Puerperual infectionà infection of reproductive tract after childbirth.

Characteristics:

• >100.4 after 2 days
• occurs during 1^st 10 days typically
• effects can be mild or life threatening

Sites:

• uterus (endometritis or metritis)
• vagina
• perineum
• cervix
• C-section incision

These can produce inflammation of:

• fallopian tubes (salpingitis)
• pelvic cavity (parametritis)
• thrombophlebitis of the pelvis

Causes:

• beta-hemolytic streptococcus
• staphylococcus
• coliform bacteria

Risk factors:

• highly vascular uterine lining
• raw placental implant site
• prolonged labor
• PROM
• C-section birth
• intrauterine manipulation
• manual extraction placenta
• anemia
• obesity
• diabetes
• frequent vaginal exams
• invasive fetal monitoring

Localized:

• episiotomy
• C-section birth
• vagina, cervix, vulva (especially with lacerations)

Cardinal signs of infection:

• pain
• swelling
• redness
• warmth

Others:

• tenderness
• purulent discharge
• Observe for R-E-E-D-A, redness, erythema, ecchymosis, discharge, approximation.

Treatment:

• warm sitz baths for mild cases
• can use 25 watt heat lamp 18 inches away from site
• oral analgesics
• topical sprays (benzocaine or dermoplast)
• antibiotics
• I&D for abcesses

1. Endometritis:

Infection of the uterine lining. MOST common.

S&S:

• flu-like
• fever
• chills
• tachycardia
• fatigue
• malaise
• headache
• backache
• abdominal pain (tender to touch and distended)
• foul lochia à scant to profuse, red to brown, sometimes smells okay, need to get a culture.

Treatment:

• antibiotics IV followed by orals
• antipyretic analgesics

2. Salpingitis, Parametritis, Peritonitis:

These are extentions of endometritis that have traveled thru blood by way of lymphatic system.

S&S:

• 102-104 temp
• chills
• malaise
• abdominal pain
• subinvolution

Peritonitis S&S:

• severe pain
• tachycardia
• shallow rapid resps
• abdominal distention
• n/v à because of paralytic ileus
• board-like abdomen

Treatment:

• IV broad spectrum antibiotics
• Antipyretics
• May need to be put in ICU à for severe cases
• Put in Semi-fowlers position for drainage into the cul-de-sac

Abcesses must be drained or they won’t ever heal.

Nursing care is focused on prevention. Using aseptic technique and good hand washing is imperative.

Assessment:

• Identify woman at risk for puerperal infection.
• Assess woman’s knowledge deficits concerning hygiene, perineum care.
• Evaluate vital signs each shift or more often if indicated, with attention to temperature elevation.
• Inspect perineum or cesarean incision for signs of local infection (each shift): erythema, unusual pain, purulent discharge, seperation of wound edges.
• Assess lochia for odor, abnormal color, amount.
• Obtain or assist with culture of lochia, exudate, wound.
• Palpate fundus with attention to size and tenderness; severe after-pains.
• Attend to complaints of abdominal or pelvic pain, dysuria, malaise, vomiting, diarrhea.

Interventions:

• ID for risk
• Good nutrition
• Good hygiene
• Treatment of pre-existing infections
• Practice medical and surgical asepsis
• Teach hand washing and peri care
• Teach S&S of infection
• Administer antibiotic, analgesic, antipyretic
• Keep IV site clean
• Teach to stay in semi-fowlers to localize infection and to increase comfort
• Promote comfort and provide rest

Normal things that go along with breast feeding:

• promotes bonding
• less expensive
• easier BM for baby
• colostrum is loaded with antibodies
• has everything baby needs
• wash hands before each feeding
• wash breast with plain water
• put all areola in mouth (prevents soreness)
• one breast for 5-10, then switch
• at next feeding start with the one that was last
• baby will eat every 3 hours
• to releaseà place finger in corner of mouth to break suction
• make sure nipples do not have cracks

Mastitis à incomplete emptying of the breasts and stasis of milk in the ducts. Generally affects one side. The milk is easily infected with organisms that enter thru the duct work.

Occurs 2-4 weeks after delivery. Cause = Staph areus.

S&S:

• localized pain
• erythema
• flu-like symptoms

Risk Factors:

• Sore cracked nipples à mother limits feeding time because of this and the milk gets backed up.
• Poor maternal hygiene.
• Poor positioning.
• Excessive or vigorous sucking.

Nursing Care:

• Teach her how to and you feel for lumps.
• Feel for engorgement.
• Assess for systemic symptoms à fever, malaise, etc.

Interventions:

• teaching is most important especially hand washing
• warm compresses
• frequent feeding on affected side

Treatment:

• rest and fluids
• sometimes analgesics
• emptying breast is primary treatment
• antibiotics for severe

Go over breast feeding that starts on page 324.

Urinary Tract Infections:

Called cystitis – bladder infection.

Causes:

• catheterizations
• trauma to bladder and urethra
• failure to empty bladder
• distended bladder because it hurts to urinate, vulva is swollen or anesthesia

Perineal pain, diminished bladder sensitivity and decreased bladder tone results in incomplete emptying of the bladder.

500-1000ml voided = normal.

100-200ml voided = retention.

Urine that remains in the bladder makes for an excellent bacteria growth medium.

S&S: 2-3 days after delivery

• frequency
• urgency
• dysuria
• suprapubic pain
• fever
• bloody urine

Fever is not significant unless infection travels to the kidneys causing pyelonephritis, which can lead to glomerulonephritis and cause permanent kidney damage.

Treatment:

Antibiotic therapy after organism is identified thru a culture.

Nursing Care:

Prevention thru good basic intrapartum and postpartum care.

After diagnosis, care is directed on comfort, healing and teaching to prevent recurrence.

Assessment:

• measure 1^st voiding
• palpation of fundus after voiding
• 500ml or more is visible and palpable (bulge over symphasis pubis)
• assess the woman who voids frequently 300ml or less for retention
• assess S&S of cystitis q shift

Interventions:

• Catheterization to determine residuals within 5 minutes after voiding.
• Encourage 1000ml fluids each 8 hours.
• Ambulate to improve bladder function.
• Teach proper peri care.

If infected:

• report S&S to MD
• get a clean catch for C&S
• administer antibiotics

Thrombophlebitis:

Cause: venous stasis.

Pressure from growing uterus that presses on the vessels of the lower extremities.

Risk:

• immobility
• C-section
• PIH
• hydramnios
• multip
• >40
• pre-existing anemia or heart disease

Superficialà firmly attached; in the legs; not likely to break off; bed rest, TED hose, elevation.

DVTà no inflammation; likely to break off and cause PE; S&S of PE = chest pain, anxious restless, initially increase in BP then fall, tachycardia, fast resps; medical emergency; give oxygen, bed rest, IV heparin.

Assessment:

• ID those at risk
• ID early symptoms
• Report foot, leg, groin, or pelvic pain
• Calf and thigh circumference
• Bleeding tenderness are assessed
• Check pedal pulses, color, warmth, cap refill

Intervention:

• aimed at prevention
• use padding for legs
• avoid knee gatch
• early ambulation
• TED hose
• Adequate fluid intake (to thin the blood)
• Elevate legs
• Bed rest
• Avoid massage

Pulmonary Embolus Diagnosis:

• to ICU
• v/s and LOC q 5-15
• high fowler
• Oxygen therapy
• Start IV
• ECG
• Chest X-ray
• ABG
• Analgesics (morphine,demerol)
• Heparin
• Drugs to correct pH and electrolyte imbalance
• Fibrolytic therapy
• Embolectomy

Psychosis:

2-4 weeks after birth. Characterized by loss of contact with reality, hallucinations, delusions, and disorientation.

Risk of harm to mom and baby is great.

Associated with prenatal stressors.

Assessment:

• risk of harm is a dominnat concern.
• Risk of killing herself and baby.

Interventions: home visits.