Saving Mothers: How Vigilance Can Defeat Maternal Sepsis

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Maternal Sepsis — Screening & Management

Sepsis is the 2nd leading cause of maternal death overall, and the leading cause of severe maternal morbidity specifically in the antepartum and postpartum periods. Most cases are considered preventable. This guide reflects the updated two-step approach from the CMQCC Obstetric Sepsis Toolkit, 2nd Edition (2025): infection alone is not sepsis — sepsis requires infection plus end-organ injury, and SIRS criteria are no longer used to define it.

🧠 WHY MATERNAL SEPSIS GETS MISSED

Wellness bias: symptoms get dismissed because the patient still "looks well" — pregnancy's usual optimism can mask early warning signs

Normalization of deviance: small abnormal vital signs get tolerated one at a time until a pattern is missed altogether

The "3 Deadly D's": Denial, Delay, Dismissal — naming this pattern is the first step to interrupting it.

"I don't feel like they ever took my concerns seriously... they wanted to send me home." — patient account, CMQCC qualitative research

🚦 AT A GLANCE — RISK STRATIFICATION

GREEN: vital signs within normal pregnancy-adjusted range, no concerning symptoms

AMBER: one or more abnormal vital signs (Step 1 screen positive) — needs bedside evaluation, not automatic dismissal

RED: screen positive and any sign of end-organ injury on bedside evaluation — this is sepsis until proven otherwise

Step 1

Pregnancy-Adjusted Vital Sign Screen

Identifies possible "serious infection" — but the false-positive rate is too high to diagnose sepsis from this step alone

Timing Rules That Matter

Heart rate: only counts as abnormal if it persists on a recheck within 20 minutes

Resp. rate & temperature: a single abnormal value counts — these aren't expected to be rechecked that quickly

All abnormal vitals must fall within 2 hours of each other to count together

Abnormal WBC must fall within 24 hours of the other abnormal criteria

A small respiratory rate change of just 3–5 breaths/min can be an early sign of deterioration — don't dismiss it as "just pain."

Step 2

Bedside Evaluation for End-Organ Injury

Default action: in the absence of a clear alternative diagnosis, the default is to act — treat the possible infection and gather more information, not to wait and watch

General observation: shivering, confusion, clammy skin, difficulty breathing, grimacing/guarding, poor perfusion

Look for an infection source: incision/laceration, breasts, urinary symptoms or CVA tenderness, cough or abnormal lung sounds

Actively exclude alternative diagnoses: heavy bleeding (haemorrhage), hypertension/oedema/headache (pre-eclampsia)

If any end-organ injury criterion is met, the diagnosis of sepsis is made — this evaluation can be performed by an RN, midwife, or physician.

Sepsis

≥1 end-organ injury criterion present, in the setting of infection

Septic Shock

Needs vasopressors to keep MAP >65 mmHg despite adequate fluids, plus lactate >2 mmol/L

Serious Infection + High Lactate

No end-organ injury yet, but elevated lactate — increased monitoring, reassess soon

Serious Infection + Normal Lactate

No end-organ injury, normal lactate — still needs increased monitoring, not discharge

💡 TEACHING PEARLS — LACTATE & CULTURES

Lactate isn't used to diagnose sepsis itself — it reflects tissue perfusion and matters most for identifying septic shock

Labor alone can raise lactate through ordinary anaerobic muscle metabolism — a woman not in labor, or more than an hour postpartum, shouldn't have lactate >2 mmol/L without explanation

Blood cultures ideally come before antibiotics — but if antibiotics were already started for a presumed infection, draw cultures at the point sepsis is diagnosed instead of withholding treatment

Blood cultures are almost never positive in chorioamnionitis alone — they can reasonably wait unless end-organ injury appears

🛠️ MANAGEMENT — FLUIDS & ANTIBIOTICS

Fluid Resuscitation

Septic shock: 30 mL/kg crystalloid bolus within the first 3 hours — dosed on ideal body weight, not actual weight

Serious infection without end-organ injury: a more modest 500–1000 mL fluid load

Antibiotics

Give within 1 hour of diagnosis — for both sepsis of known and unknown origin

For chorioamnionitis/endometritis, ceftriaxone + metronidazole is gaining favor (including for penicillin allergy); piperacillin-tazobactam offers single-drug broad coverage

Let your local antibiogram guide empiric choice — options vary meaningfully by site

🗣️ ESCALATING WHEN YOU MEET RESISTANCE

Use CUS words — Concerned, Uncomfortable, Safety issue — when a screen is positive but the response is "let's just keep monitoring"

Example: "Although vital signs are often elevated in pregnancy, her current vital signs meet sepsis screening criteria. This is now a safety issue we must address."

Start The Clock

Time Zero

1

HOUR TO
ANTIBIOTICS

The moment sepsis is diagnosed is "time zero" — the clock for antibiotics, fluids, and escalation starts immediately, not once every question is answered.

Antibiotics within 1 hour of diagnosis — every minute of delay matters

Don't wait for a "sicker-looking" patient — act on the numbers and the pattern, not just appearance

Use CUS language early if the team is inclined to just keep watching

After the event: a brief, honest debrief and a clear discharge conversation about warning signs measurably changes how patients experience their recovery

Reminder: the patient who "looks fine" is exactly the patient wellness bias is most likely to fail — trust the numbers.

Swaraj Hospital & Research Institute · Department of Obstetrics & Gynaecology, Bolangir, Odisha

Adapted for clinical teaching from the CMQCC "Improving Diagnosis and Treatment of Obstetric Sepsis" Toolkit, 2nd Edition (2025) — cmqcc.org. This summary paraphrases toolkit concepts for education; it is not a reproduction of the toolkit and does not replace it or define local standard of care. Confirm dosing, antibiotic choice, and escalation pathways against your institution's protocol and antibiogram.