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Referral and warning signs
When to refer
Requires management in hospital (HC4/H/RR) capable of IV antibiotics, monitoring, C/S, and neonatal care.
Red flags
- High fever / Signs of maternal sepsis
- Signs of fetal distress
- Failure to progress in labour
- Purulent amniotic fluid
Signs and symptoms
- Maternal Fever (>38°C) during labour or after ROM.
- Maternal Tachycardia (>100 bpm).
- Fetal Tachycardia (>160 bpm).
- Uterine tenderness.
- Foul-smelling or purulent amniotic fluid/vaginal discharge.
- Maternal leucocytosis (elevated WBC count).
Risk factors
- Prolonged rupture of membranes (>18-24 hours).
- Prolonged labour.
- Multiple vaginal examinations.
- Internal fetal monitoring.
- Untreated lower genital tract infections (BV, GBS, STIs).
- Preterm labour/PPROM.
Diagnosis
Clinical assessment
Diagnosis usually based on clinical signs: Maternal Fever PLUS >=1 of: Maternal tachycardia, Fetal tachycardia, Uterine tenderness, Foul/purulent amniotic fluid.
Investigations
- Maternal temperature, pulse.
- Fetal heart rate.
- Assess uterine tenderness.
- Observe amniotic fluid character.
- FBC (maternal leucocytosis).
- Amniotic fluid analysis (rare).
- Blood cultures (if sepsis suspected).
Diagnostic criteria
Clinical diagnosis based on fever plus other associated signs.
Management
Non-pharmacological management
- Expedite delivery (vaginal preferred if safe/progressing, C/S for standard indications).
- Supportive care (hydration).
Pharmacological treatment
- Broad-Spectrum IV Antibiotics IMMEDIATELY: Ampicillin 2g IV Q6H PLUS Gentamicin 5 mg/kg IV Q24H. ADD Metronidazole 500mg IV Q8H (or Clindamycin 900mg IV Q8H) if Caesarean Section. Continue until afebrile 24-48h.
- Antipyretics (Paracetamol).
Monitoring
Monitor maternal vitals, FHR, labour progress. Monitor neonate closely for sepsis postpartum.
Complications
- Maternal: Puerperal sepsis, Bacteraemia/Shock, PPH, Abscess, Wound infection, Thrombophlebitis.
- Fetal/Neonatal: Neonatal sepsis, Meningitis, Pneumonia, Preterm birth complications, Cerebral palsy, Stillbirth/Death.
Prevention
- Limit duration of ROM (induce term PROM).
- Minimize vaginal exams.
- Treat genital infections.
- Prophylactic antibiotics (GBS, prolonged ROM).
Patient education
- Explanation of infection and risks.
- Need for IV antibiotics and delivery.
- Potential need for C/S.
- Need for neonatal assessment/antibiotics.
Uganda-specific notes
Significant cause of maternal/neonatal sepsis. Prompt recognition and antibiotics (Amp/Gent standard) crucial. Plan for neonatal management.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 16, Section 16.3.5