Postpregnancy Genital Tract and Wound Infections

Nell Tharpe, CNM, CRNFA, MS

J Midwifery Womens Health. 2008;53(3):236-246.

Infection of the Perineum

Maintaining intact vaginal and perineal tissues is a common goal in midwifery practice. In a study evaluating the effect of second-stage midwifery practices on perineal trauma, a group of 12 experienced midwives maintained an intact genital tract in women they attended in more than 23% of vaginal births, and had only minimal trauma (i.e., trauma that did not require suturing) in 73% of vaginal births.^[43] Maintaining genital tract tissue integrity is particularly important for women who have factors that predispose to infection, such as diabetes mellitus. Evidence-based recommendations for the performance of episiotomy are restricted to maternal or fetal indications rather than routine performance of this procedure.^[44]

Most women who give birth vaginally and require perineal repair experience rapid and uneventful perineal healing. However, a small subset of women experience significant pain and a delay in healing secondary to infection. Postpartum perineal infection is most often associated with midline episiotomy, third- or fourth-degree laceration or episiotomy extension, and vaginal hematoma.^[45]

The differential diagnosis of perineal infection is based on the presence of either purulent drainage from the episiotomy or laceration site, or the presence of a perineal abscess.^[28] Evaluation includes assessment of the presence and level of perineal pain, and examination for approximation of tissues and the presence of edema, redness, ecchymosis, temperature elevation, and wound discharge.^[46,47] Women with perineal infections require a rectovaginal examination to rule out occult rectal injury with its devastating potential for rectovaginal fistula formation. Occult rectal injury has been noted in the absence of episiotomy.^[29] The rectovaginal examination also provides an opportunity to assess for the presence of inadvertent rectal stitches, undetected rectal injury that may result in fistula formation, or the presence of a hematoma.

Women with localized perineal infection, as evidenced by heat, redness and erythema and an absence of systemic signs or symptoms, or those with superficial breakdown of a first- or second-degree repair, are commonly treated with expectant management and perineal wound care, such as frequent sitz baths and meticulous attention to perianal hygiene.^[44] In the absence of co-morbidities, antibiotic therapy is rarely indicated for these women.

For women with serious perineal wound infection, as evidenced by the presence of perineal abscess, purulent drainage, systemic symptoms and/or extensive repair breakdown, prompt referral for evaluation and treatment is indicated. Initiation of antibiotic therapy and surgical debridement may be required to remove devitalized tissue.^[44] Severe systemic symptoms may be an indication of sepsis from organisms such as community-acquired methicillin-resistant S aureus, which is derived from an infected episiotomy site.^[40]

The recommended surgical treatment of perineal wound infections consists of taking down the repair; removal of all suture material; and thorough debridement of infected or necrotic tissue under local, regional, or general anesthesia. Careful inspection is performed to identify the development or presence of necrotizing fasiitis.^[48] Unlike infected abdominal incisions, which are left to close by secondary intention, the early closure of perineal wounds may be attempted in order to maintain perineal integrity.^[44,45]

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Cite this: Postpregnancy Genital Tract and Wound Infections - Medscape - May 01, 2008.

Risk Factors for Obstetric Reproductive Tract Infection
Pre-existing Maternal Conditions	Events During Labor, Birth, or Abortion	Procedure- or Provider-Related Conditions or Events
Extremes of maternal age	Preterm labor and birth	Preoperative shaving
Elevated body mass index	Prolonged rupture of membranes	Preoperative skin preparation technique
Smoking	Prolonged labor	General anesthesia
Primiparity	Intrapartum fever	Hypothermia
Low socioeconomic status	Multiple internal exams	Poor aseptic technique
Poor maternal hygiene	Post-term pregnancy	Inadequate sterilization of instruments
Poor nutrition	Thick meconium staining	Delayed or omitted prophylactic antibiotics
Poor oxygenation Poor tissue perfusion Multiple comorbidities Diabetes Hypertension Immune compromise Splenectomy Severe anemia Bacterial vaginosis Chlamydia and/or gonorrhea Trichomoniasis	Internal fetal scalp electrode or uterine monitoring with an intrauterine pressure catheter Operative vaginal delivery Foley catheter Cesarean section Uterine perforation Manual removal of placenta Retained products of conception Hemorrhage	Suboptimal hemostasis Practitioner skill Practitioner experience Length of procedure Operative trauma Contamination of wound or surgical site Residual dead space following wound closure

Sources: Mangram et al.,^[2] Andrews et al.,^[19] Smaill and Hofmeyr,^[15] and Maharaj.^[16]

Postpartum and Postoperative Infections: Preventive Measures
Maternal Care	Recommended Practices	Surgical Technique
Screen and treat pre-existing genital tract infection	Minimize activity in the procedure room	Maintain excellent surgical or delivery technique
Screen and treat medical conditions, particularly those leading to vasoconstriction	Wear clean scrubs and personal protective equipment	Limit blood loss, maintain hemostasis
Preprocedure antiseptic shower	Perform recommended surgical/delivery scrub	Ensure rigorous adherence to aseptic technique
Minimize number of vaginal exams in labor	Provide sterile drapes between patient and potential source of infection	Minimize tissue trauma, limit use of ties and cautery
Avoid hair removal or use clippers shortly before procedure	Provide supplemental oxygen during and post procedure	Remove or debride devitalized tissue
Provide adequate skin prep, use occlusive incise drape	Pre- and intra-operative warming	Eliminate dead space during closures
Provide antibiotic prophylaxis as appropriate	Correct volume deficits	Use monofilament suture when possible
Maintain perineal integrity	Maintain normoglycemia	Elevate partial pressure of oxygen (PaO₂)
Encourage adequate vitamin C, vitamin A, zinc and omega-3 fatty acid intake	Provide adequate pain control	Replace fluid losses to maintain peripheral circulation

Sources: Mangram et al.,^[2] Ueno et al,^[14] Maharaj,^[16] Greif et al.,^[37] and Melling et al.^[38]

Select Antibiotic Regimens for Obstetric Infections
Infection Type	Pathogens	Sample Regimens Generic (Brand)	Comments
Septic abortion	Bacteroides Group B, A streptococcus Enterobacteria Chlamydia	Cefoxitin (Mefoxin) 2 g IV q 6-8h, or Ticarcillin/clavulanate (Timentin) 3.1 g IV q 4-6h, with doxycycline 100 mg q 12 h IV or PO	Consult or refer for evaluation and treatment Refer for uterine evacuation, prn
Endometritis parenteral therapy	Bacteroides Group B, A streptococcus Enterobacteria Chlamydia	Clindamycin (Cleocin) 450-900 mg IV q 8 h, with gentamicin (Garamycin), 1.5 mg/kg IV q 8 h, or Cefoxitin (Mefoxin) 2 gm IV q 6-8 h, or Ticarcillin/clavulanate (Timentin) 3.1 gm IV q 4-6 h, plus Chlamydia suspected: add doxycycline* (Vibramycin hyclate for injection) 100 mg IV or PO q 12 h	Consult or refer for evaluation and treatment plan
Endometritis oral therapy	Chlamydia M hominis	Ofloxacin (Floxin) 400 mg PO bid, or Doxycycline* (Doryx, Monodox, Vibramycin, and others) 100 mg PO q 12 h, or Clindamycin (Cleocin) 450-900 mg IV q 8 h	Reserved for mild cases in afebrile women
Wound infection	S aureus Group A, B, C strep, enterococci Bacteroides	Piperacillin/tazobactam (Zosyn) 4 gm q 6 h, or Cefotaxime (Claforan) 2 gm q 4-8 h, plus metronidazole (Flagyl IV)1 gm q 12 h	Refer for wound exploration and/or surgical debridement prn