Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 583595

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Best Practice & Research Clinical

Obstetrics and Gynaecology
journal homepage: www.elsevier.com/locate/bpobgyn

Managing the risks of sepsis in pregnancy

Jacqueline E.A.K. Bamfo, MBBS BSc MD (Res)
MRCOG, Subspecialty Trainee in Maternal-Fetal Medicine *
St Marys Hospital, Oxford Rd, Manchester M13 9WL, UK

Keywords:
sepsis in pregnancy
septic shock
maternal mortality
maternal morbidity
risk management
quality improvement (QI)
RADICAL framework

Sepsis is a major cause of maternal mortality and morbidity

worldwide. In the UK, sepsis is now the leading cause of direct
maternal deaths. Raising awareness among healthcare professionals about the risks of maternal sepsis and the importance of
early management is urgently needed. The challenge in the management of maternal sepsis is the translation of the vast knowledge gained from sequential condential enquiries into maternal
death and research ndings, into clinical practice, to ensure an
improvement in patient quality of care and maternal mortality and
morbidity. In this chapter, I give an overview of the management of
the risks of sepsis, and discuss implementation strategies that may
reduce these risks.
2013 Elsevier Ltd. All rights reserved.

Introduction
Sepsis is a major cause of maternal death and morbidity worldwide. In the 18th and 19th centuries,
puerperal fever or childbed fever was the most common cause of maternal death, resulting in over 50%
of maternal deaths in Europe.1 Today, sepsis still accounts for 15% of maternal deaths a year worldwide,
despite advances in hygiene, antibiotic use and efcient healthcare systems.24 Puerperal sepsis causes
at least 75,000 maternal deaths every year in low-income countries.3 A health disparity exists, with up
to three times higher maternal death rates in low-income countries compared with high-income
countries.5
In the UK, the triennial Condential Enquiries into Maternal Deaths reported Genital tract sepsis as
the leading cause of direct maternal death.6 Between 2006 and 2008, 29 direct maternal deaths from
sepsis were reported, reecting an increase in mortality rate caused by sepsis from 0.85 (95% CI 0.54 to

* Tel.: 44 (0) 1612761234.

E-mail address: Jacqueline.bamfo@cmft.nhs.uk.
1521-6934/$ see front matter 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.bpobgyn.2013.04.003

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1.35) per 100,000 maternities in 2003 and 2005 to 1.13 (95% CI 0.77 to 1.67) per 100,000 maternities
between 2006 and 2008.6 The Netherlands has also reported an increase in maternal mortality from
sepsis.7,8 A nationwide Dutch study reported an incidence of severe maternal morbidity from sepsis of
21 per 100,000 deliveries (78 out of 371,021), of which 79% of cases required admission to the intensive
care unit.9
Maternal deaths from sepsis are largely preventable. The 20062008 Condential Enquiries into
Maternal Deaths report6 commented on the lack of recognition of the signs of sepsis and lack of
healthcare guidelines on its management. The Royal College of Obstetricians and Gynaecologists
(RCOG) has since issued guidelines on bacterial sepsis in pregnancy and sepsis after pregnancy.10,11 This
is timely and has a huge bearing on patient safety, clinical risk management, and clinical negligence. In
this chapter, I discuss the risks of sepsis in pregnancy and highlight management options for eliminating and mitigating these risks.
Denition of sepsis in pregnancy
Understanding and tackling the challenge of sepsis in pregnancy is hampered by inconsistent terminology and numerous denitions. The various terms used include puerperal sepsis, puerperal
fever, puerperal infection, puerperal pyrexia, genital tract sepsis, maternal sepsis, intrapartum
septic pyrexia, intrapartum infection, maternal pyrexia, maternal fever. Some of these terms focus
attention on the puerperium, but sepsis could also pose a serious threat to maternal health in pregnancy and in labour.
The World Health Organisation (WHO) has a denition of puerperal sepsis and a more general
denition of puerperal infections, with the intention of including infections not isolated to the genitourinary system (Table 1).12 Puerperal sepsis is dened as infection of the genital tract occurring at
any time between the rupture of membranes or labour, and the 42nd day postpartum, of which two or
more of the following are present: pelvic pain, fever 38.5  C or more, abnormal vaginal discharge,

Table 1
Denition of sepsis and infection.
Puerperal sepsis (World Health
Organization, 1995)

Puerperal infections
(World Health Organization)

ICD-10

Systemic inammatory response

syndrome (SIRS)

Sepsis
Severe sepsis

Septic shock

Infection of the genital tract occurring at any time between the rupture of membranes
or labour, and the 42nd day postpartum in which two or more of the following are
present: pelvic pain; fever 38.5 or over; abnormal vaginal discharge (e.g. pus);
abnormal smell of discharge; delay in the rate of reduction of size of uterus
(less than 2 cm a day during the rst 8 days).
A more general term than puerperal sepsis and includes all extra-genital infections
and incidental infections in addition to infections caused by sepsis. Infections of the
genitourinary system related to labour, delivery and the puerperium include
infections related to the uterus and its associated structures (endometritis); infections
related to the urinary tract; infections specically related to the birth process but not
of the genitourinary system (e.g. breast abscess). Incidental infections include malaria
and respiratory tract infections.
A temperature rise above 100.4 F (38  C) maintained over 24 h or recurring during
the period from the end of the rst to the end of the 10th day after childbirth
or abortion.
SIRS describes the inammatory process generated by localised or generalised
infection, trauma, thermal injury, or sterile inammatory processes (i.e. acute
pancreatitis). SIRS
is present when two or more of the following clinical ndings are present: body
temperature over 38  C or less than 36  C; heart rate over 90 beats/min; respiratory
rate over 20 breaths per min or PaCO2 less than 32 mmHg; white blood cells greater
than 12$109/dL or less than 4$109/dL or greater than10% immature (band) forms.
Sepsis is dened as SIRS plus infection.
Severe sepsis is sepsis associated with organ dysfunction, hypoperfusion, or
hypotension. The manifestations of hypoperfusion may include, but are not limited
to, lactic acidosis, oliguria, or an acute alteration in mental status.
Septic shock is dened as sepsis with arterial hypotension, despite adequate uid
resuscitation.

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abnormal smell of discharge, and delay in the rate of reduction of size of uterus (less than 2 cm a day
during the rst 8 days). According to the WHO, in addition to infections caused by sepsis, puerperal
infections include all extra-genital infections and incidental infections and all infections specically
related to the birth process but not of the genitourinary system. These include infections of the
genitourinary system related to labour, delivery and the puerperium; infections related to the uterus
and its associated structures (endometritis); infections related to the urinary tract (e.g. breast abscess);
and incidental infections (e.g. malaria and respiratory tract infections).
The International Classication of Diseases (ICD-10) denes sepsis as systemic disease associated
with presence and persistence of pathogenic micro-organisms or their toxins in the blood. In order to
create homogeneity, the American College of Chest Physicians and Society of Critical Care Medicine
created standard denitions of sepsis; however, this only applied to non-pregnant women.13,14 The
denition described the systemic inammatory response syndrome (SIRS), an inammatory process
generated by localized or generalized infection, trauma, thermal injury, or sterile inammatory processes. The clinical criteria for SIRS are listed in Table 1. Sepsis was thereby dened as SIRS plus
infection.
Severe sepsis is sepsis associated with organ dysfunction, hypoperfusion, or hypotension. Septic
shock is dened as sepsis with arterial hypotension despite adequate uid resuscitation.13 The
American College of Chest Physicians and Society of Critical Care Medicine sepsis denitions have not
been validated for pregnant women.
Epidemiology of sepsis in pregnancy
The reported incidence of sepsis in pregnancy is likely to be inaccurate owing to under-reporting or
erroneous classication. In the UK and the USA, contemporary data are lacking. Blanco et al.15 reported
a prevalence of bacteraemia in US obstetric patients of 7.5 per 1000 obstetric admissions, and a rate of
sepsis of 810% in that population.15
Sepsis has an insidious onset, but progression can be rapturous with a sudden catastrophic circulatory collapse and mortality up to 50%.16,17 Septic shock in pregnancy has a reported incidence of 2.3
per 100,000 maternities.15 A study in the Netherlands9 found a case fatality rate of 7.7%. Other studies
have reported rates of 12% overall maternal mortality in women admitted to the intensive care unit and
2028% maternal mortality in those with septic shock.18,19 The UK Obstetric Surveillance system is
currently carrying out a population-based case-control study to estimate the incidence of severe
maternal sepsis and investigate risk factors, causes and outcomes.
Risk factors for sepsis in pregnancy
In the 20062008 Condential Enquiries into Maternal Deaths,6 Lanceeld classication Group A
streptococcus (GAS) or Streptococcus pyogenes was a signicant cause of maternal death.6 Obstetric
interventions, obesity, maternal age over 35 years, articial reproduction, and multiple pregnancies
and low socioeconomic status are risk factors.9,20 The risk factors for maternal sepsis in pregnancy are
shown in Table 2.
Group A streptococcus
In the 20062008 the Condential Enquiries into Maternal Deaths6 reported that 13 out of the 29
maternal deaths were caused by GAS. In a study on maternal mortality in the Netherlands, GAS
accounted for 42.9% (9 out of 21) of direct maternal deaths from sepsis and 31.8% (14 out of 44) of cases
of maternal morbidity from sepsis. The reported case fatality rate for GAS was 14.3%.9 About 530% of
the populations are thought to be asymptomatic carriers.21 Spread occurs directly through contact with
mucus or droplet or skin sores, or perineal contamination. Family members, in particular, young
children or closed communities, facilitate spread.22 Group A streptococcus has a myriad of presentations, but commonly throat and respiratory tract infections. Rarely, scarlet fever, streptococcal
toxic shock syndrome, and necrotising fasciitis.6,22

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Table 2
Risk factors for sepsis in pregnancy.
Obstetric
History of group B streptococcal infection
Vaginal discharge
History of pelvic infection
Prolonged spontaneous rupture of membranes
Amniocentesis and other invasive procedures
Cervical cerclage
Caesarean section
Vaginal trauma, wound haematoma
Multiple pregnancy
Assisted reproduction
Non-obstetric
Recent sore throat or upper respiratory tract infection in family
(Group A streptococcus infection in close contacts and family members)
Anaemia
Obesity
Impaired glucose tolerance and diabetes
Impaired immunity and immunosuppressant medication
Medical conditions
Sickle cell disease
Malaria
Hepatitis
HIV/AIDS
Ethnicity: of black or other minority ethnic group origin
Maternal age over 35 years
Low socioeconomic factors
Adapted from 20062008 Condential Enquiries into Maternal Deaths,6 and Royal College of Obstetricians and Gynaecologists Green-top Guideline No. 64 a10 and b.11

Obesity
Obesity is a modern day global epidemic and escalating public health issue. It is dened as a
condition of abnormal or excessive body fat accumulation to the extent that health may be impaired.23
Body mass index (BMI, kg/m2) reects overweight if BMI is 2529.9 kg/m2, obese if BMI 30 kg/m2 or
over, and morbidly obese if BMI 40 kg/m2 or over.24 Recent UK data suggest that 24% of women aged
between 16 and 44 years are obese and 3% are morbidly obese.25 In the USA, one-third of women of
reproductive age are obese.26 Obese women have a 3.5-fold increase in the rate of infection compared
with women of an ideal BMI.27 Wound infections are common, and their rate increases with worsening
obesity.28
Caesarean section
In high-income countries, rates of caesarean section have increased and range from 14.342.7%.29
Non-medically indicated caesarean sections are also increasing.30 Caesarean section carries a ve to
20-fold increased risk of infectious morbidity compared with vaginal birth.3133 Wound infections,
urinary tract infections, pyelonephritis, respiratory tract infections, and mastitis are common. Emergency caesarean section (OR 1.39 [95% CI] 1.11 to 1.75),33 prolonged rupture of membranes over 18 h (OR
3.13 [95% CI] 1.34 to 7.38),34 increased intrapartum vaginal examinations (e.g. over 7) (OR 1.9 [95% CI]
1.23.1),35 and absence of antibiotic prophylaxis (OR 2.63 [95% CI] 1.50 to 4.6)36 further increase risks.
Prelabour rupture of membranes and chorioamnionitis
Prelabour rupture of membranes (PROM) refers to rupture of the fetal membranes before the onset
of labour. It is termed pre-term prelabour rupture of membranes (PPROM) if occurring before 37 weeks
of gestation. It occurs in about 810% of pregnancies, and PPROM occurs in about 2% of pregnancies.37,38

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Ruptured membranes are a signicant risk factor for chorioamnionitis, an acute inammation of the
chorion and placenta.6,9,39
Medical conditions
In the Condential Enquiries into Maternal Deaths report,6 three black women (two with sickle cell
disease and one with sickle cell trait) died after suffering spontaneous PPROM between 17 and 23
weeks of gestation. In sickle cell disease, autosplenectomy increases infection risk.40 In low and
middle-income countries, signicant infectious mortality from HIV/AIDS, tuberculosis, pneumonia,
and meningitis occur.41,42
Causes of sepsis in pregnancy
Sepsis presents throughout pregnancy and postpartum. In one study, 21.8% of cases occurred before
26 weeks gestation, 21.8% occurred after 26 weeks gestation, 10.3% were intrapartum, and 46.2%
postpartum.9
Early in pregnancy
Miscarriage or termination of pregnancy (abortion), particularly with retained products of
conception or inadequate antibiotic treatment, is associated with severe maternal sepsis.6
Urinary tract infections and pyelonephritis
Urinary tract infections have an incidence of 4%, and are concerning because they are often
asymptomatic.43 Pyelonephritis affects one in four pregnant women with inadequately treated urinary
tract infections.44 Urolithiasis occurs in 1 out of 1500 pregnancies, and may lead to recurrent urinary
tract infections.45 Urinary catheterisation is a risk factor.
Wound infections or surgical-site infections
Infections may occur at abdominal incision sites or perineal sites (episiotomy, third- and fourthdegree tear repair). Necrotising fasciitis is a life-threatening surgical emergency, a soft tissue infection that leads to rapid and progressive destruction of the supercial fascia and subcutaneous tissue.46
The mortality is 3060%.46 The implicated organisms are group A beta-hemolytic streptococci,
Staphylococcus aureus, anaerobic streptococci and Clostridium difcile.47 Necrotising fasciitis has been
reported after caesarean section and vaginal delivery.46,48,49
Mastitis
Mastitis may lead to breast-abscess formation requiring incision and drainage. Organisms include S.
aureus and coagulase-negative staphylococci.50 Postpartum mastitis resulting in necrotising fasciitis
caused by group A streptococci, and toxic shock syndrome caused by S. aureus51,52 have been described.
Also, community-acquired methicillin-resistant S. aureus (MRSA) causing breast abscess has been reported.53 In the Condential Enquiries into Maternal Deaths 20062008 report,6 maternal deaths occur
as a result of necrotising mastitis attributable to GAS and S. aureus.
Respiratory tract infections
Respiratory tract infections can lead to acute respiratory distress syndrome in pregnancy. The
estimated prevalence of antepartum pneumonia is similar to non-pregnant women at 0.78 to 2.7 per
1000.54 Pneumonia may be bacterial, viral and fungal. Inuenza A and B and varicella are the most
common pathogens in pneumonia in pregnancy.55 Acute varicella infection affects 0.50.7 in 1000
pregnancies.54

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Community-acquired pneumonia complicates 0.5 to 1.5 per 1000 pregnancies in the USA, and
Streptococcus pneumoniae accounts for 1520% of cases.56 Mycoplasma pneumoniae or Legionella
species are reported. Pneumonia in pregnancy is associated with a higher rate of morbidity and
mortality than among non-pregnant women. Medical co-morbidities exacerbate poor outcomes.54
Treatment with a beta-lactam antibiotic together with a macrolide cover typical and atypical
organisms.11
Consequences of maternal sepsis include septic shock, endotoxic shock, circulatory collapse, and
fetal demise.6,18,57 The causes of sepsis in pregnancy are presented in Table 3.
Micro-organisms in maternal sepsis
The major contributor to severe maternal sepsis, GAS, has been described above. Group B streptococcus (Streptococcus agalactiae) has a vaginal carriage rate of 2030% in women of reproductive
age.58,59 Group B streptococcus can cause urosepsis, endometritis, mastitis, wound infections, and
meningitis.60 Group B streptococcus bacteriuria affects 8% of pregnancies,61,62 and causes about 10% of
cases of acute pyelonephritis.63
Escherichia coli is the most common pathogen in urinary tract infections in pregnancy.64 Proteus
mirabilis and Klebsiella pneumoniae also cause urosepsis.65 Resistance is an increasing problem with
gram-negative bacteria that produce extended-spectrum beta-lactamases.6
S. aureus, E. coli, and anaerobes are common causes of bacteraemia after caesarean section.66 The
Condential Enquiries into Maternal Deaths report6 identied one maternal death from PantonValentine leukocidin caused by Methicillin-resistant S. aureus MRSA after caesarean section. Listeria
monocytogenes is more classically associated with fetal loss; however, it can cause severe maternal
sepsis.6668
Other organisms include Enterococcus faecalis, S. aureus (MRSA), coliforms, S. pneumoniae, Morganella morganii and Clostridium septicum.6
In low- and middle-income countries, human immunodeciency virus and acquired immunodeciency syndrome, Pneumocystis carinii pneumonia, tuberculosis, and malaria are signicant contributors to maternal sepsis.69 In countries where these organisms are not normally signicant
contributors, these organisms should be tested for and excluded when immigrant women present with
sepsis.

Table 3
Causes of sepsis in pregnancy.
Pregnancy-related infections
Chorioamnionitis
Endometritis
Wound infection
Perineal infection
Mastitis
Infection related to regional anaesthesia
General infections
Pharyngitis
Gastroenteritis
Respiratory tract infection and pneumonia
Hepatitis
Urinary tract infection
Pyelonephritis
Chicken pox
Sickle cell sepsis
Malaria
Human immunodeciency virus
Appendicitis
Pancreatitis
Adapted from 20062008 Condential Enquiries into Maternal Deaths,6 and Royal College
of Obstetricians and Gynaecologists Green-top Guideline No. 64 a10 and b.11

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Diagnosis
Clinical presentation of maternal sepsis
Symptoms and signs may be subtle. Physiological cardio-respiratory changes and the maternal
immune system modulated in pregnancy may mask the initial symptom.6,70
Symptoms may be u like. A sore throat or upper respiratory-tract symptoms may point to GAS.
Vomiting and diarrhoea suggest severe sepsis. Symptoms may be system dependent (e.g. supra-pubic
pain and ank pain with urosepsis). Pyrexia is not always present, and women may be hypothermic.
Analgesics and antipyretics can be falsely reassuring. Sepsis may lead to fetal compromise or demise.
Prompt hospital referral is indicated for women in the community.6 Common clinical presentations are
listed in Table 4.
Investigation and monitoring
Blood should be obtained for culture, full blood count, urea and electrolytes C-reactive protein,
arterial blood gas analysis, and plasma lactate measurement. Swabs should be sent, and antibiotic
treatment tailored for the suspected infection. Symptoms of tonsillitis or pharyngitis warrant a throat
swab. Vaginal swabs, placental swabs, sputum, cerebrospinal uid, epidural site swab, caesarean
section or episiotomy site wound swabs, expressed breast milk, and urine for microscopy culture and
sensitivity. A stool sample and C. difcile toxin testing should be carried if diarrhea is present. Imaging
with chest or abdominal X-ray, ultrasound scan, computerized, tomography or magnetic resonance
scan should be carried out to search for the source of the infection. Fetal monitoring or delivery is
individualised.
Early involvement of the consultant obstetrician, clinician, anaesthetist, microbiologist, and
intensivist is recommend, with timely critical-care-unit admission if there is clinical deterioration.
Regular observations should be made with Modied Early Obstetric Warning Score systems.10,11
Treatment
High-dose broad-spectrum intravenous antibiotics should be administered as early as possible,
always within the rst hour of recognising severe sepsis and septic shock. Blood cultures should have
been obtained before antibiotic administration; however, this should not delay antibiotic treatment.
Surgery may be necessary to remove the source of the sepsis.
Rapid deterioration may occur, and circulatory support should be given with uid resuscitation,
inotropic support, and cardiovascular monitoring in a controlled critical-care environment. The Surviving

Table 4
Septic shock care bundle management.
The care bundle should be applied within 6 h:
1. Measure serum lactate.
2. Obtain blood cultures and culture swabs before antibiotic administration.
3. Administer broad-spectrum antibiotic(s) within the rst hour of recognition of severe sepsis and septic shock
according to local protocol.
4. In the event of hypotension, lactate over 4 mmol/l, or both:
Deliver an initial minimum of 20 ml/kg of crystalloid or colloid
Once adequate volume replacement has been achieved, a vasopressor (e.g. norepinephrine, epinephrine), inotrope
(e.g. dobutamine), or both, may be used to maintain mean arterial pressure over 65 mmHg.
Further management consists of:
5. In the event of hypotension despite uid resuscitation (septic shock), lactate over 4 mmol/l, or both:
Achieve a central venous pressure of at least 8 mmHg (or over 12 mmHg if the woman is mechanically ventilated)
with aggressive uid replacement.
Consider steroids.
6. Maintain oxygen saturation with facial oxygen. Consider transfusion if haemoglobin is below 7 g/dl.
Adapted from Dellinger RP et al., 2008.,71 RCOG Green-top Guideline No. 64,10,11 and Lucas et al., 2012.70

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sepsis campaign resuscitation bundle is an International guideline for the management of severe sepsis
and septic shock.71 The sepsis care bundle should be applied immediately or within 6 h of suspicion or
recognition of severe sepsis.71 Non-compliance with the 24-h sepsis bundle results in a 76% increase in
risk for hospital death.72 The Royal College of Obstetricians and Gynaecologists recommends that septic
shock should be managed in accordance with the Surviving Sepsis Campaign guidelines.10,11 Salient
points of the management of sepsis are presented in Table 4.
Maternal complications include adult respiratory distress syndrome, renal failure, hepatic failure,
thromboembolism, cardiovascular collapse, cerebral ischaemia, and disseminated intravascular coagulation. Prognosis is poor if initial diagnosis is delayed, the patient has pre-existing debilitating disease,
a poor response to uid resuscitation, reduced cardiac output, reduced oxygen extraction, high serum
lactate (greater than 4 mmol/L), and multiple organ dysfunction.10
Antibiotic treatment
Antibiotic treatment should continue for 710 days with regular review. Limitations in antibiotic
bacterial coverage, medical co-morbidities, and patient allergies should be noted. For critically ill cases
of suspected GAS infection not responding to rst-line treatment, The Royal College of Obstetricians
and Gynaecologists recommends intravenous immunoglobulin (doses of 12 g/kg), which may facilitate clearance of bacterial toxins.10 Antibiotic treatment is presented in Table 5.
Risk management in sepsis in pregnancy
Risk management describes the culture, processes and structures that are directed towards realising potential opportunities whilst managing adverse effects.73 It is the systematic identication,
assessment, evaluation and management of risk. In the UK, risk management is encouraged by the
RCOG, patient safety agencies, Clinical Negligence Scheme for Trusts (a scheme that rewards maternity
units that meet risk standards with a discount) amongst others. Improved outcomes reduce complaints
and legal claims.74
Risk-management strategies can be applied to improve outcomes in maternal sepsis. As an example,
an integrative framework for implementing and monitoring risk management (Raise Awareness,
Design for safety, Involve users, Collect and Analyse patient safety data, and Learn from patient safety
[RADICAL]) can be applied to sepsis.75 The different elements are discussed below.
Raise awareness
Healthcare professionals should be made aware of the danger and risk factors of sepsis through
education, guidelines, skills training, and multidisciplinary forums. For example, the 20062008
Condential Enquiries into Maternal Deaths6 report describes red ag symptoms of sepsis.

Table 5
Suggested intravenous antibiotic treatments in obstetric sepsis.
Where the organism is unknown and
the woman is not critically ill
In cases of allergy to penicillin and
cephalosporins
In severe sepsis or septic shock

If Group A streptococcal infection

is suspected
If there are risk factors for methicillinresistant Staphylococcus aureus

Co-amoxiclav 1.2 g 8-hourly or cefuroxime 1.5 g 8-hourly or cefotaxime

12 g 8-hourly or 6-hourly plus metronidazole 500 mg 8-hourly.
Use clarithromycin 500 mg 12-hourly or clindamycin 600 mg to 1.2 g
8-hourly or 6-hourly plus gentamicin to give Gram-negative cover, while
waiting for microbiological advice.
Seek urgent microbiological advice Piperacillintazobactam 4.5 g 8-hourly
or ciprooxacin 600 mg 12-hourly plus gentamicin 35 mg/kg daily in
divided doses every 8 hours by slow intravenous injection. A carbapenem
such as meropenem 500 mg to 1 g 8-hourly /gentamicin. Metronidazole
500 mg 8-hourly may be considered to provide anaerobic cover.
Clindamycin 600 mg to 1.2 g three or four times daily, 8-hourly is more
effective than penicillins.
Add teicoplanin 10 mg/kg 12-hourly for three doses, then 10 mg/kg
24-hourly or linezolid 600 mg 12-hourly.

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Design for safety

Examples from this element of the framework include (1) optimising pre-pregnancy health in
women with pre-existing medical conditions; (2) using local infection control policies (hand hygiene or
septic patient septic side room isolation), antibiotic prophylaxis to contacts, and notication of
communicable infections; (3) use of the Modied Early Obstetric Warning Score; (4) use of Surviving
Sepsis Resuscitation Bundle or local guideline; and (5) effective communication between healthcare
staff (situation, background, assessment, recommendation [SBAR]).
Further examples are presented in Table 6.
Skin preparation
Pre-operative skin preparation techniques used to prevent infection include hair removal and
antiseptic. A recent Cochrane review76 involving ve randomised-controlled trials, with a total of 1462
women, evaluated the effects of different methods of preoperative skin preparation in preventing
infection after caesarean section. No difference was found in wound infection in the following comparison groups; drape compared with no drape (two trials of 1294 women, one trial using iodine and
the other using chlorhexidine); alcohol scrub and iodophor drape compared with iodophor scrub
without drape (one trial of 79 women); parachlorometaxylenol plus iodine compared with iodine
alone (one trial of 50 women).76 Two trials evaluated methods to prevent endometritis and reported no
difference; alcohol scrub and iodophor drape compared with iodophor scrub only (one trial); parachlorometaxylenol plus iodine compared with iodine alone (one trial of 50 women).76
Table 6
Design for safety measures in sepsis prevention and management.
Cause of sepsis
Surgical site infection

Design for safety

Preoperative surgical hand wash
Hand hygiene
Double gloving
Surgical mask and gown
Aseptic technique
Caesarean section
Avoid unnecessary vaginal examinations or instrumentation in labour
Pre-operative skin preparation with antiseptic
Antibiotics at caesarean section
Bladder care
Appropriate microscopy, culture and sensitivity
Appropriate wound swab

Urinary tract infection/Pyelonephritis

Pelvic abscess
Perineal infection

Thrombophlebitis
Mastitis

Prelabour rupture of membranes

Termination of pregnancy or abortion

Perineal infection
Appropriate antibiotic
Surgical exploration of episiotomy or drainage and debridement if indicated
Computerised tomography scan if indicated
Appropriate wound swab
Third-degree tear antibiotics
Appropriate microscopy, culture and sensitivity
Appropriate antibiotic (oral or intravenous)
Ultrasound or computerised tomography scan
Appropriate antibiotic or surgical management
Erythema or swelling, hip pain, discharge
Antibiotic or exploration of episiotomy or drainage and debridement. May
require computerised tomography scanning.
Anticoagulation low-molecular-weight heparins.
Immediate referral to hospital if there is no response to oral antibiotics within
48 h if mastitis recurs or symptoms severe or unusual symptoms.
Culture of breast milk or abscess.
Appropriate microscopy, culture and sensitivity of swabs Antibiotics
Appropriate microscopy, culture and sensitivity of swabs
Prophylactic antibiotics

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Specic indications for antibiotics

Antibiotics are indicated for women undergoing surgical and medical termination of pregnancy.6,77
Prophylactic antibiotics in premature rupture of membranes and preterm premature rupture of
membranes are associated with reductions in chorioamnionitis and endometritis, respectively.78,79 In
the UK, the RCOG recommends broad-spectrum antibiotics after obstetric anal sphincter repair.80
The benets of prophylactic antibiotics in reducing infection in women undergoing caesarean
section are undisputed.81 Ampicillin and rst-generation cephalosporins are equally effective in
reducing postoperative endometritis. A single dose of rst-generation cephalosporin is as efcacious as
multiple doses of broad-spectrum agents.82 Although there is agreement on the use of antibiotics to
prevent infection after caesarean section, the timing of administration of antibiotics is controversial.83
Some clinicians advocate pre-operative administration, whereas others suggest administration after
umbilical cord clamping.8486 Recent evidence favours pre-operative administration, with up 41%
reduction in the rate of endometritis compared with intraoperative administration in one study.84,87
Involve users
Incidents of severe sepsis or near miss cases should be reported in an open culture. Examples
include medication error in antibiotics, inappropriate choice of antibiotics, retained swabs, unsterile
equipment, unplanned critical care admission, failure of senior input when required, and protocol
violation and service user complaint. Patient and healthcare professional opinions should also be
encouraged. Safety newsletters will ensure all users are informed of outcomes.
Collect and analyse data
Cases of sepsis should be collected and standards audited. This allows evaluation of temporal trends
and benchmarking. Root cause analysis of high-risk cases should be carried out.
Learn from incidents
Lessons learned from cases of sepsis should be shared though multidisciplinary meetings.
Improvement science in maternal sepsis
Evidence shows that current approaches are not effective enough in predicting sepsis in pregnancy.6,88 Quality improvement is an emerging process that aims to translate research evidence into
clinical practice through a process of learning and implementing small changes, leading to a sustained
improvement in patient care and outcomes.89 WE Deming conceptualised improvement science, a
theory of profound knowledge and model of improvement. His theories helped to improve post-war
Japanese manufacturing.90
The model of improvement asks three questions; What are we trying to accomplish? How will we
know that a change is an improvement? What change can we make that will result in improvement?
The answers are combined with plan, do, study, act (PDSA) or Shewhart cycle, where small changes
are carried out, tested, the impact of change evaluated through data collection, and changes amended
and re-tested before nal implementation. Leadership and addressing challenges in human relationship and behaviors are essential for improvement.90
One recent study using quality improvement showed a reduction in the overall rate of caesarean
section wound infections from 3.1% to 1%. Interventions such as preoperative surgical hand wash,
which was improved by a hand-wash timer being installed at every sink in the operating room, was
implemented.91 Potentially, PDSA cycles may result in the implementation of sepsis integrated care
pathways and infection care bundles and laminated icon charts amongst others.
Conclusion
In this chapter, the risks and consequences of maternal sepsis have been highlighted. The take
home message for healthcare professionals is the need to increase awareness of this maternal sepsis

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593

and instigate early treatment. Quality-improvement initiatives on implementing evidence-based

maternal sepsis recommendations are required.
Conict of interest
None declared.

Practice points
 Early recognition and early treatment are vital in the management of maternal sepsis.
 The Surviving sepsis resuscitation bundle or similar protocols should be used in suspected
maternal sepsis.
 Healthcare professionals need to be vigilant in caring for women with pre-existing prepregnancy medical conditions or those newly diagnosed in pregnancy, because of maternal
immunosuppression and the increased risk of infection.

Research agenda
 To create a standard universal denition of sepsis in pregnancy and investigate the true
incidence of mortality and morbidity in maternal sepsis.
 The extent of morbidity from sepsis and its effect on a womans overall birth experience,
quality of life and subsequent birth option is unknown and needs to be ascertained.
 Quality improvement and implementation projects in maternal sepsis should be undertaken.

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