Endometritis

Postpartum Endometritis Evidence base Paper March 13, 2012 Endometritis is the inflammation or irritation of the uterus, which is a common post partum complication that occurs in much than 15% of every(prenominal) pregnancies and is currently the leading ca discolor plague of maternal mortality (Scott & adenosine monophosphate Hasik, 2001). When metritis is not related to pregnancy, it is referred to as pelvic inflammatory disease (pelvic inflammatory disease).The Centers for illness Control and legal profession (CDC) 2010 sexually transmitted diseases actment guideline defines PID as some(prenominal) combination of metritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis. From a pathologic perspective, metritis weed be classified as acute versus chronic. Acute metritis is distinguished by the presence of neutrophils inwardly the endometrial glands. Chronic metritis is characterized by the presence of plasma cells and lymphocytes within the endometrial stro ma.Chronic endometritis in the postnatal or post abortion forbearing is ordinarily associated with retained products of conception later address or abortion. In the nonobstetric population, chronic endometritis has been associated with transmission systems much(prenominal) as chlamydia, tuberculosis, bacteriuml vaginosis, and the presence of intrauterine devices (Rivlin, 2011). Early-onset postnatal endometritis occurs within two days of obstetrical auction pitch, and the late-onset of the disease can occur up to six weeks postpartum.This fix will usually start as a local contagious disease at the placental attachment site and if left field untreated, can spread to the entire uterine endometrium (French & vitamin A Smaill, 2004). There atomic number 18 numerous put on the lines associated with this condition, and diagnosis relies heavily on the clinical judgment of the practiti wholenessr. The pollution of the uterine cavity with vaginal organisms during labor and delivery pay offs the disease. Both bacterial and viral contagions may initiate endometritis and many of the agents that cause the transmission system argon naturally present in the vagina.This condition arises comm completely subsequently delivery because delivery results in tears, rips or incisions in the vagina, cervix or uterus that al impression these agents to enter the uterine lining. The infection can pass several species of motivating agents that can be aerobic or anaerobiotic flora (French & angstrom 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 cesarian p atomic number 18ntages, the occurrent of certain bacteria much(prenominal) as group A haemolytic streptococci, staphylococci B, Neisseria gonorrhoeae, or Mycoplasma hominis in amniotic fluid cultures will coiffe the patient at an change magnitude risk for this infection (French & Smaill, 2004). With the change magnitude number of people opting for natural birth methods, including water births, the danger only multiplies. This is because disinfecting procedures as they be carried out forwards major surgery is usually not practiced in a home environment.Prompt treatment is meaty to prevent the spread of the infection through early(a)wise areas of the body, including the family. Pro tenacio utilise infection can be fatal. The immediate postpartum ut nearly fol small-scaleing birth is a time of increased risk for all women for infection. Microorganisms entering the fruitful tract and migrating into the blood and other parts of the body could result in life baneful septicemia (French & Smaill, 2004). Timely diagnosis and militant treatment is essential to prevent these complications.Complications of endometritis incl ude 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 clog ups 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 let go 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 endometri tis 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 afford been identified in supererogatory studies, including no prior cesarean delivery, preterm or postterm gestation, low infant Apgar scores, antepartum infections, preeclampsia, amnioinfusion, postpartum anemia, the presence of immanent 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, febricity (100 to 104 degrees Fahrenheit), usual dis still, uneasiness, or ill feeling (malaise), and lower abdominal or pelvic imposition (uterine pain). Anemia occurs when a patients red blood cell amount is lower than 4. -6. 0 million red blood cells per little 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 range (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 found 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 c ell count (the leukocyte count) above the normal range in the blood. The stock definition for puerperal fever used for reporting rates of puerperal morbidity is an viva temperature of 100. 4 degrees centigrade or more on any two of the first ten days postpartum or 101. degrees or blueer during the first 24 hours postpartum (French amp Smaill, 2004). Additionally, when the above symptoms occur, uranalysis 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) later 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 approach 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. endovenous 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 viands is associated with fewer side effects.Once uncomplicated, endometritis has clinically modify with intravenous therapy, and oral therapy is not needed (French, 2003) . Furthermore, it is essential that the patient receive demonstrative of(predicate) economic aid including hydration, rest and pain relief. antibiotic drugs should be discontinued 24 hours after the patient is asymptomatic. Assessments should be taken of the lochia, vital signs, and changes in the womens 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 addicted to the possibility that the woman may have complications requiring specific treatment. The most efficient treatment and least expensive treatment of postpartum infection is prevention. hinderance measures include good prenatal nutrition to reign over anemia and intrapartal hemorrhage. ripe(p) maternal perineal hygiene with thro ugh hand hygiene is emphasized.Strict affection to aseptic techniques by all health misgiving masters 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 staph 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 mothers 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 proper increasingly common, despite the higher risks a ssociated with the surgery compared to a vaginal birth. bingle important concern is the risk of infection, which is between five and 20 measure greater for women who undergo scheduled or emergency Caesarean section.According to the Cochrane Review, the angiotensin converting enzyme most important risk factor for postpartum maternal infection is Caesarean section. The surveil further cited that antibiotics to women undergoing Caesarean section reduced the relative incidence of fever by 45 percent, wound infection by 39 percent, inflammation of the uterine lining by 38 percent and heartrending 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 covered intravenously immediately after the babys umbilical cord is clamped. If you are at high risk, a second dose may be given eightsome hours later (French amp Smaill, 2004). The overall goal for the postpartum client with endometritis is, The patient will be acquit 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 calorifacient and cold. Non-pharmacological interventions can restore the clients sense of self-control, personal efficacy, and mobile participation in her care. It is essential that the teaching 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, in return agreed upon, heal thcare maintenance plan. (The nurse should assume that first-time mothers lack adapted knowledge regarding condition and treatment diagnosis, and therefore, needs education and specific book of 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 a great deal and washing her hands afterwards.The presence of a wet pad against sutures is an beautiful 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 nurses responsibility to promote adequate rest and encourage a bighearted intake of nutrients and fluids. The patient will report that pain management regi mens achieves comfort run short goal without adverse effects (Ackley amp Ladwig, 2011).The nurse should administer comfort measures to ease pain and teach the patient proper reasonableness 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 accommodative levels (less than 100. 4 degrees). Evaluate the womans 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 meter provides a more accurate temperature than tympanic measurement, auxiliary, or use of a chemic 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 patients responsibility.An important step toward improved control of pain is a better client understanding of the genius 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 okay regimen note improvement in 48-72 hours. Delay in mental institution 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 Womens 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 extend 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 port 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. edu2048/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, &am p Neonatal Nursing, 30(3), 332-41.