EVALUATION AND MANAGEMENT OF CHORIOAMNIONITIS

Elizabeth Mendoza
Updated: May 2020

1. Definition or Key Clinical Information (Posner, Dy, Black, & Jones, 2013; Jordan, Farley, & Grace, 2019)
- Usually infection of the chorion and amnion, but can also include fluid, placenta, cord, and fetus
- polymicrobial infection
- Most common organisms = Ureaplasma spp., Mycoplasma spp., E. coli, strep (A & B), coliforms, staph,
and fusobacterium spp.
- Incidence is about 1-4% of pregnant people
- Definitive diagnosis is usually only made after birth, so treatment decisions are made on s/sx alone

2. Assessment
i. Risk Factors (causative and associative) (Posner, Dy, Black, & Jones, 2013; King et al., 2015; Tharpe,
Farley, & Jordan, 2017)
- Repeated intrapartum - Periodontal disease - Alcohol, substance,
vaginal exams - Intrapartum internal and/or cigarette use
- Prolonged labor/labor monitoring, IUPC, - Use of IUD
dystocia amnioinfusion, or - High BMI
- Nulliparity amniocentesis - Immunocompromised
- BV - Epidural use status
- GBS colonization - MSAF - Black race
- UTI - Cesarean birth

ii. Subjective Symptoms (Posner, Dy, Black, & Jones, 2013)

- Could be subclinical or asymptomatic
- Malaise / flu-like symptoms
- Uterine contractions (w/o labor/cervical change)
- Uncoordinated uterine contractions
- Tachysystole uterine contractions
- Tender uterus/fundus
- Lower abdominal pain

iii. Objective Signs (Posner, Dy, Black, & Jones, 2013; King et al., 2015; Tharpe, Farley, & Jordan, 2017)
- fever (>100.4 degrees F) (diagnosis not made until an hour with fever)
- foul-smelling discharge/amniotic fluid, may be purulent
- tachycardia (birthing person: >100 bpm
- abnormal or non-reassuring fetal heart tracing

iv. Differential Diagnosis (King et al., 2015; Jordan, Farley, & Grace, 2019)
- dehydration, overheated room, prolonged time in the tub or shower, epidural fever

v. Clinical Test Considerations (Posner, Dy, Black, & Jones, 2013; King et al., 2015)
- Physical exam: vital signs, abdominal exam, possible bimanual exam, or other evidence of
infection
- Cultures/PCR of blood or amniotic fluid (not quick enough to be diagnostic intrapartum, but can be
helpful when determining specific treatment)
- CBC (possible elevated leukocytes)
- Placenta may be sent for pathology examination by hospital-based provider (only way for
definitive diagnosis)

3. Management plan

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 i. Therapeutic measures to consider (King et al., 2015; Jordan, Farley, & Grace, 2019)
- IV fluids to reduce fever (with probable catheter to monitor I/O); IV bolus as temp begins to rise,
then re-check in an hour
- Treatments provided by hospital-based provider:
o Acetaminophen may be given to address fever
o broad-spectrum IV abx are indicated and will be administered (often ampicillin/PCN and
gentamicin OR clindamycin w/ allergy to PCN)
o abx should be continued for 24 hours after client is afebrile postpartum

ii. Complementary measures to consider (Tharpe, Farley, & Jordan, 2017; Davis 2012)
- In addition to abx treatment:
o Rest
o Hydration (oral fluids or IV therapy)
o Rescue remedy to pulse points
o Cool cloths to head and neck
o Probiotics (via food or supplemental)
o Heating source to abdomen
o Herbs to boost immune system: black walnut tincture, oregano tea, echinacea tea or
tincture
o Nutritional support to boost immune system: vitamin C, zinc, complex carbs, protein
o Practical support to allow for rest and recovery

iii. Considerations for pregnancy, delivery, and lactation (Posner, Dy, Black, & Jones, 2013; King et
al., 2015; Jordan, Farley, & Grace, 2019)
- Associated with PPROM, PTL (via increased cytokines, chemokines, and prostaglandins), low Apgar
scores, NICU admission, low birth weight, PPH, placental abruption, sepsis, and endometritis
- Increased chance of infection in the fetal compartment (Fetal Inflammatory Response Syndrome),
possibly leading to multi-organ damage, cerebral palsy, neonatal sepsis, meningitis, pneumonia,
- When diagnosis is made or highly suspected, delivery plan (induction/operative delivery) must be
made and if already in labor, active management will likely be instigated by hospital-based
provider
- Neonates born to people with chorioamnionitis should be thoroughly evaluated for s/sx of
residual infection/effects/sepsis

iv. Client and family education (Tharpe, Farley, & Jordan, 2017)
- Educate and counsel on abstaining from substances and cigarettes
- Educate on importance of rest and adequate hydration and nutrition in pregnancy and in the first
stage of labor
- Educate on hygiene techniques to reduce infection, especially in labor and after ROM
- Educate on importance of proper treatment and adherence to treatment
- Educate on supportive alternative measures
- Educate clients on warning signs/when to call a midwife for signs of infection and when to seek
higher level of care

v. Follow-up (Tharpe, Farley, & Jordan, 2017)

- Improvement of s/sx could be seen within hours or up to 48-72 hours
- ensure access to foods and resources that will promote proper healing and immune support
- ensure practical support to allow rest and healing
- process birth experience with birthing person and support team as need or desired

4. Indications for Consult, Collaboration or Referral (Department of State, 2017)

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- Any evidence of chorioamnionitis is an indication for transfer to the hospital; infection of the birthing
person is out of scope for Arizona CPMs

5.References
Davis, E. (2012). Heart & hands: A midwife's guide to pregnancy and birth. (5th ed.). Berkeley, CA: Ten Speed Press.
Department of State, Office of the Secretary of State. (2017). Arizona Administrative Code, Title 09. Health
Services, Chapter 16. Department of Health Services - Occupational Licensing. Retrieved from
https://apps.azsos.gov/public_services/Title_09/9-16.pdf
Jordan, R. G., Farley, C. L., & Grace, K. T. (2019). Prenatal and postnatal care: A woman-centered approach (2nd
ed.). Hoboken, NJ: Wiley.
King, T., Brucker, M., Fahey, J., Kriebs, J., Gegor, C., & Varney, H. (2015). Varney's midwifery (5th ed.). Sudbury, MA:
Jones & Bartlett Learning.
Posner, G., Dy, J., Black, A., & Jones, G. (2013). Oxorn-Foote human labor and birth (6th ed.). McGraw-Hill
Education.
Tharpe, N., Farley, C. L., & Jordan, R. G. (2017). Clinical practice guidelines for midwifery & women's health (5th ed.).
Burlington, MA: Jones & Bartlett Learning.