NCM 109 Lecture – Puerperal

Carnacer, Lyndee May

In fection S.

» A puerperal infection occurs when bacteria infect

the uterus and surrounding areas after a woman
gives birth.
» It’s also known as a postpartum infection.
» Organisms commonly cultured postpartally
include:
o group B streptococci
o staphylococci
o aerobic gram-negative bacilli such
as
Escherichia
coli.
Assessment
» The management for puerperal infection focuses on (1)
the use of an appropriate antibiotic after culture and Fever
sensitivity testing of the isolated organism. •3rd or 4th postpartal day
•> 38°C for 2 consecutive 24 hours periods
Risk Factor Basis for (2) Chills, loss of appetite, and general
malaise (3) Uterus painful to touch and not
Membrane Risk
rupture Bacteria may have invaded contracted (4) Strong afterpains
more than 24 hrs. the uterus while the fetus is (5) Dark brown lochia with foul
before birth in utero. odor
Retained placenta Tissue necrosis serves as • Increased due to poor uterine involution
fragments excellent bed for bacterial
growth Management
Postpartal hemorrhage General condition is
1. Clindamycin (Cleocin)
weakened.
2. Methylergonovine for ↑ uterine contraction
Pre-existing anemia General condition is
3. ↑ fluid intake to combat the fever.
weakened.
4. Analgesic
Prolonged and difficult Tissue trauma leaves 5. Sitting in a semi-Fowler’s position or
labor laceration. walking
Instrument Births encourages lochia drainage by gravity and helps
Internal FHM electrode Contamination introduced prevent pooling of infected secretions.
with placement of the scalp
electrodes. Infection of the Perineum
Local Vaginal Direct spread of infection
 suture line on her perineum (episiotomy /
Infection has occurred
laceration repair) can cause bacterial invasion
at time of
Uterus birth
explored after Infection introduced with
birth for a retained exploration Assessment
placenta or abnormal
bleeding site (1) Pain
(2) Heat, and a feeling of
pressure. (3) Possible fever
(4) Inflammation of suture line
Endometritis
(5) Purulent drainage present
 infection of the endometrium
 Bacteria gain access to the uterus through the Management
vagina and enter at birth or during the postpartum
 Associated with: 1. Systemic or topical antibiotic
o Chorioamnionitis 2. Analgesic
o Cesarean Section 3. Remove perineal sutures for drainage
4. Sitz baths, moist warm compresses, or Hubbard
NCM 109 Lecture – Puerperal
Carnacer, Lyndee May
In fect
tank ion S.
5. Change perineal pads frequently Assessment
6. Wipe from front to back
7. Do not place the infant on the bottom bed sheet Femoral thrombophlebitis
of the woman’s bed because of pathogenic (1) Redness
bacteria (2) Swelling
8. Encourage woman to ambulate (3) Warmth
(4) Hard inflamed vessel in the affected
Thrombophlebitis leg
(5) Homan’s sign (dorsiflexion sign
Phlebitis test)
• Inflammation of blood vessel lining (6) Doppler ultrasound or contrast venography will
 inflammation with the formation of blood clots be prescribed to confirm the diagnosis
 Classified as:
Management
o Superficial vein disease
(SVD)
1. Ambulation and limiting the time a woman
o Deep vein thrombosis
remains in obstetric stirrups help prevent
(DVT)
thrombophlebitis
 Occurs when:
• encourages circulation in the lower
o ↑ fibrinogen level, ↑ blood clotting
extremities
o Dilation of lower extremity veins due
• promotes venous return
to pressure of fetal head
• decreases the possibility of clot formation
2. Wearing support stockings for the first 2
Risk Factors
weeks after birth can help increase venous
circulation and prevent stasis if she had varicose
1) Prolonged time in a birthing room with their veins before or during pregnancy
legs positioned in stirrups • Encourage her to remove the support
2) Preexistent obesity stockings 2x/day and assess her skin
3) > Recommended pregnancy weight underneath for mottling or inflammation
gain
3. Women are not normally prescribed
4) Preexisting varicose veins
aspirin because it is a mild anticoagulant
5) Postpartal infection
• However, women who are high risk
6) High incidence of thrombophlebitis in family
for thrombophlebitis may be prescribed
7) Smokes cigarettes
aspirin every 4 hours as a preventive
measure.
Femoral thrombophlebitis 4. Anticoagulant administration (3-6
months)
o Involves femoral saphenous and popliteal vein • Unfractionated Heparin (given IV)
o Arterial spasms = ↓ arterial circulation  Continued until symptoms resolve
o 4 – 6 weeks before fully resolved and INR is >2 for at least 24 hrs.
o ↓ arterial circulation + edema = white leg • Low–molecular-weight Heparin
o “Milk leg” (given
o “Phlegmasia alba dolens” subcutaneously)
(white inflammation) • Warfarin (Coumadin)
 discontinue breastfeeding
• Thrombolytics – dissolve clots
 initiated within the first 24 hours for
best results.
• Blood coagulation study will be done
to establish baseline values
• Be certain that protamine sulfate, the
antagonist for heparin, and vitamin K, the
antagonist for warfarin, are both readily
available until the woman’s
anticoagulation therapy is stabilized.
 5. Antibiotic administration (if needed)
6. Application of moist heat • wearing non-constricting clothing on
• Decreases inflammation their lower extremities
• Difficult treatment because dressings can • resting with the feet elevated
be dry or become cold and dampen clothes • ambulating daily
• Cover wet, warm dressings with a
plastic pad to hold in heat and moisture. Pulmonary Embolus
• Weight of a hot pack or pad does not rest
on the leg, causing an obstruction to flow  Obstruction of the pulmonary artery by a blood
of blood. clot
7. Bed rest with the affected leg elevated (bed  a complication of thrombophlebitis when a
cradle) blood clot moves from a leg vein to the
8. Assess risk for pressure ulcer pulmonary artery
9. Never massage the skin over the clotted area
because this could loosen the clot, causing a
pulmonary or cerebral embolism.
10. Check the woman’s bed frequently to be certain
the mattress does
11. not become wet from seeping water.
12. Help her select activities to exercise the
other parts of her body or stimulate her mind
such as reading a good book or information on
newborn care.
Assessment
Pelvic thrombophlebitis
(1) Sudden, sharp chest pain
o Inflammation of the blood vessels in the (2) Tachypnea
pelvic area (3) Tachycardia
o 6-8 weeks (4) Orthopnea
o Involves: Ovary, Uterus, and Hypogastric veins (5) Cyanosis
o follows mild endometritis and occurs later than
femoral thrombophlebitis, often around the 14th
Management
or 15th day of the puerperium.
1. A woman needs oxygen administered
immediately and is at high risk for
Assessment
cardiopulmonary arrest.
Symptoms are present 10 days after birth. 2. Her condition is extremely guarded until the clot
can be lysed or adheres to the pulmonary artery
Pelvic thrombophlebitis
wall and is reabsorbed.
(1) Elevated temperature
3. Because of the seriousness of this condition, a
(2) Chills
woman with a pulmonary embolism commonly is
(3) Pain transferred to an intensive care unit for continuing
(4) Weakness care.
(5) General malaise
Mastitis

Management

1. Total bedrest
2. Administration of:
• Analgesics
• Antibiotics
• Anticoagulants
3. Teach preventive measures
NCM 109 Lecture – Puerperal
Carnacer, Lyndee May
In fection S.
(6) Breast lumps
(7) Nipple discharge

Management

1. Antibiotics
• Amoxicillin/clavulanate
(Augmentin)
875 mg twice daily
• Cephalexin (Keflex)
500 mg four times daily

 Infection of the breast

• Ciprofloxacin (Cipro)
 “epidemic mastitis” or “epidemic breast abscess”
500 mg twice daily
 Cured in 2-3 days if symptoms treated ASAP
• Clindamycin (Cleocin)
 If untreated, can become localized abscess
300 mg four times daily
 Cause by:
• Dicloxacillin (Dynapen)
o Trapped milk
500 mg four times daily
o A blocked milk duct
• Trimethoprim/sulfamethoxazole
o Bacteria entering breasts
(Bactrim, Septra)
 Occurs as early as 7th postpartal day or later
160 mg/800 mg twice daily
 Bacteria from nasal-oral cavity of infant: 2. Cold or ice compresses and a good supportive bra
o Staphylococcus aureus help with pain relief until the process improves,
o Methicillin-resistant S. aureus infection although warm, wet compresses can also be
(MRSA helpful because this reduces inflammation and
) edema.
o Candidiasis while in the hospital. 3. Encourage women to continue to pump breast
milk, if possible, until the abscess has resolved in
PREVENTION: order to preserve breastfeeding.

 Making certain the baby is positioned correctly

and grasps the nipple properly, including both the Peritonitis
nipple and areola
 Helping a baby release a grasp on the nipple before
removing the baby from the breast
 Washing hands between handling perineal pads and
touching breasts
 Exposing nipples to air for at least part of every
day.
 Using a vitamin E ointment daily to soften nipples
 Encouraging women to begin breastfeeding (when
the infant sucks most forcefully) on an unaffected
nipple (if a woman has one cracked nipple and one
well nipple).
 inflammation of the peritoneum, the thin layer of
Assessment tissue covering the inside of your abdomen and
most of its organs.
(1) Mastitis is usually unilateral, although epidemic  occurs as an extension of endometritis.
mastitis because it originates with the infant, may  Infection spreads from the uterus through the
be bilateral. lymphatic system or directly through the
(2) Breast pain (mastalgia) fallopian tubes or uterine wall to the peritoneal
(3) The affected breast appears swollen and cavity.
reddened.  Caused by:
(4) Fever accompanies these first symptoms
o Abdominal injury
within hours
o Underlying medical condition
(5) Breast milk becomes scant.
NCM 109 Lecture – Puerperal
Carnacer, Lyndee May
In fection S.
o Treatment device (dialysis catheter
or feeding tube)
 Abscess may form at cul-de-sac of Douglas
 Peritonitis can interfere with future fertility
because it can leave scarring and adhesions in the
peritoneum, which separate the fallopian tubes
from the ovaries to the extent that ova can no
longer easily enter the tubes.

Assessment

(1) Tenderness in your abdomen

(2) Abdominal pain that gets more intense with
motion or touch
(3) Rigid abdomen, abdominal bloating or distention
(4) Nausea and vomiting
(5) Diarrhea
(6) Constipation or the inability to pass gas
• Due to paralytic ileus (a blockage of
inflamed intestines).
(7) Low urine output
(8) Anorexia, or loss of appetite
(9) Excessive thirst
(10) Fatigue
(11) Fever and chills
(12) Rapid pulse

Management

1. Insertion of a nasogastric tube

• to prevent vomiting and to rest the bowel.
2. Intravenous fluid or total parenteral nutrition
3. A woman will need analgesics for pain relief
and intravenous antibiotics to treat the infection.