Key messages

  • Sepsis is one of the leading causes of maternal deaths in Australia.1
  • This guideline provides an evidence-based guide for clinical staff to identify and manage suspected or confirmed sepsis in pregnant women, from 16 weeks gestation to around 2 weeks postpartum. 
  • It focuses on ensuring prompt diagnosis, appropriate investigations and antibiotic therapy.
  • It has been developed to guide initial diagnosis and management, for health services to adapt as required.
On this page

    Acknowledgement

    This guidance uses the terms ‘woman’ and ‘mother,’ which are intended to be inclusive of anyone who may use other self-identifying terms and aims to encompass all for whom this guidance is relevant.

    Consumer Engagement Statement

    All interactions between health care staff with consumers (women, mothers, patients, carers and families) should be undertaken with respect, dignity, empathy, honesty and compassion.

    Health care staff should actively seek and support consumer participation and collaboration to empower them as equal partners in their care.

    Definitions/abbreviations

    TermDefinition
    CPOs (Carbapenemase Producing Organisms)Bacteria that have developed resistance to several antibiotics, including carbapenems
    CSUCatheter specimen of urine
    DBPDiastolic blood pressure
    ESBL (extended spectrum beta lactamase)An enzyme found in some strains of bacteria. ESBL-producing bacteria can't be killed by many antibiotics such as penicillins and some cephalosporins. 
    FiO2 Fraction of inspired oxygen
    Group A streptococcus (GAS) infectionAlso known as Streptococcus pyogenes 
    HVSHigh vaginal swab
    LVSLow vaginal swab
    MAP

    Mean arterial blood pressure

    Diastolic BP + 1/3 (systolic BP – diastolic BP)

    MROs (multi-resistant organisms)Organisms that are resistant to some antimicrobials
    MRSA (methicillin-resistant Staphylococcus aureus)Staphylococcus aureus that is resistant to methicillin/ flucloxacillin 
    MSUMidstream urine
    PaO2 Partial pressure of oxygen (assessed with arterial blood gas)
    Puerperal sepsisPeripartum sepsis resulting from the genitourinary tract 
    SBP Systolic blood pressure
    Sepsis A life-threatening organ dysfunction caused by a dysregulated host response to infection. A diagnosis of sepsis is considered in any patient with an acute illness or clinical deterioration that may be due to infection6 Sepsis is a life-threatening condition
    Septic shockSeptic shock is defined as ‘a subset of sepsis in which the underlying circulatory, cellular and metabolic abnormalities are associated with a greater risk of mortality than sepsis alone6

    Local health service adaptation

    • The specific areas that may need local adaptation are: 
    • Pathways of escalation, including the availability of senior staff, of expertise in infectious diseases and when intra- or inter-hospital transfer is required.
    • Choice of antibiotics depending on local conditions – this is particularly relevant for aminoglycosides. Regimens have been provided for gentamicin, tobramycin and amikacin.

    Background

    Sepsis can be a life-threatening condition that requires a time critical response. The effects can be life-changing, leading to lasting maternal illness affecting the woman’s passage to motherhood, the establishment of breastfeeding and her ongoing connection to her baby. 

    Clinicians should provide open and consistent communication with the woman (when feasible) and her support people.

    Common causes of sepsis in this cohort are: 

    • Septic abortion, chorioamnionitis, pneumonia/influenza, pyelonephritis, wound infection, mastitis, endometritis. (with or without retained products of conception)
    • E. coli is the most common cause of maternal bacterial infection. The most frequent cause of maternal death from sepsis is infection with Group A streptococcus (GAS) species. Invasive GAS infection typically manifests as sepsis, endomyometritis, cellulitis, necrotising fasciitis, or toxic shock syndrome.

    Recognising sepsis

    Recognition of sepsis is a critical first step in appropriate assessment and management, regardless of the care setting, in community or a hospital. Consider sepsis in all patients with acute illness or physiological deterioration who may have an infection and ask the question ‘could it be sepsis?’ as part of regular clinical assessments.

    In pregnancy, diagnosis may be more difficult because physiological changes associated with pregnancy and/or labour may mimic the signs of sepsis (e.g. elevated heart rate and respiratory rate, lower blood pressure, raised white blood cell count, increased lactate during labour). 

    Risk factors that may assist with the early recognition of maternal sepsis could include bleeding in pregnancy, miscarriage, prolonged rupture of membranes, prolonged labour, retained products of conception and fetal tachycardia.

    This guidance utilises a modification of the California Maternal Quality Care Collaborative (CMQCC) 2020 screening criteria.2 The CMQCC reports fewer missed cases with fewer false positives, compared with other screening tools.

    Initial sepsis screen

    Recognise

    Consider sepsis if there is evidence of an infection and the woman has two or more of the following:

    Site of concernSigns or symptoms
    Fevers and rigors
    • self-reported or observed

    Neurological

     

    • altered conscious state
    • headache
    • neck stiffness
    • agitation

    Poor peripheral perfusion

     

    • cool peripheries
    • delayed capillary refill time or mottled skin
    Chest
    • cough
    • shortness of breath
    Abdomen
    • pain/tenderness
    • peritonism 
    • diarrhoea 
    • vomiting
    Malodorous vaginal discharge
    • self-reported or detected
    Urine
    • dysuria 
    • frequency 
    • flank pain
    Skin and soft tissue
    • cellulitis 
    • mastitis
    • wound erythema or discharge  
    Line insertion sites
    • erythema
    • pain 
    • swelling 
    • discharge
    Blood pressure
    • MAP < 65mmHg
    Two or more of the following
    • temperature < 36°C or > 38°C
    • respiratory rate > 24 per minute sustained for 15 minutes
    • heart rate > 110 sustained for 15 minutes
    • WCC 15 × 109 or < 4 × 109 or > 10% immature neutrophils (bands) (Diagnosis of sepsis should not be delayed while waiting for results. A white blood cell count that has been obtained within 24 hours can be used for the initial screen

    If the initial sepsis screen is positive and there is clinical suspicion or evidence of infection, start treatment.

    Respond

    Rapid response - most tasks will need to be carried out concurrently.

    Oxygen 
    • Continuous oximetry
    • Administer supplementary oxygen to maintain SpO2 > 95%
    IV access
    • Insert 2 × large bore peripheral cannula 
    Investigations
    • FBE, U&Es, LFTs, INR, APTT 
    • Venous blood gas for lactate
    • Two sets of anaerobic and aerobic blood cultures 
    Observations
    • Heart rate and blood pressure every 15 minutes for the first hour, then according to local guidance depending on degree of physiological disturbance
    • Document on Maternal Observations and Response Chart (MORC)
    Antibiotics
    • Complete intravenous antibiotic administration within 60 minutes of presentation
    • Refer to Table 1 for antibiotic recommendations where source is chorioamnionitis or unknown
    • Refer to Therapeutic Guidelines – Antibiotic where the source of infection is known 
    • Refer to Table 2 for additional antibiotic considerations
    • Refer to Table 3 for administration guidance

    Source screening

     

    Do not delay antibiotic treatment for culture collection.

    • Investigations as determined by clinical assessment of likely source of infection:
    • midstream urine (MSU)/catheter specimen of urine (CSU)
    • high vaginal (HVS) / low vaginal (LVS) / endocervical swab for   microscopy/culture/sensitivities (MCS)
    • sputum MCS
    • chest x-ray
    • nasal/ throat swabs for extended panel respiratory viruses multiplex PCR, including COVID-19
    • wound swab for MCS
    • cultures from lumens of central lines 
    • stool testing for faecal multiplex PCR including C. difficile
    • breast milk MCS
    Fluid management
    • Fluid resuscitation if systolic BP < 90 mmHg (or if lactate ≥ 2 mmol/L in the absence of labour) 
    • stat fluid bolus of 500 mL of IV crystalloid, i.e. 0.9% sodium chloride; then further 500 mL STAT if required. Be aware of comorbidities, e.g. cardiac or respiratory disease, that may make fluid overload more likely
    • monitor for fluid overload
    • escalate if no improvement in SBP after 1L of IV fluid.
    • insert IDC with hourly measure
    • monitor urine output hourly 
    • escalate if urine output < 20 mL/hr and/or 0.5mL/kg/hour
    Fetal considerations
    • Consider fetal surveillance if appropriate for the gestation of the pregnancy.
    • Consider urgent birth if chorioamnionitis is suspected. At pre- or peri-viable gestations, delivery may be required for maternal wellbeing.
    • If pre-term birth is likely, give corticosteroids according to local protocol. Maternal health is the priority rather than fetal lung maturity.
    • Consider contacting PIPER for further advice on 1300 137 650
    Escalate
    • Involve senior staff – consider anaesthetics, medical teams, ICU, ED or ARV in line with local escalation procedures
    • Consider transfer to a higher acuity ward or a higher maternity capability level service

    Confirmation of sepsis 

    Further tests: These tests/observations may be useful for considering care setting including transfer to a higher level of care or downgrading care. They will not be required for all women and should be undertaken in consultation with senior clinicians.

    Measure Criteria (any one is diagnostic)

    Respiration

    PaO/FiO2

    • Acute respiratory failure as evidenced by acute need for invasive or non-invasive mechanical ventilation or 
    • PaO2/FiO2 < 300
    Coagulation (FBE, INR, APTT)
    • Platelets < 100 × 109/L or 
    • INR > 1.5 or 
    • PTT > 60 seconds < 100
    Liver (LFT)
    • Bilirubin > 30 μmol/L       

    Cardiovascular

     

    Persistent hypotension (SBP < 85 mmHg) after fluid administration 

    or 

    MAP < 65 mmHg  

    Or 

    BP > 40 mmHg decrease in SBP

    Renal (U&E, urine output)

     

    • Serum creatinine > 100 μmol/L or 
    • Doubling of creatinine or 
    • Urine output < 20mL/hr and/or 0.5 mL/kg/hour (for 2 hours)
    Mental status assessment 
    • Agitation, confusion, or unresponsiveness
    Lactate
    • ≥ 2 mmol/L in the absence of labour

    Ongoing management

    Reassess management
    • The woman requires close observation and re-evaluation
    • Perform targeted history, examination and investigations to elicit cause of sepsis
    • Review any modifications to reportable observations / MET criteria 
    • Inform senior staff and document discussion and assessment in medical records
    • Ensure clinical handover includes sepsis history
    • Review all antibiotics and de-escalate as appropriate.
    General measures
    • Consider need for anticoagulation
    • Consider use of antipyretics
    • Source control

    Antibiotic prescribing and administration

    1. Prescribe antibiotics

    • Unknown source or chorioamnionitis These regimens are for initial intravenous doses for sepsis/septic shock and should be used for all women to minimise delays to administration (Table 1).
    • Known source: According to Therapeutic Guidelines3 or local, evidence-based guidelines.
    • Also consider additional risk factors (Table 2).

    2. Administer complete dose of antibiotics within 60 minutes of consideration of sepsis

    • In the setting of a critically unwell woman, antibiotics can safely be given at faster rates than in usual practice and multiple antibiotics can be given concurrently, intravenously at different sites4 (Table 3). Hospital protocols will dictate administration method of choice – e.g. syringe pump, slow push.

    3. Seek pharmacist/infectious diseases advice for ongoing maintenance dosing, including in the setting of renal impairment or obesity.

    4. Aminoglycosides: 

    • Each hospital should choose a single agent from gentamicin, amikacin or tobramycin, in consultation with local expertise and then use that agent consistently (Table 1).

    Additional considerations

    • Abnormal temperature and elevated heart rate may be the most common combination, however not all women with sepsis will have a fever at ≥ 38.0°C. 
    • Maternal corticosteroid administration often increases the white blood cell count, but the suspicion for infection should not be discounted without further evaluation. White blood cell values peak 24 hours after administration and return close to baseline values by 96 hours after administration.
    • Support for ongoing breastfeeding or assistance with expressing of breast milk, in keeping with the woman’s wishes, should be offered. 
    • Women and their families should be informed that they have/had a diagnosis of sepsis and provided with appropriate opportunities for information provision and debriefing.

    Summary flow chart

    Think sepsis if any 2 of the following are present, plus a clinical suspicion of sepsis:

    • Temperature < 36oC or ≥ 38oC
    • Heart rate > 110 for at least 15 minutes
    • Respiratory rate > 24 per minute for at least 15 minutes
    • White cell count > 15 × 109 or < 4 × 109
    • MAP < 65 mmHg.

    Call for help flowchart

    Table 1: Antibiotic recommendations: Unknown source of infection or chorioamnionitis

    For women with allergies to any of the antibiotics above, escalate for specialist advice.

    *Aminoglycoside:

    Each hospital should choose their primary aminoglycoside in accordance with local susceptibility patterns and in conjunction with regional partners and local expertise. Dosing is based on estimated or measured weight, rather than ideal body weight. (adjusted body weight for women with a BMI>30)

    Use the same dose regardless of renal function for initial dose.

    Gentamicin – initial dose 7 mg/kg for septic shock to maximum 600 mg (Routinely used in pregnancy)

    Amikacin – 28 mg/kg to maximum 2,800 mg

    Tobramycin 7 mg/kg to maximum 600 mg

    Table 2: Additional antibiotic considerations, including Group A Streptococcus

    IndicationsAntibiotic 

    Septic shock: persisting hypotension despite resuscitation

     

    		ADD vancomycin  25mg/kg loading dose, then 1.5g IV 12-hourly  (if at risk of MRSA colonisation and/or presence of lines)

    Group A Streptococcus

    Contact with GAS infection case

    Toxic shock

    ADD clindamycin 600mg IV 8 hourly

    CONSIDER IV immunoglobulin 1-2 g/kg IV (with ID consultation)

    Suspected Neisseria meningitidis infection, or suspected CNS infectionADD ceftriaxone 2g, IV, 12 hourly 

    Woman with prior history of multi-resistant Gram-negative colonisation – e.g. CPOs, ESBLs, multi-resistant organisms (MRO), or

    Overseas hospitalisation or travel in the previous 6 months 

    		REPLACE all empiric antibiotics with single agent meropenem 2g, IV, 8 hourly
    MRSA carrier: Based on previous swabs/ cultures or residence in NT, remote communities in FNQ or northern WA or recent incarceration, or recent prolonged hospital stayADD  vancomycin 25mg/kg loading dose, then 1.5g IV, 12-hourly 

    Table 3: Rapid antibiotic administration advice 

    AntibioticAdministration instructions 
    Amoxycillin1g with 20 mL water for injection over 3–4 minutes (2x1g amoxicillin vials are needed)
    ClindamycinDilute 600 mg in 50 mL sodium chloride 0.9% and infuse over 20 minutes
    Ceftriaxone2g with 40 mL water for injection and infuse over 5 minutes 
    Cefazolin2g with 19 mL water for injection and infuse over 5 minutes
    Flucloxacillin2g with 40 mL water for injection and infuse over 6–8 minutes
    GentamicinDilute with 20 mL sodium chloride 0.9% and infuse over 3–5 minutes
    MetronidazoleInfuse over 20 minutes
    Piperacillin/ tazobactam4.5g with 20 mL water for injection and infuse over 5 minutes

    Vancomycin

     

    500 mg with 10 mL water for injection and 1g with 20 mL water for injection to make a concentration of 50mg/mL. Dilute to 5 mg/mL with sodium chloride 0.9%, i.e. dilute 1g to at least 200 mL.* 1g may be infused over 1 hour, 1.5g over 1.5 hours and 2g over 2 hours.

    * If fluid restriction, max concentration 10 mg/mL, i.e. dilute 1g in 100 mL

    Table 4: White cell count in pregnancy – normal range: a reference table for clinicians

    Non pregnant adult5.3.5–9.1 × 103 mm3
    First trimester5.7–13.6 × 103 mm3
    Second trimester5.6–14.8 × 103 mm3
    Third trimester 5.9–16.9 × 103 mm3

    References

    1. Australian Institute of Health and Welfare. Maternal deaths in Australia. Cat. no. PER 99. 2020 [cited 2024 May 01]. Available from: https://www.aihw.gov.au/reports/mothers-babies/maternal-deaths-australia
    2. Gibbs R, Bauer M, et al. Improving Diagnosis and Treatment of Maternal Sepsis: A Quality Improvement Toolkit. [Internet]. Stanford CA., California Maternal Quality Care Collaborative; 2020 [cited 2024 May 7]. Available from: https://www.cmqcc.org/resources-toolkits/toolkits/improving-diagnosis-and-treatment-maternal-sepsis
    3. Therapeutic Guidelines: Antibiotic. Available from: https://tgldcdp.tg.org.au/guideLine?guidelinePage=Antibiotic&frompage=etgcomplete
    4. Australian Injectable Drugs Handbook (AIDH) 9th Edition. Available from: https://www.shpa.org.au/publications-resources/aidh
    5. Abbassi-Ghanavati M, Greer LG, Cunningham FG. Pregnancy and Laboratory Studies: A Reference Table for Clinicians. Obstetrics & Gynecology. 2009 Dec;114(6):1326-1331. DOI: 10.1097/AOG.0b013e3181c2bde8. 
    6. Australian Commission on Safety and Quality in Health Care. Sepsis Clinical Care Standard. Sydney: ACSQHC; 2022. Available from: https://www.safetyandquality.gov.au/publications-and-resources/resource-library/sepsis-clinical-care-standard-2022

    Additional resources

    Citation

    To cite this document use: Safer Care Victoria. Maternal Sepsis Guideline [Internet]. Victoria: Maternity eHandbook; 2024 [cited xxxx] Available from: https://www.safercare.vic.gov.au/clinical-guidance/maternity

    Acknowledgement

    Safer Care Victoria would like to acknowledge Victoria’s four tertiary maternity services, the Royal Women’s, Mercy Hospital for Women, Joan Kirner Women’s and Children’s and Monash Women’s, for their significant contribution in the development of this guidance, as part of the Maternity and Neonatal eHandbook updating project 2023.

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    Get in touch

    Clinical Guidance Team
    Safer Care Victoria
    clinicalguidance@safercare.vic.gov.au

    Version history

    First published: 
    December 2024

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