Atoosa Benji

October 2019

1. Evaluation and Management of Chorioamnionitis

Definition:
An acute infection or inflammation of the amniotic sac, amnion, chorion, decidua, placenta, and/or amniotic fluid.
Organisms responsible for the infection include Group B Streptococcus, Esherichia coli, Mycoplasma hominis,
Fusobacterium, and Ureaplasma urealyticum. Commonly, infection results as a result of bacteria moving into the
uterus from the genital tract. These bacteria typically reside in the genital are of 70% of women.
2. Assessment:
i. Risk Factors:
Prolonged rupture of membranes, long labor, frequent digital exams (particularly after rupture of
membranes), manipulative intrauterine or vaginal procedures i.e internal monitoring, poor nutrition,
compromised immune system, drug/alcohol use, nulliparity, African-American descent, presence of
pathogens such as STI, GBS, BV.
ii. Subjective Symptoms
Maternal fever, maternal tachycardia, uterine pain/ tenderness, vaginal pain/tenderness, foul-smelling
amniotic fluid, meconium stained amniotic fluid. Maternal malaise, shivering, weakness, temperature
changes.
iii. Objective Symptoms
Maternal fever of 100.4 degrees F or higher, fetal tachycardia (above 160BPM), maternal tachycardia
(above 100BPM), foul smelling and/or purulent vaginal discharge, meconium staining, uterus and/or
vaginal walls tender to palpation, poor labor pattern, possible BP elevation.
iv. Clinical Testing
Note: Chorioamnionititis can only be confirmed through histology examination of the placenta and/or
umbilical cord. Complete Blood Count showing elevated white blood cells (defined as WBC
>12,000/mm3 or >15,000/mm3) or rise in C-Reactive Protein, positive culture of amniotic fluid.
3. Management Plan
i. Therapeutic Measures
Acetaminophen to reduce fever and pain, IV hydration (Lactated Ringers). In the absence of penicillin
allergy,-Amoxicillin 2G IV q. 6 hours and Gentamycin loading dose of 2mg/Kg. If client is allergic to
penicillin-Clindamycin 900mg q. 8 hours and Gentamcyin loading dose of 2mg.Kg. *Tansfer to hospital
must be initiated.
ii. Complementary Measures
Measures to reduce maternal fever and make the client more comfortable, i.e. ice packs under the knees and
armpits, removal of heavy blankets, oral hydration. Initiate transfer to hospital.
iii. Considerations for pregnancy, childbirth, and lactation
Maternal- Endomyometritis, postpartum hemorrhage, septic shock, respiratory distress, possible death
(rare), skin infections, pelvic abscesses, increased risk of cesarean section.
Fetal- Fetal Inflammatory Response Syndrome, sepsis, death, cerebral palsy, chronic lung disease, multi-
organ injury.
Lactation- Infection and antibiotics may reduce milk supply. A sick infant and/or mother may have more
trouble with initial breastfeeding due to being separated and less skin on skin time and need for
interventions.
iv. Client and Family Education
Client must me educated on GBS testing and prophylaxis in order to make an informed decision. In the
case of ROM, client must be informed that digital exams increase the risk of infection. If client begins to
present with fever or any combination of the signs and symptoms leading to suspected chorioamnionitis,
the client and family will be informed of the risks of the infection and be given informed consent about all
interventions used and the initiation of transfer to the hospital for physician back up.
v. Follow-Up
Midwife will provide continuity of care at the hospital until the birth of the baby and up to 2 hours
postpartum. Midwife will provide postpartum care in collaboration with the MD taking over care once the
client is discharged from the hospital. Postpartum care will include evaluation of healing, checking
maternal and baby vital signs and ensuring a successful breastfeeding relationship and a baby who is
gaining weight and being monitored for signs of complications such as jaundice or sequelae from maternal
infection. Midwife will use discretion as to whether or not the case will be shared at peer review.
4. Indications for Consult, Collaboration or Referral:
If client or fetus begin to show signs and symptoms of infection at any point (including the postpartum
period) while in the care of primary care midwife, consultation will take place with the back-up physician
and a transfer of care will be initiated. Midwife will follow MD’s recommendations while providing
continuity of care, within the scope of the midwife. Other conditions warranting transfer are PROM longer
than 24 hours with no labor progress, and meconium with no imminent delivery of the baby.
5. References
King, T.L., Brucker, M.C., Kriebs, J.M., Fahey, J.O., Gegor, C.L. & Varney, H. (2015). Varney’s
Midwifery
(5th ed.). Burlington, MA: Jones & Bartlett Learning.
New Mexico Midwives Association: Practice Guidelines. (n.d.). Retrieved October 6, 2019, from
https://nmhealth.org/.
Tita, A. T., & Andrews, W. W. (2010). Diagnosis and management of clinical chorioamnionitis. Clinics in
perinatology, 37(2), 339–354. doi:10.1016/j.clp.2010.02.003