Midwifery - Post-natal wound care in the community

A recent audit led to a reduction in wound infection rates for new mothers in a community midwifery service, writes Aileen Fox

Part two of a two-part series – part one was published in WIN June

Infant feeding method: The clients who were referred for review had the feeding method of their infant recorded. Results, shown in Table 7, indicate a higher incidence of wound infection among the combined feeding group.

Infant feed type
Type of feed Total feed types % feed types of reviewed wounds
Artificially fed 662 51 (7.7%)
Breast fed 708 49 (6.9%)
Combination fed 168 19 (11.3%)

Pathogens
Upon presentation to the NMH for review, each client had a wound swab to identify offending pathogens. Perineal swab results are shown in Table 8. Some swab results showed a combination of two or more pathogens, while 24.7% of clients were reviewed by their GP so the swab result was unavailable. Similarly, the abdominal group also had a swab taken of their wound site to identify offending pathogens and the results are displayed in Table 9.

Perineal pathogens
GP review with no swab result 22 (24.7%)
No swab taken/monitored only 10 (11.2%)
Nil noted 8 (9.0%)
Anaerobic atrep 9 (10.1%)
Mixed anaerobes 5 (5.6%)
Bacteroides 3 (3.4%)
Anaerobes + strep bacteroides 2 (2.2%)
Anaerobic strep + gardnerella 1 (1.1%)
GBS + staph 4 (4.5%)
GBS + anaerobes 3 (3.4%)
Staph aureus 6 (6.7%)
GBS + e-coli 1 (1.1%)
GBS + GGS 1 (1.1%)
GDS +bacteroides +staph 1 (1.1%)
GCS +anaerobic strep 1 (1.1%)
GFS + bacteroides 1 (1.1%)
GBS + GGS 1 (1.1%)
GBS + candida 1 (1.1%)
MRSA + GGS 1 (1.1%)
e-coli + bacteroides + strep 1 (1.1%)
e-coli + enterococcus 1 (1.1%)
Klebsiella bacteroides 1 (1.1%)
e-coli 4 (4.5%)
? result-perineum re-sutured 1 (1.1%)

SSI pathogens
Nil isolated 4 (13.3%)
Anaerobic strep 3 (10.0%)
Bacterial vaginosis 1(3.3%)
Staph aureus + anaerobic strep 3 (10.0%)
Staph aureus + mixed anaerobes 1 (3.3%)
Staph aureus + GBS 1(3.3%)
GBS + proteus + mirabilis + enterococcus 1(3.3%)
GFS + bacteroides 1(3.3%)
e-coli + anaerobic strep 1(3.3%)
Enterobacter cloacae + klebsella 1(3.3%)
Staph aureus 3 (10.0%)
MRSA 1(3.3%)
e-coli 1(3.3%)
GBS 1(3.3%)
Morganella 1(3.3%)
Bacteroides 1(3.3%)
Haematoma 1(3.3%)
Staph epidermis 1(3.3%)
Monitored only 1(3.3%)
c/o GP - no swab result 2(6.7%)

Audit outcomes

Perineal
Of the 119 clients who were referred to the NMH for review 72 (80.9%) were treated with antibiotics, 12 (13.5%) had their wounds monitored which then resolved spontaneously, four (4.5%) were referred to their GP for review, treatment unknown, and one (1.1%) had the wound re-sutured.

Case report
Name: Mary X (pseudonym used for confidentiality reasons)
Age: 33; BMI: = 30; Parity: 1+0; PMH: Nil of note; POH: Nil of note; FHx: Nil of note
Social Hx; Married with good family support. Non smoker and no alcohol consumed during pregnancy.
Antenatal Care: Uneventful
Intrapartum: SVD of live male infant 4.05kg on 30/09/06. An uneventful delivery with minimal intervention required.
Postnatal: Initial recovery uneventful. Breast feeding well on demand and availed of ETHP on day 2 on 03/10/06. Her Hb level was recorded on 11/08/06 and the results were 11.3g/ dl. Mary received visits from the ETHP on days 3, 4 and 5.
Day 3: Postnatal check NAD and perineal care advice given.
Day 4: Wound separating sloughy and painful.
Day 5; Wound appeared completely separated and very sloughy with approximately 20ml of purulent discharge noted. Client was referred to the NMH for review.
Day 6: Client contacted. Upon review a swab was obtained and the results showed scanty growth of GBS and staph aureus. Mary was commenced on PO antibiotics. Following 24 hours of same, Mary felt improvement in pain levels and reported a reduced level of perineal wound discharged. Follow up advice given and care transferred to the GP and PHN.

Abdominal
Within the LSCS group 13 (43.3%) were treated with antibiotics and 17 (56.7%) had their wounds monitored which then resolved spontaneously.

Time to referral
The ETHP staff generally see their clients up until day five following which their care is transferred to the public health nurse and GP. The day upon which the client was referred to the NMH for review was recorded and incorporates both perineal and LSCS groups.

Typically, for both groups the wound appeared sloughy and gaping on day four and clients were subsequently referred to the NMH for review. Of the referred clients 78 (65.5%) were referred in between 0-5 days; 35 (29.4%) were referred in between days 6-10; and 6 (5.0%) were referred for review on day 10 or later.

These results indicate that a large proportion of postpartum infections are reported after discharge from the care of the ETHP, as can be noted from previous studies.17

Discussion
Following the initial report, various measures were put in place to audit and monitor hospital infection rates including:

Standard care post audit Following the audit in 2005/2006 ETHP team members reviewed the results and proposed changes to their practice. Subsequently, in 2007/2008 the team advised all clients to avoid the use of tea tree oil baths and regular douches. There’s no scientific evidence to support its use. Instead, clients were advised to bathe daily in warm tap water and continue the practice of regular pad changing and pelvic floor exercises. Post audit general results can be seen in Table 1.

The results in Table 3 show a significant reduction in the wound infection rate when compared to 2005/2006.

Post audit results/abdominal:
Similarly, the SSI rate was significantly less than previously reported and are noted in Table 6. A total of 302 ladies delivered by LSCS and 14 (4.7%) were referred to the NMH for review and further treatment. Again clients who had their wound closed with clips were noted to have a higher SSI rate.

None of the parameters previously recorded were included in this section of the audit, but the clients were referred to the NMH in the same time frame and were discharged to the care of the GP and PHN before day 10 postnatal.

In 2010, following completion of this audit, we continue to monitor the wound breakdown rate which has remained significantly lower than those noted in 2005/2006.

Conclusion
Wound infection, either perineal or SSI, can cause great discomfort to newly delivered mothers and can result in increased maternal morbidity.5,7,11,22 Our audit suggested that there was a greater incidence of both perineal and abdominal wound infections when compared with other reports.16 However, allowing wounds, either abdominal or perineal, to heal naturally and without the use of tea tree oil or douching may help reduce the infection rate. Also, it is recognised that there are many other variables that may account for increased wound breakdown rates and need to be explored.

The ETHP care for only 12% of the NMH client caseload and therefore may not be representative of the total population. Also, the team generally transfers client care to the public health nurse and GP on day five, and our report indicates that up to 35% of clients developed a wound infection beyond this time frame. Hence, there could potentially be a higher ratio of clients who required referral beyond this period of time.

Our findings suggest that there is a greater incidence of wound infections among women who had an instrumental delivery and sustained an episiotomy. Women who have had their abdominal wound closed with clips are more likely to develop a SSI. Anaerobic streptococci and staph aureus are the more common pathogens noted. It indicates the need for further studies in the area.

Wound care patient information after discharge

This information has been developed in conjunction with the advice of your carer prior to discharge. In most circumstances the wound dressing will be removed prior to discharge. It may take two to six weeks for the wound to totally heal. Once the dressing is removed:

DO:

  • Keep the wound clean and dry
  • Have a daily shower or bath using unperformed soap. However, do not use soap directly on the wound. Wash your wound with water only and gently pat the area with a clean towel
  • Try to find time each day to lie down and loosen all clothing from the skin around the wound. Fresh air will dry your wound and help it to heal. This is especially important during warmer weather and if you are overweight
  • If you need to touch your wound, do wash your hands with soap and water before and after.

DO NOT:

  • Touch your wound unnecessarily
  • Place a dressing on the wound, unless advised by your nurse, midwife, or doctor
  • Use antiseptic creams, washes or sprays on your wound
  • Use vaginal douching. This may get rid of the 'good bacteria' and make you more likely to develop an infection
  • Use swimming pools, saunas, jacuzzis and hot tubs until the wound is completely healed.

If you experience any of the following symptoms please contact the hospital and ask to be put through to the ward that you were cared for in, where you will be advised or alternatively contact your GP:

  • Fever > 101°F or 38°C for two readings taken four hours apart
  • Increased pain or swelling of the wound
  • The wound oozes blood-stained fluid, yellow fluid or becomes smelly
  • Redness spreads to the skin around the wound
  • The wound appears to be opening

Recommendations
This wound audit report emphasises the need for more detailed studies in perineal and abdominal wound infection detection, management, and care. The provision of an information leaflet on perineal wound care could assist staff ensure uniformity of care. Regular wound management guideline review would also ensure evidence based practice thus enhancing client care.

Aileen Fox is co-ordinator Early Transfer Home Programme

Acknowledgements
Many thanks to all who helped me compile this report.

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Midwifery - Post-natal wound care in the community

 


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