Postpartum wound infection

91 Postpartum wound infection




Overview/pathophysiology


Wound infection is one of the postpartum (puerperal) infections that women may develop after childbirth. The infection rate for patients with a cesarean is 5%-15%, whereas it is 1%-3% for patients who have given birth vaginally (Kentucky, 2007). Wound infections after childbirth can develop anywhere there is a break in the skin or mucous membranes to provide a portal of entry for bacteria. Incision infections may develop from endogenous or exogenous bacteria. When identified early, most postpartum infections can be treated without complications. If untreated, infections may generalize into septic shock. When there is little to no improvement in wound site infection with first-choice antibiotics, methicillin-resistant Staphylococcus aureus (MRSA) infection must be considered and treated appropriately and aggressively.


Postpartum infections may manifest early, within the first 24 hr, or late, often after hospital discharge and around days 6-8. The continued definition for puerperal infection centers on fever. A diagnosis is established with a fever of 38° C (100.4° F) or higher in two of the first 10 days postpartum, not including the first 24 hr (when dehydration and the exertion of labor can contribute to a low-grade fever).


The following are other types of postpartum infections:


Endometritis: An infection of the endometrium is the most common postpartum infection. It usually starts at the open site of placental attachment. It can spread easily through the interconnected genital tract or to a wound.

Urinary tract infection ([UTI] or cystitis): Bladder infections readily respond to antibiotics when identified early. Postpartum women with diabetes, women who have been catheterized, and women with lacerations extending into the urethral meatus are most at risk for UTI.

Mastitis: Infections of the breast usually involve one breast, manifest about 2 wk after delivery, and are usually preventable with good hand hygiene and daily variation of the newborn’s feeding positions at the breast. If left untreated, mastitis may become an abscess.

Septic pelvic thrombophlebitis: Patients with this condition generally do not appear ill and may have minimal to no pain. A patient who persistently has a fever and does not respond to multiple antibiotic therapies may have this condition. Treatment includes both anticoagulant and antibiotic therapy.


Health care setting


Primary care (outpatient clinic), acute care (hospital), or home care; rehospitalization is common



Assessment


Assessments of the wound and other systemic signs of infection are necessary for all postpartum patients. Assess the post cesarean patient and those with other risk factors more frequently to monitor and report early signs of infection. The defining characteristics of wound infection are fever, pain or tenderness, edema, redness (erythema) surrounding the wound, induration (hardened tissue under the skin), purulent drainage, and separation of wound edges or wound dehiscence.




Cardiopulmonary:


Tachycardia, hypotension, tachypnea, or syncope may be seen in the acutely ill patient when sepsis is present.



Fever:


The temperature pattern may vary with the type of infection. It may be 101° F (38.3° C) or higher, with or without spiking episodes. With mild infection the patient may remain afebrile. Headache and overall “body aches” may accompany fever.



Chills:


Patient may feel she cannot get warm even in the presence of an elevated temperature. Body shakes may accompany the chills. An overall flu-like feeling may be present.



Malaise:


A feeling of generalized uneasiness, discomfort, and fatigue may be present.



Pain:


Pain may be present with light or deep external palpation of the abdomen or wound site, or with bimanual palpation of the uterus. Cervical motion tenderness on bimanual exam may be present with a uterine infection. With an episiotomy infection, pain may be localized (throbbing, aching, or sharp) and deep tissue in nature. The patient may describe a sensation of vaginal pressure or “fullness.”



Vaginal discharge:


With an episiotomy infection, discharge may be purulent. It may be foul smelling if endometritis coexists with the infected episiotomy.



Abdominal surgical incision:


The area around the incision is often erythematous and warm to the touch, and it may become edematous. If the tissue is very congested (indurated) it may have a “woody” appearance and feel hard to palpation. If the wound is not already open and draining bloody, serosanguineous, or purulent discharge, it may be probed with a cotton-tipped applicator to promote drainage. Dehiscence may or may not occur.



Episiotomy or perineal laceration:


A thorough wound assessment may be guided by the acronym “REEDA” to monitor localized redness (erythema), edema, ecchymosis (bruising) drainage (exudates), and approximation of skin edges. Dehiscence of the episiotomy may or may not occur. Any episiotomy, whether infected or not, interrupts tissue integrity and can lead to stress incontinence, pelvic floor prolapse, anal incontinence, and pelvic floor muscle dysfunction.



Complications—neonatal:


If the maternal infection is caused by an antepartum uterine infection (chorioamnionitis), the neonate is at increased risk for infection or sepsis and generally would be admitted to the intensive care nursery (ICN) for close and careful monitoring. Group B streptococcus is the leading cause of newborn sepsis. When an infection appears in the newborn, it usually manifests within 48 hr after birth. The newborn may deteriorate rapidly; mortality rate is high.



Physical assessment:


Not every patient with a wound infection looks or feels acutely ill. Some mild infections, such as cellulitis, respond well to early oral antibiotic therapy. Others will require double or triple intravenous (IV) antibiotic therapy administration, wound débridement, or daily wound packing that allows the open incision to heal from the inside out via secondary intention (tissue granulation). In some instances, as in the case when there is a large blood clot behind the incision, reopening of the complete incision may be necessary. This condition requires use of a wound vacuum device or secondary surgical closure using retention sutures and extended hospitalization.


Early assessment and treatment are critical in reducing maternal morbidity/mortality. Sepsis is rare but can occur.



Risk factors:


Advanced maternal age, obesity, type 1 diabetes, low socioeconomic status, malnutrition, positive group B streptococci culture, anemia, prolonged preoperative hospitalization, extended duration of ruptured membranes before delivery, long labor, frequent vaginal examinations during labor, corticosteroid therapy, immunosuppressed state, hemorrhage (loss of leukocytes), duration of the surgery (cesarean section or postpartum tubal ligation), razor shaving the operative site, use of electrosurgical knife, use of open drains (e.g., Jackson Pratt, Penrose), closure technique (suture vs. staples), and emergency surgery (e.g., for fetal distress).



Diagnostic tests




Complete blood count with differential:


Leukocytes (white blood cells) will be elevated in the presence of infection. The differential lists the five types of leukocytes, which all perform a special function. The type of leukocyte elevation will depend on the type of infection present (e.g., monocytes = severe infection by phagocytosis; lymphocytes = viral infections).



Blood cultures:


During acute febrile illness, blood cultures identify the source of bacteria causing the infection, and sensitivity analysis determines the most effective antibiotic therapy.



Gram stain and culture of foul-smelling lochia:


Helps to identify Clostridia, anaerobes, and Chlamydia and indicates sensitivity analysis for the most effective antibiotic to use.



Urinalysis for microscopy:


Detects presence of UTI, which may be seen postoperatively after removal of an indwelling urinary catheter.



Pelvic ultrasound:


Detects and locates possible abscesses and hematomas.



Computed tomography (CT) scan and magnetic resonance imaging (MRI) scan:


In patients who do not respond to antibiotic therapy and have a negative ultrasound examination, these studies can detect obscure pelvic abscesses and pelvic thrombi.





Nursing diagnoses:


Impaired skin integrity


Impaired tissue integrity

related to wound infection and/or dehiscence


Desired Outcome: After initiation of therapy, the patient describes sensations and characteristics of the infected wound that necessitate nursing intervention and measures she can take to improve wound condition, and begins to regain integrity in skin and underlying tissue without evidence of complications.































ASSESSMENT/INTERVENTIONS RATIONALES
Assess pain q2h after vaginal and cesarean childbirth and provide pain relief with analgesics, warm compresses, or sitz baths for episiotomy incisions, as prescribed by the health care provider. Pain relief encourages patient movement. Both movement and heat increase circulation to promote wound healing.
Assess the cesarean surgical site, episiotomy, or other wounds q4h for REEDA (see description under “Assessment,” earlier). Early identification of infection and promptly reporting the need for medical intervention reduces maternal morbidity, the possibility of rehospitalization, and the length of treatment.
– Cesarean surgical site: redness surrounding incision, abdomen warm to touch, drainage from incision, wound dehiscence (incision partially or fully open), and evisceration (protrusion of an organ, usually bowel, through open surgical wound).

– Episiotomy: extreme pain in any position but especially sitting, foul vaginal odor in the absence of abdominal tenderness, drainage of pus, or dehiscence of sutures. Patient may use a mirror for self-examination or ask a family member to examine her perineum.
Assess temperature, pulse, respirations, and pain characteristics q2-4h. This assessment aids in early identification of a developing postpartum infection. A temperature increase of 38° C (100.4° F) or higher in two of the first 10 days postpartum indicates infection. Pulse rises with fever and increases more with sepsis. Tachypnea may develop with sepsis.
Demonstrate and have patient, family, or significant other return demonstration of their ability to practice scrupulous hand hygiene, cleansing of the wound area, and aseptic techniques to care for the wound, such as, wearing gloves (nonsterile acceptable) after thorough hand washing, disposing of soiled dressings in plastic bags, maintaining a clean field for irrigation and packing, using alternatives to tapes for holding dressings in place, applying a new dressing as prescribed, and maintaining a clean and dry wound environment after discharge to home with outpatient care. Hand hygiene and regularly changing a dressing remove bacteria, thereby reducing incidence of contamination. Tape can cause skin reactions and break down sensitive tissue. Maintaining a clean and dry wound provides an optimal environment to assist the body’s natural healing processes.
See Appendix A for “Infection Prevention and Control,” p. 721, for more information.
As prescribed by the health care provider at discharge, provide patient with a referral to community health nursing for supervision of progressive wound changes, monitoring patient’s care, or providing daily dressing changes if wound care is complex. Professional referral decreases stress on the patient and family, reinforces newly learned skills, improves knowledge, and assists with unforeseen problems during transition to home care (e.g., adaptation to the home environment, conflict with work commitments, or uneasiness in self-management of a surgical wound). Home care also enables patient to be home, which decreases medical costs.
Encourage patient to eat a well-balanced diet that includes protein, carbohydrates, fruits, vegetables, and adequate fluid intake. An adequate diet provides nutrients, especially vitamin C, and a positive nitrogen state, which promote wound healing. Adequate hydration also promotes wound healing.
Encourage patient to report changes that indicate complications and to keep all medical appointments. Good communication likely will promote early identification of complications. Adherence to appointments enables timely evaluation of the wound’s healing process and initiation of care in response to complications.
Provide patient with abdominal support or binder after a cesarean section or bilateral tubal ligation. A binder provides support and decreases stretching/tension on muscles or surrounding tissue of the wound to promote healing. This is especially important with patients who are obese.
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Jul 18, 2016 | Posted by in NURSING | Comments Off on Postpartum wound infection

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