Sepsis is one of the leading causes of maternal death, but there has been no national consensus on its management — until now. A multicenter panel of obstetrics & gynecological leaders convened to create the Consensus Bundle on Sepsis in Obstetric Care, producing for the first time a set of standards to be used across the country by all providers caring for women during and after pregnancy. Laura Riley, MD, Chair of Obstetrics and Gynecology at NewYork-Presbyterian/Weill Cornell Medicine, was one of the experts working on the consensus. The guidelines were published in Obstetrics & Gynecology in September 2023.
“Sepsis is not only one of the leading causes of maternal mortality, but one of the preventable causes,” explains Dr. Riley, a maternal-fetal medicine specialist who participated in the Alliance for Innovation on Maternal Health (AIM) panel that drafted the guidelines. “Anyone involved in the care of pregnant or postpartum women displaying certain symptoms should have a high index of suspicion of sepsis and be prepared to promptly initiate treatment once the diagnosis is made.”
Anyone involved in the care of pregnant or postpartum women displaying certain symptoms should have a high index of suspicion of sepsis and be prepared to promptly initiate treatment once the diagnosis is made.
— Dr. Laura Riley
Addressing All Healthcare Providers
The consensus bundle is divided into five modules, each of which contains three to five sepsis management guidelines. The modules promote:
- Readiness, where every unit is educated and prepared and maintains a culture of efficient communication.
- Recognition and Prevention, with protocols in place to minimize the risk of sepsis, educate all patients about symptoms, and diagnose it early when it does develop.
- Response, with care teams up to date about the appropriate antibiotic doses and protocols and other measures required to escalate sepsis treatment quickly.
- Reporting and Systems Learning, with review of all cases of confirmed or potential sepsis on every unit so teams can learn from their experiences.
- Respectful, Equitable, and Supportive Care on every unit by every team member, with increased attention to Black, Indigenous, and Hispanic individuals, who have a higher rate of maternal sepsis.
What also makes the new consensus bundle unique is its use not only by obstetricians and obstetric nurses, but anyone who may be providing health care to a woman during or after pregnancy. “One of the major foci of this bundle is its appeal to people working in emergency rooms, family practitioners, and nurse midwives,” notes Dr. Riley. “Those are likely to be spaces where cases have gone undetected because women show up in the ER four weeks after delivery and no one puts together that their symptoms might be related to maternal sepsis.”
A Subtle Diagnosis
Pregnant and post-partum women are typically a young, generally healthy patient population. Because sepsis symptoms may or may not include fever, it can be easy to dismiss them. This is especially true for Black women. “The increased rate of sepsis among non-white women is not due to biology, but rather systemic racism,” says Dr. Riley. “They are less likely to be listened to and told, ‘Oh, you’re just tired because you had a baby.’ Their higher rate of sepsis may also be related to socioeconomic status and reduced access to care.”
The increased rate of sepsis among non-white women is not due to biology, but rather systemic racism. They are less likely to be listened to and told, ‘Oh, you’re just tired because you had a baby.’ Their higher rate of sepsis may also be related to socioeconomic status and reduced access to care.
— Dr. Laura Riley
Dr. Riley encourages health care providers to have a high index of suspicion for sepsis in pregnant or post-partum women presenting with:
- Malaise
- Increased heart rate
- Low blood pressure
- Low-grade fever
- A history of C-section or instrumentation during vaginal delivery (a major risk factor for postpartum infection)
- Ruptured membranes
“It can be a subtle diagnosis. You may see a young healthy woman who has normal vital signs for a long period of time until she quickly becomes very sick,” Dr. Riley adds. “It’s not unusual for pulse to be a little faster and blood pressure to be a little lower during pregnancy, but these signs may also be due to a patient getting sick.”
It can be a subtle diagnosis. You may see a young healthy woman who has normal vital signs for a long period of time until she quickly becomes very sick.
— Dr. Laura Riley
Moving Quickly
Once the diagnosis of sepsis is made, prompt treatment with antibiotics and blood pressure support is essential. “It’s important to be prepared and to act quickly. There are data in pregnant and non-pregnant individuals showing that if there is a delay in sepsis diagnosis and a delay in treatment, the outcomes are significantly worse,” Dr. Riley explains.
She advises physicians to have an order set ready for patients with sepsis. Antibiotic selection is tailored to the source of the infection, such as the vagina, uterus, or urinary tract. Mastitis and pneumonia may also contribute. “Patients need antibiotics, IV fluids, and an evaluation to determine if there are retained products of conception in the uterus. It’s important the uterus is empty because antibiotic penetration cannot occur if there is placental tissue remaining.”
Equitable Care for Every Patient
To draft the bundle components pertaining to patient education, patients who had experienced sepsis were part of the AIM committee. Because the consensus bundle is a set of guidelines for all U.S. hospitals to follow, they should increase the equity of care. “Bundles like this reduce some of the inequities we see because everyone should be getting the same care,” Dr Riley says. “That’s the beauty of the bundle.
“Practitioners should make sure all patients who leave the hospital are adequately educated about the signs and symptoms of sepsis, and that they know how to get in touch with someone if they have any of those symptoms.”
