19.4 Infection

Risk for Perinatal Infection

The risk for infection in perinatal clients is highest for those with a history of sexually transmitted infection, chorioamnionitis, premature or prolonged rupture of membranes before delivery, or third- or fourth-degree lacerations from delivery. Chorioamnionitis is an infection of the membranes (amnion and chorion) that surround the fetus in the uterus during pregnancy. Chorioamnionitis is caused by bacteria present in the vagina that ascend into the amniotic area, commonly Group B streptococcus. Risk factors for chorioamnionitis include prolonged labor, multiple vaginal exams, use of internal fetal monitors, meconium-stained fluid, and genital tract bacteria. Maternal complications resulting from chorioamnionitis include dysfunctional labor, postpartum uterine atony resulting in postpartum hemorrhage, endometritis, and sepsis. Complications affecting neonatal morbidity and mortality include pneumonia, meningitis, and sepsis. Symptoms of chorioamnionitis are maternal or fetal tachycardia, uterine tenderness, foul-smelling amniotic fluid, and purulent cervical discharge. Treatment includes broad-spectrum antibiotics that are continued until after the birth.^[1]

Recognizing Signs of Postpartum Infection

There are several common infections that may occur during the postpartum period, including endometritis, mastitis, urinary tract infection, and wound infection. Nurses routinely assess for general signs of infection, such as the following:

• Fever and/or chills
• Headache
• Fatigue
• Muscle aches
• Nausea and vomiting
• Diarrhea
• Localized symptoms such as redness, warmth, swelling, pain, or purulent discharge
• Dysuria

Treatment of Infection

Infection is treated based on culture and sensitivity results. Based on the severity of infection, a broad-spectrum antibiotic may be initially prescribed with a different antibiotic prescribed based on the culture and sensitivity results.

Sepsis

Nurses are aware that clients with any type of infection can develop a systemic inflammatory response (SIRS) and sepsis. SIRS is characterized by a widespread release of inflammatory mediators in response to a variety of triggers, which can lead to multiple organ dysfunction. Sepsis is specifically caused by infection and causes widespread inflammation and potential organ damage.

Recognizing SIRS and Sepsis

Nurses closely monitor for early signs of systemic inflammatory response syndrome (SIRS) and sepsis in clients with infection, including the following^[2]:

• Temperature over 38 or under 36 degrees Celsius
• Heart rate greater than 90 beats/minute
• Respiratory rate greater than 20 breaths/minute or PaCO2 less than 32 mmHg
• White blood cell count greater than 12,000 or less than 4,000 /microliters or over 10% of immature forms (bands)

A client with sepsis may also demonstrate decreased level of consciousness; warm, clammy skin; intense fatigue; pain; or loss of function of the affected part of the body. If untreated, sepsis can lead to septic shock.^[3]

Septic Shock

Septic shock is a life-threatening decrease in blood pressure (i.e., systolic pressure less than 90 mm Hg) that prevents cells and other organs from receiving enough oxygen and nutrients, causing multi-organ failure and death. It is a medical emergency that requires immediate treatment in an intensive care unit (ICU). Treatment of septic shock may include the following:

• Antibiotics: Broad-spectrum antibiotics are typically initially prescribed, followed by a more specific antibiotic after culture and sensitivity tests identify the type of bacteria and the types of antibiotics to which it is susceptible. Antibiotics should be started as soon as possible after blood is drawn for diagnostic testing.

• Fluids: Intravenous fluids are given to increase blood pressure and rehydrate the client.

• Oxygen: Oxygen is administered and titrated according to provider orders. Intubation and mechanical ventilation may be required to treat hypoxemia or hypercapnia.

• Vasopressors: Vasopressors may be prescribed to increase blood flow to organs. Examples of vasopressors include vasopressin and norepinephrine.

• Inotropes: Inotropic medications, such as dobutamine, increase cardiac contractility to improve transport of oxygen-rich blood to organs and tissues.

• Insulin: Insulin may be administered if the client’s blood glucose levels are elevated due to the stress response associated with severe infection.

• Dialysis: Dialysis may be indicated if the client experiences acute renal failure as a result of hypotension.