Puerperal infection is a reproductive tract infection occurring within 28 days following childbirth or abortion. It is one of the major causes of maternal death (ranking second behind postpartum hemorrhage). It includes localized infectious processes and more progressive processes that may result in endometritis (inflammation of endometrium), peritonitis, or parametritis/pelvic cellulitis (infection of connective tissue of broad ligament and possibly connective tissue of all pelvic structures).
Theoretically, the uterus is sterile during pregnancy and up until the membranes rupture. After rupture, pathogens can begin to invade; the risk of infection grows even greater if tissue edema and trauma are present. Organisms commonly cultured post-partially include group B streptococci, staphylococci, and aerobic gram-negative bacilli such as Escherichia coli.
Tissue trauma during labor, the open wound of the placental insertion site, surgical incisions, cracks in the nipples of the breasts, and the increased pH of the vagina after birth are all risk factors for the postpartum woman.
Prevention measures of puerperal infection should be taken before pregnancy and during pregnancy, delivery, and puerperium. During puerperium, it is recommended that puerperae get enough sleep, strengthen nutrition reasonably, and improve the body’s immunity, health management is strengthened, and prevention measures be actively taken for puerperae with high-risk factors, thereby improving the prognosis of clients and reducing the incidence of puerperal infection (Song et al., 2019).
Table of Contents
- Nursing Care Plans and Management
- Nursing Problem Priorities
- Nursing Assessment
- Nursing Diagnosis
- Nursing Goals
- Nursing Interventions and Actions
- Recommended Resources
- See Also
- References and Sources
Nursing Care Plans and Management
The nursing management of clients diagnosed with puerperal infection includes preventing the spread of infection, promoting healing, and improving the attachment/bonding of parent and infant.
Nursing Problem Priorities
The following are the nursing priorities for patients with puerperal & postpartum infections:
- Infection identification and diagnosis. Promptly identifying and diagnosing prenatal infections through appropriate testing and evaluation to guide timely intervention and management.
- Maternal health assessment. Evaluating the overall health of the mother, including monitoring vital signs and assessing for any signs or symptoms of infection, to ensure her well-being.
- Fetal monitoring. Monitoring the well-being of the fetus through regular ultrasounds, non-stress tests, or other appropriate methods to assess the impact of the infection on fetal health.
- Antibiotic therapy. Administering appropriate antibiotics to treat the specific prenatal infection, considering factors such as the type of infection, drug safety during pregnancy, and the patient’s individual circumstances.
- Prevention of transmission. Implementing strategies to prevent transmission of the infection from mother to fetus, such as counseling on hygiene practices, safe sexual practices, and avoiding exposure to known sources of infection.
- Maternal education and support. Providing education to the mother about the infection, its potential risks, and the importance of adherence to prescribed treatments, as well as addressing any concerns or questions she may have.
- Prevention of complications. Implementing measures to prevent potential complications associated with prenatal infections, such as preterm labor, fetal growth restriction, or birth defects, through close monitoring and appropriate interventions.
- Postpartum care and follow-up. Providing appropriate postpartum care to monitor for any lingering effects of the infection, ensure the well-being of both the mother and the baby, and address any necessary follow-up treatments or evaluations.
Assess for the following subjective and objective data:
- See nursing assessment cues under Nursing Interventions and Actions.
Following a thorough assessment, a nursing diagnosis is formulated to specifically address the challenges associated with puerperal & postpartum infections based on the nurse’s clinical judgment and understanding of the patient’s unique health condition. While nursing diagnoses serve as a framework for organizing care, their usefulness may vary in different clinical situations. In real-life clinical settings, it is important to note that the use of specific nursing diagnostic labels may not be as prominent or commonly utilized as other components of the care plan. It is ultimately the nurse’s clinical expertise and judgment that shape the care plan to meet the unique needs of each patient, prioritizing their health concerns and priorities.
Goals and expected outcomes may include:
- The client will verbalize understanding of individual causative risk factors.
- The client will initiate behaviors to limit the spread of infection as appropriate and reduce the risk of complications.
- The client will achieve timely healing, free of additional complications.
- The client will identify/use individually appropriate comfort measures.
- The client will report a decreased level of pain/discomfort.
- The client will meet nutritional needs, evidenced by timely wound healing, appropriate energy level, and laboratory values within normal postpartal expectations.
- The client will demonstrate progressive weight gain or stable weight.
- The client will demonstrate behaviors or lifestyle changes to regain and maintain an appropriate weight.
- The client will demonstrate measures to improve wound condition.
- The client will regain the integrity of the skin and underlying tissues without complications.
- The client will display timely wound healing and the absence of signs of pressure or breakdown.
- The client will exhibit ongoing attachment behaviors during parent-infant interactions.
- The client will maintain/assume responsibility for the physical and emotional care of the newborn as able.
- The client will express comfort with the parenting role.
Nursing Interventions and Actions
Therapeutic interventions and nursing actions for patients with puerperal & postpartum infections may include:
1. Promoting Infection Control and Management
During the delivery process, changes in the physiological structure of pregnant women, hemorrhage, delivery injury, etc., lead to a decline in the body’s immunity, resulting in puerperal infection under some risk factors. Birth canal injury is caused due to fetal delivery via the reproductive tract during the puerperium, and the body’s immunity of pregnant women significantly declines during the puerperium. As a result, pathogenic microorganisms invade the human body, leading to infection, septicopyemia, and threatening maternal life (Song et al., 2019). Postpartum infections often occur at the placental implantation site, in the laceration or episiotomy after vaginal birth, or in the abdominal wound after cesarean birth. Women are susceptible to genital tract infection if their resistance is decreased or if bacteria have an opportunity to colonize. Risk factors for perineal wound infections are similar to those for genital tract infections of the uterus. They include prolonged rupture of membranes, episiotomy or large lacerations, and compromised skin integrity (Karsnitz, 2014).
Review prenatal, intrapartal, and postpartal record.
A review of the client’s previous health records identifies factors that place the client in a high-risk category for the development/spread of postpartal infection. Analyses of risk factors for puerperal infection showed that the body mass index >25, placenta previa, placenta accreta, postpartum hemorrhage, premature rupture of membranes, gestational diabetes, and anemia during pregnancy were relevant and independent risk factors for puerperal infection (Song et al., 2019).
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. The fever is most often caused by endometritis, an inflammation of the inner lining of the uterus. Puerperal fever is a temperature of 38℃ (100.4℉) or higher after the first 24 hours and for at least two days during the first ten days after birth. A pulse rate that is higher than expected and an elevated temperature often occur when the client has an infection.
Observe perineum/incision for other signs of infection (e.g., redness, edema, ecchymosis, discharge, and approximation [REEDA scale]).
This allows early identification and treatment; promotes resolution of infection. The assessment of any cesarean birth wound or episiotomy wound using the REEDA criteria or hardening of the operative area should be promptly reported and documented.
Note subinvolution of uterus, extreme uterine tenderness, and lochia.
The client’s uterus usually is not well contracted and is painful to touch. She may feel strong afterpains. Lochia usually is dark brown and has a foul odor. It may be increased in amount because of poor uterine involution, but if the infection is accompanied by high fever, lochia may, in contrast, be scant or absent.
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 reducing fever. Slight temperature elevations with no other signs of infection often occur during the first 24 hours because of dehydration.
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. The levels of fibrinogen and other clotting factors normally increase during pregnancy. In contrast, levels of clot-dissolving factors (plasminogen activator and antithrombin III) are normally decreased, resulting in a state of hypercoagulability.
Demonstrate and maintain a strict hand-washing policy for staff, clients, and visitors.
Proper hand hygiene is the primary method to prevent the spread of infectious organisms. The client should be taught to wash her hands before and after performing self-care that may involve contact with secretions.
Ensure the proper handling of sterile instruments and the proper use of personal protective equipment (PPE).
To help prevent infection, any articles such as gloves or instruments that are introduced into the birth canal during labor, birth, and the postpartum period should be sterile. In addition, adherence to standard infection precautions is essential. Gloves should be worn when contacting blood, body fluid, or other potentially infectious materials.
Demonstrate correct perineal cleaning after voiding and defecation and frequent changing of peripads.
Changing pad removes moist medium that favors bacterial growth. Be certain to instruct a postpartal client in proper perineal care, including wiping from front to back so that she doesn’t bring E. coli organisms forward from the rectum. When giving perineal care, the nurse must wash hands and wear gloves. Each postpartal client should have their supplies and should not share them to prevent the transfer of pathogens from one client to another.
Demonstrate proper fundal massage. Review the importance and timing of the procedure.
Fundal massage may enhance uterine contractility. It may promote involution and passage of any retained placental fragments. Subinvolution may result from a small retained placental fragment, mild endometritis, or an accompanying problem such as uterine myoma that interferes with complete contraction.
Encourage semi-Fowler’s position.
Sitting in a semi-Fowler’s position or walking encourages lochia drainage by gravity and helps prevent the pooling of infected secretions.
Encourage the client to consume a high-protein and vitamin C-rich diet.
Ultimately, the client’s body must overcome infection and heal any wound. Nutrition is an essential component of her body’s defenses. The nurse, and sometimes a dietitian, should teach her about foods that are high in protein (meats, cheese, milk, legumes) and vitamin C )citrus fruits and juices, strawberries, and cantaloupe) because these nutrients are especially important for healing.
Promote early ambulation, balanced with adequate rest—advance activity as appropriate.
The nurse should explore ways to help the client get enough rest. This may increase circulation, promote clearing respiratory secretions and lochial drainage, and enhance healing and general well-being. Ambulation and limiting the time the client remains in obstetric stirrups encourages circulation to the lower extremities, promotes venous return, and decreases clot formation. Help the client select her activities to exercise other body parts or stimulate her mind.
Recommend that the breastfeeding mother 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. Be certain the breastfeeding client is not prescribed antibiotics incompatible with breastfeeding. Alert them to observe for problems in their infant, such as white plaques or thrush in their mouth that can occur when a portion of maternal antibiotic passes into breast milk and causes an overgrowth of fungal organisms in the infant.
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. Women discharged from the hospital may be cared for at home on bed rest.
Instruct 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. If the client is continuing drug therapy at home, stress that she must take the full course to prevent the infection from recurring.
Discuss the importance of pelvic rest as appropriate (avoidance of douching, tampons, and intercourse).
This promotes healing and reduces the risk of reinfection. Bacteria may gain access to the vagina and uterus through these practices and lead to endometritis or peritonitis. 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 it is cleansing. The nurse can play an important role in educating the woman to prevent PID.
Monitor laboratory studies, as indicated.
See Diagnostic and Laboratory Procedures
Encourage the application of moist heat in the form of sitz baths, compresses, and 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. Cover wet, warm dressings with a plastic pad to hold heat and moisture. In addition, position a commercial pad with circulating heating coils or chemical hot packs over the plastic to ensure soaks stay warm.
Provide supplemental oxygen when necessary.
Oxygen promotes healing and tissue regeneration, especially in anemia; it may enhance oxygenation when pulmonary emboli are present. When there is a pulmonary embolus, the client needs oxygen administered immediately and is at high risk for cardiopulmonary arrest. The blood clot may block blood flow to the lungs and return to the heart.
Demonstrate perineal application of antibiotic creams, as appropriate.
Topical antibiotics eradicate local infectious organisms, reducing the risk of spreading infection. Infections of the perineum usually remain localized. The client may or may not have an elevated temperature depending on the systemic effect and spread of the infection.
Administer medications as indicated.
See Pharmacologic Management
Administer whole blood/packed RBCs, if needed.
These blood products replace blood losses and increase oxygen-carrying capacity in the presence of severe anemia or hemorrhage. Extensive blood loss is one of the precursors of postpartum infection because of the general debilitation that results.
Arrange for transfer to intensive care setting as appropriate.
It may be necessary for clients with severe infection (e.g., peritonitis, sepsis) or pulmonary emboli to provide appropriate care leading to optimal recovery. Puerperal infection is always potentially serious because, although it usually begins only as a local infection, it has the potential to spread to the peritoneum (peritonitis) or the circulatory system (septicemia) conditions that can be fatal in a client whose body is already stressed from childbirth.
Assist with procedures, such as incision and drainage (I&D) or D&C, as necessary.
Draining the infected area and possibly inserting iodoform gauze packing promotes healing and reduces the risk of rupturing the peritoneal cavity. D&C may be needed to remove retained products of conception and/or placental fragments. In some instances, placenta accreta is so deeply attached that balloon occlusion and embolization of the internal iliac arteries may be necessary to minimize blood loss. In others, a hysterectomy must be performed.
Assess the surgical site, episiotomy, or other wounds every four hours for REEDA (redness, edema, ecchymosis, discharge, approximation).
Early identification of infection and prompt reporting of the need for medical intervention reduces maternal morbidity, the possibility of rehospitalization, and the length of treatment. The REEDA acronym is also useful when assessing a cesarean birth incision for healing. Pain with redness may indicate an infection. Severe edema and larger bruises interfere with healing.
Assess the client’s vital signs and pain characteristics every two to four hours.
This assessment aids in the early identification of a developing postpartum infection. A temperature increase of 38℃ (100.4℉) 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.
Emphasize the importance of hand hygiene and aseptic techniques in wound care, and have the client and significant others perform a return demonstration of their ability to practice these techniques.
Hand hygiene and regular changes of dressings, including frequent changing of peripads, remove bacteria and thereby reduce the incidence of contamination. This may include wearing gloves, thorough hand hygiene, disposal of soiled dressings, applying a new prescribed dressing, and maintaining a clean, dry wound environment after discharge. Maintaining a clean and dry wound environment provides an optimal environment to assist the body’s natural healing processes.
Encourage the client to eat a well-balanced diet that includes protein, carbohydrates, fruits, vegetables, and adequate fluid intake.
Ultimately, the client’s body must overcome infection and heal any wound. Nutrition is an essential component of her body’s defenses. The nurse, and sometimes a dietitian, should teach her about foods that are high in protein (meats, cheese, milk, legumes and vitamin C, citrus fruits and juices, strawberries, and cantaloupe) because these nutrients are especially important for healing.
Educate the client on how to recognize and report signs of complications and adhere to follow-up checkups.
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.
Apply cold and warm compresses to the perineal area as appropriate.
An ice pack or chemical cold pack is applied for the first 12 to 24 hours to reduce edema and bruising and to numb the perineal area. The cold pack should be covered with a paper cover or a washcloth to prevent tissue damage. When the ice melts, the cold pack is left off for 10 minutes before applying another for maximum effect. After 24 hours, heat from a warm chemical pack, a bidet, or sitz bath increases circulation and promotes healing.
Provide abdominal support or a binder after a cesarean birth or bilateral tubal ligation.
A binder provides support and decreases stretching, or tension on the muscles or surrounding wound tissue to promote healing. This is especially important with clients who are obese.
Educate the client regarding the care of the breasts, especially if the client plans to breastfeed.
The nipples should be washed with plain water to avoid the drying effects of soap, which can lead to cracking. Exposure of the nipples to air for at least part of every day allow them to dry, as a moist environment promotes the growth of microorganisms. The use of vitamin E ointment daily to soften nipples can also be recommended. The nipples are inspected for redness and cracking, making breastfeeding more painful and offering a port of entry for microorganisms. Remind the client to wash hands between handling perineal pads and touching the breasts.
2. Managing Acute Pain
Many factors typically cause infection during the puerperal period: infection of the perineum, mastitis, retained placental fragments, peritonitis, endometritis, etc. Infection of the perineum is usually revealed by symptoms similar to any suture-line infection, such as pain, heat, and a feeling of pressure. Peritoneal infection elicits abdominal pain and a rigid abdomen as it can be accompanied by paralytic ileus. In mastitis, the affected breast feels painful and appears swollen and reddened. Pain is a distressing experience associated with actual or potential tissue damage with sensitive, emotional, cognitive, and social components. The postpartum period is unique for each client, and pain may make recovery, self-care, and care of the newborn more difficult while also being a risk factor for depression (Brito et al., 2021).
Assess the location and nature of discomfort or pain, and rate pain on a 0–10 scale.
This helps in the differential diagnosis of tissue involvement in the infectious process. In a study, abdominal pain was the most frequent (64.7%), followed by perineal and genital pain (38.4%). Regarding pain intensity, 49.8% of clients reported moderate pain, with a mean of 5.6 per the Verbal Numeric Pain Scale (Brito et al., 2021).
Assess the extent of perineal lacerations and swelling of the breast.
Perineal pain, caused by spontaneous laceration or episiotomy, may affect up to 65% of women after vaginal delivery. Breast engorgement and inadequate emptying of milk associated with mastitis may result in abscess if left untreated.
Assess for non-verbal pain cues.
Non-verbal cues such as crying, grimacing, or withdrawn behavior may indicate pain. The experience of pain is subjective and affects the quality of life negatively. According to the Brazilian Society for the Study of Pain, the perception of pain varies from one individual to another and is influenced by culture and previous experiences (Brito et al., 2021).
Provide instruction regarding, and assist with, the maintenance of cleanliness and warmth.
This promotes a sense of general well-being and enhances healing. It may also alleviate discomfort associated with chills. Ensure that the client adheres to strict hand hygiene between handling perineal pads and touching the breasts since the organism that causes the infection usually enters through cracked and fissured nipples.
Instruct client in relaxation techniques; provide diversionary activities such as radio, television, or reading.
Relaxation techniques and diversionary activities refocus the client’s attention, promote a positive attitude, and enhance comfort. Relaxation techniques require concentration, thus occupying the mind while reducing muscle tension. Diversion and distraction techniques such as imagery, music, or television may stimulate the client’s brain, thus limiting the ability to perceive sensations as painful.
Encourage continuation of breastfeeding as the client’s condition permits. Otherwise, suggest and provide instruction on using a manual or electric breast pump.
This prevents the discomfort of engorgement and promotes adequacy of milk supply in breastfeeding clients. Both breasts should be emptied regularly to reduce milk stasis, which increases the risk of abscess formation. If the affected breast is too painful for the client to breastfeed, she can use a breast pump to empty it. Nursing first on the unaffected side starts the milk flow in both breasts and can improve emptying with less pain.
Change client’s position frequently. Provide comfort measures, e.g., back rubs and linen changes.
This reduces muscle fatigue and promotes relaxation and comfort. When performing compresses, check the client’s bed frequently to ensure that the mattress does not become wet from seeping water, and change the bed linens when it becomes wet or soiled.
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. Evaluate the client’s verbal and non-verbal communication to help identify the need for pain relief in clients who may not directly communicate their need for pain relief or who do not speak the prevailing language.
Instruct about the use of cold compresses.
Cold or ice compresses may help with pain relief until the process improves, although warm, wet compresses can also be helpful because this reduces inflammation and edema. Cold packs should be applied to the breast after emptying to reduce edema and pain (Blackmon et al., 2022). Studies also show that applying ice to the perineum for 15 and 20 minutes relieves pain, leading to numbness and anesthesia in this area (Brito et al., 2021).
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. Heat also promotes a complete emptying of the breast and comfort. Moist heat can be applied with chemical packs. Placing a warm, wet cloth in a plastic bag and applying it to the breasts can create an inexpensive warm pack. A warm shower taken just before nursing provides warmth and cleanliness and stimulates milk flow.
Educate the client about wearing a good support bra.
Advise the client to wear a good support bra to support the breasts and limit movement of the painful breast; the bra should not be too tight, or it will cause milk stasis.
Administer analgesics or antipyretics.
This reduces associated discomforts of infection. Mild analgesics may make the client feel more comfortable. Nonsteroidal anti-inflammatory drugs (NSAIDs) can also be used for pain control. If the symptoms of lactational mastitis persist beyond 12 to 24 hours, antibiotics should be administered (Blackmon et al., 2022).
3. Maintaining Adequate Nutrition
Consumption of decreased amounts of food during the postpartum period can cause malnutrition. Malnutrition can inhibit insulin secretion and increase blood glucose, resulting in a depletion of protein calories that can inhibit the wound healing process; anemia can decrease the availability of oxygen and nutrients useful for wound healing. Based on the phenomenon of the culture of eating recess, which can cause slow healing of the perineal wound, it can lead to infection during the puerperium (Wigati & Sari, 2020).
Note total daily intake. Maintain a diary of calorie intake, patterns, and times of eating.
This will help reveal changes that should be made in the client’s dietary intake. The higher the culture of abstinence from food, the longer wound healing will be. During the postpartum period, the client needs three times more nutrition than the usual condition for restoring the client’s energy or activity, metabolism, reserves in the body, healing birth canal wounds, and meeting the baby’s needs in the form of milk production (Wigati & Sari, 2020).
Monitor intake and output and compare with periodic weight.
Following the client’s intake and output may provide information about replacement needs and the effects of therapy. Some cultures adhere to the “hot” and “cold” theory of diet after childbirth. The temperature has nothing to do with the foods that are considered hot and those that are considered cold; it is the believed intrinsic property of the food itself that classifies it. For example, “hot” foods include eggs, chicken, and rice. Women may also prefer their drinking water hot rather than cold or cool.
Weigh the client periodically as appropriate.
Regular weighing monitors the client’s weight loss and the effectiveness of nutritional interventions. The postpartum period increases nutritional demands and marks a significant life transition that can impact diet quality and subsequently predisposes the client to a great risk of being underweight. Poor diet during this period is directly related to diminished immune function and disease susceptibility (Sebeta et al., 2022).
Discuss eating habits, including food preferences and intolerances.
Postpartum clients need the nutrients to accelerate the healing of wounds or infections. However, mothers still abstain from eating in the name of the food recommended for consumption. This may cause a delay in the healing of wounds (Wigati & Sari, 2020). Including what the client likes or desires for food may help increase their appetite.
Promote intake of at least 2000 ml/day of juices, soups, and other nutritious fluids.
This provides calories and other nutrients to meet metabolic needs and replace fluid losses, thereby increasing circulating fluid volume. Consumption of various food groups provides various essential nutrients for the body’s normal growth and disease prevention, while malnutrition results from a lack of dietary diversity (Sebeta et al., 2022).
Encourage choice of foods high in protein, iron, and vitamin C when oral intake is permitted.
The diet given must be of high quality with sufficient calories, protein, fluids, and lots of fruits because postpartum clients experience hemoconcentration (Wigati & Sari, 2020). Protein helps promote the healing and regeneration of new tissue. Iron is necessary for hemoglobin synthesis. Vitamin C facilitates iron absorption and is necessary for cell wall synthesis.
Encourage adequate sleep and rest.
This reduces metabolic rate, allowing nutrients and oxygen to be used for healing. Today’s modern lifestyle often requires the woman to work through most of her pregnancy, room-in after delivery with responsibility for newborn care, and then return home after delivery, in 48 hours or less, to accept complete home responsibilities. Therefore many women do not have the opportunity to rest and adapt in the postpartum phase.
Recommend small, frequent meals and between-meal nourishment.
Small, frequent meals may reduce fatigue and enhance intake while preventing gastric distention. Ensure, Isomil or similar products may provide additional protein and calories.
Assist with placement of nasogastric (NG) or Miller- Abbott tube.
This may be necessary for gastrointestinal decompression in presence of abdominal distension or peritonitis. Peritonitis is often accompanied by a paralytic ileus, which is a blockage of inflamed intestines. This requires a nasogastric tube to prevent vomiting and rest the bowel.
Administer parenteral fluids or nutrition, as indicated.
This may be necessary to combat dehydration, replace fluid losses, and provide nutrients when oral intake is limited/restricted. Maintenance fluid requirements are equal to measured fluid losses plus insensible fluid losses. Initial management of severe dehydration includes placement of an intravenous line and rapid administration of 20 mL/kg of an isotonic crystalloid (lactated Ringer’s solution, 0.9% sodium chloride). Additional fluid boluses may be required depending on the severity of the dehydration (Huang & Corden, 2018).
Administer iron preparations and/or vitamins, as indicated.
This is useful in correcting anemia or deficiencies when present. Clients diagnosed with gestational iron deficiency anemia (IDA) have an increased risk of postpartum infections despite the mode of delivery. Chronic tissue hypoxia caused by anemia leads to decreased resistance to infection and, thus, may partly explain this finding (Kemppinen et al., 2020).
Consult with a dietitian.
Referring the client to a dietitian aids in establishing a dietary plan to meet individual needs.
4. Initiating Patient Education and Health Teachings
Healthcare agencies have well-defined guidelines on whether a woman who has an infection should be separated from other women or the newborn. It’s difficult for many women to accomplish their new role change even when things are going well. Studies indicate that the process of mother-baby separation due to prematurity or newborn complications in the immediate postpartum period makes the mother feel fear, anxiety, insecurity, and distress, emotions that may negatively influence the perception of pain. In these situations, nurses should act as facilitators of skin-to-skin contact as soon as possible, fostering the bond between mother and baby (Brito et al., 2021).
Monitor the client’s emotional responses to illness and separation from the infant, such as depression and anger. Encourage the client to verbalize feelings and reinforce normalcy as appropriate.
Normal expectations are of an uncomplicated postpartal 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. If the client is segregated from others, frightened by her condition, and denied the pleasure of holding and feeding her newborn, her situation may seem overwhelming. The isolated client may need friendly, understanding support from the hospital personnel during such a stressful time.
Assess the client’s and family’s acceptance and confidence in caring for the wound on an outpatient basis.
This assessment evaluates their comfort level with providing home wound care and enables mutual development of an individualized plan for the client to take control of her care.
Observe maternal-infant interactions.
This provides information regarding the status of the bonding process and client needs. Appropriate support and interventions depend on accurate assessment of attitudes and behaviors to distinguish what is related to the complication versus psychologic causes, cultural practices, or interrupted attachment.
Assess for signs of complications with parenting.
Parents usually attach without ambivalence to their newborns, want to parent them, and have the energy and motivation to do so. Still, they also may need to develop infant care and decision-making skills as new parents and learn to balance individual needs with infant needs daily. A maternal infection complicates this process.
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 the mother during the febrile period).
This facilitates attachment and prevents the client from engaging in self-preoccupation to the exclusion of the infant. One of the nurse’s major goals during this period is to assist with the parent-infant attachment process and to promote sensorimotor activities. This can be fostered by providing means for the infant and significant caregiver to interact and by attempting to ease the tension of the parents.
Encourage the father or other family members to care for and interact with the infant.
This may encourage the 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 the newborn because of other responsibilities, including care of siblings. Father may require additional support during this stressful time. In a study, the paternal-newborn skin-to-skin contact was indicated to shorten the duration of crying, stabilize babies’ physical condition, and facilitate breastfeeding (Huang & Zhang, 2019).
Discuss the 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. Adaptation is most effective when the support system is consistent, flexible, and related to individual needs. The client may need assistance with personal care, newborn care/feeding, parenting her other children, and homemaking tasks to modify her daily living so that complications can occur.
Identify individual support systems. Refer to visiting nurse services and 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. Arranging community referrals as support in the home environment is likely to promote healthier adaptation and strengthen the family system.
Establish empathetic communication and encourage open expression of feelings and thoughts by the client, family, and significant others.
Honesty and empathy promote effective therapeutic communication and support. For example, “I know this is difficult to deal with while also caring for a newborn. Let’s talk about it. I want to be of support to you in this unexpected transition.”
Explain diagnostic tests and medical interventions, and procedures.
Anticipating the client’s and the family’s needs and explaining what to expect to strengthen their coping mechanisms.
5. Administer Medications and Provide Pharmacologic Support
Administering medications and providing pharmacologic support in patients with puerperal and postpartum infections play a crucial role in managing these conditions and promoting a successful recovery. Close monitoring of the patient’s response to medication, including the resolution of symptoms and improvement in laboratory markers of infection, ensures the effectiveness of treatment.
Antibiotics, initially broad-spectrum, then organism-specific, as indicated by results of cultures/sensitivity.
Antibiotics combat pathogenic organisms, helping prevent infection from spreading to surrounding tissues and the bloodstream. Note: Parenteral route is preferred for parametritis, peritonitis, and, on occasion, endometritis. Frequently used antibiotics include ampicillin, gentamicin, and third-generation cephalosporins such as cefixime.
Oxytocics, such as Pitocin and methylergonovine maleate (Methergine).
Oxytocics promote myometrial contractility to retard the spread of bacteria through the uterine walls and aid in the expulsion of clots and retained placental fragments.
Anticoagulants (e.g., heparin).
In the presence of pelvic thrombophlebitis, anticoagulants prevent or reduce additional thrombi formation and limit the spread of septic emboli. The client undergoing anticoagulant therapy at home should be taught how to give herself the drug and signs of excess anticoagulation.
6. Monitoring Results of Diagnostic and Laboratory Procedures
Monitoring the results of diagnostic and laboratory procedures is essential in the management of patients with puerperal and postpartum infections. These procedures include various tests such as blood work, cultures, and imaging studies. By closely monitoring these results, healthcare providers can assess the severity of the infection, identify the specific pathogen causing the infection, and determine the most appropriate treatment approach.
Culture(s)/sensitivity; CBC, WBC count, differential, and ESR.
This aids in tracking the resolution of the infectious or inflammatory processes. Identifies the degree of blood loss and determines the presence of anemia. WBCs are normally elevated during the early postpartum period to about 20,000 to 30,000 cells/mm³, limiting the blood count’s usefulness in identifying infection. Leukocyte counts in the upper limits are more likely to be associated with infection than lower counts.
Partial thromboplastin time/prothrombin time (PTT/PT), clotting times.
This help identifies alterations in clotting associated with the development of emboli and aid in determining the effectiveness of anticoagulation therapy. A blood coagulation study will be necessary to establish a baseline value followed by sequential tests to determine the effectiveness of heparin therapy, as appropriate.
Renal/hepatic function studies.
Hepatic insufficiency and decreased renal function may develop, altering drug half-life and increasing toxicity risks. Sepsis, including puerperal sepsis and pyelonephritis, are common causes of pre-renal acute kidney injury. In addition, sepsis is increasingly recognized to have direct nephrotoxic effects (Hall & Conti-Ramsden, 2019).
Recommended nursing diagnosis and nursing care plan books and resources.
Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
We love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions and an alphabetized listing of nursing diagnoses covering more than 400 disorders.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!
All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health
Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ!
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
- Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.
Other care plans related to the care of the pregnant mother and her baby:
- Abortion (Termination of Pregnancy) | 8 Care Plans
- Cervical Insufficiency (Premature Dilation of the Cervix) | 4 Care Plans
- Cesarean Birth | 11 Care Plans
- Cleft Palate and Cleft Lip | 7 Care Plans
- Gestational Diabetes Mellitus | 8 Care Plans
- Hyperbilirubinemia (Jaundice) | 4 Care Plans
- Labor Stages, Induced, Augmented, Dysfunctional, Precipitous Labor | 45 Care Plans
- Neonatal Sepsis | 8 Care Plans
- Perinatal Loss (Miscarriage, Stillbirth) | 6 Care Plans
- Placental Abruption | 4 Care Plans
- Placenta Previa | 4 Care Plans
- Postpartum Hemorrhage | 8 Care Plans
- Postpartum Thrombophlebitis | 5 Care Plans
- Prenatal Hemorrhage (Bleeding in Pregnancy) | 9 Care Plans
- Preeclampsia and Gestational Hypertension | 6 Care Plans
- Prenatal Infection | 5 Care Plans
- Preterm Labor | 7 Care Plans
- Puerperal & Postpartum Infections | 5 Care Plans
- Substance Abuse in Pregnancy | 9 Care Plans
References and Sources
Recommended journals, books, and other interesting materials to help you learn more about puerperal and postpartum infections nursing care plans and nursing diagnosis:
- Blackmon, M. M., Nguyen, H., & Mukherji, P. (2022, May 15). Acute Mastitis – StatPearls. NCBI. Retrieved June 10, 2022.
- Brito, A. P. A., Caldeira, C. F., & Salvetti, M. d. G. (2021). Prevalence, characteristics, and impact of pain during the postpartum period. Revista da Escola de Enfermagem da USP, 55.
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2010). Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span. F.A. Davis Company.
- Hall, D. R., & Conti-Ramsden, F. (2019, May). Acute kidney injury in pregnancy including renal disease diagnosed in pregnancy. Best Practice & Research Clinical Obstetrics and Gynaecology, 57, 47-59.
- Huang, L. H., & Corden, T. E. (2018, December 7). Dehydration Treatment & Management: Medical Care, Diet, Prevention. Medscape Reference. Retrieved June 14, 2022.
- Huang, X., & Zhang, L. (2019, January-March). Effects of Paternal Skin-to-Skin Contact in Newborns and Fathers After Cesarean Delivery. Perinatal and Neonatal Nursing, 33(1), 68-73.
- Karsnitz, D. B. (2014, January 9). Puerperal Infections of the Genital Tract: A Clinical Review. Journal of Midwifery & Women’s Health, 58(6), 632-642.
- Kemppinen, L., Mattila, M., Ekholm, E., Pallasmaa, N., Törmä, A., Varakas, L., & Mäkikallio, K. (2020, December 21). Gestational iron deficiency anemia is associated with preterm birth, fetal growth restriction, and postpartum infections. Journal of Perinatal Medicine.
- Leifer, G. (2018). Introduction to Maternity and Pediatric Nursing. Elsevier.
- Pillitteri, A., & Silbert-Flagg, J. (2018). Maternal & Child Health Nursing: Care of the Childbearing & Childrearing Family. Wolters Kluwer.
- Sebeta, A., Girma, A., Kidane, R., Tekalign, E., & Tamiru, D. (2022, April 24). Nutritional Status of Postpartum Mothers and Associated Risk Factors in Shey-Bench District, Bench-Sheko Zone, Southwest Ethiopia: A Community Based Cross-Sectional Study. Nutrition and Metabolic Insights.
- Silbert-Flagg, J., & Pillitteri, A. (2018). Maternal & Child Health Nursing: Care of the Childbearing & Childrearing Family. Wolters Kluwer.
- Song, H., Hu, K., Du, X., Zhang, J., & Zhao, S. (2019, December 28). Risk factors, changes in serum inflammatory factors, and clinical prevention and control measures for puerperal infection. Journal of Clinical Laboratory Analysis, 34(3), e23047.
- Swearingen, P. L. (2018). All-in-one Nursing Care Planning Resource: Medical-surgical, Pediatric, Maternity, and Psychiatric-mental Health (P. L. Swearingen & J. Wright, Eds.). Elsevier.
- Wigati, P. W., & Sari, D. K. (2020, November 18-19). Relationship between diet restriction and acceleration of perineum wound healing in postpartum normal delivery mothers in Tiron Public Health Center, Kediri, East Java.
Reviewed and updated by M. Belleza, R.N.