CHORIOAMNIONITIS

PREPARED BY:
Nurul Bainee Binti Azaree
S2005614
 Outlines
2
 INTRODUCTION -> why I chose this case study

 CHORIOAMNIONITIS -> definition, signs & symptoms, risk factors, pathophysiology, complications,
management

 PATIENT CONDITION/PROBLEM -> history of patient illness, past history & management

 SUMMARY OF PATIENT PROGRESS -> antenatal & postnatal

 DISCHARGE PLAN

 NURSING CARE PLAN

 DISCUSSION & RECOMMENDATION -> role of APN/Midwives

 CONCLUSION

 REFERENCES

MQD 7010 NURSING PRACTICUM (Case Study - Chorioamnionitis)

 Introduction
3
 Intraamniotic infection  chorioamnionitis, infection with resultant inflammation of any combination (amniotic
fluid, placenta, fetus, fetal membranes, or decidua)

 Frequent cause of preterm birth

 Can effects every organ of developing fetus

 Neonatal care team is essential to include in communication to optimize neonatal evaluation & management

 7.6% cases are related to early-onset sepsis due to GBS

MQD 7010 NURSING PRACTICUM (Case Study - Chorioamnionitis)

 Introduction
4
Case Justification

LONG-TERM
PREVALENCE MATERNAL &
ADVERSE REACTION
40–70% of women who NEWBORN
Adverse maternal
deliver prematurely OUTCOME
- 67% (21-22w) outcomes include
Minimize morbidity &
- 22% (33-36w) postpartum infections &
mortality for women &
sepsis (Tita & Andrews,
(Czikk et al. 2011) newborns (ACOG, 2017)
2010)

MQD 7010 NURSING PRACTICUM (Case Study - Chorioamnionitis)

 Chorioamnionitis
5
Signs & Symptoms Risk factor
• Fever  present in 95–100% of cases of clinical • Longer duration of membrane rupture
chorioamnionitis
• Meconium-stained amniotic fluid
• Uterine fundal tenderness • Prolonged labor *nulliparity
• Maternal tachycardia (>100/min)  50–80% • African American ethnicity
• Fetal tachycardia (>160/min) 40–70% • Internal monitoring of labor *multiple vaginal exams
• Purulent or foul amniotic fluid  more likely with • Smoking, alcohol or drug abuse
severe or prolonged infection
• Immune-compromised states
• Colonization with group B streptococcus, bacterial
vaginosis, sexually transmissible genital infections &
vaginal colonization with urea plasma
• Epidural anesthesia,

MQD 7010 NURSING PRACTICUM (Case Study - Chorioamnionitis) (Tita & Andrews, 2010)
 Chorioamnionitis
6
Pathophysiology Complication
Maternal origin Neonatal
• when there’s chemotatic gradient --> migrate toward • Congenital sepsis &infections: (pneumonia, dermatitis,
amniotic cavity from decidua --> acute & otitis media)
chorioamnionitis

Fetal origin Neonatal Adverse Reaction

• neutrophils from fetal circulation --> invading • Neurodevelopment
umbilical vein & arteris wall --> inflammation of - Inflammatory cytokines released possible cause of
umbilical cord & chorionic vessels cerebral injury
• Cellular stress or cell death can induce release of
neutrophil chemokines
• Occur in intact membranes (99%) - Sampson et al.,
(1997)

MQD 7010 NURSING PRACTICUM (Case Study - Chorioamnionitis)

 Chorioamnionitis
7
Management
Term & late preterm neonates:
• Isolated maternal fever
• Suspected Triple 1
-majority asymptomatic,closely observed w/o abx
• Confirmed Triple 1
- neonates treated according current guidelines

Neonates born at <34 0/7:

• Isolated maternal fever: well-appearing preterm neonates observed if laboratory data are not favoring sepsis.

• Suspected or confirmed Triple I: Neonates should be started on antibiotics as soon as cultures are obtained

MQD 7010 NURSING PRACTICUM (Case Study - Chorioamnionitis)

 Patient Condition/Problem
8
P1 @ 37/52 + 6/7 EMLSCS for poor progress with Chorioamnionitis post ECV

SUBJECTIVE DATA:
HISTORY
- Ostetric hx: low risk
ASSESSMENT: GENERAL
NAME: TING KEE HAN pregnancy -
- Able to rest & sleep
RN : 37113126 Gynae hx: menarche at 13 - Good appetite
LMP : 05.03.2023 y/o, regular cycyle, flow 5- - FKC X10
EDD/REDD : 10.12.2023 7 days, no dysmenorrhea -
- Normal elimination
AGE : 30 y/o Medical & surgical hx: nil
- Family hx: nil
- Social hx: teacher,
teetotaler

MQD 7010 NURSING PRACTICUM (Case Study - Chorioamnionitis)

 Patient Condition/Problem
9
P1 @ 37/52 + 6/7 EMLSCS for poor progress with Chorioamnionitis post ECV

ASSESSMENT: PHYSICAL
ASSESSMENT: PHYSICAL ASSESSMENT: PHYSICAL
- Conscious & alert -Breast examination: No -
- Hair: clean scalp, no itchy Abdominal examination
skin changes /no lump -
- Conjunctiva: pink Size: appropriate to GA
detected, no discharges -
- Oral cavity: no dental caries Shape: round
- Neck: no enlarge of thyroid, - Skin changes: Linea Nigra
- Lower limb: No edema at -
gland/no prominent of jugular gland Scar on abdomen: nil
pedal/ankle/pre-tibia -
- Hand: no tremors/no clubbing Fundal height: 36cm
fingers - Fundal palpation: 36 weeks
- Vaginal discharge: normal - Lateral palpation: fetal back
vaginal discharge

MQD 7010 NURSING PRACTICUM (Case Study - Chorioamnionitis)

 Patient Condition/Problem
10
P1 @ 37/52 + 6/7 EMLSCS for poor progress with Chorioamnionitis post ECV

- Pelvic palpation: longitudinal lie

- Presentation: breech ASSESSMENT: PHYSICAL ASSESSMENT: PHYSICAL
- Engagement: 5/5th
- Auscultation of FHR using - VITAL SIGNS - LAB INVESTIGATIONS
daptone: 144rpm, regular rhythm, BP: 98/57 mmHg FBC: 12.3g/dl
strong Pulse: 86 bpm HIV/RPR/HBsAg – not reactive
Respiration Rate: 19 rpm Blood group: O positive,
- CTG: 141 bpm (baseline), 5-15 bpm
Temperature:36.7 OC antibody negative
(btb variability), 2 accelerations, no
Urine sugar: negative
deceleration, reactive findings
Urine albumin: negative

MQD 7010 NURSING PRACTICUM (Case Study - Chorioamnionitis)

 Summary of Patient Progress
11
Antenatal

- TAS findings as: singleton, flexed breech,

Date: 23.11.2023 (Thursday)
- Patient walked-into LDS at 0845H accompanied by
husband d/t elective admission for ECV.
- On arrival patient alert & conscious with no s&s of
labor (no leaking, no PV bleed, no contractions).
Good fetal movements felt by mother.
- Patient led to K-Bed in LDS by staff nurse for V/S
recording prior procedure of ECV requiring TAS
and ECG. BP: 118/76mmHg. PR: 88 bpm. ECG
normal.
placenta at anterior upper segment, normal AFI.
FH shown to mother.
- After bedside USG done, patient counselled by
Dr. Izzati pertaining possible risk & complication
of ECV including failure, cord prolapse and
abruptio placenta.
- Patient understood agreed to proceed with
consent. Before ECV performed, blood sample
taken (FBC, GSH, RP), patient to remain fasting,
contractions to time and ECG done before given
S/C Terbutalin 250mcg (pre-procedure).

MQD 7010 NURSING PRACTICUM (Case Study - Chorioamnionitis)

 Summary of Patient Progress
12
Antenatal

Date: 23.11.2023 @ 1430H (Thursday)

- ECV successfully done by Dr. Yunesh & Dr. Izzati
using forward somersault x1, followed reverse
somersault x1. Patient reviewed by physician after - She then transferred to ante-natal ward at
CTG post ECV shown normal before next plan.
15445H with plans to start T.EES 400mg
- Patient been given option either to go home first BD and for sputum C&S for complaining
cough. Vital signs and daptone 4 hourly and
then re admit next week for IOL or IOL coming
CTG BD in ward.
morning. Patient decided for IOL cm after
explanation given regarding risk of spontaneous
reversion to cephalic 5%.

MQD 7010 NURSING PRACTICUM (Case Study - Chorioamnionitis)

 Summary of Patient Progress
13
Antenatal

Date: 24.11.2023 @ 0650H (Friday)

- Dr. Nadiah & Dr. Ainee reviewed patient prior
Prostin 3mg induction d/t suitability after physical
examination. At 0900H, Prostin 3mg inserted at
posterior fornix by Dr. Ainee after VE findings as:
VV NAD, OS 1cm with cervix 1.5cm soft, axial.
No cord, no placenta palpable. Station: - 2.
- Planned to transfer K-bed once available, to review
at 1500H and for CTG at 1H, & 5th H.to inform if
strong regular contraction/ SROM/ PV bleeding/
reduce FM.
Date: 24.11.2023 @ 1330H (Friday)
- Patient transferred into LDS, K-bed in view
of IOL patient. To continue as planned and
for NRVE in 24H post Prostin insertion.
- At 1515H Foley’s inserted, inflated with
60cc sterile water to aggravate labor
progress after VE findings as: VVNAD, OS
2cm, membranes intact, head well-applied.
No cord, no placenta palpable with station:
-2.

MQD 7010 NURSING PRACTICUM (Case Study - Chorioamnionitis)

 Summary of Patient Progress
14
Antenatal

Date: 25.11.2023 @ 0945H (Saturday) - Patient suddenly complaints of feverish at 1800H

- Foley’s catheter removed after OS opening progress
 attended stat by Dr. Deborah for T. PCM 1g
into 4cm. Patient transferred to LDS for ARM –
stat, IV Hartmann ran fast for 1 hour followed by
(done at 1100H, clear liquor) and Augmentation
4pint maintenance 24-hour. IV Cefuroxime 1.5 g
(IVI Oxytocin 6ml), to plot partogram, to start IV
given stat, 750mg TDS. IV Flagyl 500mg stat
drip HM 100cc/hr, CTG continuously, NRVE at
given and TDS. Septic workup done for FBC,
1500H also to refer anesthetist for maternal request
CRP, blood C&S, UEFEME, urine C&S, VBG.
of epidural. - However, 1 hr later temperature shown 38.3 0C.
- VE findings at 1500H as OS 5cm, cervix 1cm, Other vital signs as BP: 128/71mmHg. PR:
99bpm. CTG baseline 150-200bpm, good
oxytocin titrated into 24ml/hr and accordingly
variability, presence of acceleration, no
before NRVE at 1900H.
deceleration.

MQD 7010 NURSING PRACTICUM (Case Study - Chorioamnionitis)

 Summary of Patient Progress
15
Antenatal

Date: 25.11.2023 @ 1900H (Saturday) - Explanation given pertaining risks of operation.

- VE done as: VVNAD, OS 5cm, cervix 0.5cm soft-
axial, membrane absent, clear liquor, no foul
smelling, no cord, no placenta palpable with
station: -2.
- Patient was initially suggested an option of
EMLSCS due to foetal tachycardia but patient keen
to wait & observe.
- At 2100H, patient attended by on duty physician to
counsel regarding in labour of 5cm OS almost 10
hours.
Patient understood and agreed for EMLSCS due
to her baby in poor progress with
chorioamnionitis. Case proceeded from LDS.
Date: 25.11.2023 @ 2153H (Saturday)
- A baby boy successfully delivered by EMLSCS
with 3.130kg, normal range Apgar Score 9 in, 10
in 5 and 10 in 10. Mother and baby sent to PNW
after recover from OT.

MQD 7010 NURSING PRACTICUM (Case Study - Chorioamnionitis)

 Summary of Patient Progress
16
Postnatal

Date: 26.11.2023 @ 0030H (Sunday) PLANS

- Patient alert, not pale post 3 hours op w BP:96/54
mmHg. PR: 76bpm. T: 37.2. per abdominal soft,
not distended, uterus well contracted. Dressing dry
w presence of bowel sound.
- Pad minimally stained with normal lochia, bilateral
calf soft, non tender
- Patient planned for v/s ½ hrly x 2, hourly x 2,
then 4 hrly if stable
- To inform if s&s of hypotension
- Pad charting, to inform if excessive bleeding
- Strict i/o: inform if urine o/put< 0.5cc/kg/hr
- Iv fluids: drip 4 pints N/S over 24 hrs until
tolerating orally
- To keep CBD til ambulating

MQD 7010 NURSING PRACTICUM (Case Study - Chorioamnionitis)

 Summary of Patient Progress
17
Postnatal

PLANS:

THROMBOPROPHYLAXIS
- TED stoking - WI: Day 2, 27.11.2023
- To start s/c Clexane 40mg OD post op 6hr, if no - No need STO
evidence of bleeding - To encourage early ambulation & bf
- Allow VBAC next pregnancy
ANALGESIA - To trace placenta c&s
- IV Cefuroxime 750mg TDS until discharge, to - To trace blood culture, urine c&s
complete cap. 1/52
- IVI Metronidazole 500mg TDS until discharge then
complete cap/tab 1/52

MQD 7010 NURSING PRACTICUM (Case Study - Chorioamnionitis)

 Discharge Plan
18

- Mother was given health education pertaining

LSCS wound care
- 1g QID PCM for pain management
- s/c Clexane 40mg OD, to complete 10/7
- Fetched by husband on 28.11.23 (Tuesday)@
- Cap. Cefuroxime 750mg TDS, until 1/52
- Cap. Metronidazole 500mg TDS. Until 1/52 1415H
- Mother also reminded on KK appointment during 6
weeks after delivery for postnatal care,
contraception and cervical screening

MQD 7010 NURSING PRACTICUM (Case Study - Chorioamnionitis)

 MQD 7010 NURSING PRACTICUM (Case Study - Chorioamnionitis)

19 Nursing Care Plan (Actual Diagnosis)

Date Nursing Patient Nursing Interventions Evaluation
diagnosis with outcome
relevant
assessment
data/evidence
25.11.2023 Infection related Patient will be 1. Assess vital signs and monitor the signs of All treatment
to able to receive nfection - To establish baseline observations and check planned to
chorioamnionitis appropriate the progress of the infection as the patient receives treat infection
as evidenced by treatment for medical treatment. are
temperature of the infection implemented.
38.20C and
borderline 2. Verify allergies and administer medications as 25.11.2023 @
tachycardia 99 necessary Antibiotics, antipyretics - administer 1900H
bpm medications via IV route and assess for allergies prior
to administering medications.

3. Administer the prescribed antibiotics - To treat

chorioamnionitis.
 MQD 7010 NURSING PRACTICUM (Case Study - Chorioamnionitis)

20
Date Nursing Patient Nursing Interventions Evaluation
diagnosis with outcome
relevant
assessment
data/evidence

4. Provide symptomatic relief for the patient –

treatment given based on their symptoms, such as
antipyretics for fever.

5. Explain to the mother that C-section may be

performed - A Caesarean delivery (C-section) may be
the preferred method of delivery in case of
chorioamnionitis for the safety of the mother and the
baby.

6. Monitor vital signs closely - To check the progress

of the patient under antibiotic treatment.
 MQD 7010 NURSING PRACTICUM (Case Study - Chorioamnionitis)

21 Nursing Care Plan (Actual Diagnosis)

Date Nursing Patient Nursing Interventions Evaluation
diagnosis with outcome
relevant
assessment
data/evidence
25.11.2023 Acute pain Patient will 1. Assess the client’s pain level by verbal, Patient
related to appear more pain scale, and nonverbal indicators. Use a reported of
uterine activity relaxed 1 to 10 scale and evaluate response to reduced pain
contraction as between Techniques used - Support the client in her score into
evidenced by contraction ability to manage pain until her epidural can be 4/10.
persistent given.
intensity of
contraction in 10 2. Time and record the frequency, intensity, 25.11.2023 @
minutes timing and duration of uterine contractile pattern - 2100H
with pain scale Monitor the labor progress and provide
6. information for the couple frequent progress
reports during labor, so they do not become
discouraged or fearful this way at a seeming
lack of progress.
 MQD 7010 NURSING PRACTICUM (Case Study - Chorioamnionitis)

22
Date Nursing Patient Nursing Interventions Evaluation
diagnosis with outcome
relevant
assessment
data/evidence
3. Assess BP and pulse every 15 min after
regional injection for the first 1 hour -
Maternal hypotension, the most common side
effect of regional block anesthesia, may
interfere with fetal oxygenation. As sympathetic
block occurs, and decreased venous return to
the heart- exacerbated by inferior vena cava
Compression

4. Assist with comfort measures - measures

can include providing back or leg rubs, sacral
pressure, backrest, mouth care, repositioning,
shower or hot tub use, perineal care, and linen
changes.
 MQD 7010 NURSING PRACTICUM (Case Study - Chorioamnionitis)

23
Date Nursing Patient Nursing Interventions Evaluation
diagnosis with outcome
relevant
assessment
data/evidence
5. Elevate head approximately 30 degrees,
alternate position by turning side to side,
and use of hip roll - promote comfort and help
the fetus to adapt the size and shape of the
patient’s pelvis. Elevating the head prevents the
block from migrating up and causing
Respiratory depression. Lateral positioning
increase venous return and
enhances placental circulation. Supine position
can result in supine hypotensive syndrome,
which reduces placental blood flow and fetal
oxygenation.
 MQD 7010 NURSING PRACTICUM (Case Study - Chorioamnionitis)

24
Date Nursing diagnosis Patient Nursing Interventions Evaluation
with relevant outcome
assessment
data/evidence
6. Teach and assist in using appropriate
breathing and relaxation techniques -
Breathing and relaxation techniques may block
pain impulses within the cerebral cortex
through conditioned responses and cutaneous
Stimulation.

7. Assist with epidural or caudal block

anesthesia using an indwelling catheter -
Pharmacological interventions provide relief
once active labor is established; reinforcement
through the catheter provides sustained comfort
during delivery. Such analgesia does not
interfere with uterine activity and Ferguson
reflex.
 MQD 7010 NURSING PRACTICUM (Case Study - Chorioamnionitis)

25 Nursing Care Plan (Potential Diagnosis)

Date Nursing diagnosis Patient Nursing Interventions Evaluation
with relevant outcome
assessment
data/evidence
26.11.2023 Risk for Maternal To prevent 1. Assess the patient’s vital signs and perform a After 24 hours
Bleeding related to or treat focused physical assessment, looking for any signs of closed
chorioamnio-nitis heavy bleeding - Chorioamnionitis increases the risk for monitoring
blood loss bleeding during delivery. Low blood pressure, low post-LSCS,
during temperature, and dizziness may result from excessive patient stable
delivery bleeding. with no
complication
2. Obtain Group and Save blood samples from the (no fever, no
patient. Anticipate the need for the patient to have a signs &
transfusion of whole blood replacements - To prepare symptoms of
for any need to perform blood transfusion as infection, no
prescribed. If the blood loss is too much and immediate active
correction is warranted, whole blood transfusion is bleeding)
administered. 27.11.2023 @
2200H
 MQD 7010 NURSING PRACTICUM (Case Study - Chorioamnionitis)

26
Date Nursing Patient Nursing Interventions Evaluation
diagnosis with outcome
relevant
assessment
data/evidence
3. Perform the blood transfusion if indicated - Blood
transfusion may be required if there is too much blood
loss

4. Assess and monitor the patient’s surgical wound

site for any signs of unexpected bleeding during
post-surgery - To treat any unexpected bleeding as
early as possible.
 MQD 7010 NURSING PRACTICUM (Case Study - Chorioamnionitis)

27
Date Nursing Patient Nursing Interventions Evaluation
diagnosis with outcome
relevant
assessment
data/evidence
5. Assess skin and mucous membranes for signs of
petechiae, bruising, hematoma formation, or oozing
of blood - Patients with reduced platelet counts or
impaired clotting factor activity may experience
bleeding into tissues that are out of proportion to the
injury

6. Teach the patient about measures to reduce

constipation such as increased fluid intake and
dietary fibre - Hard and dry faeces may cause trauma
to the mucous membranes of the colon and rectum.
Increasing fluid intake and dietary fibre soften the fecal
mass for easier defecation.
 Discussion & Recommendation
28
Discussion Recommendation
• Midwives lack knowledge regarding chorioamnionitis • APN’s role towards Midwives (encouragement)

• Incorrect practices including a lack of screening,  Professional development bridges the gap between
misdiagnosis and mismanagement of the infectious knowledge and evidence-based practice (Greenaway
condition et al. 2019)

• Mistake signs and symptoms of chorioamnionitis with
other conditions in pregnancy – for example, UTIs
and vaginosis
 Upscale the in-service training program to assist
midwives in gaining specific knowledge related to
conditions such as chorioamnionitis
 Strengthening the Up-to-date implement the guideline
by policy medium
• Screening tools availability as well as a linked
treatment plan in antenatal clinic setting

MQD 7010 NURSING PRACTICUM (Case Study - Chorioamnionitis) (Tita & Andrews, 2010)
 Conclusion
29
Conclusion
Chorioamnionitis by Prevention:
• providing patient care have an opportunity to decrease this risk
• Elective inductions may increase the use of invasive interventions and procedures such as ARM, VE a woman
receives during labor
• Appropriate nursing care
- encourage ambulation
- upright positions
- provide labor support
- decrease early epidurals
- provide regular perineal hygiene
- Discourage unnecessary rupture of membranes
- VE should performed if the information obtained will change labor mx
• Changes in verbalization, facial expression & body language, presence of bloody show & involuntary pushing
(Borders, Lawton, & Martin, 2012).
• Risk of chorioamnionitis begins to rise after > 3 VE & after 8 VE the risk increases five-fold (Borders, Lawton, &
Martin, 2012).

MQD 7010 NURSING PRACTICUM (Case Study - Chorioamnionitis)

 References
30
1. Czikk, M. J., McCarthy, F. P., & Murphy, K. E. (2011). Chorioamnionitis: from pathogenesis to
treatment. Clinical microbiology and infection : the official publication of the European
Society of Clinical Microbiology and Infectious Diseases, 17(9), 1304–1311.
https://doi.org/10.1111/j.1469-0691.2011.03574.x

2. Borders, N., Lawton, R., & Martin, S. (2012). A clinical audit of the number of vaginal
examinations in labor: ANOVEL idea. Journal of Midwifery and Women’s Health, 57(2),
139-144.
doi:10.1111/j.1542-2011.2011.00128x

2. Boo, N.Y., Ang, E.B.K, Neoh, S.H., et al. (2022). Early-onset sepsis in Malaysian neonatal intensive
care units. Malays J Pathol 2022; 44(3): 443 – 459.
https://www.mjpath.org.my/2022/v44n3/sepsis.pdf

MQD 7010 NURSING PRACTICUM (Case Study - Chorioamnionitis)

 References
31
4. Du Plessis, A.H., Van Rooyen, D. & ten Ham-Baloyi, W. (2021) ‘Midwives’ knowledge and practices
regarding the screening for and management of chorioamnionitis: A qualitative study’,
Health SA Gesondheid 26(0), a1631.
https://doi.org/10.4102/hsag.v26i0.1631

5. Heine, R.P., Puopolo, K.M., Beigi, R., et al.

(2017)Intrapartum Management of Intraamniotic
Infection. The American College of Obstetricians and Gynecologists, Women’s Health
Care Physicians; 712.
https://www.acog.org/clinical/clinical-guidance/committee
opinion/articles/2017/08/intrapartum-management-of-intraamniotic-infection

6. Jain, V.G., Willis, K.A., Jobe, A. et al. (2022). Chorioamnionitis and neonatal outcomes. Pediatr Res
91, 289–296.
https://doi.org/10.1038/s41390-021-01633-0

MQD 7010 NURSING PRACTICUM (Case Study - Chorioamnionitis)

 References
32
7. Kim, C.J., Romero, R., Chaemsaithong, P., et al. (2015). Acute chorioamnionitis and funisitis:
definition, pathologic features, and clinical significance. ajog.org
http://dx.doi.org/10.1016/j.ajog.2015.08.040

8. Tita, A. T., & Andrews, W. W. (2010). Diagnosis and management of clinical chorioamnionitis.
Clinics in perinatology, 37(2), 339–354.
https://doi.org/10.1016/j.clp.2010.02.003

MQD 7010 NURSING PRACTICUM (Case Study - Chorioamnionitis)