PART TWO

Post-Partum Infections (General Overview)

• Definition- Any clinical infection of bladder, uterus, wound, breast occurring ≤ 28 days after birth, miscarriage, or induced abortion.

  • Diagnostic threshold: maternal temperature ≥ 38\ ^\circ \text C\,(100.4\ ^\circ \text F) after the first 24 h or on any 2 days within the first 10 post-partum (PP) days.

• Common sites- Bladder (UTI)

  • Uterus (Endometritis)

  • Wounds (cesarean incision, episiotomy, lacerations, birth-canal trauma)

  • Breast (Mastitis)

• Major complication- Septicemia = systemic bacterial infection of genital tract up to 42 days PP ➔ can progress to septic shock.

• Pathophysiology pearls- Immediate PP period: cervical os open + lochia present → "open wound" increases microbial entry.

  • Micro-organisms can ascend to bloodstream (hematogenous spread).

Global Risk Factors for PP Infection

• Medical / obstetric- Cesarean birth (esp. non-scheduled / intrapartum)

  • PROM (Premature Rupture of Membranes)

  • Retained placental fragments & manual placental removal

  • Prolonged labor, prolonged ROM, internal FHR/uterine monitoring

  • Multiple or frequent vaginal exams after ROM

  • Foley catheterization, bladder hypotonia, epidural anesthesia

  • Post-partum hemorrhage (PPH)

  • UTI, mastitis, pneumonia, venous thrombus already present

• Maternal factors- Diabetes mellitus, anemia, malnutrition, immunodeficiency

  • Alcohol / substance use disorder

Endometritis (Uterine Lining Infection)

• Incidence: most common puerperal infection.

• Onset: typically 3^{rd}–4^{th} PP day; may begin at placental site and spread to entire endometrium.

• Expected findings- Pelvic/uterine tenderness, lower abdominal pain

  • Dark, profuse, purulent or foul-smelling lochia

  • Fever > 38\, ^\circ \text C, chills, tachycardia

  • Fatigue, loss of appetite

• Labs / diagnostics- ↑ WBC (leukocytosis), ↑ ESR, anemia possible

  • Blood & endocervical cultures

• Nursing / collaborative care- Frequent VS, pain, fundal height/consistency, lochia quantity/odor

  • Obtain cultures → IV broad-spectrum antibiotics (penicillins, cephalosporins, clindamycin, gentamicin)

  • Analgesics, IV fluids, comfort (warm blankets/cool compresses)

  • Aseptic technique, hand hygiene, maintain interaction w/ newborn

  • High-protein diet for healing

Wound Infections (Cesarean, Episiotomy, Lacerations)

• Sites: cesarean incisions, perineal repairs, vaginal tears.

• Expected findings- Local warmth, erythema, tenderness, pain, edema

  • Seropurulent drainage; wound dehiscence/evisceration possible

  • Fever > 38\, ^\circ \text C on ≥ 2 consecutive days

• Management- Inspect perineum/incision each shift

  • Wound care, possible opening & irrigation, culture

  • IV antibiotics, analgesics, sitz baths, front-to-back pad changes

Mastitis (Breast Infection)

• Etiology: usually unilateral infection of interlobular connective tissue; agent = Staphylococcus aureus (often infant’s nasopharynx).

• Timing: as early as day 7 PP; peak first 6 weeks of lactation but may occur anytime during breastfeeding.

• Specific Risk Factors- Milk stasis: blocked duct, engorgement, tight/underwire bra

  • Nipple trauma: cracked/fissured nipples, poor latch, infrequent feeds (bottle supplementation)

  • Poor breast hygiene

• Clinical picture- Localized hard, tender mass; erythema, warmth, edema

  • Flu-like Sx: chills, fever, body aches, headache, fatigue

  • Axillary adenopathy (tender nodes) on affected side

• Interventions & education- Continue breastfeeding or empty affected breast (pump/manual)

  • Antibiotics (dicloxacillin, cephalexin, or per provider) × 7–14 days

  • Analgesics (NSAIDs), fluids \ge 3\,\text L/day,

  • Warm compresses before feeds / ice packs after

  • Proper latch, frequent feed q 2–3 h, air-dry nipples, change pads, handwash before feeds, supportive well-fitting bra

  • Report signs of abscess (no improvement, fluctuance) ➔ drainage

Urinary Tract Infection (Post-Partum)

• Cause: bladder trauma, hypotonia, catheterization

• Risk factors: epidural, frequent exams, prior UTI, cesarean, genital injuries

• Manifestations- Urgency, frequency, dysuria, suprapubic pain

  • Fever, chills, malaise; cloudy/blood-tinged/malodorous urine; CVA tenderness suggests pyelonephritis

• Diagnostics: Urinalysis (WBCs, RBCs, bacteria, protein), C&S

• Nursing care - Increase fluids \ge 3\,\text L/day,

  • Educate perineal hygiene (front→back), handwash

  • Antibiotics, antipyretics, monitor VS; potential progression to pyelonephritis → hospitalize if severe

Laboratory & General Nursing Measures for Any PP Infection

• Cultures: blood, intrauterine, intracervical, wound, urine as suspected

• CBC: leukocytosis; Hgb/Hct for anemia; ESR ↑

• Core nursing bundle- Aseptic technique, hand hygiene, glove use

  • Vital signs trends (temp ≥ 38\ ^\circ \text C × 2 days is red flag)

  • Assess fundus, lochia, pain, incision/wounds, breasts, bladder

  • Maintain/secure IV access for fluids + IV antibiotics

  • Comfort remedies: warm blankets, cool compresses; rest & nutrition

  • Teach completion of antibiotic course & warning signs

Post-Partum Mental Health Disorders

Spectrum & Incidence

• Post-partum “Blues”- Incidence ≈ 85\%; onset first few days, resolves ≤ 10 days without Tx

  • Sx: mood swings, sadness, crying, anxiety, insomnia, ↓ appetite

• Post-Partum Depression (PPD)- Onset within 12 months; persistent sadness + intense mood swings; affects 8\% – 20\% (≈ 1 in 7) birthing parents

  • Requires intervention (psychotherapy, SSRIs, etc.)

• Post-Partum Psychosis- Onset 2^{nd}–3^{rd} PP week; ↑ risk with bipolar Hx

  • Sx: confusion, hallucinations, delusions, paranoia, disorientation, possible infanticide/suicide → psychiatric emergency

Risk Factors for PPD/Psychosis

• Hormonal crash (rapid ↓ estrogen & progesterone)

• Low socio-economic status, limited support, unintended pregnancy

• Anxiety re: parenting role, low self-esteem, partner violence

• Thyroid imbalance, diabetes, infertility, breastfeeding difficulties

• Multiples, younger maternal age

Clinical Assessment Findings

• PPD Sx cluster: guilt, inadequacy, irritability, anhedonia, persistent sadness, fatigue beyond normal, sleep/appetite disturbance, thoughts of self-harm/newborn-harm

• PP Psychosis: pronounced sadness, disorientation, rapid mood swings, paranoia, hallucinations, delusional thinking

Nursing Interventions & Management

• Screen at each prenatal & PP visit (EPDS or similar)

• Promote bonding: skin-to-skin, room-in, verbal encouragement

• Validate feelings; educate that transient “blues” are common but persistence > 2 weeks needs evaluation

• Assess directly for suicidal or infanticidal ideation; ensure safety

• Coordinate referrals: psychotherapy, support groups, social work

• Pharmacology- SSRIs (e.g., sertraline) first-line for PPD

  • Antipsychotics, mood stabilizers, benzodiazepines for psychosis; olanzapine second-line when SSRI ineffective

Post-Partum Hemorrhage (PPH)

• Definition (per ACOG, 2017): Cumulative blood loss ≥ 1000\,\text{mL} OR bleeding accompanied by hypovolemia within 24 h after birth (regardless of route).

• Complications: hypovolemic shock, anemia → multi-organ failure

• Emphasis on Quantification of Blood Loss (QBL) = weighing pads & drapes, measuring suction, aggregating volumes

Global PPH Risk Factors

• Uterine atony (most common), over-distension (multiples, polyhydramnios, macrosomia), high parity

• Prolonged/precipitous labor, oxytocin induction/augmentation

• Magnesium sulfate tocolysis, general anesthesia

• Lacerations/hematomas, retained placenta, uterine inversion/rupture, placenta previa/abruption, coagulopathies

Clinical Manifestations & Labs

• Sudden ↑ lochia, pad saturated ≤ 15 min, clots ≥ quarter size, bright-red flow/oozing

• VS: tachycardia, hypotension, ↑ RR, pale cool clammy skin, oliguria

• Labs: ↓ Hgb/Hct, coag profile (PT/INR, fibrinogen), type & crossmatch

Immediate Nursing Actions (Primary Survey)

• Fundal massage → assess height, tone, position; if boggy fundus, massage while calling for help

• Call for "Massive Transfusion Protocol" as indicated; emergency-release blood products

• Measure blood loss (weigh pads/linen: 1\,\text g} = 1\,\text mL)

• VS q 5 min, O_2 10–12 L NRB, Foley catheter (I&O), elevate legs 20$–30° to improve venous return

• Locate bleeding source: atony vs laceration vs retained tissue vs hematoma

• Maintain/bolus IVF (LR/NS); consider second large-bore IV

• Pharmacologic uterotonics (sequential or simultaneous):- Oxytocin 10 – 40\,\text{units}/\text{L} IV or 10\,\text{units} IM

  • Methylergonovine 0.2\,\text{mg} IM q 2–4 h (CI: hypertension)

  • Carboprost tromethamine 250\,\mu\text g} IM q 15–90 min (max 2\,\text{mg}) (CI: asthma)

  • Misoprostol 600–800\,\mu\text g} PO/SL/PR

  • **Tranexamic acid 1\,\text g} IV over 10 min (repeat in 30 min if bleeding persists) *within 3 h of delivery*; CI: active thromboembolic disorder

Uterine Atony Specifics

• Risk factors: retained fragments, precipitous/prolonged labor, overstretch, MgS\text O_4, anemia, multiparity

• Assessment: boggy enlarged uterus displaced laterally (full bladder), excessive lochia

• Diagnostic/therapeutic procedures: bimanual compression, uterine sweep for fragments, intrauterine balloon tamponade, uterine artery ligation, hysterectomy if refractory

• Nursing care: empty bladder, maintain uterotonics + fluids, avoid fundal "pushing" on uncontracted uterus (risk inversion)

Subinvolution of Uterus

• Definition: uterus fails to return to normal size; persists enlarged with prolonged lochia

• Causes: pelvic infection (endometritis), retained placental fragments

• Findings: uterus higher than expected, prolonged/irregular bleeding

• Labs: cultures; Tx: methylergonovine, antibiotics, D&C if fragments

Uterine Inversion (Emergent)

• Uterus turns inside-out, may prolapse through cervix or vagina.

• Provoking factors: excessive cord traction, uterine atony, fundal placenta, vigorous massage before placental separation, short cord

• Symptoms: sudden hemorrhage, severe pain, shock (hypotension ↑ pulse), visible red mass at introitus

• Management- Call OB stat, stop oxytocin, start tocolytic (terbutaline 0.25\,\text{mg} SQ) to relax uterus, manual replacement then oxytocin post-reposition

  • IVF/O_2, avoid excessive cord traction thereafter, anticipate OR if unsuccessful

Retained Placenta

• Definition: placenta not expelled within 30 min post-delivery or pieces remain.

• Consequence: uterine atony/subinvolution, PPH, infection

• Risk factors: accessory lobe, adherent placenta (accreta, increta, percreta), preterm 20–24 wks, constriction ring, traction on cord

• Manifestations: persistent bleeding, rubra beyond day 3, malodorous lochia, uterine atony/inversion, ↑ temp

• Management: manual removal or D&C; oxytocin to aid expulsion; antibiotics PRN

Lacerations & Hematomas

• Lacerations—cervical, vaginal, vulvar, perineal, rectal; risk ↑ with operative delivery, precipitous birth, macrosomia, CPD, episiotomy extension.- Sx: continuous bright-red trickle despite firm uterus.

• Hematomas—clotted blood collection (vulva, vagina, broad ligament).- Sx: severe perineal/rectal pain/pressure, bulging bluish mass, difficulty voiding; minimal visible bleeding.

• Interventions- Identify source, assist repair/suturing, ligate vessel or evacuate hematoma if > 3\,\text{cm}.

  • Analgesia, ice packs first 24 h, then sitz baths, frequent VS

  • Monitor H&H, I&O; perineal hygiene education

Hemorrhage Risk-Assessment Tool (AWHONN)

• Low, Medium, High risk stratification on admission, labor, PP.

• High-risk indicators: active bleeding, placenta previa/accreta, coagulopathy, >1 prior PPH, Hct < 30\% plus risk factors, PLT < 100\,000, BMI > 35 + macrosomia, etc.

"MOTHIVE" Mnemonic for PPH Response

• M – Massage uterus (uterine tone)

• O – Oxytocic drugs (oxytocin ± others)

• T – Tranexamic acid

• H – Hemodynamic support (IV fluids, blood products)

• I – Invasive procedures (balloon tamponade, B-Lynch, hysterectomy)

• V – Verification: examine genital tract for lacerations/hematomas

• E – Escalation to multidisciplinary team & senior support early

Patient Education Highlights (Across Topics)

• Finish full antibiotic course; report recurrent fever, worsening pain, foul lochia, breast abscess signs, urinary changes.

• Hand hygiene, perineal care front→back, frequent pad change.

• Adequate protein & iron (⬆ RBC production post hemorrhage).

• Breast care: correct latch, avoid milk stasis, continue breastfeeding even with mastitis unless abscess/contraindication.

• Mental health: normal to feel "blue" for ≤ 10 days; seek help if persistent sadness, anxiety, or any thoughts of self/infant harm.