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.

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.

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.

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:

• The appointment of a microbiologist as head of the infection control team
• Regulated referral system
• Regular hygiene audits
• Regular staff education information sessions re-hand hygiene, waste disposal systems and wound management updates
• Hospital refurbishment incorporating upgrading of bathroom and toilet facilities
• Tracing mechanism for equipment used for invasive procedures
• Division of data analysis to monitor readmission rates secondary to infection
• Development of an abdominal wound care patient information leaflet (See box).

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.

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.

1. References
   Brooten D, Roncoli MM, Finkler S, Arnold L, Cohen A, Mennuti M. A randomized controlled trial of early discharge and home follow-up of women having caesarean birth. Obs Gynae 1994; 84: 832-838
2. Winterburn S, Fraser R. Does the duration of postnatal stay influence breastfeeding rates at one month in women giving birth for the first time? A randomized controlled trial. J Adv Nursing 2000; 32(5): 1152-1157
3. Wray J. Postnatal care, is it an afterthought? The Practicing Midwife 2003; 6(4): 4-5
4. Uygur D, Yesildaglar N, Kis S, Tevfik S. Early repair of episiotomy dehiscence. Aust NZ J Obs Gynae 2004; 44: 244-246
5. Williams AM, Chames MC. Risk factors for the breakdown of perineal laceration and repair after vaginal delivery. Am J Obs Gynae 2006; 195(3) Sept: 755-9
6. Hillian EM. Postoperative morbidity following caesarean delivery. J Adv Nursing 1995; 22: 1035-42
7. Ophir E, Strulov A, Solt I. Delivery mode and maternal hospitalization. Arch Gynaecologists Obstetricians 2007; 277: 401-404.
8. CDC Infection control and hospital epidemiology. USA, 1999: 252
9. Henderson C, Macdonald S. Mayes midwifery a textbook for Midwives. 13th ed. UK: Bailliere Tindall, 2005
10. Opoien HK, Valbo A, Grinde-Andersen A, Walberg M. Post-caesarean surgical site infections according to CDC standards: rates and risk factors. A prospective study. Acta Obstetricia et Gynecologica 2007; 86: 1097-1102.
11. Boyle M. Caesarean section wound management; A challenge for midwives. The Practicing Midwife 2001; 4(2): 20-22
12. Bick D, MacArthur C, Knowles H, Winter H. Postnatal care; evidence and guidelines for management. Churchill and Livingston, 2003
13. Olsen M, A Butler AM, Willers DM, Devkota P, Gross GA, Fraser VJ. Risk factors for surgical site infection after low transverse Caesarean section. Infect Control Hosp Epidemiol 2008; 29(6): 477-484
14. Sarsam S, Elliot J, Garrett K. Management of wound complications from Caesarean delivery. CME Review Article. Obstetrical Gynaecological Surv 2005; 60(7): 462-473
15. Kettle C. Management of perineal trauma. Presentation of Current Research Dublin, 2008
16. Glazner C, MacArthur C. Postnatal morbidity. The Obstetrician and Gynaecologist 2001; 3(4): 179-183
17. Yokoe DS, Christiansen CL, Johnson R et al. Epidemiology of and surveillance for postpartum infections. CDC Emerging Infectious Diseases 2001; 7(5): 1-8
18. Austin J. An audit of third degree perineal tears. Br J Midwifery 2003; 11(11): 649-54
19. Buppasiri P, Lumbiganon P, Thinkhamrop J, Thinkhamrop B. Antibiotic prophylaxis for fourth-degree perineal tears during vaginal delivery. Corcoran Database of Systematic Reviews, 2007
20. Ramin SM, Ramis RM, Little BB, Gilstrap LC. Early repair of episiotomy dehiscence associated with infection. Am J Obs Gynae 1992; 167: 1104-1107
21. Steen M. Perineal tears and episiotomy; how do wounds heal? Br J Midwifery 2007; 15(5): 273-280
22. Metcalfe A, Bick D, Tohill S, Williams A, Haldon V. A prospective cohort study of repair and non-repair of second- degree perineal trauma: results and issues for future research. Evidence Based Midwifery 2006; 4(2): 60-4

Midwifery - Post-natal wound care in the community