5 Prenatal Infection Nursing Care Plans

Risk For Maternal/Fetal Infection

Bacterial infections are the single most common medical complication encountered by healthcare professionals. Some infections, such as puerperal endometritis and lower urinary tract infection, are of principal concern to the mother and pose little or no risk to the fetus or neonate. Others, such as listeriosis and group B streptococcal (GBS) infection, are of greatest concern to the fetus. Still others- such as pyelonephritis, chorioamnionitis, and syphilis- may cause serious morbidity, even life-threatening complications, for both the mother and the baby (Galan et al., 2020).

Nursing Diagnosis

• Risk for Infection

Risk Factors

• Inadequate primary defenses (e.g., broken skin, stasis of body fluids)
• Inadequate secondary defenses (e.g., decreased hemoglobin, immunosuppression)
• Inadequate acquired immunity
• Environmental exposure
• Malnutrition
• Rupture of amniotic membranes

Possibly evidenced by

• [Not applicable]

Desired Outcomes

• The client will verbalize understanding of individual causative/risk factors.
• The client will review techniques and lifestyle changes to reduce the risk of infection.
• The client will initiate behaviors to limit the spread of infection and reduce the risk of complications.
• The client will achieve timely healing, free of complications.

Nursing Assessment and Rationales

1. Obtain information regarding the client’s past and present sexual partners and exposure to sexually transmitted infections (STIs).
Multiple sexual partners or intercourse with bisexual men increases the risk of exposure to STIs and HIV/AIDS. STIs are diseases that are spread through sexual contact with an infected partner. The client should also include any sexual contact with persons who are intravenous drug users.

2. Obtain information about the client’s cultural background for risk factors.
In Africa, the male-to-female ratio of HIV is 1:1 owing to cultural, sexual practices, poor hygiene, and inadequate health care, while recent arrivals from Asia, South America, and the Caribbean islands have increased the risk of exposure to the Hepatitis B virus.

3. Review lifestyle and profession for the presence of associated risk factors.
Drug abusers and healthcare professionals are at risk for exposure to HIV/AIDS and HBV through contact with contaminated needles, body fluids, and blood products; tuberculosis through airborne droplets. Adolescents now account for almost half of the new cases of STIs each year. Pay particular attention to adolescents who do not have a strong family support system because it may be difficult for these youth to receive correct information about preventing STIs.

4. Assess for any specific signs and symptoms, if present, and notify the healthcare provider. These may include visible lesions/warts, urinary frequency, dysuria, cloudy, foul-smelling urine, and changes in color, consistency, and amount of vaginal discharge.
Identifiable signs of infection assist in determining the mode of treatment. Some organisms have a predilection for the fetoplacental unit and the neonate, although the client may be asymptomatic; i.e., Mycoplasma and Ureaplasma organisms affect many pregnant women and have been cultured in aborted fetuses, even though the mothers have been free of symptoms. Visible lesions and warts may indicate herpes simplex virus type II (HSV II)/condyloma, which can be transmitted to the newborn at the time of delivery if a lesion is present at term or if viral shedding is occurring. Urinary tract infection symptoms may be associated with Escherichia coli or GBS, or the client may have asymptomatic bacteriuria. Abnormal characteristics of vaginal discharges (discoloration, foul-smelling odor, excessive amount) may indicate an STI.

5. Determine if the infection is either primary or recurrent.
Both herpes viruses (CMV and herpes simplex virus II [HSV-II]) recur in times of stress. Yet only primary CMV is problematic to the fetus, and only 50% of the fetuses exposed are affected. Although recurrent HSV-II is associated with reduced viral shedding time, the newborn, if exposed to the virus at delivery, can be affected with either visible lesions or a disseminated type of disease. When this occurs, a severe systemic infection that is often fatal can result.

6. Determine the status of maternal membranes. If they are ruptured, monitor blood cell count and fetal heart rate; or if the vaginal discharge has an odor.
Infectious organisms transmitted via the ascending route, including Chlamydia, mycoplasmas, and Ureaplasma urealyticum, develop bacteremia and pneumonia or possibly meningitis. Chlamydial infections are associated with premature rupture of membranes, preterm labor, and endometritis in the postpartum period. An infant born while a chlamydial infection is present can develop conjunctivitis or pneumonia after birth.

7. Perform a comprehensive STI and HIV screening.
STI screening is recommended by the CDC because STIs are biological markers of risk, particularly for HIV acquisition and transmission among certain men who have sexual activities with other men. STI screening is an essential and underused component of an STI and HIV risk assessment. Persons seeking treatment or evaluation for a particular STI should be screened for HIV and other STIs as indicated by community prevalence and individual risk factors. The client must be informed about all the tests for STIs they are receiving and notified about tests for common STIs (Centers for Disease Control and Prevention, 2021).

8. Screen the pregnant woman for HIV during the first prenatal visit and during the third trimester.
All pregnant women should be tested for HIV during the first prenatal visit. A second test during the third trimester, preferably at <36 weeks gestation, should be considered and is recommended for women who are at high risk for acquiring HIV infection, women who receive health care jurisdictions with high rates of HIV, and women examined in clinical settings in which HIV incidence is ≥1 per 1,000 women screened per year (Centers for Disease Control and Prevention, 2021).

Nursing Interventions and Rationales

1. Educate the client regarding the proper use of tampons, diaphragms, and cervical caps.
To prevent toxic shock syndrome, the client should be taught to wash her hands well when using tampons or a diaphragm. The tampons should be changed every four hours and not used during sleep, which usually lasts longer than four hours. The diaphragm should not be used during menstruation or eight weeks after childbirth.

2. Provide information on how to prevent STIs.
Abstinence or condom use provides the best protection against STIs. Additional measures include voiding immediately and washing the genitals well with soap and water after coitus, as well as choosing sexual partners who are at low risk for infection. Educating adolescents about safer sex practices, including the need for condom use and the importance of health screening for these disorders, is an important nursing responsibility.

3. Inform the client about the importance of vaccines against STIs.
Approach the subject of immunization with the client with sensitivity because some clients, especially teenagers with their parents, are not ready to admit they might be or soon will become sexually active and need this protection. Immunizing adolescents against human papillomavirus (HPV) infection should reduce not only the incidence of HPV infections in the future but also the rate of cervical and penile cancer as well. The hepatitis B vaccine can prevent the disease, and immunoglobulin can be administered if known exposure has occurred.

4. Instruct against the use of douching.
Douching results in changes in the vaginal flora and predisposes the client to develop pelvic inflammatory disease (PID), bacterial vaginosis, and ectopic pregnancies. However, many women practice regular douching, believing that it is cleansing. The nurse can play an important role in educating the client to prevent PID.

5. Educate the client on how to prevent acquiring toxoplasmosis.
Removing a cat from the home during pregnancy as a means of prevention is unnecessary as long as the cat is healthy. However, taking in a new cat, which could be infected, is unwise. Instruct the pregnant client to avoid undercooked meat and also not to change a cat litter box or garden in the soil in an area where cats may defecate to avoid exposure to the disease. Reinforce proper hand washing after handling uncooked meat.

6. Offer the client prevention counseling on STI or HIV.
Prevention counseling is most effective if provided in a nonjudgmental and empathetic manner appropriate to the client’s culture, language, sex and gender identity, sexual orientation, age, and developmental level. Prevention counseling for STIs and HIV should be offered to all sexually active adolescents and to all adults who have received an STI diagnosis, have had an STI during the previous year, or have had multiple sexual partners. One such approach, known as client-centered STI and HIV prevention counseling, involves tailoring a discussion of risk reduction to the person’s situation (Centers for Disease Control and Prevention, 2021).

7. Obtain appropriate specimens and monitor laboratory/ diagnostic studies as indicated.
Candidal infections are diagnosed by removing a sample of the discharge from the vaginal wall and placing it on a glass slide with drops of hydroxide solution added. Under a microscope, typical fungal hyphae indicate the presence of Candida organisms. Most STIs are diagnosed by microscopic examination of a sample of the vaginal discharge. Culture of lesion secretions or isolation of HSV antibodies diagnoses Herpes infection. Urine culture should be obtained from clients with vulvovaginitis to rule out gonorrhea.

8. Assist as necessary with sputum collection and chest x-rays for clients with respiratory symptoms.
This helps in identifying causative organisms in bacterial pneumonia and active tuberculosis. Screening of tuberculosis early in pregnancy is important because it is a chronic and debilitating disease that increases the risk of miscarriage. Additionally, the change in the shape of the maternal lung tissue as the growing uterus presses on the lungs may reactivate already healed lesions, thus worsening the disease.

9. Administer antibiotics and other medications as indicated to the client and her sexual partner.
Treatment or alleviation of symptoms for STIs may include antibiotics such as azithromycin, doxycycline, erythromycin, ceftriaxone, and benzathine penicillin G; antivirals such as acyclovir; and antifungals such as miconazole, clotrimazole, or fluconazole. Metronidazole or tinidazole is indicated for treating trichomonas and Gardnerella infections and bacterial vaginosis.

10. Prepare for/assist in transfer to the tertiary care center as indicated.
Availability of staff and equipment ensures optimal care of high-risk clients and fetuses/newborns. Treatment for toxic shock syndrome includes hospitalization for the administration of vasopressor drugs and fluid replacement.

11. Prepare to assist with procedures to remove lesions or warts.
Treatment for human papillomavirus includes cryotherapy, laser vaporization, electrodiathermy, and electrofulguration with a loop electrode excision procedure. Therapy for such lesions is aimed at dissolving the lesions and also ending any secondary infection present. With cryocautery, edema at the site is evident immediately; lesions become gangrenous, and sloughing occurs in seven days, with healing complete in four to six weeks with only slight depigmentation present.

12. Prepare for termination of pregnancy or labor induction, as indicated.
Pregnancy may be terminated for such conditions as toxoplasmosis occurring before 20 weeks of gestation or rubella in the first trimester. An infant born after contracting either cytomegalovirus or toxoplasmosis may be born with congenital anomalies from the virus invasion. Elective termination is mainly a surgical procedure. Therefore, nurses employed in healthcare agencies where induced abortions are rendered and be asked to assist as part of their duties.