Semmelweis’ Discovery: The Birth of Infection Control

In the 1840s, Semmelweis observed a stark difference in maternal mortality rates between two clinics at Vienna General Hospital:

• Clinic 1: Staffed by male physicians and medical students who performed autopsies — had mortality rates of 98.4 per 1000 births
• Clinic 2: Staffed by midwives who did not perform autopsies — had mortality rates of only 36.2 per 1000 births

Semmelweis hypothesized that physicians were transferring “cadaveric particles” from autopsies to women in labor. In May 1847, he implemented mandatory handwashing with chlorinated lime solution before examining patients, resulting in a dramatic reduction in maternal mortality in Clinic 1 to match the rates of Clinic 2.

This breakthrough occurred before the development of germ theory, making Semmelweis a pioneer in infection control. Despite his significant finding, his theory was rejected by the medical establishment of the time. Only years later, with the advancement of bacteriology and germ theory, was the importance of his discovery fully recognized.

Today, Semmelweis is known as “the savior of mothers” and his discovery forms the foundation of modern infection prevention practices in healthcare.

Understanding Puerperal Sepsis

Global Burden:

• Puerperal sepsis is one of the top five causes of maternal mortality worldwide
• Accounts for approximately 10-15% of all maternal deaths
• Globally, around 75,000 maternal deaths occur each year due to puerperal sepsis
• Highest incidence rates in low-income countries:
  • Asia: 11.6%
  • Africa: 9.7%
  • South America: 7.7%

Incidence:

Incidence rates vary significantly depending on:

• Mode of delivery (5-10 times higher after cesarean section compared to vaginal delivery)
• Geographic location and healthcare quality
• Socioeconomic factors
• In developed countries with modern healthcare: 1-3% of live births
• In developing countries: up to 10% of deliveries may be complicated by puerperal sepsis

Mechanism of Infection and Progression

Routes of Bacterial Invasion:

1. Ascending infection: Most common route – bacteria from the vagina ascend into the uterine cavity
2. Direct inoculation: During obstetric procedures, examinations, or surgical interventions
3. Lymphatic spread: Through lymphatic channels to surrounding tissues
4. Hematogenous spread: Via bloodstream from other infection sites

Microbiology:

Puerperal sepsis is typically polymicrobial, involving both aerobic and anaerobic bacteria:

• Group A & B Streptococci: Historically significant cause (Group A strep was known as “the childbed fever”)
• Escherichia coli: Common pathogen from intestinal flora
• Staphylococcus aureus: Can cause severe infection and toxic shock syndrome
• Klebsiella pneumoniae: Particularly in healthcare-associated infections
• Anaerobes: Bacteroides, Peptostreptococcus, Clostridium species
• Enterococci: Especially in cases with prior antibiotic exposure

Progression of Infection:

1. Endometritis: Initial infection of the endometrial lining
2. Myometritis: Spread to the uterine muscle layer
3. Parametritis: Extension to the broad ligament and pelvic cellular tissue
4. Peritonitis: Infection of the peritoneal cavity
5. Septicemia: Bacteria enter the bloodstream causing systemic infection
6. Septic shock: Severe sepsis with tissue hypoperfusion and organ dysfunction

Systemic Inflammatory Response:

In severe cases, bacterial endotoxins and exotoxins trigger a systemic inflammatory cascade:

• Cytokine release: Pro-inflammatory mediators (TNF-α, IL-1, IL-6) cause vasodilation and increased capillary permeability
• Endothelial damage: Leading to microvascular dysfunction
• Coagulation activation: Triggering the clotting cascade, potentially leading to DIC (Disseminated Intravascular Coagulation)
• Impaired tissue perfusion: Resulting in organ dysfunction

Unique Factors in Puerperal Sepsis:

Several factors unique to the postpartum period increase susceptibility to infection:

• Placental site: Open wound with exposed vessels at the placental implantation site
• Immunological changes: Relative immunosuppression during pregnancy and postpartum period
• Tissue trauma: From delivery process, episiotomy, or cesarean incision
• Retained products: Placental fragments or blood clots provide excellent medium for bacterial growth
• Physiologic changes: Increased heart rate, decreased blood pressure, and leukocytosis can mask early signs of infection

Predisposing Factors for Puerperal Sepsis

Pre-existing Patient Factors:

• Malnutrition and anemia: Impair immune function and wound healing
• Obesity (BMI >30): Associated with impaired wound healing and increased surgical complications
• Diabetes mellitus: Affects immune function and increases susceptibility to infection
• Immunocompromised status: HIV infection, use of immunosuppressants
• Pre-existing genital tract infections: Bacterial vaginosis, group B streptococcal colonization
• Low socioeconomic status: Often associated with poor nutrition and limited access to healthcare

Intrapartum (During Labor and Delivery) Factors:

• Prolonged rupture of membranes (>18 hours): Allows ascending bacterial colonization
• Prolonged labor (>24 hours): Increases risk of tissue trauma and bacterial colonization
• Multiple vaginal examinations: Each examination increases risk of introducing pathogens
• Cesarean delivery: 5-20 times higher risk compared to vaginal delivery
• Intrauterine manipulation: Manual removal of placenta, internal version
• Traumatic delivery: Extensive tissue damage, hematoma formation
• Retained placental fragments: Provide medium for bacterial growth
• Poor aseptic techniques: During obstetric procedures

Postpartum Factors:

• Postpartum hemorrhage: Increases risk of infection and reduces host defenses
• Poor perineal hygiene: Allows bacterial colonization and ascension
• Invasive procedures: Catheterization, IV lines
• Wound hematoma: Provides excellent medium for bacterial growth
• Endometrial damage: From instrumentation or cesarean delivery

Healthcare System Factors:

• Limited access to healthcare: Delays in seeking care
• Poor infection control practices: In healthcare facilities
• Inadequate sterilization: Of medical instruments
• Overcrowded facilities: Increase risk of cross-infection
• Lack of trained personnel: For proper management of labor and delivery

Signs and Symptoms

Early Signs and Symptoms:

• Fever: Temperature ≥38°C (100.4°F) after the first 24 hours postpartum
• Pelvic or lower abdominal pain: Often described as dull, constant, or cramping
• Foul-smelling lochia: Abnormal odor, may become purulent
• Abnormal lochia volume: Either excessive or decreased
• Uterine tenderness: Pain on palpation of the uterine fundus
• Subinvolution of uterus: Delayed return to normal size
• Tachycardia: Pulse rate disproportionate to temperature

Signs of Progression and Spreading Infection:

• Parametritis: Pain and induration extending to the pelvic side wall
• Peritonitis: Generalized abdominal pain, rigidity, decreased bowel sounds
• Pelvic abscess: Fluctuant mass on pelvic examination, severe localized pain
• Septic pelvic thrombophlebitis: Persistent fever despite antibiotic therapy, minimal abdominal findings

Signs of Sepsis and Septic Shock:

System	Clinical Manifestations
Cardiovascular	Tachycardia (HR >100 bpm) Hypotension (SBP <90 mmHg or MAP <65 mmHg) Cold, clammy skin Decreased capillary refill
Respiratory	Tachypnea (RR >20 breaths/min) Dyspnea Hypoxemia (SpO₂ <95%) Pulmonary edema
Renal	Oliguria (<0.5 ml/kg/hr) Acute kidney injury Elevated BUN and creatinine
Neurological	Altered mental status Confusion Agitation or lethargy
Gastrointestinal	Ileus Nausea/vomiting Diarrhea
Hematological	Thrombocytopenia Coagulopathy (DIC) Purpura or petechiae
Metabolic	Lactic acidosis Hyperglycemia Elevated liver enzymes

Clinical Manifestations Based on Specific Site of Infection:

Site of Infection	Specific Clinical Manifestations
Endometritis	Uterine tenderness Purulent lochia Subinvolution of uterus
Perineal wound infection	Localized pain and tenderness Erythema and edema of perineum Purulent discharge from episiotomy/laceration Wound dehiscence
Cesarean section wound infection	Erythema and induration of incision site Purulent discharge from wound Wound dehiscence Severe abdominal pain
Mastitis	Localized breast pain, redness, and swelling Breast engorgement Flu-like symptoms

6.1 Diagnostic Criteria

WHO Diagnostic Criteria:

According to the World Health Organization (WHO), puerperal sepsis is diagnosed when infection of the genital tract occurs between rupture of membranes/labor and the 42nd day postpartum with two or more of the following:

• Pelvic pain
• Fever (oral temperature ≥38.5°C/101.3°F)
• Abnormal vaginal discharge (purulent, foul-smelling)
• Delay in the reduction of uterine size (subinvolution)

Sepsis Diagnosis (Updated Criteria):

For puerperal sepsis progressing to septic shock, the current diagnostic approach uses:

• Sequential Organ Failure Assessment (SOFA) score for ICU patients
• Quick SOFA (qSOFA) for non-ICU settings

qSOFA criteria (2 or more indicates higher risk):

• Respiratory rate ≥22 breaths/min
• Altered mental status (Glasgow Coma Scale <15)
• Systolic blood pressure ≤100 mmHg

Assessment Tools:

Several assessment tools can help identify sepsis in obstetric patients:

1. Modified Obstetric Early Warning Score (MOEWS)
2. Maternal Early Warning Criteria (MEWC)
3. Sepsis in Obstetrics Score (SOS)

6.2 Laboratory Findings

Initial Laboratory Studies:

Test	Findings in Puerperal Sepsis	Notes
Complete Blood Count (CBC)	Leukocytosis (WBC >15,000/mm³) Left shift (increased immature neutrophils) Thrombocytopenia in severe cases	WBC count is normally elevated in postpartum period (15,000-30,000/mm³)
C-Reactive Protein (CRP)	Elevated (>100 mg/L suggests severe infection)	Also elevated after uncomplicated delivery but to lesser extent
Procalcitonin	Elevated in bacterial infections (>0.5 ng/mL)	More specific marker than CRP
Lactate	Elevated (>2 mmol/L) in tissue hypoperfusion	Important prognostic marker in sepsis
Blood Cultures	Positive in bacteremia (15-30% of cases)	Collect before antibiotics if possible
Urinalysis/Urine Culture	May show evidence of UTI	To rule out urinary source of infection

Additional Studies for Organ Dysfunction:

Test	Abnormal Findings
Coagulation Studies	Prolonged PT/INR and PTT Decreased fibrinogen Elevated D-dimer
Renal Function Tests	Elevated BUN and creatinine Decreased urine output
Liver Function Tests	Elevated transaminases Elevated bilirubin
Arterial Blood Gas	Metabolic acidosis (decreased pH, increased base deficit) Hypoxemia

Microbiological Studies:

• Blood cultures: Collect before antibiotic administration
• Vaginal/cervical swabs: For culture and sensitivity
• Wound swabs: From perineal or abdominal incisions
• Lochia culture: Though often contaminated with normal flora
• Urine culture: To rule out urinary source

Imaging Studies:

• Transvaginal or abdominal ultrasound: To identify retained products of conception, endometrial thickening, fluid collections, or abscesses
• CT scan: For suspected abscess formation or pelvic thrombophlebitis
• MRI: Better soft tissue contrast; particularly useful for pelvic thrombophlebitis
• Chest X-ray: In cases of suspected pneumonia or ARDS

7.1 Antibiotic Therapy

Empiric Antibiotic Regimens:

Initial therapy should cover common pathogens, including aerobic and anaerobic bacteria:

Severity	Recommended Regimen	Notes
Mild-Moderate Endometritis	Clindamycin 900 mg IV q8h OR Clindamycin 600 mg IV q6h PLUS Gentamicin 5 mg/kg IV daily OR Gentamicin 1.5 mg/kg IV q8h	Classic regimen with best evidence
Severe infection or suspected resistant organisms	Above regimen PLUS Ampicillin 3g IV q6h (for enterococci coverage)	Triple therapy for broader coverage
Alternative regimens	Piperacillin-tazobactam 4.5g IV q6h OR Ertapenem 1g IV daily OR Cefoxitin 2g IV q6h OR Ampicillin-sulbactam 3g IV q6h	Single-agent options with broad spectrum
Septic shock or life-threatening infection	Piperacillin-tazobactam 4.5g IV q6h OR Meropenem 1g IV q8h OR Imipenem-cilastatin 500mg IV q6h PLUS Vancomycin 15-20 mg/kg IV q12h (for MRSA) PLUS Clindamycin 900mg IV q8h (for anti-toxin effect)	Maximum coverage for critically ill patients

Duration of Therapy:

• Continue parenteral antibiotics until 48 hours after clinical improvement (defervescence and reduced pain)
• Total duration typically 7-10 days depending on severity
• For uncomplicated cases: may switch to oral antibiotics after clinical improvement for outpatient completion
• For severe cases or with complications: longer courses may be needed

7.2 Fluid Management and Supportive Care

Fluid Resuscitation:

• Initial fluid bolus: 30 mL/kg of balanced crystalloid solution within the first 3 hours for patients with hypotension or elevated lactate
• Further fluid administration guided by hemodynamic assessment
• Target mean arterial pressure (MAP) ≥65 mmHg
• Monitor for signs of volume overload

Vasopressors:

• Indicated if hypotension persists despite adequate fluid resuscitation
• Norepinephrine is first-line agent (start at 0.05-0.1 mcg/kg/min, titrate as needed)
• Vasopressin may be added as a second agent

Additional Supportive Measures:

• Oxygen therapy: To maintain SpO₂ >94%
• Venous thromboembolism prophylaxis: Unless contraindicated
• Glycemic control: Target blood glucose <180 mg/dL
• Stress ulcer prophylaxis: For patients with risk factors
• Nutritional support: Early initiation when possible
• Pain management: Appropriate analgesics based on pain severity

Monitoring Parameters:

• Vital signs: at least hourly in severe cases
• Urine output: goal >0.5 mL/kg/hour
• Serial lactate measurements to assess response to therapy
• Central venous pressure and ScvO₂ monitoring in severe cases
• Daily assessment of organ function (renal, hepatic, coagulation parameters)

7.3 Surgical Interventions

Indications for Surgical Intervention:

• Retained products of conception
• Abscess formation requiring drainage
• Necrotizing soft tissue infection
• Uterine necrosis or perforation
• Failure to respond to medical management

Potential Procedures:

Procedure	Indications
Dilation and Curettage (D&C)	Removal of retained products of conception
Incision and Drainage	Abscess drainage, wound dehiscence management
Laparoscopy/Laparotomy	Peritonitis, suspected bowel injury, extensive abscess
Hysterectomy	Uterine necrosis, persistent infection despite medical therapy, life-threatening hemorrhage
Debridement	Necrotizing fasciitis, extensive wound infection

Special Considerations in Severe Cases:

• ICU admission criteria: Hypotension requiring vasopressors, respiratory failure requiring mechanical ventilation, altered mental status, or multiple organ dysfunction
• Multidisciplinary approach: Obstetrics, infectious diseases, critical care, surgery, and nursing
• Transfer to tertiary care: Consider for cases requiring specialized care not available at current facility

8.1 Nursing Diagnosis

Priority Nursing Diagnoses:

1. Risk for Infection (Progression/Spread)
2. Acute Pain related to inflammatory process and tissue damage
3. Hyperthermia related to infectious process
4. Deficient Fluid Volume related to fever, decreased oral intake, and third spacing
5. Imbalanced Nutrition: Less Than Body Requirements related to increased metabolic demands and decreased intake
6. Risk for Impaired Skin/Tissue Integrity at surgical/perineal sites
7. Activity Intolerance related to inflammatory process and fatigue
8. Anxiety related to illness and separation from newborn
9. Risk for Ineffective Breastfeeding related to illness and possible separation
10. Risk for Impaired Parent-Infant Attachment related to maternal illness and separation

8.2 Nursing Interventions

1. Infection Control and Management:

• Monitor vital signs: Temperature, pulse, respiration, blood pressure at least every 4 hours or more frequently if unstable
• Assess for signs of progressive infection: Worsening pain, spreading redness, increased drainage, systemic symptoms
• Perform comprehensive assessment: Use the REEDA scale to monitor wound healing
• Perform/assist with proper specimen collection: Blood cultures, wound swabs, urine samples
• Administer prescribed antibiotics: Ensure timely administration, monitor for effectiveness and adverse effects
• Practice and teach proper hand hygiene: Before and after all patient contact and procedures
• Maintain aseptic technique: During wound care, IV line management, catheter care
• Implement isolation precautions: As needed based on pathogen and institutional policy
• Monitor laboratory values: WBC count, CRP, procalcitonin, lactate
• Assess lochia: Amount, color, consistency, odor
• Assess uterine involution: Fundal height, firmness, tenderness
• Maintain strict intake and output monitoring: Ensure adequate hydration (at least 2000 ml/day)
• Position client in semi-Fowler’s position: To promote lochia drainage

2. Pain Management:

• Assess pain: Location, quality, intensity using a 0-10 scale, aggravating and relieving factors
• Administer prescribed analgesics: On schedule rather than PRN for severe pain
• Apply cold/warm compresses: To perineal area or incision site as appropriate
• Position for comfort: Support with pillows, assist with position changes
• Teach relaxation techniques: Deep breathing, guided imagery, distraction
• Monitor effectiveness of interventions: Reassess pain after interventions

3. Thermoregulation:

• Monitor temperature: At least every 4 hours or more frequently during febrile episodes
• Administer antipyretics: As prescribed
• Provide cooling measures: Light clothing, reduced room temperature, cool cloths
• Monitor for shaking chills: Provide warm blankets during chills, then remove when chills subside
• Encourage fluid intake: To replace losses from increased metabolic rate and diaphoresis

4. Fluid and Nutritional Management:

• Monitor hydration status: Skin turgor, mucous membranes, urine output, weight
• Administer IV fluids: As prescribed, monitor infusion rates and sites
• Encourage oral fluids: At least 2000-3000 ml/day if able to tolerate
• Provide high-protein, high-calorie diet: To support healing and immune function
• Encourage small, frequent meals: If patient has decreased appetite
• Monitor nutritional intake: Document food consumption, caloric count if needed
• Administer supplements: As prescribed (e.g., vitamins, iron)
• Consult dietitian: For individualized nutrition plan

5. Activity and Rest:

• Promote progressive activity: Based on tolerance and clinical condition
• Encourage early ambulation: To prevent complications of immobility
• Assist with activities of daily living: As needed
• Provide frequent rest periods: Between activities
• Implement venous thromboembolism prophylaxis: Early ambulation, sequential compression devices, anticoagulants as prescribed

6. Wound Care:

• Perform wound assessment: Using REEDA scale
• Maintain proper wound care: Clean with prescribed solution, apply dressings as ordered
• Teach perineal care: Proper cleansing technique, front-to-back wiping
• Encourage sitz baths: For perineal wounds, 2-3 times daily for 15-20 minutes
• Change peripads: Frequently to reduce bacterial growth
• Monitor wound drainage: Amount, color, consistency, odor
• Teach wound care: For discharge planning

7. Psychosocial Support:

• Assess emotional status: Fears, concerns, understanding of condition
• Provide emotional support: Therapeutic presence, active listening
• Facilitate mother-infant contact: When appropriate based on mother’s condition and infection control
• Support breastfeeding: Assist with breast pump if direct breastfeeding not possible
• Include family/support persons: In care and education
• Refer to social services: For additional support as needed

8. Patient and Family Education:

• Explain diagnosis and treatment: In clear, simple terms
• Teach medication administration: Purpose, dosage, schedule, side effects
• Instruct on signs of worsening infection: Increased pain, fever, redness, drainage
• Provide wound care instructions: Cleaning, dressing changes
• Discuss activity restrictions: Including pelvic rest (no tampons, douching, intercourse)
• Review follow-up care: Appointments, when to call healthcare provider
• Address breastfeeding concerns: Safety with antibiotics, maintaining milk supply

Evidence-Based Prevention of Puerperal Sepsis

Antenatal Prevention:

• Regular antenatal care: Identification and management of risk factors
• Screening and treatment: For urinary tract infections, bacterial vaginosis, Group B Streptococcus
• Nutritional support: To correct anemia and malnutrition
• Management of medical conditions: Diabetes, HIV, other immunocompromising conditions
• Education: Personal hygiene, recognition of warning signs

Intrapartum Prevention:

• Hand hygiene: Proper handwashing before all examinations and procedures
• Aseptic techniques: For all vaginal examinations and procedures
• Minimize vaginal examinations: Only when necessary and with sterile gloves
• Appropriate antibiotic prophylaxis: For cesarean delivery, Group B Streptococcus carriers, prolonged rupture of membranes
• Proper surgical technique: For cesarean delivery and episiotomy

WHO Recommendations for Antibiotic Prophylaxis:

Procedure/Condition	Recommendation
Cesarean Section	Single dose of first-generation cephalosporin or penicillin prior to skin incision Additional doses for prolonged procedures or significant blood loss
Manual Removal of Placenta	Single dose of first-generation cephalosporin or penicillin
Third or Fourth Degree Perineal Tear	Single dose of first-generation cephalosporin or penicillin
Operative Vaginal Delivery	Antibiotic prophylaxis recommended

Postpartum Prevention:

• Early detection of complications: Regular vital sign monitoring, assessment of lochia and uterine involution
• Proper perineal care: Regular cleansing, frequent pad changes
• Early ambulation: To prevent thromboembolic complications
• Adequate nutrition and hydration: To support immune function and healing
• Education on warning signs: When to seek medical attention
• Proper wound care: For cesarean incision or episiotomy

Healthcare System Interventions:

• Implementation of standardized protocols: For prevention and early management
• Regular training of healthcare providers: On aseptic techniques and recognition of sepsis
• Adequate supplies: Of sterile equipment, gloves, antiseptic solutions
• Infection control committees: For monitoring and quality improvement
• Surveillance systems: For tracking maternal infections and outcomes
• Access to emergency obstetric care: For timely intervention when complications arise

Learning Tools for Puerperal Sepsis

Clinical Application: Puerperal Sepsis Case

Presentation:

Maria has developed a fever of 38.7°C (101.6°F), tachycardia (heart rate 118 bpm), and is complaining of increasing pain at the incision site. She reports feeling generally unwell with chills and fatigue. On examination, the cesarean incision is erythematous with purulent discharge from the lower edge. Her uterus is tender on palpation with foul-smelling lochia. Maria is worried about caring for her newborn as she feels too weak.

Assessment Findings:

• Vital signs: Temperature 38.7°C, Heart rate 118 bpm, Respiratory rate 24/min, BP 110/70 mmHg
• Abdominal examination: Tender uterus, incision site with erythema, edema, and purulent discharge
• Lochia: Moderate amount, foul-smelling
• Laboratory: WBC 18,000/mm³ with left shift, CRP 12 mg/dL, Hemoglobin 9.8 g/dL

Nursing Diagnosis:

1. Risk for Infection (Progression) related to cesarean wound infection and endometritis
2. Acute Pain related to inflammatory process
3. Hyperthermia related to infectious process
4. Anxiety related to illness and concern about newborn care
5. Risk for Ineffective Breastfeeding related to maternal illness

Interventions:

1. Immediate Actions:

• Notify healthcare provider of assessment findings
• Collect blood cultures, wound swab, and urine sample before starting antibiotics
• Begin monitoring vital signs every 4 hours
• Administer prescribed IV antibiotics promptly
• Start IV fluid therapy as ordered

2. Ongoing Nursing Care:

• Monitor temperature, vital signs, and incision site regularly
• Perform wound care per protocol, documenting wound appearance using REEDA
• Administer pain medication as prescribed and evaluate effectiveness
• Monitor intake and output, encourage adequate oral hydration
• Support breastfeeding as appropriate based on Maria’s condition
• Provide emotional support and reassurance
• Involve family members in baby care with close supervision

3. Patient Education:

• Explain the nature of the infection and treatment plan
• Instruct on the importance of completing the full course of antibiotics
• Teach signs of worsening infection that would require immediate attention
• Educate on wound care and hygiene practices
• Discuss strategies for balancing rest and newborn care

Outcome:

After 3 days of IV antibiotics (Clindamycin and Gentamicin), Maria’s temperature normalized and her pain decreased. The wound began healing with decreased erythema and discharge. Blood cultures were negative but wound cultures grew Staphylococcus aureus sensitive to the prescribed antibiotics. She was discharged on oral antibiotics to complete a 10-day course, with instructions for follow-up in 1 week and warning signs that would require immediate attention.

1. World Health Organization. (2015). WHO recommendations for prevention and treatment of maternal peripartum infections. WHO Press.
2. Bonet, M., Souza, J. P., Abalos, E., Fawole, B., Knight, M., Kouanda, S., … & Gülmezoglu, A. M. (2017). The global maternal sepsis study and awareness campaign (GLOSS): study protocol. Reproductive health, 15(1), 1-17.
3. Karsnitz, D. B. (2014). Puerperal infections of the genital tract: a clinical review. Journal of Midwifery & Women’s Health, 58(6), 632-642.
4. Song, T., Yu, B., Chen, T., Dong, L., Wang, R., & Liu, X. (2019). Prevention and management of puerperal infection. Biomedical Research, 30(6), 982-985.
5. Blackmon, M. M., Nguyen, H., & Mukherji, P. (2022). Postpartum Infection. In StatPearls. StatPearls Publishing.
6. Brito, F. S., Ferreira, M. B. G., Palma, E., Narchi, N. Z., Pinto, L. F., & Souza, S. R. (2021). Factors associated with the presence, intensity, impact, and relief of perineal pain in women after normal birth. Revista Latino-Americana de Enfermagem, 29, e3427.
7. Wigati, P. W., & Sari, B. M. (2020). Nutritional status associated with the incidence of puerperal infection. Indonesian Journal of Nutrition and Dietetics, 8(1), 23-30.
8. Royal College of Obstetricians and Gynaecologists (RCOG). (2017). Bacterial Sepsis following Pregnancy. Green-top Guideline No. 64b.
9. American College of Obstetricians and Gynecologists (ACOG). (2019). ACOG Practice Bulletin No. 211: Critical Care in Pregnancy. Obstetrics & Gynecology, 133(5), e303-e319.
10. Society for Maternal-Fetal Medicine. (2023). Diagnosis and Management of Maternal Sepsis. Consult Series #67.
11. Acosta, C. D., Kurinczuk, J. J., Lucas, D. N., Tuffnell, D. J., Sellers, S., Knight, M., & United Kingdom Obstetric Surveillance System. (2014). Severe maternal sepsis in the UK, 2011–2012: a national case-control study. PLoS medicine, 11(7), e1001672.
12. Bonet, M., Nogueira Pileggi, V., Rijken, M. J., Coomarasamy, A., Lissauer, D., Souza, J. P., & Gülmezoglu, A. M. (2017). Towards a consensus definition of maternal sepsis: results of a systematic review and expert consultation. Reproductive health, 14(1), 1-13.