21.2: Postpartum Infections

Learning Objectives

By the end of this section, you will be able to:

• Explain the risk factors and signs and symptoms of wound infections related to birth
• Explain the risk factors and signs and symptoms of postpartum endometritis
• Explain the risk factors and signs and symptoms of postpartum urinary tract infections
• Explain the risk factors and signs and symptoms of postpartum mastitis
• Explain the risk factors and signs and symptoms of postpartum thrush
• Develop a plan of care based on the specific postpartum infection the person is experiencing

Postpartum infections can be caused by multiple factors. Endometritis and wound infections are more likely to occur in persons with prolonged rupture of membranes and chorioamnionitis. Urinary tract infections can be caused by indwelling catheters. Mastitis can occur with a break in skin integrity from a poor latch. Some of these infections are preventable, while others are not. The nurse assesses for signs of postpartum infections and provides education to help prevent and decrease the risk for infections.

Care of the Postpartum Person with a Wound Infection

Infections occur more often in persons with STIs, chorioamnionitis, prolonged rupture of membranes, and third- or fourth-degree lacerations. Infections can be related to trauma or lacerations that occur during birth, allowing the introduction of bacteria. Chorioamnionitis can cause wound infections, endometritis, and sepsis (Daifotis et al., 2020). Postpartum wound infections can occur from bacteria ascending from the vagina, colonized on the skin, or introduced during a cesarean birth. Persons with a body mass index (BMI) ≥ 30 have higher risks of developing postpartum infections, especially wound infections. Persons with a BMI ≥ 40 are at higher risk for morbidity related to postpartum infection (Mitchell et al., 2020).

Signs of postpartum wound infections are the same as those of other laceration or perioperative wound infections. Signs include redness and purulent drainage from the laceration, episiotomy, or abdominal incision; fever (temperature greater than 100.4° F/38° C); pain; and fatigue. Nursing care of the postpartum person includes assessment of the laceration, episiotomy, or incision for signs of infection and pharmacologic treatment of the infection per provider’s orders. The nurse educates the postpartum person to keep the wound clean and dry, to wash hands before and after touching the wound, and to call the health-care provider for worsening signs of infection after discharge from the birthing facility, such as increase in purulent drainage, increase in wound pain, and increase in fever.

Pharmacology Connections

Antibiotics for Postpartum Wound Infections

Ampicillin and gentamicin are often administered to postpartum persons to treat wound infections in the perineum and after a cesarean birth. Both of these antibiotics are safe to use if the postpartum person is breast-feeding. The postpartum person is provided with instructions to call their health care provider if the signs and symptoms of the infection do not improve after 3 to 5 days of antibiotics.

Ampicillin (Omnipen)

• Classification: penicillin antibiotic
• Route/Dosage: PO: 250 or 500 mg; IM: 1–2 g; IV: 1–2 g
• Indications: treatment of infections caused by gram positive and negative infections
• Mechanism of Action: kills the bacteria by interfering with cell wall synthesis during replication
• Contraindications: hypersensitivity to any penicillin; renal disease
• Adverse Reactions/Side Effects: nausea, vomiting, rash, hives, urticaria, pancytopenia,
• Nursing Implications: The nurse ensures the postpartum person understands it is important to take all of the antibiotic. The nurse monitors the patient’s vital signs, CBC, and culture reports.
• Parent/Family Education: Call health care provider for difficulty breathing, dark urine, severe diarrhea, wheezing, chest tightness, fever, itching, swelling of face, lips, tongue, or throat

Gentamicin (Garamycin)

• Classification: aminoglycoside antibiotic
• Route/Dosage: IM or IV: 1 mg/kg/day
• High Alert/Black Box Warning: gentamicin toxicity is associated nephrotoxicity and ototoxicity
• Indications: treatment of infections caused by gram positive and negative infections
• Mechanism of Action: kills the bacteria by inhibiting protein synthesis in susceptible bacteria
• Contraindications: hypersensitivity to gentamicin; renal disease
• Adverse Reactions/Side Effects: rash, hives, urticaria, tinnitus, dizziness, vertigo, seizures
• Nursing Implications: The nurse ensures the postpartum person understands it is important to take all of the antibiotic. The nurse monitors the patient’s vital signs, CBC, and culture reports.

(Vallerand & Sansoski, 2023)

Care of the Postpartum Person with Endometritis

Infection of the uterus that occurs in the postpartum period is postpartum endometritis. It occurs more often with chorioamnionitis, prolonged rupture of membranes, and cesarean birth (Elsevier, 2024). Symptoms of postpartum endometritis include uterine tenderness or pain with fundal massage, foul-smelling lochia, increased bleeding, and fever. The nurse will administer antibiotics and antipyretics according to the health-care provider’s orders. The nurse monitors the patient for signs of worsening infection (severe uterine pain, increase in odor of lochia, rising fever). Endometritis can lead to sepsis (Shields et al., 2023). The nurse closely monitors the postpartum person for early signs of sepsis (increased or decreased white blood cell [WBC] count, fever, chills, low body temperature, tachycardia, dizziness, decreased urine output, and discolored skin). Onset of altered mental state and hypotension are signs of worsening sepsis (Centers for Disease Control and Prevention [CDC], 2023b). When providing discharge instructions to the postpartum person diagnosed with endometritis, the nurse educates the person on finishing their medications once discharged, continuing peri-care, handwashing, the importance of getting rest, and contacting their health-care provider if signs of worsening infection appear.

Clinical Judgment Measurement Model

Recognize Cues: Postpartum Endometritis

The nurse will recognize the cues of postpartum endometritis by:

1. assessing the fundus
   • recognizing pain or tenderness
   • recognizing increased bleeding
2. assessing vital signs
   • recognizing fever (temperature ≥100.4° F/38° C)
3. assessing lochia
   • recognizing foul-smelling lochia
4. assessing level of coping
   • recognizing the postpartum person is extremely tired
   • recognizing the person is complaining of malaise
   • recognizing the person is not wanting to get out of bed

Care of the Postpartum Person with a Urinary Tract Infection

Urinary tract infections (UTIs) occur in 2 percent to 4 percent of births and are the most common postpartum infection (Gundersen et al., 2018). UTIs occur more often in those with a urinary catheter during labor. However, some postpartum persons experience urinary retention after birth, and this can contribute to UTIs. The nurse assesses for signs of overdistention of the bladder or urinary retention during the postpartum period, such as palpable bladder, uterine atony and displacement, and frequently voiding in small amounts.

Signs of a UTI include frequency, urgency, dysuria, hematuria, fever, and pain. The nurse assesses the postpartum person for signs the UTI has ascended to the kidneys by noting costovertebral angle tenderness (CVAT), high fever, nausea, and chills. The health-care provider is notified of these signs, and many times a urine culture and sensitivity are ordered (Milton, 2024). The nurse administers antibiotics and antipyretics per the health-care provider’s orders and monitors the culture and sensitivity reports. Education provided to the postpartum person includes encouraging increased water intake and frequent urination, finishing all antibiotics after discharge from the birthing facility, importance of perineal care and handwashing, and instructions to call the health-care provider for worsening symptoms (increase in fever, increase in suprapubic or flank pain, and flu-like symptoms).

Care of the Postpartum Person with Mastitis

Inflammation and/or infection of the breast, or mastitis, occurs most often while breast-feeding. Causes of mastitis include clogged ducts, engorgement, hyperlactation, nipple trauma, decreased immune system, or poor handwashing routine. Clogged ducts occur with constricting clothes or compression of the breast and cause milk to collect and create a painful, firm area. If the inflammation and milk stasis continue, mastitis can occur. Another cause of mastitis is an incorrect nursing latch that causes cracks or fissures in the nipple (Şahin et al., 2023). Such breaks in skin integrity allow bacteria to enter the nipple.

Symptoms of mastitis include fever, chills, flu-like symptoms, and a painful, hot, reddened area of the breast (Figure 21.2). The nurse assesses the patient while breast-feeding for a good latch and examines nipples for cracking or redness. The nurse or lactation consultant can assist the patient to establish a good latch (See 21.3 Breasts and Breast-Feeding and Chapter 24 Care of the Typical Newborn for more information on LATCH). The nurse provides education regarding nipple integrity, explaining the importance of establishing a good latch and, if the latch hurts, to remove the baby and relatch. The nursing person should examine the nipples for cracking or bleeding. The person can use nipple ointment for faster healing in hopes of preventing mastitis. For the patient with mastitis, the nurse should encourage nursing every 2 to 3 hours to empty breasts for comfort and to avoid engorgement. If the breasts are too painful for nursing, the patient can pump to empty the breasts and maintain milk supply. The nurse can teach the patient to apply a cool (or warm) compress to the reddened area and to use nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen (Tylenol) to decrease pain (Louis-Jacques et al., 2023). Increasing water intake is important to maintain milk supply. Prompt evaluation by the health-care provider is important, as antibiotics are routinely ordered and should be started soon after the diagnosis to prevent progression to breast abscess.

Figure 21.2 Mastitis This breast shows classic signs of the redness and inflammation of mastitis. (CC BY 4.0; Rice University & OpenStax)

Care of the Postpartum Person with Thrush

Thrush is a yeast (fungal) infection of the breast that causes a red rash around the nipple. Thrush causes the nipple to itch and burn and can cause shooting breast pain upon latching. Thrush present in the newborn’s mouth can be passed between the newborn and the breast-feeding person; therefore, both must be treated with an antifungal medication. The nurse assesses the breast and nipple after a nursing session to observe for signs of nipple trauma (cracking, redness, pain), a risk factor for developing thrush (Louis-Jacques et al., 2023). When the nurse observes nipple thrush, education is provided to the breast-feeding person to allow nipples to dry before putting on a bra or nursing pads, to change nursing pads as soon as they are damp, and to wash hands well prior to every nursing. Wet, dark areas are perfect media for yeast, especially with milk present to feed the yeast. Once thrush is resolved, the breast-feeding person should continue to monitor the newborn’s mouth for any signs of thrush in the future and contact the pediatrician and their health-care provider to initiate treatment for them both as soon as possible if thrush is detected.

Nursing Interventions for the Person Experiencing a Postpartum Infection

As discussed previously, nursing interventions begin with prevention of postpartum infections. Postpartum infections account for 5 percent to 10 percent of the morbidity and mortality of postpartum persons (Boushra & Rahman, 2023). The importance of handwashing and perineal care is reinforced. The nurse also encourages the postpartum person to get as much sleep as possible, eat a healthy diet with plenty of protein, and boost the immune system with fruits, vegetables, vitamin C, and vitamin D. Pelvic rest (avoiding sex, tampons, or douching) to prevent infections is reviewed at discharge. Sitz baths are encouraged, as they promote cleansing and healing of the perineum (Milton, 2024).

Recognizing the signs of infection and treating it promptly decreases the risk of morbidity and mortality from postpartum infections. During nursing assessments, a temperature of 38° C/100.4° F is considered a fever and should be addressed. Tachycardia can be another sign of infection. Infections of the perineum or incision are assessed using the REEDA scale (redness, edema, ecchymosis, discharge, and approximation; see Table 20.4) (Ernawati et al., 2020). Uterine infections are often recognized during a fundal massage that causes pain or a fundus that is not involuted properly. Nausea and vomiting and other flu-like symptoms are additional signs of infection.

Caring for the person with a postpartum infection includes administering antibiotics per the health-care provider’s orders. Breast-feeding persons should continue to breast-feed because the majority of antibiotics used to treat postpartum infections are not contraindicated. Monitoring the person’s pain and administering pain medication are important interventions. The nurse is aware that increasing pain could signal worsening of the infection. Reviewing lab results for WBCs can help determine improvement or worsening of an infection. Prompt notification of the health-care provider is essential if the nurse notices signs of sepsis.

Clinical Safety and Procedures (QSEN)

QSEN: Evidence-Based Practice of Sepsis

The California Maternal Quality Care Collaborative (CMQCC) has developed a screening system for maternal sepsis that was adopted by the Society for Maternal-Fetal Medicine (Shields et al., 2023). The evidence shows that early recognition of maternal sepsis decreases maternal mortality. The CMQCC recommends the following initial sepsis screen:

The screen is positive if 2 of 4 criteria are met:

• oral temperature <36° C (98.8° F) or ≥ 38° C (100.4° F)
• heart rate >110 beats per minute
• respiratory rate >24 breaths per minute
• WBCs >15,000/mm³ or <4,000mm³ or >10 percent bands

Nurses can help decrease maternal morbidity and mortality by using evidence-based screening such as this sepsis screen.

Discharge teaching for the person with a postpartum infection includes teaching the person when to take any prescribed medications, whether to take the medications with or without food, which food(s) to avoid during antibiotic therapy, and the importance of completing the antibiotic regimen. Teaching also includes watching for signs of worsening infection and indications to contact their health-care provider, such as pain, fever, increased lochia, foul-smelling discharge, breakdown of perineal wound, purulent discharge from the incision, painful urination, and abdominal pain. Persons should be instructed to ask for help with housework and childcare, as rest is important for healing.