The Prevention of Puerperal Fever

Kai Tiaki : the journal of the nurses of New Zealand, Volume XIV, Issue 2, 1 April 1921, Page 63

The Prevention of Puerperal Fever

On reading* the report of the proceeding's of the British Medical Association (Section of Obstetrics and Gynaecology), vide " Lancet/ 1 August 21st, the discussion on puerperal sepsis is undoubtedly the one of most interest to midwives. Mr. Victor Bonney read an introductory paper on prevention and treatment; and although his views of the common sources of infection are not those which up to now have been generally held, they give food for thought, and we ask ourselves if there is anything more that can be done by midwives to prevent the occurrence of sepsis m their practice. "The solution of the problems how to prevent and how to cure septic infection of the puerperal uterus necessitates the correct answering of three fundamental questions : " (1) What is the original source of the organisms ? "(2) How do they get into the uterus? "(3) What is their exact situation by the time they have produced symptoms of sepsis?" This does not concern the midwife, but the first two are important. 1. The original source of the organisms. In nearly all severe cases of puerperal sepsis the streptococcus, either alone or m conjunction with B. coli communis, is the predominant organism. The organisms may have been resident m the patient before the confinement, or may have been introduced from without durin,g its course or afterwards ; this latter was undoubtedly the cause of epidemics of puerperal sep sis which m the past periodically decimated lying-in hospitals, and which the introduction of antiseptic midwifery has succeeded m abolishing. At the present day it is still operative m those instances where a series of cases of puerperal fever occurs m the practice of a doctor or midwife. The occurrence of the present day is sporadic, not epidemic. It would appear that theare is some other .mode of infection for which the antiseptic precautions m use up to the present time are in-

adequate. Organisms capable of producing puerperal sepsis commonly pre-exist m the woman; they can be constantly isolated from the lower bowel and perineal skin. In the large intestines nearly all the organisms are potentially pathogenic; their character is probably continually altering, e.g., a purgative probably changes it by producing conditions favourable to one organism and not to another. A septic state of the teeth, mouth, or throat, a suppurating appendix, a catarrhal patch on the colic mucosa, or a chronically inflamed pile — any of these are potential sources of organisms, which, having obtained entrance into the uterus, may set up the most virulent sepsis. Again, the ano-perineal skin is the most heavily infected area m the body, as can be proved by streaking a sterilised needle over it and then streaking the needle over an aigar plate. Prom the vulva and entrance to the vagina, as one would expect, bowel organisms can be isolated, and it is inconceivable that anything can be passed into the vagina without carrying them into it. It may be asked, If it be true that the commonest cause of puerperal sepsis is faecal infection, why has so simple an explanation of the continued prevalence of the disease been generally overlooked till now? The answer is that the appreciation of the evil potentialities of intestinal organisms is of comparatively recent date. The principle of antiseptic surgery is the creation of aseptic conditions m the wound primarily, and therefore as a corollary m all that surrounds or touches the wound. This is exceedingly difficult m the case of the vagina; unless steps can be taken to render the vagina and the approaches to the vagina aseptic, this Listerian principle is unfulfilled. To prevent the conveyance of organisms from the adjacent skin into the wound the up-to-date surgeon attaches towels to cut the skin out of the operation area altogether. It is impossible to apply this method fully to the vagina m labour, but at least the

anus should be excluded by fixinjg over it a large gauze pad soaked m a strong nonirritant antiseptic. The recent introduction of the antiseptics belonging to the aniline and chlorine groups goes far to place at the service of the obstetrician the means of achieving the sterility of the vagina and its approaches. A 2 per cent, solution of iodine is already used m this way by certain practitioners, but as a rule nothing more deadly to bacteria than a weak solution of Ivsol or one of the mercurial salts is employed; these have little value as bactericides having regard to the brief period over which they are applied. Professor BroAvning and Mr. Victor Bonney have proved that practical sterilisation of the ano-perineal skin may be effected by the use of "violet-green"—- a 1 per cent, solution of equal parts of crystal violet and brilliant green m half-and-half alcohol and water — and Mr. Bonney suggests that this antiseptic should be used to paint the vagina and its approaches prior to any operate procedure, and that it should be used as the lubricant every time a vaginal examination is made. In his opinion, the lithotomy position igives a better exposure of the parts and renders the conveyance of bowel organisms into the vagina less likely. 2. Hoav do the organisms get into the uterus? They may be carried by hands or instruments; the danger is greater when the uterine Avail is stripped bare. But. m far the larger number of cases of puerperal sepsis no introduction of anything into the uterus has taken place, the most that could have happened being the implantation of organisms into the cervix or vagina. Hoav are these transported into the body of the uterus? There would appear to be a current along the surfaces of these canals floAving m the reverse direction to the main stream of its contents; another possible route of infection maybe the transmission of organisms direct from the bowel to the uterus across the peritoneal cavity, or to the vagina through the recto-vaginal septum, but this route is not a likely one, as post-mortem examination invariably indicates that the infection of the tissues has begun on the placental site.

In the discussion, which followed Mr. Eardley Holland agreed that m many cases the source of the infective bacteria was the patient's own perineum and vagina, and that infection occurred from the transportation of bacteria into the cervix or cavity of the uterus by vaginal examinations or by use of obstetrical instruments — it was infection of the patient by her own bacteria. He believed that routine vaginal examinations should be abolished altogether. He employed rectal examinations, which bad all the advantages of vaginal and none of their disadvantages. The recto-vaginal septum was thin and lax. and the state of the cervix, the sutures and fontanelles, the degree of the descent of the head into the pelvis and even a prolapsed cord could be felt with the utmost clearness. Dr. Routh owned to being unconverted to the view that puerperal fever was often due to intestinal organisms, as individuals were usually immune from infection by organisms normally existing m their own tissues. The exceptions seemed, however, to be B. coli uystitis and pregnancy pyelitis. Miss Ivens thought more could be done to prevent auto-infection from the intestinal tract if the nurse shaved the patient as if she were igoing to have an operation. Dr. Lap'horn Smith laid emphasis on the fact that the rectum could be made as clean as the mouth ; colon bacilli increased enormously with constipation; the dose of castor oil and an enema when labour began. Avas advisable; he 'supported Dr. Holland's suggestion that rectal examinations should be made instead of vaginal one, and urged that the condition of the woman was an important factor; an aiuvmic woman was not m a proper condition to fight infection. He found that citrate of iron and quinine sometimes woi'ked wonders. Dr. Johnstone called attention to the fact that a large number of cases of puerperal sepsis, when carefully examined, showed clinical signs of inflammation of the lower part of the vagina and perineum, of the cervix and of the lymphatics of the broad ligaments, while the

body of the uterus was comparatively free. He regarded the infection m the vast majority of cases as being derived from the patient herself, mainly from the chronically infected skin of the perineum. Doctors and midwives must learn to be as efficient m sterilising the patient's vulva and perineum as m sterilising their own hands. He had lately been trying the results of using a saturated solution of picric acid m alcohol, as it was a more powerful antiseptic than iodine, penetrated more deeply into the skin, and was not so easily washed away by the flow of secretion which took place during the first and second stages of labour. These are the opinions of experts on the prevention of puerperal sepsis. Let us briefly consider them from the point of view of the midwife. It is well known that puerperal sepsis is compartively rare m patients who are delivered naturally, and have no operative interference; but since cases do occur, it is important to emphasise not only strict antiseptic ritual, but the dangers of infection of the patient by her own organisms. (1) During pregnancy and labour, constipation, carious teeth, septic throat, infections of the bowel, inflamed haemorrhoids, are potential sources of organisms, which may set up virulent puerperal sepsis. The anaemic woman is not m a proper condition to fight infection, therefore medical treatment during pregnancy and the prevention of severe hsemorrhages are factors m preventing severe cases of sepsis. (2) During labour, efficient antisepsis of the ano-perineal area should be secured by close cutting or shaving of the hair, and application of an efficient germicide. Mere swabbing with lvsol or mercurial solution does not secure this. The anus must be protected during delivery by a pad soaked m an efficient germicide; and a clean area secured round the vagina by means of clean or sterile towels or sheeting. (3) Vaginal examinations should not be made as a routine; where an examination is necessary a 'rectal examination might be better than a vaginal examina-

tion, but it should be followed by very efficient disinfection of the hands. (4) Great care .must be taken during the puerperium to secure sterilisation of the ano-perineal area, or wounds of the perineum, vagina, and cervix may become infected and an ascending lymphangitis may lead on to septicaemia. A paint such as was suggested by the different authorities is most likely to secure sterilisation. If the bacillus coli can give rise to cystitis and pyelitis and is also found m cases of puerperal fever, it seems unsafe to reckon the immunity of patients to infection from organisms normally existing m their own tissues; on the other hand, if they are so dangerous it is amazing that so few patients contract puerperal fever. In district practice, especially when the midwife is called late, the anoperineal area is often septic m the extreme, and yet m the majority of cases the patient makes an uninterrupted recovery. We are not yet convinced that the antiseptic precautions taken outside hospitals leave nothing to be desired. How can it he explained that m those cases m which the disinfection of the hands and vulva are, to say the least of it, perfunctory, few women contract puerperal fever ? Nine-ty-nine cases may show no signs ar symptoms; the hundredth may have virulent sepsis. Is it not a question of the defences of the body? It can hardly he conceived that labour can take place without invasion of germs; if there are no manipulations, germs from, the anoperineal area invade the vulva. And yet, as a rule, small tears heal by first intention, and the patient has a normal puerperium, while m a few cases m which surgical cleanliness has been secured to the — nth degree the patient has puerperal fever ! Nothing, then, can be more necessary than building up the defences of the body by securing health during pregnancy, and practising surgical cleanliness m the conduct of labour and the puerperium. But with our present knowledge, the causes of puerperal fever m a few cases are ohscuro.—M.O.H., m "The Nursing Times."