstetric hospital / ED; do not discharge until re-assessment after antipyretics.
• Call ambulance early; if remote, meet en-route if necessary.
• Start sepsis bundle within 1 hour where possible:
– IV access × 2
– Blood cultures \rightarrow before antibiotics when feasible
– Broad-spectrum IV antibiotics (hospital to dictate; aim to cover GAS quickly)
– IV fluids for perfusion
• Avoid NSAIDs/ ibuprofen or combined IGCs when sepsis suspected – they inhibit polymorph function vs. GAS.
• Oxygen if SpO_2 < 94\%.

Hospital Investigations (ordered by the team)

• \text{FBC},\ \text{CRP}
• Blood cultures × 2 sets
• Mid-stream urine (MSU)
• Cervical/ high vaginal swabs
• Pelvic ultrasound: retained products? endometrial thickness?
• Chest X-ray: assess for PE, pneumonia, pulmonary oedema
• Coagulation profile, group & hold/ cross-match when indicated

Antibiotic Principles

• Empiric broad-spectrum to cover GAS ± Gram-negatives, then tailor to cultures.
• Early administration reduces progression to septic shock/ ICU admission.

Complications to Monitor

• Septic shock (hypotension refractory to fluids)
• Acute kidney injury (oliguria, elevated creatinine)
• Disseminated intravascular coagulation (DIC)
• ICU admission & mechanical ventilation
• Maternal death

Case Illustrations (from lecture)

• Case 1: Woman discharged, collapsed en-route home, spent 16 days in ICU for GAS sepsis.
• Case 2: Community midwife received call 24 h post-discharge – pyrexia 38.5^{\circ}\text{C} + rigors; immediate ambulance → 48 h IV antibiotics in maternity unit, total 5 day admission, full recovery.
• Rural anecdotes: Midwives meeting ambulance halfway or transporting by private car/ even horse in isolated regions.

Guidelines & Inter-professional Actions

• Follow national/ local sepsis recognition tools & escalation pathways.
• Multi-disciplinary “team early” approach: obstetrician, anaesthetist, ICU, microbiology.
• Midwife role limits: recognise, resuscitate, refer without delay.

Legal / ACC Support (NZ Context)

• Long ICU stays (e.g., 16 days) impose financial strain; ACC can fund family support, travel, ambulance costs, lost income.
• Midwife should document that ambulance was instructed under her clinical advice to aid ACC processing.

Special Considerations for Remote Practice

• Distance (≥ 1 h 20 min) amplifies risk; plan community protocols: who drives, where to meet ambulance, costs.
• Engage local resources (community vehicles, rural health teams).

Prevention & Discharge Safety Checks

• Thorough physical exam before discharge; repeat assessment after administering paracetamol if fever present.
• Provide clear education to woman & family: Warning signs, when to call, temperature monitoring, importance of early help.
• Schedule proactive follow-up (especially D2-D4 window).

Quick-Reference “Sepsis Red Flags”

• T \ge 38^{\circ}\text{C} (or feeling abnormally cold)
• HR > 100\ \text{bpm}
• RR > 20\ \text{/min} or new breathlessness
• Rigors, severe abdominal/ uterine pain, foul lochia
• Feeling profoundly unwell/ “about to collapse”
• Rash, especially purpuric/ petechial (rare but ominous)

High-Yield Take-Home Points

• GAS is enemy #1 in post-partum sepsis; uterus is usual battlefield.
• Day 2-4 fevers are not automatically “milk coming in.”
• Early vital-sign changes: RR \uparrow,\ HR \uparrow,\ T \uparrow; BP drop is late.
• Do not mask signs with NSAIDs; do start IV antibiotics fast.
• Rapid referral + good documentation + multi-disciplinary management ↓ ICU admissions & saves lives.