Bacterial Sepsis in Pregnancy and the Puerperium NHSCT/12/616

This is an official Northern Trust policy and should not be edited
in any way
Bacterial Sepsis in Pregnancy and the
Reference Number:
Target audience:
This policy is directed to Obstetricians, Midwives, Anaesthetists, Paediatricians,
Neonatologists, Neonatal Nurses, Student Midwives and Medical Students.
Sources of advice in relation to this document:
Caroline Diamond, Lead Midwife
Sinead O’Kane, Head of Midwifery and Gynae Services
Replaces (if appropriate): N/A
Type of Document:
Directorate Specific
Approved by:
Policy, Standards and Guidelines Committee
Date Approved:
14 September 2012
Date Issued by Policy Unit:
13 November 2012
NHSCT Mission Statement
To provide for all the quality of services we would expect for our families
and ourselves
Bacterial Sepsis in Pregnancy
and the Puerperium
September 2012
Bacterial Sepsis in Pregnancy and the Puerperium
1. Introduction to the Policy
In the 2006-2008 Report of the Confidential Enquiries into Maternal Deaths,
sepsis rose to be the leading cause of direct maternal deaths in the UK.
Substandard care, in particular lack of recognition of signs of sepsis and lack
of guidelines on the investigation and management of genital tract sepsis,
were identified in many cases with deaths due to Group A Streptococcal
(GAS) having risen to 13 women.
2. Aim of policy
The purpose of this guideline is to provide guidance on the recognition and
management of sepsis in pregnancy and in the puerperium (i.e. sepsis
developing after birth until 6 weeks postnatally), in response to the findings of
the Centre for Maternal and Child Enquires (CMACE) Eighth Report on
Confidential Enquiries into Maternal Deaths in the United Kingdom (CMACE,
3. Target Audience
This policy is directed to Obstetricians, Midwives, Anaesthetists,
Paediatricians, Neonatologists, Neonatal Nurses, Student Midwives and
Medical Students.
4. Responsibilities
Clinical Director
The Clinical Director is accountable for ensuring that the policy and guidelines
are fit for purpose and their effectiveness evaluated.
He will seek assurance from Managers that the policy is implemented and
practice is consistent with policy.
Managers (or their nominated lead)
Managers with responsibility for clinical or care will be accountable for
that the policy and guidelines are implemented in all services
that directorate audit plans include audit and audit findings are
when the need for training is identified, it is resourced;
releasing staff for training when there is an assessed need; and
ensuring dissemination and easy access to policy.
Clinical and Care Staff
All staff are individually responsible for ensuring that:
their practice is consistent with the law, the NHSCT guidelines and
Trust policy; and
patients and clients are given information and, when appropriate,
written information on the procedure/intervention they may be
consenting to in a format/language, as appropriate.
5. Policy statement
Sepsis may be defined as infection plus systemic manifestations of infection.
Severe sepsis may be defined as sepsis plus sepsis-induced organ
dysfunction or tissue hypoperfusion.
Septic shock is defined as the persistence of hypoperfusion despite
adequate fluid replacement therapy.
Severe sepsis with acute organ dysfunction has a mortality rate of 20-40%
which rises to 60% if septic shock develops. The onset of life-threatening
sepsis in pregnancy or the puerperium can be insidious, with rapid clinical
deterioration. All health professionals need to be aware of the signs and
symptoms of maternal sepsis and how rapidly the condition can develop into
severe sepsis and septic shock.
Risk factors for maternal sepsis in pregnancy as identified by the
Confidential Enquiries into Maternal Deaths
Impaired glucose tolerance/ diabetes
Impaired immunity/ immunosuppressant medication
Vaginal trauma, caesarean section, wound haematoma
Retained products of conception
Vaginal discharge
History of pelvic infection
History of group B streptococcal infection
Amniocentesis and other invasive procedures
Cervical cerclage
Prolonged spontaneous rupture of membranes
GAS infection in close contacts/ family members
Black or other ethnic minority groups
All healthcare professionals should be aware of the signs and
symptoms of maternal sepsis and of the rapid, potentially lethal course
of severe sepsis and shock. Suspicion of significant sepsis should
trigger an urgent referral to secondary care.
Signs and Symptoms and likely causes of sepsis in pregnancy and the
Vomiting +/- diarrhoea
Constant severe abdominal or pelvic pain and tenderness
Rash, generalised streptococcal maculopapular rash or purpura fulminans
Temp < 36 or > 38°C
Pulse > 90beats
Resp > 20 breaths
Hypotension/Pallor / Clamminess
Sub-involution of the uterus and/ or offensive lochia
Productive cough
Fetal tachycardia
WCC < 4 or > 12 x 10 and/or raised C - reactive protein
Impaired consciousness
Failure to respond to treatment
Hypoxia early or late depending on source of infection
Poor peripheral perfusion (prolonged capillary refill)
Glucose > 7.7(not diabetic)
Investigations when sepsis is suspected
Blood cultures are the key investigation and should be obtained prior to
antibiotic therapy.
Other samples as guided by clinical suspicion of focus of infection e.g. throat
swabs, midstream urine, high vaginal swab; cerebrospinal fluid may also be
Other investigations should include FBC, CRP, U&E, LFT, Coagulation
screen. Aim to obtain samples within the first hour of the suspicion of sepsis.
Tests can be repeated at least 6hours as indicated by the clinical situation.
Serum lactate should be measured within 6 hours of the suspicion of severe
sepsis in order to guide the need for referral to critical care colleagues.
Results may be as follows: Normal level 0.5-1.0mmol/litre. Level > 2.0mmol/l
indicate sepsis. But the critical level for concern is level > 5.0mmol/l. This
can be obtained from ABG however if difficulty obtaining arterial sample,
venous sample can be used.
Management of sepsis
Monitoring of the woman with suspected/ established sepsis should be
multidisciplinary but preferably under the leadership of a single consultant.
The expert advice of a consultant microbiologist and/or infection control team
should be sought when serious sepsis is involved.
As soon as a diagnosis of severe sepsis is suspected the ‘Surviving Sepsis
Campaign Resuscitation Bundle’ (Dellinger et al, 2008) should be undertaken
within an hour as survival chances are greatly improved. (Appendix 1)
Regular observations of all vital signs (including temperature, pulse, blood
pressure and respiratory rate) should be recorded on a Modified Early
Warning Score (MEOWS) chart. Abnormal scores should not just be
recorded but should also trigger an appropriate response (CMACE, 20062008).
All staff taking observations should have annual training in the use of the
MEOWS chart.
Community carers should be aware of the importance of early referral to
hospital of recently delivered women who feel unwell and have pyrexia.
Women with sepsis in the puerperium are best managed in a hospital where
diagnostic services are easy to access and intensive care facilities are readily
The woman should be isolated in a single room with en suite facilities to
reduce the risk of transmission of infection.
Healthcare workers should use appropriate personal protective equipment
(PPE) when in direct contact with the woman and their immediate
The presence of shock or other organ dysfunction is an indication for
admission to ICU.
Treatment in the antenatal period
Treatment, including delivery should not be delayed once septicaemia has
developed because deterioration can be extremely rapid.
Administration of intravenous broad spectrum antibiotics within 1 hour of
suspicion of sepsis with or without septic shock.
If pelvic sepsis is suspected a combination of high dose broad spectrum
antibiotics is recommended.
Intravenous immunoglobulin (IVIG) is recommended for severe invasive
streptococcal or staphylococcal infection if other therapies have failed.
A decision on the timing and mode of birth should be made by a senior
obstetrician following a discussion with the patient anaesthetist and neonatal
Cautious consideration should be given to the use of corticosteroids for fetal
lung maturity in the woman with sepsis.
Changes in fetal CTG such as baseline variability or new onset decelerations
must prompt reassessment of maternal mean arterial pressure, hypoxia and
Epidural/Spinal anaesthesia should be avoided in women with sepsis and a
general anaesthetic will usually be required.
Treatment in the Intrapartum period
At term maternal pyrexia may be defined as a temperature of 37·8°C or
higher during labour. A temperature of 37·5°C may be of less significance in a
woman undergoing a prostaglandin induction or an epidural.
Administer Paracetamol 1G IV 4 hourly.
Secure aseptically IV access using 16G cannula – document IV bundle details
and file within the medical notes.
Commence continuous fetal monitoring.
Administer antibiotic therapy (after cultures, swabs have been taken.
Advise Neonatal paediatrician of sepsis in labour / consult with anaesthetist
about need for postpartum Intensive Care.
When a mother has been found to have invasive Group A streptococcal
infection in the intrapartum period, prophylactic antibiotics should be
administered to the baby. Close household contacts should be warned to
seek medical attention should symptoms develop and may warrant
prophylaxis. MRSA and Group A β-haemolytic Streptococci are easily
transmitted via the hands of healthcare workers and via close contacts in
Invasive group A Streptococcal infections are notifiable and the Infection
control team and Consultant for communicable diseases should be informed.
Indication for transfer to ICU
Hypotension or raised serum lactate
persisting despite fluid resuscitation
suggesting the need for inotrope
Pulmonary oedema
Mechanical ventilation
Airway protection
Tracheal toilet
Renal replacement therapy
Significantly decreased conscious
Multi-organ failure
Uncorrected acidosis
Treatment in the puerperium
Puerperal sepsis is defined as infection of the genital tract occurring at any
time between the onset of rupture of membranes or labour, and the 42nd day
postpartum in which two or more of the following are present:
Pelvic pain,
Fever i.e. oral temperature 38.5°C/101.3°F or higher on any occasion,
Abnormal vaginal discharge, e.g. presence of pus,
Abnormal smell/foul odour of discharge,
Delay in the rate of reduction of the size of the uterus (involution) (<2 cm/day
during first 8 days.
Puerperal infections are a more general term than puerperal sepsis and
include not only infections due to puerperal sepsis, but also all extra-genital
infections and incidental infections. Mastitis, urinary tract infection,
pneumonia, skin and soft tissue infection, gastroenteritis and pharyngitis.
Sepsis should be considered in all recently delivered women who feel unwell
and have pyrexia. A history of recent sore throat or (prolonged) contact with
family members with known streptococcal infections (pharyngitis, impetigo,
cellulitis) has been implicated in cases of GAS sepsis.
The common symptoms are fever, diarrhoea, vomiting, abdominal pain, rash
(generalised streptococcal or staphylococcal maculopapular rash) offensive
vaginal discharge and wound infection.
Mastitis must never be over looked.
Agonising pain, fever (greater than 38°C) and tachycardia (greater than
100bpm) are indications for intravenous antibiotics and clinical review.
6. Equality, Human Rights and DDA
The policy is purely clinical in nature and will have no bearing in terms of its
likely impact on equality of opportunity or good relations for people within the
equality and good relations categories.
7. Alternative formats
This document can be made available on request on disc, larger font, Braille,
audio-cassette and in other minority languages to meet the needs of those
who are not fluent in English.
8. Sources of Advice in relation to this document
The policy author, responsible assistant director or director as detailed on the
policy title page should be contacted in relation to any queries on the content
of this policy.
Centre for Maternal and Child Enquiries (CMACE). 2006–08 Saving Mothers’
Lives: reviewing maternal deaths to make motherhood safer: The Eighth
Report on Confidential Enquiries into Maternal Deaths in the United Kingdom.
BJOG 2011;118 Suppl 1:1–203.2.
Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke Ret
al.(2008). Surviving Sepsis Campaign: International guidelines for
management of severe sepsis and septic shock. Crit Care Med;36:296–327
[published correction appears in Crit CareMed 2008;36:1394-1396].
Royal College of Obstetricians and Gynaecology. 2010 Green Top
Guideline No. 64a Bacterial Sepsis in Pregnancy. London: RCOG; 2010.
Royal College of Obstetricians and Gynaecology. 2010 Green Top
Guideline No. 64b Bacterial Sepsis following Pregnancy. London: RCOG;
Appendix 1
Consider sepsis
Known/ suspected infection and any 2 of the following (SIRS criteria)
Heart rate >100bpm
Resp rate >20/min
White cell count <4 or >12 x109/l
(exception: up to 16 x 109/l is normal in third trimester and in labour)
Temperature <36 or >38.3°C
Altered mental state
(eg drowsy, restless, agitated, unresponsive)
Contact obstetric registrar to review woman
Inform midwife/ sister in charge on ward and on delivery
Inform anaesthetic registrar covering delivery suite
Within first hour
Move to delivery suite special monitoring room
1. High flow oxygen by facemask to keep SpO2 > 95%
2. Fluid challenge if systolic blood pressure <90mmHg or lactate >2. Suggest
500mls Hartmanns solution initially
3. Measure lactate either on arterial blood gas or a venous sample (heparinised
sample in ABG machine)
4. Blood cultures and any other cultures as indicated (eg urine, wound swab etc)
5. Give IV antibiotics eg piperacillen-tazobactam 4.5mg IV 8hrly and
gentamicin 5mg/kg IV 24hrly. Consult microbiologist in serious penicillin allergy
or complex cases
Measure hourly urine output and other observations at least every 15 mins
Airway compromise or profound hypotension at any time call for immediate
assistance from anaesthetics
• After first hour, assess response in lactate and other
• If not returned within normal limits, request anaesthetics review
for consideration of ICU admission