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What is Puerperal Infection and Its Assessment:Nursing Case Study

Saturday, 15 March 2014


Puerperal infection occurs in the postpartum period and affects the uterus and higher structures, with a characteristic pattern of fever. According to the Joint Committee on Maternal Welfare, puerperal morbidity can be defined by a temperature of 100.4° F (38° C) or higher that occurs on any 2 of the first 10 postpartum days, exclusive of the first 24 hours. Temperature should be measured orally by a standard technique at least four times per day.

Pathophysiology
Puerperal infection results from the introduction of vaginal microorganisms into the sterile uterine cavity via premature rupture of membranes, operative incisions, hematomas, damaged tissues, or lapses in sterile technique. Microorganisms that commonly cause puerperal infection include group B hemolytic Streptococci, coagulase-negative Staphylococci, Clostridium perfringens, Bacteroides fragilis, Klebsiella, Proteus mirabilis, Pseudomonas, Staphylococcus aureus, and Escherichia coli. Most of these organisms are considered normal vaginal flora but are known to cause puerperal infection in the presence of certain predisposing factors, including:

■ prolonged and premature rupture of the membranes (over 24 hours, allowing bacteria to enter while the fetus is still in utero)
■ prolonged (more than 24 hours) or difficult labor
■ frequent or nonsterile vaginal examinations or nonsterile delivery
■ delivery requiring the use of instruments that can traumatize the tissue, providing a portal of entry for microorganism invasion
■ internal fetal monitoring use with placement of electrodes, which allows introduction of organisms
■ retained products of conception, such as retained placental fragments, which allows tissue necrosis, providing an excellent medium for bacterial growth
■ hemorrhage, which weakens the patient's overall defenses
■ maternal conditions, such as anemia or debilitation from malnutrition, that lower the woman's ability to defend against microorganism invasion
■ cesarean birth
■ existence of localized vaginal infection at delivery, allowing direct infection transmission.


Complications
■ Endometritis
■ Parametritis
■ Pelvic or femoral thrombophlebitis
■ Peritonitis
■ Localized endometritis or salpingitis
■ Pelvic cellulitis

Assessment
Nutrition and metabolism
■ Thirst (peritonitis)

Elimination
■ Urinary retention
■ Constipation

Activity and exercise
■ Easy fatigability

Cognition and perception
■ Pain

Sleep and rest
■ Fatigue

Self-perception and self-concept
■ Anxiety

Sexuality and reproduction
■ Vaginal bleeding or discharge

Roles and relationships
■ Role strain as new mother

Physical examination
Mental status and behavior
■ Anxious expression and restlessness (peritonitis)

Respiratory
■ Decreased ventilatory function if small pulmonary emboli ensue (thrombophlebitis)
■ Shallow respirations (peritonitis)

Cardiovascular
■ Tachycardia
■ Pain, erythema, and edema of affected leg (thrombophlebitis)

Gastrointestinal
■ Severe abdominal pain with rigidity (peritonitis)
■ Abdominal distention with decreased bowel sounds (peritonitis)
■ Nausea, vomiting (commonly projectile and eventually containing feces), and diarrhea (peritonitis)
■ Excessive thirst or brown tongue and foul breath (peritonitis)
■ Constipation (endometritis)

Neurologic
■ Low‑grade fever (temperature less than 101° F [38.3° C]) (localized infection of external genitalia)
■ Possibly chills and rapid onset of pyrexia (localized infection of external genitalia, mastitis)
■ Localized pain (localized infection of external genitalia)
■ Wound pain disproportionate to extent of repair (localized infection of external genitalia)
■ Irregular fever, with temperature varying from 101° to 103° F (38.3° C to 39.4° C) (endometritis or metritis)
■ Pyrexia of 103° to 104° F (39.4° to 40° C) (salpingitis or oophoritis)
■ Persistent pyrexia (102° to 104° F [38.9° to 40° C]) (parametritis or pelvic cellulitis)
■ Pyrexia 4 to 10 days postpartum (thrombophlebitis)
■ Pelvic, lower abdominal, or flank pain (thrombophlebitis)
■ Chills and spiking fever in pelvic thrombophlebitis; fever may spike to 105° F (40.6° C) and then fall precipitously (thrombophlebitis)
■ Marked, rapid pyrexia (peritonitis)

Renal and urinary
■ Dysuria, with or without urine retention (localized infection of external genitalia)

Reproductive
■ Edema, erythema, necrosis of wound edges (localized infection of external genitalia)
■ Wound edges no longer approximated (localized infection of external genitalia)
■ Sanguinopurulent or purulent discharge (localized infection of external genitalia)
■ Severe breast engorgement (mastitis)
■ Hard, red, painful breasts; possibly purulent discharge from nipple (mastitis)
■ Soft, tender uterus larger than involutional stage would warrant; protracted afterbirth pains (endometritis or metritis)
■ Profuse, foul‑smelling, bloody, occasionally frothy lochia; scant, odorless lochia in beta‑hemolytic streptococcal infection (endometritis or metritis)
■ Unilateral or bilateral lower abdominal pain (salpingitis or oophoritis)
■ Frequent unilateral or bilateral abdominal tenderness; pain on pelvic examination associated with uterine movement, possibly preceded by signs and symptoms of endometritis (parametritis or pelvic cellulitis)
■ Possible uterine fixation and pelvic mass on vaginal examination (parametritis or pelvic cellulitis)
■ Possible abscess formation that can be palpated vaginally, rectally, or abdominally, depending on location; inguinal focal point under skin possibly causing edema, erythema, tenderness (parametritis or pelvic cellulitis)

Diagnostic studies
■ White blood cell (WBC) count reveals an increasing pattern, with counts of 15,000 to 30,000/mm3 usually occurring in 36 to 48 hours.
■ Culture of blood, urine, or intrauterine material reveals the causative agent and confirms diagnosis.
■ Ultrasonography may reveal signs of pelvic or femoral thrombophlebitis.

Teaching checklist
■ Signs and symptoms of infection
■ Hand washing
■ Perineal care
■ Nutrition
■ Activity and exercise guidelines
■ Breast care
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