Skip to main content
  1. Right Decisions
  2. GGC - Clinical Guideline Platform
  3. Maternity
  4. Back
  5. Infections (Maternity)
  6. Maternal Sepsis (572)
Announcements and latest updates

Right Decision Service newsletter: April 2024

Welcome to the Right Decision Service (RDS) newsletter for April 2024. 

Issues with RDS and Umbraco access

Tactuum has been working hard to address the issues experienced during the last week. They have identified a series of three mitigation measures and put the first of these in place on Friday 3rd May.  If this does not resolve the problems, the second mitigation will be actioned, and then the third if necessary.

Please keep a lookout for any slowing down of the system or getting locked out. Please email myself, mbuchner@tactuum.com and onivarova@tactuum.com if you experience any problems, and also please raise an urgent support ticket via the Support Portal.

Thank you for your patience and understanding while we achieve a full resolution.

Promotion and communication resources

A rotating carousel presenting some of the key RDS tools and capabilities, and an editable slideset, are now available in the Resources for RDS providers section of the Learning and Support toolkit.

Redesign and improvements to RDS

The redesign of RDS Search and Browse is still on-track for delivery by mid-June 2024. We then plan to have a 3-week user acceptance testing phase before release to live. All editors and toolkit owners on this mailing list will be invited to participate in the UAT.

The archiving and version control functionality is also progressing well and we will advise on timescales for user acceptance testing shortly.

Tactuum is also progressing with the deep linking to individual toolkits within the mobile RDS app. There are several unknowns around the time and effort required for this work, which will only become clear as the work progresses. So we need to be careful to protect budget for this purpose.

New feature requests

These have all been compiled and effort estimated. Once the redesign work is complete, these will be prioritised in line with the remaining budget. We expect this to take place around late June.

Evaluation

Many thanks to those of you completed the value and impact survey we distributed in February. Here are some key findings from the 65 responses we received.

Figure 1: Impact of RDS on direct delivery of care

Key figures

  • 93% say that RDS has improved evidence-informed practice (high impact 62%; some impact 31%)
  • 91% report that RDS has improved consistency in practice (high impact 65%, some impact 26%)
  • 85% say that RDS has improved patient safety (high impact 59%, some impact 26%)
  • Although shared decision-making tools are only a recent addition to RDS, and only represent a small proportion of the current toolset, 85% of respondents still said that RDS had delivered impact in this area (53% high impact, 32% some impact.) 92% anticipate that RDS will deliver impact on shared decision-making in future and 85% believe it will improve delivery of personalised care in future.

Figure 2 shows RDS impact to date on delivery of health and care services

 

Key figures

These data show how RDS is already contributing to NHS reform priorities and supporting delivery of more sustainable care.

Saving time and money

  • RDS clearly has a strong impact on saving practitioner time, with 90% of respondents reporting that this is the case. 65% say it has a high impact; 25% say it has some impact on time-saving.
  • It supports devolved decision-making across the multi-professional team (85% of respondents)
  • 76% of respondents confirm that it saves money compared, for example, to investing in commercial apps (54% high impact; 22% some impact.)
  • 72% believe it has impacted already on saving money and reducing waste in the way services are delivered – e.g. reducing costs of referral management, prescribing, admissions.

Quality assurance and governance

  • RDS leads are clear that RDS has improved local governance of guidelines, with 87% confirming that this is the case. (62% high impact; 25% some impact.)

Service innovation and workforce development

  • RDS is a major driver for service innovation and improvement (83% of respondents) and has impacted significantly on workforce knowledge and skills (92% of respondents – 66% high impact; 26% some impact).

New toolkits

A few examples of toolkits published to live in the last month:

Toolkits in development

Some of the toolkits the RDS team is currently working on:

  • SARCS (Sexual Assault Response Coordination Service)
  • Staffing method framework – Care Inspectorate.
  • SIGN 171 - Diabetes in pregnancy
  • SIGN 158 – British Guideline on Management of Asthma. Selected sections will be incorporated into the RDS, and complemented by a new chronic asthma pathway being developed by SIGN, British Thoracic Society and NICE.
  • Clinical pathways from NHS Fife and NHS Lanarkshire

Please contact his.decisionsupport@nhs.scot if you would like to learn more about a toolkit. The RDS team will put you in touch with the relevant toolkit lead.

Quality audit of RDS toolkits

Thanks to all of you who have responded to the retrospective quality audit survey and to the follow up questions.  We still have some following up to do, and to work with owners of a further 23 toolkits to complete responses. An interim report is being presented to the HIS Quality and Performance Committee.

Implementation projects

Eight clinical services and two public library services are undertaking tests of change to implement the Being a partner in my care app. This app aims to support patients and the public to become active participants in Realistic Medicine. It has a strong focus on personalised, person-centred care and a library of shared decision aids, as well as simple explanations and videoclips to help the public to understand the aims of Realistic Medicine.  The tests of change will inform guidance and an implementation model around wider adoption and spread of the app.

With kind regards

Right Decision Service team

Healthcare Improvement Scotland

Maternal Sepsis (572)

Please report any inaccuracies or issues with this guideline using our online form

NB  Sepsis can kill mothers AND babies. If either of this pairing is infected ensure that those looking after the mother/baby know about this promptly to ensure risk evaluation of cross-infection is made.

Sepsis remains an important cause of maternal death (1). The development of sepsis is often insidious and the physiological adaptations in normal pregnancy may mask developing sepsis or make it more difficult to identify. Once infection becomes systemic the woman’s condition can deteriorate extremely rapidly over the course of a few hours into septic shock, disseminated intravascular coagulation and multi-organ failure2. A high index of suspicion should be maintained.

Briefly learn that SIRS > sepsis > septic shock unless appropriate action taken

 SIRS (systemic inflammatory response syndrome) -  a  clinical state consisting of two or more coexisting conditions: fever or hypothermia, tachycardia, tachypnoea, and an abnormally high leukocyte count.

Severe sepsis with acute organ dysfunction has a mortality rate of 20-30%, rising to 40-50% if septic shock (sepsis with hypotension refractory to fluid resuscitation) develops. Severe Sepsis with multi-organ failure carries a mortality rate >60%3.

The purpose of this guideline is to provide a structured approach to investigation and management of these women. The screening tool is to be filed in the patient notes and completed goals documented.

  • IT IS IMPORTANT TO NOTE THAT MOST LABOURING WOMEN WILL MEET NON-PREGNANT “SIRS” CRITERIA: see MODIFIED MATERNITY SEPSIS TOOL BELOW
  • SIMILARLY, NON-PREGNANT RISK ASSESSMENTS (eg CURBS 65) DO NOT PERFORM WELL IN THE PREGNANT POPULATION.
  • IF IN DOUBT MANAGE AS SEPSIS AND THEN REVIEW DIAGNOSIS.

Signs and symptoms

Modified Early Warning Scoring System charts should be used to aid timely recognition, treatment and referral of women who have or who are developing a critical condition. These do not take into account the physiological changes in pregnancy, however, they allow a trend in the patients’ observations to be documented and acted upon. SEE SEPSIS SCREENING TOOL BELOW

In labour changes in some parameters are highlighted in red and should be considered. Err on overdiagnosis / response if in doubt

Temperature <36°C or >38°C 4

In labour a temperature of ≥ 37.5°C on 2 separate occasions at least 2 hours apart

Persistent tachycardia > 100bpm5
Or

>110bpm in labour

Tachypnoea >20 breaths per minute4
Or

>22 in labour

WCC <4 or >16 x 109 /L  4

WCC in labour >20 x 109 /L(although WCC of up to 30 have been seen in labour, a WCC of 20 is the generally recommended threshold for investigation in the literature)3,5

Oliguria <0.5mls/hour4

Arterial Hypoxaemia <8k Pa on air and/or metabolic acidosis pH <7.35 / H+ >45nmol/l

(pregnancy results in a relative respiratory alkalosis)4

Hypotension MAP <65mmHg or systolic BP <90mmHg4

Abnormal U&Es, LFTs , Coagulation 

CRP – However a normal CRP may be falsely reassuring and does not rule out systemic sepsis.  There is often a delay in CRP increase in acute sepsis.

Fetal tachycardia and/or non reassuring CTG

  • this can be evidence of intrauterine infection / choriomamnioitis
  • these changes may serve as an early warning sign for derangements in maternal end-organ systems  

Hyperglycaemia in the absence of diabetes


The Common Organisms

The organisms most commonly implicated are2:

  • Streptococcus pyogenes ( Group A strep)
  • Group B streptococcus 
  • Escherichia coli
  • Staphylococcus aureus
  • Gram- positive and gram – negative mixed infections
  • Streptococcus pneumoniae
  • Klebsiella
  • Enterococcus faecalis
  • MRSA

Investigations

Seek the organism

This should ideally be guided by the history and take place before administration of antibiotics – HOWEVER, do not delay starting antibiotic therapy.

  • Take a History and examine the patient
  • Blood cultures
  • Midstream specimen of urine
  • Stool cultures
  • Vaginal swabs
  • Wound/perineal swabs
  • Placental swabs if delivered
  • Baby/fetal swabs if delivered
  • Chest X ray
  • Throat swabs
  • Imaging of the abdomen if suspected intra-abdominal sepsis
  • Breast examination
  • Wound examination
  • Consider the need for:
    • Lumbar puncture
    • Respiratory secretions culture

Bloods

  • FBC +/- blood film
  • COAGULATION STUDIES
  • UREA AND ELECTROLYTES
  • CRP
  • LFT
  • LACTATE
  • Group and Save (X-match if appropriate : see separate MSBOS)
  • Consider Blood Gas analysis (NOT ROUTINE)

Serum lactate

A measure of tissue perfusion and prognostic indicator4.  This can be performed on a venous or arterial blood gas.  A lactate of >4 mmol/l is indicative of tissue hypoperfusion.

  • 2.1- 3.9 Intermediate
  • > 4 Severe

Management

Antibiotics

  • Broad spectrum intravenous antibiotics can be life saving. Immediate aggressive treatment should be initiated as each hour of delay is associated with a measurable increase in mortality3. 
  • Microbiology advice should be sought in severe sepsis or septic shock.
  • Breastfeeding may limit the use of some antimicrobials.
  • If no response after 24-48hrs of antibiotics consider change/addition of antibiotics under microbiology guidance.

See the Antibiotics Policy for Obstetric Patients GG&C guideline. The following table summarises GGC Antibiotic guidance in SEPSIS only. 

Haemodynamic Management

  • Loss of vasomotor tone, myocardial depression and increased vascular permeability contribute to the real risk of pulmonary oedema3. Fluid therapy should be titrated against the womans urine output, blood pressure and central venous pressure (if CVP line in place).
  • Initial fluid bolus of 500mls Hartmanns over 30 mins (caution in PET)
  • Hourly urine output >25mls/hr
  • Mean arterial pressure >65mmHg (used in discussion with anaesthetics)
    • Vasopressors indicated if the MAP is <65mmHg after adequate fluid resuscitation 
  • Consideration of central venous monitoring
    • if CVP line in place aim for CVP 8-12 mmHg 

 

Blood Products

  • Transfuse if Hb<70g/L until in the range 70 to 90g/L2
  • Keep platelet >50 x109/L if there is a significant risk of bleeding or if surgery or invasive procedures are planned
  • Be guided by haematological advice

 

Focus of infection

The focus of infection may need surgical evacuation, drainage or excision of necrotic tissue , e.g. uterine evacuation or breast, wound or pelvic abscess drainage 

 

Thromboprophylaxsis

  • TEDS
  • Low molecular weight heparin2
    • Prophylactic dose based on most recent weight
    • Once platelet count reviewed

 

The Fetus

  • The decision regarding timing and mode of delivery will be made by a consultant obstetrician.
  • During the intrapartum period continuous electronic fetal monitoring should be employed in gestations from 26+0 weeks. Below this gestation, discuss fetal monitoring with the Consultant Obstetrician. 
  • If delivery is required the choice of anaesthesia will be made after discussion with a Consultant Anaesthetist.
  • The paediatric team must be informed of any neonate born to a mother with suspected sepsis

 

Multidisciplinary Team

  • Consultant Obstetrician
  • Consultant Anaesthetist
  • Intensive care specialists
  • Microbiology
  • Haematology
  • Appropriate specific specialty (e.g. Surgical, renal etc.)
  • Pharmacy

 

Indications for Referral to ITU2

  • Cardiovascular - Hypotension or raised serum lactate persisting despite fluid resuscitation, suggesting the need for inotrope support
  • Respiratory - Pulmonary oedema/ Mechanical ventilation/ Airway protection
  • Renal - Renal dialysis
  • Neurological - Significantly decreased conscious level
  • Miscellaneous - Multi-organ failure/ Uncorrected acidosis/ Hypothermia

Referral to ITU should be from a discussion with the consultant obstetrician and consultant anaesthetist.

Once referral for ITU care has been made, the patient should continue receiving at least level 2 care until transferred out of the Obstetric HDU.  This includes maintaining CVP ≥ 8 mmHg, MAP >65mmHg (used in discussion with anaesthetics) and monitoring of appropriate bloods.

There is no place in this guideline for the use of high dose corticosteroids or recombinant human activated protein C

 

Editorial Information

Last reviewed: 17/09/2019

Next review date: 31/12/2022

Author(s): Julie Murphy.

Version: 2

Approved By: Obstetrics Clinical Governance Group

Document Id: 572

Related guidelines