This study guide is about puerperal infection, nursing management of puerperal infection, and 4 nursing care plan examples for puerperal infection. It can be used to develop educational nursing care plans for puerperal infection.
What is puerperal infection?
- Puerperal infection is an infection developing in the birth structures after delivery.
- Puerperal infection is a major cause of maternal morbidity and mortality.
- The incidence ranges from 14% to 8% of all deliveries; there is a higher incidence in cesarean deliveries.
- The major site of postpartum infections is the pelvic cavity; other common sites include the breast, urinary tract, and venous system.
- Localized infections may affect the vagina, vulva, and perineum.
- Endometritis, localized infection of the uterine lining, occurs 48 to 72 hours after delivery.
What causes puerperal infection?
- Puerperal infections can be caused by poor sterile technique, delivery with significant manipulation, cesarean birth, or overgrowth of local flora.
1. Causative organisms
- Aerobic organisms include beta-hemolytic streptococci, Escherichia coli, Klebsiella, Proteus mirabilis, Pseudomonas, Staphylococcus aureus, and Neisseria.
- Anaerobic organisms include Bacteroides, Peptostreptococcus, Peptococcus, and Clostridium perfringens.
2. In parametritis (pelvic cellulitis), the infection spreads by way of the lymphatics of the connective tissue surrounding the uterus.
3. Puerperal infection may extend to the peritoneum by way of the lymph nodes and uterine wall.
What are the signs of puerperal infection?
- Puerperal morbidity is marked by a temperature of 38°C (100.4°F) or higher after the first 24 hours postpartum on any two of the first 10 postpartum days.
- Localized vaginal, vulval, and perineal infections are marked by pain, elevated temperature, edema, redness, firmness, and tenderness at the site of the wound; sensations of heat; burning on urination, and discharge from the wound.
- Manifestations of endometritis include a rise in temperature for several days. In severe endometritis, symptoms include malaise, headache, backache, general discomfort, loss of appetite, large tender uterus, severe postpartum cramping, and brownish red, foul-smelling lochia.
- Parametritis (pelvic cellulitis) commonly produces an elevated temperature of more than 38.6°C (102° to 104°F), chills, abdominal pain, subinvolution of uterus, tachycardia, and lethargy.
- Signs and symptoms of peritonitis include high fever, rapid pulse, abdominal pains, nausea, vomiting, and restlessness.
What are the risk factors of puerperal infection?
Your risk for developing an infection after you deliver is different depending on the method used to deliver your baby. Your chance of contracting an infection is:
- 1 to 3 percent in normal vaginal deliveries
- 5 to 15 percent in scheduled cesarean deliveries performed before labor begins
- 15 to 20 percent in non-scheduled cesarean deliveries performed after labor begins
There are additional factors that may make a woman more at risk for developing an infection. These can include:
- bacterial vaginosis
- multiple vaginal exams during labor
- monitoring the fetus internally
- prolonged labor
- the delay between amniotic sac rupture and delivery
- colonization of the vaginal tract with Group B streptococcus bacteria
- having remains of the placenta in the uterus after delivery
- excessive bleeding after delivery
- young age
- low socioeconomic group
What will happen if a puerperal infection is left untreated?
Complications are rare. But they can develop if the infection isn’t diagnosed and treated quickly. Possible complications include:
- abscesses, or pockets of pus
- peritonitis, or an inflammation of the abdominal lining
- pelvic thrombophlebitis, or blood clots in the pelvic veins
- pulmonary embolism, a condition in which a blood clot blocks an artery in the lungs.
- sepsis or septic shock, a condition in which bacteria get into the bloodstream and cause dangerous inflammation
Nursing Management of Puerperal Infection
How can nurses manage puerperal infection?
1. Promote resolution of the infectious process.
- Inspect the perineum twice daily for redness, edema, ecchymosis, and discharge.
- Evaluate for abdominal pain, fever, malaise, tachycardia, and foul-smelling lochia.
- Obtain specimens for laboratory analysis; report the findings.
- Offer a balanced diet, frequent fluids, and early ambulation.
- Administer prescribed antibiotics or medications; document the client’s response.
2. Provide client and family teaching. Describe and demonstrate self-care, stressing careful perineal hygiene and handwashing.
4 Nursing Care Plan Examples for Puerperal Infection
What are some of the available nursing care plans for puerperal infection?
The nursing management of clients with puerperal infection includes preventing the control spread of infection, promoting healing, and improving the attachment/bonding of parent and infant.
Risk For Infection
- Risk for Infection
- Presence of infection, broken skin, and/or traumatized tissues.
- high vascularity of the involved area.
- Invasive procedures and/or increased environmental exposure.
- Chronic disease (e.g., diabetes), anemia, malnutrition.
- Immunosuppression and/or untoward effect of medication (e.g., opportunistic/secondary infections)
Possibly evidenced by
- [Not applicable]
- The patient will verbalize understanding of individual causative risk factors.
- The patient will initiate behaviors to limit the spread of infection, as appropriate, and reduce the risk of complications.
- The patient will achieve timely healing, free of additional complications.
|Review prenatal, intrapartal, and postpartal record.||Identifies factors that place the client in high-risk
category for the development/spread of postpartum infection.
|Demonstrate and maintain a strict hand-washing policy for staff, clients, and visitors.||Helps prevent cross-contamination.|
|Instruct the proper disposal of contaminated linens, dressings, and peripads. Maintain isolation, if indicated.||Prevents the spread of infection.|
|Demonstrate correct perineal cleaning after voiding and defecation and frequent changing of peripads.||Cleaning removes urinary/fecal contaminants. Changing pad removes moist medium that favors bacterial growth.|
|Demonstrate proper fundal massage. Review the importance and timing of the procedure.||Enhances uterine contractility; promotes involution and passage of any retained placental fragments.|
|Monitor temperature, pulse, and respiration. Note the presence of chills or reports of anorexia or malaise.||Elevations in vital signs accompany infection; fluctuations, or changes in symptoms, suggest alterations in client status. Note: Persistent fever unresponsive to antibiotic therapy may indicate pelvic thrombophlebitis.|
|Observe perineum/incision for other signs of infection (e.g., redness, edema, ecchymosis, discharge, and approximation [REEDA scale]). Note subinvolution of uterus, extreme uterine tenderness.||Allows early identification and treatment; promotes resolution of infection. Note: Although localized infections are usually not severe, occasional progression to necrotizing fasculitis can be life-threatening.|
|Monitor oral/parenteral intake, stressing the need for at least 2000 ml fluid per day. Note urine output, degree of hydration, and presence of nausea, vomiting, or diarrhea.||Increased intake replaces losses and enhances circulating volume, preventing dehydration and aiding in fever reduction.|
|Encourage semi-Fowler’s position.||Enhances flow of lochia and uterine/pelvic drainage.|
|Promote early ambulation, balanced with adequate rest. Advance activity as appropriate.||Increases circulation; promotes clearing of respiratory secretions and lochial drainage; enhances healing and general well-being. Note: Presence of pelvic/femoral thrombophlebitis may require strict bed rest.|
|Investigate reports of leg or chest pain. Note pallor, swelling, or stiffness of the lower extremity.||These signs and symptoms are suggestive of septic thrombus formation. Note: Embolic sequelae, especially pulmonary embolism, may be an initial indicator of thrombophlebitis.|
|Recommend that breastfeeding mothers periodically check the infant’s mouth for the presence of white patches.||Oral thrush in the newborn is a common side effect of maternal antibiotic therapy.|
|Encourage client/couple to prioritize postdischarge responsibilities (e.g., homemaking tasks, child care)||The client will require additional rest to facilitate recuperation/healing. Household duties need to be reassigned or delayed as appropriate.|
|Instruct in proper medication use (e.g., with or without meals, take the entire course of antibiotic, as prescribed).||Oral antibiotics may be continued after discharge. Failure to complete medication may lead to relapse.|
|Discuss the importance of pelvic rest as appropriate (avoidance of douching, tampons, and intercourse).||Promotes healing and reduces the risk of reinfection.|
|Monitor laboratory studies, as indicated:||Identifies infectious process/causative organism and appropriate antimicrobial agents.|
||Aids in tracking resolution of the infectious or inflammatory process. Identifies degree of blood loss and determines the presence of anemia.|
||Helps in identifying alterations in clotting associated with the development of emboli. Aids in determining the effectiveness of anticoagulation therapy.|
||Hepatic insufficiency and decreased renal function may develop, altering drug half-life and increasing risks of toxicity|
|Encourage the application of moist heat in the form of sitz baths and of dry heat in the form of perineal lights for 15 min 2–4 times daily.||Water promotes cleansing. Heat dilates perineal blood vessels, increasing localized blood flow and promoting healing.|
|Provide supplemental oxygen when necessary.||Promotes healing and tissue regeneration, especially in presence of anemia; may enhance oxygenation when pulmonary emboli are present.|
|Demonstrate perineal application of antibiotic creams, as appropriate.||Eradicates local infectious organisms, reducing the risk of spreading infection.|
|Administer medications as indicated:|
||Combats pathogenic organisms, helping prevent infection from spreading to surrounding tissues and bloodstream. Note: Parenteral route is preferred for parametritis, peritonitis, and, on occasion, endometritis.|
||Promotes myometrial contractility to retard the spread of bacteria through the uterine walls, and aids in the expulsion of clots and retained placental fragments.|
||In presence of pelvic thrombophlebitis, anticoagulants prevent or reduce additional thrombi formation and limit the spread of septic emboli.|
|Administer whole blood/packed RBCs, if needed.||Replaces blood losses and increases oxygen-carrying capacity in presence of severe anemia and/or hemorrhage.|
|Arrange for transfer to intensive care setting as appropriate.||May be necessary for clients with severe infection (e.g., peritonitis, sepsis) or pulmonary emboli to provide appropriate care leading to optimal recovery.|
|Assist with procedures, such as incision and drainage (I&D) or D & C, as necessary.||Draining the infected area, and possible insertion of iodoform gauze packing promotes healing and reduces the risk of rupture into the peritoneal cavity. D & C may be needed to remove retained products of conception and/or placental fragments.|
- Acute Pain
It may be related to
- Body response to the infective agent, properties of infection (e.g., skin/tissue edema, erythema)
Possibly evidenced by
- Verbalizations, restlessness, guarding behavior, self-focusing.
- Autonomic responses
- The patient will identify/use individually appropriate comfort measures.
- The patient will report a decreased level of pain/discomfort.
|Assess location and nature of discomfort or pain, rate pain on a 0–10 scale.||Helps in the differential diagnosis of tissue involvement in the infectious process.|
|Assess for non-verbal pain cues.||Non-verbal cues such as crying, grimacing, or withdrawn behavior may indicate pain.|
|Provide instruction regarding, and assist with, maintenance of cleanliness and warmth.||Promotes a sense of general well-being and enhances healing. Alleviates discomfort associated with chills.|
|Instruct client in relaxation techniques; provide diversionary activities such as radio, television, or reading.||Refocuses client’s attention, promotes a positive attitude and enhances comfort.|
|Encourage continuation of breastfeeding as the client’s condition permits. Otherwise suggest and provide instruction in the use of manual or electric breast pumps.||Prevents discomfort of engorgement; promotes adequacy of milk supply in breastfeeding client.|
|Change client’s position frequently. Provide comfort measures; e.g., back rubs, linen changes.||Reduces muscle fatigue, promotes relaxation and comfort.|
|Encourage the woman to ask for pain medications before the pain becomes severe/intolerable.||Pain is a lot easier to control before it becomes severe.|
|Apply local heat using a heat lamp or sitz bath as indicated.||Heat promotes vasodilation, increasing circulation to the affected area and promoting localized comfort.|
|Administer analgesics or antipyretics.||Reduces associated discomforts of infection.|
Risk For Altered Parent-Infant Attachment
- Risk for Altered Parent-Infant Attachment
- Interruption in the bonding process.
- Physical illness.
- The perceived threat to own survival.
Possibly evidenced by
- [not applicable]
- The patient will exhibit ongoing attachment behaviors during parent-infant interactions.
- The patient will maintain/assume responsibility for physical and emotional care of the newborn, as able.
- The patient will express comfort with the parenting role.
|Monitor client’s emotional responses to illness and separation from infants, such as depression and anger. Encourage the client to verbalize feelings and reinforce normalcy as appropriate.||Normal expectations are of an uncomplicated postpartum period with the family unit intact. Illness due to infection alters the situation and may result in the separation of the client from family or newborn, which can contribute to feelings of isolation and depression.|
|Observe maternal-infant interactions||Provides information regarding the status of the bonding process and client needs.|
|Provide opportunities for maternal-infant contact whenever possible. Place pictures of the infant at the client’s bedside (especially if the nature of infection/client’s condition or hospital policy requires separation of the infant from mother during the febrile period).||Facilitates attachment, prevents the client from engaging in self-preoccupation to the exclusion of the infant.|
|Encourage the father or other family members to care for and interact with the infant.||May be encouraging to mother to know that the family is caring for the infant and providing emotional support. Note: Unexpected/prolonged hospital stay may reduce the father’s ability to spend time with a newborn because of other responsibilities, including care of siblings. Father may require additional support during this stressful time.|
|Discuss availability or effectiveness of support systems in-home setting.||The client requires additional support to accomplish homemaker tasks, allowing the client to obtain adequate rest and spend time with infant/other children.|
|Identify individual support systems. Refer to visiting nurse services, home care agencies, as indicated.||The client may require assistance with home maintenance and activities of daily living while following discharge instructions for rest and recuperation.|
Imbalanced Nutrition: Less Than Body Requirements
- Imbalanced Nutrition: Less Than Body Requirements
It may be related to
- Intake insufficient to meet metabolic demands (anorexia, nausea/vomiting, medical restrictions).
Possibly evidenced by
- Aversion to eating.
- Decreased oral intake or lack of oral intake.
- Unanticipated weight loss
- The patient will meet nutritional needs, as evidenced by timely wound healing, appropriate energy level, and Hb/Hct within normal postpartum expectations.
|Discuss eating habits including, food preferences and intolerances.||To appeal to the client what she likes/desires.|
|Note total daily intake. Maintain a diary of calorie intake, patterns, and times of eating.||To reveal changes that should be made in the client’s dietary intake.|
|Promote intake of at least 2000 ml/day of juices, soups, and other nutritious fluids.||Provides calories and other nutrients to meet metabolic needs and replace fluid losses, thereby increasing circulating fluid volume.|
|Encourage choice of foods high in protein, iron, and vitamin C when oral intake is permitted.||Protein helps promote the healing and regeneration of new tissue. Iron is necessary for Hb synthesis. Vitamin C facilitates iron absorption and is necessary for cell wall synthesis.|
|Encourage adequate sleep/rest.||Reduces metabolic rate, allowing nutrients and oxygen to be used for the healing process.|
|Assist with placement of nasogastric (NG) or Miller- Abbott tube.||May be necessary for gastrointestinal decompression in presence of abdominal distension or peritonitis.|
|Administer parenteral fluids/nutrition, as indicated.||May be necessary to combat dehydration, replace fluid losses, and provide necessary nutrients when oral intake is limited/restricted.|
|Administer iron preparations and/or vitamins, as indicated.||Useful in correcting anemia or deficiencies when present.|