Infection during the postpartum period is a common cause of maternal morbidity and mortality. Overall, postpartum in- fection is estimated to occur in up to 8% of all births. There is a higher occurrence in cesarean births than in vaginal births (Gilbert, 2011). Postpartum infection is defined as a fever of 100.4° F (38° C) or higher after the first 24 hours af- ter childbirth, occurring on at least 2 of the first 10 days after birth, exclusive of the first 24 hours (Dorland, 2011). Risk factors include surgical birth, prolonged rupture of mem- branes, long labor with multiple vaginal examinations, ex- tremes of client age, low socioeconomic status, and anemia during pregnancy (Bick, Beake, & Pellowe, 2011).
Infections can easily enter the female genital tract externally and ascend through the internal genital struc- tures. In addition, the normal physiologic changes of childbirth increase the risk of infection by decreasing the vaginal acidity due to the presence of amniotic fluid, blood, and lochia, all of which are alkaline. An alkaline environment encourages the growth of bacteria.
Postpartum infections usually arise from organisms that constitute the normal vaginal flora, typically a mix of aerobic and anaerobic species. Generally, they are polymi- crobial and involve the following microorganisms: Staphy- lococcus aureus, Escherichia coli, Klebsiella, Gardnerella vaginalis, gonococci, coliform bacteria, group A or B he- molytic streptococci, Chlamydia trachomatis, and the an- aerobes that are common to bacterial vaginosis (Wong &
Rosh, 2012). Common postpartum infections include metri- tis, wound infections, urinary tract infections, and mastitis.
whole-blood partial thromboplastin time, and platelet levels. A therapeutic aPTT value typically ranges from 35 to 45 seconds, depending on which standard values are used (Pagana & Pagana, 2011). Also apply warm moist compresses to the affected leg and administer analgesics as ordered to decrease the discomfort.
After several days of IV heparin therapy, expect to begin oral anticoagulant therapy with warfarin (Couma- din) as ordered and monitor coagulation studies. In most cases, the woman will continue to take this medication for several months after discharge.
For the woman who develops a pulmonary embolism, institute emergency measures immediately. The objectives of treatment are to prevent growth or multiplication of thrombi in the lower extremities, prevent more thrombi from traveling to the pulmonary vascular system, and pro- vide cardiopulmonary support if needed. Administer oxy- gen via mask or cannula as ordered and initiate IV heparin therapy titrated according to the results of the coagulation studies. Maintain the client on bed rest, and administer analgesics as ordered for pain relief. Be prepared to assist with administering thrombolytic agents, such as alteplase (tPA), which might be used to dissolve pulmonary emboli and the source of the thrombus in the pelvis or deep leg veins, thus reducing the potential for a recurrence.
Educating the Client
Provide teaching about the use of anticoagulant ther- apy and danger signs that should be reported (Teaching Guidelines 22.1). Provide anticipatory guidance, support,
Teaching Guidelines 22.1
TEACHING TO PREVENT BLEEDING RELATED TO ANTICOAGULANT THERAPY
• Watch for possible signs of bleeding and notify your health care provider if any occur:
• Nosebleeds
• Bleeding from the gums or mouth
• Black tarry stools
• Brown “coffee grounds” vomitus
• Red to brown speckled mucus from a cough
• Oozing at incision, episiotomy site, cut, or scrape
• Pink, red, or brown-tinged urine
• Bruises, “black and blue marks”
• Increased lochia discharge (from present level)
• Practice measures to reduce your risk of bleeding:
• Brush your teeth gently using a soft toothbrush.
• Use an electric razor for shaving.
• Avoid activities that could lead to injury, scrapes, bruising, or cuts.
• Do not use any over-the-counter products contain- ing aspirin or aspirin-like derivatives.
C h a p t e r 2 2 Nursing Management of the Postpartum Woman at Risk 781
Urinary Tract Infections
Urinary tract infections are most commonly caused by bacteria often found in bowel flora, including E. coli, Klebsiella, Proteus, and Enterobacter species. Invasive manipulation of the urethra (e.g., urinary catheteriza- tion), frequent vaginal examinations, and genital trauma increase the likelihood of a urinary tract infection.
Mastitis
A common problem that may occur within the first 2 weeks postpartum is an inflammation of the breast, termed mastitis. An estimated 2% to 33% of breast- feeding women develop lactational mastitis (Jahanfar, 2012). As well as causing significant discomfort, it is a frequent reason for women to stop breast-feeding. It can result from any event that creates milk stasis: insufficient drainage of the breast, rapid weaning, oversupply of milk, pressure on the breast from a poorly fitting bra, a blocked duct, missed feedings, and breakdown of the nipple via fissures, cracks, or blisters (Cusack & Brennan, 2011). The most common infecting organism is S. aureus, which comes from the breast-feeding infant’s mouth or throat. Staphylococcus albus, E. coli, and streptococci are also causative agents, but found less frequently. Infection can be transmitted from the lactiferous ducts to a secret- ing lobule, from a nipple fissure to periductal lymphat- ics, or by circulation (Gilbert, 2011) (Fig. 22.3). A breast abscess may develop if mastitis is not treated adequately.
Flu-like symptoms are often the first symptoms experi- enced by the mother. Breasts are red, tender, and hot to the touch. The upper, outer quadrant of the breast is the most common site for mastitis to occur because most of the breast tissue is located there with both the right and left breasts being equally affected. Effective milk removal, pain medication, and antibiotic therapy have been the mainstays of treatment.
Metritis
Although usually referred to clinically as endometritis, postpartum uterine infections typically involve more than just the endometrial lining. Metritis is an infectious condition that involves the endometrium, decidua, and adjacent myometrium of the uterus. Extension of metri- tis can result in parametritis, which involves the broad ligament and possibly the ovaries and fallopian tubes, or septic pelvic thrombophlebitis, which results when the infection spreads along venous routes into the pelvis (Tharpe, Farley, & Jordan, 2013).
The uterine cavity is sterile until rupture of the am- niotic sac. As a consequence of labor, birth, and associ- ated manipulations, anaerobic and aerobic bacteria can contaminate the uterus. In most cases, the bacteria re- sponsible for pelvic infections are those that normally reside in the bowel, vagina, perineum, and cervix, such as E. coli, Klebsiella pneumoniae, or G. vaginalis.
The risk of metritis increases dramatically after a ce- sarean birth; it complicates from 10% to 20% of cesarean births. This is typically an extension of chorioamnion- itis that was present before birth (indeed, that may have been why the cesarean birth was performed). In addition, trauma to the tissues and a break in the skin (incision) provide entrances for bacteria to enter the body and mul- tiply (Mattson & Smith, 2011).
Wound Infections
Any break in the skin or mucous membranes provides a portal for bacteria. In the postpartum woman, sites of wound infection include cesarean surgical incisions, the episiotomy site in the perineum, and genital tract lacerations (Fig. 22.2). Wound infections are usually not identified until the woman has been discharged from the hospital because symptoms may not show up until 24 to 48 hours after birth.
A B
FIGURE 22.2 Postpartum wound infections. (A) Infected episiotomy site. (B) Infected cesarean birth incision.
782 U N I T 7 Childbearing at Risk
frequency of nursing is advised. Lactation need not be suppressed. Control of infection is achieved with antibi- otics. In addition, ice or warm packs and analgesics may be needed. In addition to antibiotics, management of lactational breast infections includes symptomatic treat- ment, assessment of the infant’s attachment to the breast, and reassurance, emotional support, education, and sup- port for ongoing breast-feeding.
Take Note!
Regardless of the etiology of mastitis, the focus is on reversing milk stasis, maintaining milk supply, and continuing breast-feeding, along with providing maternal comfort and preventing recurrence.
Nursing Assessment
Perinatal nurses are the primary caregivers for postpar- tum women and have a unique opportunity to identify subtle changes that place women at risk for infection.
Nurses play a key role in identifying signs and symptoms that suggest a postpartum infection. Today women are commonly discharged 24 to 48 hours after giving birth.
Therefore, nurses must assess new mothers for risk fac- tors and identify early, subtle signs and symptoms of an infectious process. Factors that place a woman at risk for a postpartum infection are highlighted in Box 22.1.
Review the client’s history and physical examina- tion and labor and birth record for factors that might increase her risk for developing an infection. Then com- plete the assessment (using the “BUBBLE-EE” parameters discussed in Chapter 16), paying particular attention to areas such as the abdomen and fundus, breasts, urinary tract, episiotomy, lacerations, or incisions and being alert for signs and symptoms of infection (Table 22.3).
Take Note!
A postpartum infection is commonly associated with an elevated temperature, as mentioned previously.
Other generalized signs and symptoms may include chills, foul- smelling vaginal discharge, headache, malaise, restlessness, anxiety, and tachycardia. In addition, the woman may have specific signs and symptoms based on the type and location of the infection.
The acronym REEDA is frequently used for assess- ing a woman’s perineum status. It is derived from five components that have been identified to be associated with the healing process of the perineum. These include:
1. Redness 2. Edema 3. Ecchymosis 4. Discharge
5. Approximation of skin edges
Therapeutic Management
When metritis occurs, broad-spectrum antibiotics are used to treat the infection. Management also includes measures to restore and promote fluid and electrolyte balance, pro- vide analgesia, and provide emotional support. In most treated women, fever drops and symptoms cease within 48 to 72 hours after the start of antibiotic therapy.
Management for wound infections involves recogni- tion of the infection, followed by opening of the wound to allow drainage. Aseptic wound management with ster- ile gloves and frequent dressing changes if applicable, good handwashing, frequent perineal pad changes, hy- dration, and ambulation to prevent venous stasis and im- prove circulation are initiated to prevent development of a more serious infection or spread of the infection to adjacent structures. Parenteral antibiotics are the main- stay of treatment. Analgesics are also important, because women often experience discomfort at the wound site.
If the woman develops a urinary tract infection, fluids are used to treat dehydration. General nutrition measures include acidifying the urine by taking large doses of vitamin C or a regular intake of cranberry juice.
Cranberry juice contains a substance with biologic activ- ity that inhibits the growth of E. coli in the urinary tract (Robinson & McCormick, 2011). Antibiotics may also be ordered if appropriate.
Treatment of mastitis focuses on two areas: empty- ing the breasts and controlling the infection. Frequent breast emptying helps both infectious and noninfec- tious mastitis. The breast can be emptied either by the infant sucking or by manual expression. Increasing the FIGURE 22.3 With mastitis, an area on one breast is tender, hot, red, and painful.
C h a p t e r 2 2 Nursing Management of the Postpartum Woman at Risk 783
BOX 22.1
FACTORS PLACING A WOMAN
AT RISK FOR POSTPARTUM INFECTION
• Prolonged (.18 to 24 hours) premature rupture of membranes (removes the barrier of amniotic fluid so bacteria can ascend)
• Cesarean birth (allows bacterial entry due to break in protective skin barrier)
• Urinary catheterization (could allow entry of bacteria into bladder due to break in aseptic technique)
• Regional anesthesia that decreases perception of need to void (causes urinary stasis and increases risk of urinary tract infection)
• Staff attending to woman are ill (promotes droplet infection from personnel)
• Compromised health status, such as anemia, obesity, smoking, drug abuse (reduces the body’s immune system and decreases ability to fight infection)
• Preexisting colonization of lower genital tract with bacterial vaginosis, Chlamydia trachomatis, group B streptococci, S. aureus, and E. coli (allows microbes to ascend)
• Retained placental fragments (provides medium for bacterial growth)
• Manual removal of a retained placenta (causes trauma to the lining of the uterus and thus opens up sites for bacterial invasion)
• Insertion of fetal scalp electrode or intrauterine pressure catheters for internal fetal monitoring during labor (provides entry into uterine cavity)
• Instrument-assisted childbirth, such as forceps or vacuum extraction (increases risk of trauma to genital tract, which provides bacteria access to grow)
• Trauma to the genital tract, such as episiotomy or lacerations (provides a portal of entry for bacteria)
• Prolonged labor with frequent vaginal examinations to check progress (allows time for bacteria to multiply and increases potential exposure to micro- organisms or trauma)
• Poor nutritional status (reduces body’s ability to repair tissue)
• Gestational diabetes (decreases body’s heal- ing ability and provides higher glucose levels on skin and in urine, which encourages bacterial growth)
• Break in aseptic technique during surgery or birthing process (allows entry of bacteria)
Adapted from Bick, D., Beake, S., & Pellowe, C. (2011). Vigilance must be a priority: Maternal genital tract sepsis. The Practicing Midwife, 14(4), 16–18; Gilbert, E. S. (2011). Manual of high-risk pregnancy and delivery (5th ed.). St. Louis, MO: Mosby Else- vier; and Wong, A. W., & Rosh, A. J. (2012). Postpartum infec- tions. eMedicine. Retrieved from http://emedicine.medscape.com/
article/796892-overview.
TABLE 22.3 SIGNS AND SYMPTOMS OF POSTPARTUM INFECTIONS Postpartum
Infection Signs and Symptoms
Metritis Lower abdominal tenderness or pain on one or both sides
Temperature elevation (.38º C) Foul-smelling lochia
Anorexia Nausea
Fatigue and lethargy Leukocytosis and elevated
sedimentation rate Wound
infection Weeping serosanguineous or purulent drainage
Separation of or unapproximated wound edges
Edema Erythema Tenderness
Discomfort at the site Maternal fever
Elevated white blood cell count Urinary tract
infection Urgency Frequency Dysuria Flank pain Low-grade fever Urinary retention Hematuria
Urine positive for nitrates Cloudy urine with strong odor Mastitis Flu-like symptoms, including malaise,
fever, and chills
Tender, hot, red, painful area on one breast
Inflammation of breast area Breast tenderness
Cracking of skin around nipple or areola Breast distention with milk
Adapted from Bick, D., Beake, S., & Pellowe, C. (2011). Vigilance must be a priority: Maternal genital tract sepsis. The Practicing Mid- wife, 14(4), 16–18; Chelmow, D., O’Grady, J. P., & Guzman, G. M.
(2011). Normal and abnormal postpartum. eMedicine. Retrieved from http://emedicine.medscape.com/article/260187-overview; and Cusack, L., & Brennan, M. (2011). Lactational mastitis and breast abscess—Diagnosis and management in general practice. Australian Family Physician, 40(12), 976–979.
Each category is assessed and a number assigned (0 to 3 points) for a total REEDA score ranging from 0 to 15.
The higher scores indicate increased tissue trauma (Nav- vabi, Abedian, & Steen-Greaves, 2009). See Figure 22.4 for the REEDA method for assessing perineum healing.
Monitor the woman’s vital signs, especially her tem- perature. Changes may also signal an infection.
FIGURE 22.4 REEDA method for assessing perineum healing. Adapted from Davidson, N. (1974). REEDA: Evaluating postpartum healing. Journal of Nurse Midwifery 19(2), 6–8;
and Hill, P. D. (2005). Psychometric properties of REEDA. Journal of Nurse Midwifery 35(3), 162–165.
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C h a p t e r 2 2 Nursing Management of the Postpartum Woman at Risk 785
• Monitor vital signs and laboratory results for any abnormal values.
• Monitor the frequency of vaginal examinations and length of labor.
• Assess frequently for early signs of infection, especially fever and the appearance of lochia.
• Inspect wounds frequently for inflammation and drainage.
• Encourage rest, adequate hydration, and healthy eating habits.
• Reinforce preventive measures during any interaction with the client.
If the woman develops an infection, review treat- ment measures, such as antibiotic therapy if ordered, and any special care measures, such as dressing changes, that might be needed (Nursing Care Plan 22.1).
Postpartum women should be offered advice on the signs and symptoms of life-threatening conditions,
Nursing Management
Nursing management focuses on preventing postpartum infections. Use the following guidelines to reduce the incidence of postpartum infections:
• Maintain aseptic technique when performing inva- sive procedures such as urinary catheterization, when changing dressings, and during all surgical procedures.
• Use good handwashing technique before and after each client care activity.
• Reinforce measures for maintaining good perineal hygiene.
• Use adequate lighting and turn the client to the side to assess the episiotomy site.
• Screen all visitors for any signs of active infections to reduce the client’s risk of exposure.
• Review the client’s history for preexisting infections or chronic conditions.
• Assess vital signs every 2 to 4 hours and record results to monitor progress of infection.
• Administer antipyretics as ordered to reduce tem- perature and help combat infection.
• Encourage fluid intake to promote fluid balance.
• Document intake and output to assess hydration status.
• Offer cool bed bath or shower to reduce temperature.
• Place cool cloth on forehead and/or back of neck to provide comfort.
• Change bed linen and gown when damp from diaphoresis to provide comfort and hygiene.
NURSING CARE PLAN 22.1
NURSING DIAGNOSIS: Impaired skin integrity related to wound infection as evidenced by purulent drainage, redness, swelling, and separation of wound edges