NCLEX Review Guide: Postpartum Endometritis

Definition and Pathophysiology

• Endometritis is an infection of the endometrial lining of the uterus that typically occurs within the first few days to weeks after delivery.
• Most commonly caused by ascending bacterial invasion from the lower genital tract, particularly after cesarean delivery or prolonged labor with frequent vaginal examinations.
• The infection can progress from the endometrium to the myometrium (endomyometritis) and potentially to the parametrium, causing serious complications.

Major Risk Factors

• Cesarean delivery - especially emergency C-section or after prolonged labor
• Prolonged rupture of membranes (>18-24 hours) and prolonged labor (>12 hours)
• Multiple vaginal examinations during labor, internal fetal monitoring, and manual placenta removal
• Retained placental fragments, chorioamnionitis, and compromised immune status

Clinical Manifestations

• Fever >100.4°F (38°C) typically within 24-72 hours postpartum, often the first and most reliable sign
• Lower abdominal pain and uterine tenderness, particularly over the fundus during palpation
• Foul-smelling lochia that may be purulent or have an abnormal color/consistency
• Tachycardia, chills, malaise, and possible nausea/vomiting indicating systemic infection

Priority Interventions

1. Obtain vital signs every 4 hours, monitoring for fever trends and hemodynamic stability
2. Assess lochia characteristics (amount, color, odor) and document changes every shift
3. Palpate uterine fundus for tenderness, firmness, and position - report increased tenderness
4. Administer prescribed antibiotics on schedule and monitor for therapeutic response
5. Encourage fluid intake (2-3L daily) unless contraindicated to support immune function

Medication Management

• Clindamycin plus gentamicin is the gold standard combination for severe endometritis treatment
• Ampicillin may be added if enterococcal infection is suspected or confirmed through cultures
• Continue antibiotics until patient is fever-free for 24-48 hours, not just for a set number of days
• Monitor for antibiotic side effects including nephrotoxicity (gentamicin) and C. difficile colitis (clindamycin)

Potential Complications

• Septic shock - monitor for hypotension, altered mental status, and decreased urine output
• Pelvic abscess formation requiring surgical drainage or prolonged antibiotic therapy
• Chronic pelvic pain and potential fertility issues if infection spreads beyond the uterus
• Necrotizing fasciitis in rare cases, requiring immediate surgical intervention

Prevention Strategies

• Prophylactic antibiotics before cesarean delivery significantly reduce endometritis risk
• Minimize unnecessary vaginal examinations during labor and use sterile technique when required
• Ensure complete placental delivery and inspect for retained fragments
• Maintain strict aseptic technique during all postpartum procedures and assessments

Self-Assessment Checklist

• ☐ I can identify the major risk factors for postpartum endometritis
• ☐ I understand the key clinical manifestations and their significance
• ☐ I know the priority nursing interventions and rationales
• ☐ I can differentiate normal postpartum changes from infection signs
• ☐ I understand antibiotic therapy and monitoring requirements