By Suzanne McMurtry Baird, DNP, RN
As Director of Nursing for Clinical Concepts in Obstetrics, Suzanne McMurtry Baird consults for hospitals and aids them in developing and implementing obstetric care programs and bundles. Speaking for Symposia Medicus since 1995, Dr. McMurtry Baird here discusses the major challenges to maternal sepsis bundle incorporation and implementation.
Maternal infection leading to sepsis is on the rise and now the second leading cause of pregnancy-related death in the United States. An estimated 12.5-23% of all maternal deaths are sepsis-related. Sepsis is a pathophysiologic, dysregulated host response to infection that results in organ dysfunction and/or failure. Sepsis may quickly progress to septic shock leading to profound circulatory and metabolic abnormalities, increasing the risk of morbidity and mortality. Sepsis is a medical emergency requiring prompt recognition and appropriate treatment. Because most sepsis research excludes pregnant patients, challenges remain with screening, recognition, and management. To overcome these challenges, reduce variation in care, and improve patient and fetal/newborn outcomes, it is essential for hospitals to plan, practice, and implement a maternal sepsis bundle.
Challenge #1: Lack of Awareness & Recognition
Sepsis bundles have been successfully implemented in hospitals for many years, but exclusion of the obstetric population in these initiatives has contributed to a lack of awareness of the severity of maternal sepsis outcomes and need for standardized screening and initial management.
Challenge #2: Early Warning Systems & Tools
Since 1997, sepsis scoring tools and early warning signs have been widely used in the non-obstetric patient population to identify infected patients at risk for morbidity and mortality and predict the likelihood of intensive care unit (ICU) admission. Although the adoption of maternal early warning signs and symptoms has been strongly recommended since 2010, implementation in many obstetric units has been limited to physician/certified nurse midwife (CNM) order sets without a standardized sepsis screening tool, defined responses, education, and team training. Several maternal early warning systems and triggers exist but lack consistent values, and sepsis screening tools may not consider physiologic changes in pregnancy. Progression from early warning signs to a diagnosis of sepsis or septic shock occurs along a continuum, with progression of deterioration at a rapid rate in some patients.
Challenge #3: Lack of Knowledge
Implementation of a maternal sepsis bundle has been delayed or lacking entirely in most obstetric care units. As a result, obstetric clinicians may be unfamiliar with early recognition, pathophysiology, and recommended practices.
Challenge #4: ICU Transfer
Without a standardized approach to maternal sepsis screening, establishing criteria for ICU admission is usually left to physician/CNM discretion, who may be hesitant if the patient is undelivered. As a result, pregnant patients are more likely to be transferred to an ICU setting when they are overtly critically ill (i.e., requiring intubation) or in shock requiring vasopressor support. Once a pregnant patient is transferred to an adult ICU, it is imperative to remember that many ICU care team members may lack education in or understanding of key physiologic and hemodynamic changes in pregnancy. Similarly, the obstetric team may have very little knowledge or experience with ICU interventions. This mutual lack of understanding and experience may lead to communication and care gaps
Challenge #5: Implementation of a Maternal Sepsis Bundle & Protocolized Care
Pregnancy should not restrict fundamental sepsis diagnostic, pharmacologic, or resuscitative management principles. Maternal sepsis bundle components to be implemented in the first hour of suspected sepsis include:
- Fluid resuscitation
- Serum lactate level
- Bacterial cultures
- Antimicrobial therapy
- Management of hypotension
If this level of care cannot be provided in the obstetric unit, the patient should be transferred to an adult ICU or an outside facility. Maternal-Fetal medicine co-management is recommended.
Challenge #6: If & When to Refer
Delivery may be necessary due to spontaneous labor, fetal indications, or may be considered to improve maternal condition. However, the birth process itself, whether vaginal or cesarean, may precipitate maternal decompensation. There are no data demonstrating improved maternal outcomes with delivery unless the uterus is the source of infection.
- Hensley, MK, Bauer, ME, Admon, LK, et al. Incidence of maternal sepsis and sepsis-related maternal deaths in the United States. JAMA. 2019;322(9):890-892.
- Levy, MM, Evans, LE, Rhodes, A. The Surviving Sepsis Campaign Bundle: 2018 update. Critical Care Medicine. 2018;46:997-1000.
- Martin, S.M. & Baird, S.M. Sepsis in pregnancy. Contemporary OB GYN. 2018;63(6), 10-18.
- Plante LA, Pacheco LD, Louis JM. SMFM Consult Series #47: Sepsis during pregnancy and the puerperium. American Journal of Obstetrics and Gynecology. 2019;220(4).
- Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign. Critical Care Medicine. 2017;45(3):486-552.
- Roberts, E., Baird, S.M., Martin, S. (2021) Key challenges in the implementation of a maternal sepsis bundle. Journal of Perinatal and Neonatal Nursing, 35(2), 132-141.
- Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801-810.
Suzanne McMurtry Baird, DNP is the Co-Owner & Director of Nursing for Clinical Concepts in Obstetrics, LLC and Adjunct Faculty at Vanderbilt University School of Nursing in Nashville, Tennessee. She lives in Brentwood, Tennessee.