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MBRRACE - Sepsis and maternal deaths
The recent report, Saving Lives, Improving Mothers’ Care, from UK maternity services watchdog MBRRACE, found that in 2013-2015, 41% of the women who died during pregnancy, childbirth or postnatally, might have had better outcomes with improved care.
Whilst the number of deaths from indirect causes of maternal sepsis had decreased overall – an improvement they attribute in part to raised awareness of the condition resulting from the campaigning work of organisations such as the UK Sepsis Trust - 24 of the reviewed maternal deaths between 2013 and 2015 had sepsis as their primary infective cause. Nearly half of these were directly caused by sepsis and four arose from urinary tract sepsis or wound infection after caesarean section.
The report referred to the World Health Organisation’s (WHO) new international definition of maternal sepsis for 2017, which describes maternal sepsis as "a life threatening condition defined as organ dysfunction resulting from infection during pregnancy, childbirth, post-abortion or post-partum period."
Multiple opportunities are being missed at all stages
It went on to make specific recommendations for prevention and treatment of sepsis in maternity services, many of which reflected the panel’s identification of a recurrent, dominant theme that multiple opportunities are being missed at all stages of pre-pregnancy, pregnancy, birth and postpartum to anticipate and take steps to reduce the patient’s risk.
With this in mind, recommendations were made for high level action to ensure that it is seen as the responsibility of all health professionals to facilitate opportunistic counselling and advice. Preventative measures should include increasing uptake of the flu jab, as influenza is a known cause of maternal sepsis-related death. In the recognition that women might be put off by having to attend yet another appointment, the report recommended that as pregnant women attend maternity services during pregnancy, funding should be made available for the delivery of influenza immunisation in maternity services as part of their antenatal care, rather than as a separate appointment in primary care.
Recommendations for the recognition and prevention of postpartum sepsis included the somewhat obvious instruction to community midwives to have a thermometer with them when they carry out home visits so that they can check the temperature of postpartum women who are unwell. The panel regarded having the ability to check the postpartum mother’s temperature as a minimum requirement, along with checking blood pressure, pulse and respiratory rate. They recommended that the new NICE Guidelines (not due for publication until 2020) should make this guidance clear.
In addition, health professionals were reminded to check the unwell woman’s overall clinical condition rather than relying solely on her MEOWS score which tracks changes over time in observations such as temperature, blood pressure, heart rate and respiratory rate. This is another recurrent theme, echoing the findings of the RCOG’s Each Baby Counts report which reminded maternity healthcare providers that accidents (and claims) could be avoided if they would assess the patient taking into account the full clinical picture rather than just looking at the CTG.
Following a reminder that the key actions for diagnosis and sepsis are:
- Timely recognition
- Fast administration of intravenous antibiotics
- Quick involvement of experts with senior review noted as essential
…other recommendations included "declaring sepsis" – by invoking a protocol to ensure that all relevant members of the multidisciplinary team are informed, aware and act upon a potential diagnosis of sepsis, again drawing on the importance of escalation and communication between the various disciplines of health professionals who together are responsible for the woman’s care.
Multiple presentations by the woman, even in different settings (eg at the GPs surgery, then at A&E) should be seen as a "red flag" warning, requiring careful review and escalation to senior clinicians.
The panel emphasised that chronic illness and immunosuppression are in themselves risk factors for sepsis. Women with chronic illness, such as diabetes or sickle cell trait which put them at increased risk of infection should, therefore, have a lower threshold for admission to hospital, antibiotic administration and input from senior clinicians.
"Critical care is a management modality not a place."
In the event of a shortage of ITU or HDU beds, the report reminds healthcare providers that "critical care is a management modality not a place" If a woman is ill enough to need intensive care, she also needs close observation and support whilst awaiting transfer to ITU. The requisite level of care should be provided wherever the woman is located and not delayed whilst waiting for a critical care unit bed.
Whilst the significant reduction in maternal deaths from sepsis between 2010-2012 and 2013-2015 is a welcome demonstration of the value of the awareness raising work of the UK Sepsis Trust, there is much work still to do if the government is to meet its target of halving the number of maternal deaths overall by 2030.
Anticipating and reducing risk, adopting responsibility, communication and timely escalation emerge as the essential learning points for health practitioners, especially in times of high activity in maternity and A&E units.
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