Postpartum Endometritis: A Common and Dangerous Complication

Postpartum Endometritis Evidence Based Paper March 13, 2012 Endometritis is the inflammation or irritation of the uterus, which is a common post partum complication that occurs in more than 15% of all pregnancies and is currently the leading cause of maternal mortality (Scott & Hasik, 2001). When endometritis is not related to pregnancy, it is referred to as pelvic inflammatory disease (PID).

The Centers for Disease Control and Prevention (CDC) 2010 sexually transmitted diseases treatment guideline defines PID as any combination of endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis. From a pathologic perspective, endometritis can be classified as acute versus chronic. Acute endometritis is distinguished by the presence of neutrophils within the endometrial glands. Chronic endometritis is characterized by the presence of plasma cells and lymphocytes within the endometrial stroma.

Chronic endometritis in the postpartum or post abortion patient is usually associated with retained products of conception after delivery or abortion. In the nonobstetric population, chronic endometritis has been associated with infections such as chlamydia, tuberculosis, bacterial vaginosis, and the presence of intrauterine devices (Rivlin, 2011). Early-onset postpartum endometritis occurs within two days of delivery, and the late-onset of the disease can occur up to six weeks postpartum.

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This condition will usually start as a local infection at the placental attachment site and if left untreated, can spread to the entire uterine endometrium (French & Smaill, 2004). There are numerous risks associated with this condition, and diagnosis relies heavily on the clinical judgment of the practitioner. The contamination of the uterine cavity with vaginal organisms during labor and delivery causes the disease. Both bacterial and viral infections may initiate endometritis and many of the agents that cause the infection are naturally present in the vagina.

This condition arises commonly after delivery because delivery results in tears, rips or incisions in the vagina, cervix or uterus that allow these agents to enter the uterine lining. The infection can have several species of causative agents that can be aerobic or anaerobic flora (French & Smaill, 2004). The method of delivery will determine which causative agents prognosticate the possibility of endometritis. For vaginal deliveries, the presence of the organisms associated with bacterial vaginosis or genital cultures positive for aerobic gram-negative organisms can indicate endometritis.

In cesarean births, the occurrence of certain bacteria such as group A hemolytic streptococci, staphylococci B, Neisseria gonorrhoeae, or Mycoplasma hominis in amniotic fluid cultures will put the patient at an increased risk for this infection (French & Smaill, 2004). With the increasing number of people opting for natural birth methods, including water births, the danger only multiplies. This is because disinfecting procedures as they are carried out before major surgery is usually not practiced in a home environment.

Prompt treatment is essential to prevent the spread of the infection through other areas of the body, including the blood. Prolonged infection can be fatal. The immediate postpartum period following birth is a time of increased risk for all women for infection. Microorganisms entering the reproductive tract and migrating into the blood and other parts of the body could result in life threatening septicemia (French & Smaill, 2004). Timely diagnosis and aggressive treatment is essential to prevent these complications.

Complications of endometritis include infertility, extension of infection to involve the peritoneal cavity with peritonitis, intra-abdominal abscess, and septic pelvic thrombophelbitis. Septic pelvic thrombophelbitis is a condition in which blood clots in one of the pelvic vessels become infected. If untreated it could progress to septic pulmonary emboli, in which the infected blood clots travel to the lungs and lead to death (French & Smaill, 2004).

Septic shock is a life-threatening systemic infection usually caused by bacteria and on rare occasions follows postpartum endometritis. The bacteria that invade the bloodstream release a substance known as endotoxin, which causes decreased blood pressure, clot formation, major tissue injury, and leakage of fluids. Accordingly, organs may fail because they are not receiving enough blood and nutrients. Fortunately, this condition during pregnancy or in the postpartum period is a rare clinical event (Mazzeffi and Chen, 2010).

Major risk factors for obstetric endometritis include the following: Cesarean delivery (especially if before 28 weeks' gestation), rupture of membranes lasting more than 24 hours, excessively long labors, severely meconium-stained amniotic fluid, manual placental removal, and extremes of patient age. Other threatening factors have been identified in additional studies, including no prior cesarean delivery, preterm or postterm gestation, low infant Apgar scores, antepartum infections, preeclampsia, amnioinfusion, postpartum anemia, the presence of internal monitors, and steroid medications (Olsen, Butler, Willers ;amp; Gilad, 2010).

Acute endometritis is typified by the existence of neutrophil cells in the endometrium. Neutrophils are white blood cells with cytoplasmic granules that consume harmful bacteria, fungi, and other foreign materials. Characteristic symptoms of endometritis include abdominal distention or swelling, abnormal vaginal bleeding, abnormal vaginal discharge, fever (100 to 104 degrees Fahrenheit), general discomfort, uneasiness, or ill feeling (malaise), and lower abdominal or pelvic pain (uterine pain). Anemia occurs when a patient’s red blood cell count is lower than 4. -6. 0 million red blood cells per micro liter of blood. Losing large amounts of blood during delivery or prior to delivery may be a contributing factor for a low red blood count, anemia and potentially endometritis. Red blood counts (RBC) are needed to indicate anemia and the sedimentation rate (ESR). The sedimentation rate measures the rate at which red blood cells sediment in a period of 1 hour. It is a common hematology test that is a non-specific measure of inflammation, which is evident in endometritis.

The diagnosis of postpartum endometritis is based on the presence of fever in the absence of any other cause. Uterine tenderness, purulent or foul-smelling lochia and leukocytosis are common clinical findings used to support the diagnosis of endometritis. Leukocytosis is a raised white blood cell count (the leukocyte count) above the normal range in the blood. The standard definition for puerperal fever used for reporting rates of puerperal morbidity is an oral temperature of 100. 4 degrees centigrade or more on any two of the first ten days postpartum or 101. degrees or higher during the first 24 hours postpartum (French ;amp; Smaill, 2004). Additionally, when the above symptoms occur, urinalysis and urine culture may be done. However, endometrial cultures are rarely indicated because specimens collected through the cervix are usually contaminated by vaginal and cervical flora. A sterile technique with a speculum is used to avoid vaginal contamination, and the sample is sent for aerobic and anaerobic cultures. If fever persists for 48 hours (Some clinicians use a 72-hour cutoff) after endometritis is adequately treated, ther causes such as pelvic abscess and pelvic thrombophlebitis should be considered. Abdominal and pelvic imaging, usually done by CT, is sensitive for abscess but detects pelvic thrombophlebitis only if the clots are large. If the results of the imaging are negative, a trial of heparin is typically begun to treat presumed pelvic thrombophlebitis as a diagnosis of exclusion (Moldenhauer, 2008). Before the advent of the antibiotic era, puerperal fever was an important cause of maternal death.

With the use of antibiotics, a sharp decrease in maternal acute postpartum infections has been observed, and it is now accepted that antibiotic treatment for postpartum endometritis is warranted. Intravenous broad-spectrum therapy (cephalsporins, penicillins, or clindamycin and genatmicin) is appropriate for the treatment of endometritis. Regimens with activity against penicillin-resistant anaerobic bacteria are better than those without. There is no evidence that any one regimen is associated with fewer side effects.

Once uncomplicated, endometritis has clinically improved with intravenous therapy, and oral therapy is not needed (French, 2003). Furthermore, it is essential that the patient receive supportive care including hydration, rest and pain relief. Antibiotics should be discontinued 24 hours after the patient is asymptomatic. Assessments should be taken of the lochia, vital signs, and changes in the women’s condition continue during treatment (Perry, Hockenberry ;amp; Lowdermilk, 2010). Treatment is usually considered successful after the woman is afebrile for 24 to 48 hours.

If the initial antibiotic regimen does not result in resolution of fever and other symptoms within three days, the antibiotic regimen is usually changed. Consideration is also given to the possibility that the woman may have complications requiring specific treatment. The most effective treatment and least expensive treatment of postpartum infection is prevention. Preventative measures include good prenatal nutrition to control anemia and intrapartal hemorrhage. Good maternal perineal hygiene with through hand hygiene is emphasized.

Strict adherence to aseptic techniques by all healthcare professionals during childbirth and the postpartum period is very important (Perry, Hockenberry ;amp; Lowdermilk, 2010). Endometritis is usually caused, in the postpartum scenario, because of a deficient care taken to avoid streptococcus and staphylococcus infections in the delivery area. These two bacteria are present on every inch of our skin, and considering that delivery is the one time when the mother's insides are most exposed, precautionary measures to maintain a sterile environment in the delivery or birthing room should be taken.

The benefit of antibiotic therapy for laboring women has been unquestionably established. Intravaginal metronidazole as surgical preparation and oral methylergometrine after delivery are two interventions that show promise as additional prophylactic interventions (French, 2003). Having a baby by Caesarean section is becoming increasingly common, despite the higher risks associated with the surgery compared to a vaginal birth. One important concern is the risk of infection, which is between five and 20 times greater for women who undergo scheduled or emergency Caesarean section.

According to the Cochrane Review, “the single most important risk factor for postpartum maternal infection is Caesarean section. ” The review further cited that antibiotics to women undergoing Caesarean section reduced the incidence of fever by 45 percent, wound infection by 39 percent, inflammation of the uterine lining by 38 percent and serious infectious complications for the mother by 31 percent (Nelson, 2010). This approach can significantly lower the risk of endometritis, particularly in women having surgery after extended labor and ruptured membranes.

To prevent future infection, most doctors prescribe Cefazolin, which is administered intravenously immediately after the baby's umbilical cord is clamped. If you are at high risk, a second dose may be given eight hours later (French ;amp; Smaill, 2004). The overall goal for the postpartum client with endometritis is, “The patient will be free from infection. ” Nursing management and general interventions of the patient would include the collection of vaginal and blood cultures, education on handy hygiene, the administration IV antibiotics and analgesics as prescribed.

Non-pharmacological interventions include distraction, imagery, relaxation, and application of hot and cold. Non-pharmacological interventions can restore the client’s sense of self-control, personal efficacy, and active participation in her care. It is essential that the information and method of delivery of information be tailored to the specific client and family (French ;amp; Smaill, 2004). Secondary to free from infection, an accurate nursing care plan for a postpartum patient with an with endometritis would include: 1.

The patient will follow a specific, mutually agreed upon, healthcare maintenance plan. (The nurse should assume that first-time mothers lack sufficient knowledge regarding condition and treatment diagnosis, and therefore, needs education and specific instructions during the postpartum recovery period). If a mother has given birth to more than one child a review of proper heath care regimens is also justifiable. The new mother should receive instruction pertaining to hygienic care for her perineal area. This care would include changing her perineal pad frequently and washing her hands afterwards.

The presence of a wet pad against sutures is an excellent medium for the development of an infection that could potentially spread to the uterus. The use tampons should be prohibited for six weeks after delivery, since tampon use can cause infection or even toxic shock syndrome. It is the nurse’s responsibility to promote adequate rest and encourage a generous intake of nutrients and fluids. The patient will report that pain management regimens achieves comfort function goal without adverse effects (Ackley ;amp; Ladwig, 2011).

The nurse should administer comfort measures to ease pain and teach the patient proper understanding of the condition as well as taking measures to correct the complications of endometritis (Perry, Hockenberry ;amp; Lowdermilk, 2010). 2. The patient will maintain oral temperature within adaptive levels (less than 100. 4 degrees). Evaluate the woman's temperature at the end of the first hour postpartum and then every four hours for the first 22 hours postpartum. Clients with endometritis typically have a fever, chills, general malaise, and may exhibit tachycardia.

Oral temperature measurement provides a more accurate temperature than tympanic measurement, auxiliary, or use of a chemical dot thermometer. Use the same site and method device for temperature measurement for a given client so that temperature trends are assessed accurately (Ackley & Ladwig, 2011). 3. The patient will report that pain management regimens achieves comfort function goal without adverse effects (Ackley & Ladwig, 2011). The importance of prompt reporting of unrelieved pain is the patient’s responsibility.

An important step toward improved control of pain is a better client understanding of the nature of pain, its treatment, and the role the client needs to play in pain control (Ackley & Ladwig, 2011). Despite the normalcy of childbirth, complications may arise that will have detrimental effects on the postpartum client. These include postpartum hemorrhage, thrombophlebitis, and infections such as endometritis. Healthcare providers working with postpartum clients must have a clear understanding of these complications, including the symptoms, nursing interventions, and treatment.

A cognizant nurse would carefully review the results of laboratory tests for signs of anemia, infection, and electrolyte imbalance. Blood cultures to identify the causative agents of potential infections are typically done, and white blood cell (WBC) counts are monitored. However, it is important to remember that the white blood cell count is normally elevated after delivery for a short period; continued monitoring of the WBC count is required in identifying endometritis (French, L. , & Smaill, F. M, 2004).

Nearly 90% of women treated with an approved regimen note improvement in 48-72 hours. Delay in initiation of antibiotic therapy can result in systemic toxicity. Endometritis is associated with increased maternal mortality due to septic shock. However, mortality is rare in the United States because of aggressive antimicrobial management. Most cases of endometritis, including those following cesarean delivery, should be treated in an inpatient setting. For mild cases following vaginal delivery, oral antibiotics in an outpatient setting may be adequate (French, L. & Smaill, F. M, 2004). References Ackley, B. J. , & Ladwig, G. B. (2011). Nursing diagnosis handbook: An evidence-based guide to planning care. (9th ed. , pp. 47,426-429,446-449,600-604). St. Louis, Missouri: Mosby Elsevier. French, L. (2003). Prevention and treatment of postpartum endometritis. Current Women’s Health Reports, 3(4), 274-279. Retrieved from http://www. ncbi. nlm. nih. gov/pubmed/12844449 French, L. , & Smaill, F. M. (2004). Antibiotic regimens for endometritis after delivery. Cochrane Database of Systematic Reviews, Retrieved from http://www. rw. interscience. wiley. com/Cochrane/clsysrev /articles/CD001067/frame. html Mazzeffi, M. A. (2010). Severe postpartum sepsis with prolonged myocardial dysfunction: A case report by michael a. mazzeffi and katherine t. chen. Journal of Medical Case Reports, (4), 318. Retrieved from http://www. jmedicalcasereports. com/content/4/1/318 Moldenhauer, J. S. (2008, November). Puerperal endometritis. Retrieved from http://www. merckmanuals. com/professional/gynecology_and_obstetrics/postpartum_care_and_associated_disorders/puerperal_endometritis. tml Nelson, C. B. (2010, January 22). Routine antibiotic use reduces mothers’ infection risk from c- section. Health Behavior News Service. Retrieved from http://www. physorg. com/news183387263. html Olsen, M. A. , Butler, A. M. , Willers, D. M. , & Gilad, A. G. (2010). Risk factors for endometritis after low transverse cesarean delivery. Infection Control and Hospital Epidemiology, 31(1), 69-77. Retrieved from http://www. jstor. org. proxy. li. suu. edu:2048/stable/10. 1086/649018 Perry, S. E. , Hockenberry, M. J. & Lowdermilk, D. L. (2010). Maternal child nursing care. (4th ed. , pp. 586-587). Maryland Heights, MO: Mosby. Pillitteri, A. (1999) Maternal & Child Health Nursing, (3rd ed. pp. 789-792). Philadelphia: PA: Lippincott. Rivlin, M. E. (2011, June 14) Endometritis. Retrieved from http://emedicine. medscape. com/article/254169-overview Scott, L. D. , & Hasik, K. J. (2001). The similarities and differences of endometritis and pelvic inflammatory disease. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 30(3), 332-41.

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