Suspected maternal sepsis
Pregnant, or within 6 weeks after birth, miscarriage or termination, with suspected infection.
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Obstetrics & GynecologyEmergency
Maternal Sepsis Management (RCOG 2024)
Maternal Sepsis Management (RCOG 2024): Suspected maternal sepsis → Screen with the maternity early warning chart → High risk: start the sepsis bundle n...
Pathway Overview
13 steps
Algorithm Steps
13 total
01Start 02Action Screen with the maternity early warning chart
Use your local maternity chart. Fever may be absent; hypothermia can occur. Beta-blockers (e.g. labetalol) can blunt tachycardia.
- High risk (any one): RR 25/min or more, SpO2 below 94% on air, HR above 130/min, SBP below 90 mmHg
- High risk: new confusion or GCS below 15; no urine for 12 h, or below 0.5 mL/kg/h if catheterised
- Moderate risk: RR 21-24/min, HR 100-130/min or SBP 91-100 mmHg: senior review within 1 hour
- Temperature below 36°C or above 38°C; fetal tachycardia; uterine tenderness; offensive discharge
- Risk factors: GAS contact, caesarean or other procedure in last 6 weeks, prolonged rupture of membranes, diabetes, immunosuppression
- Do not blame fever on an epidural until sepsis is excluded
03Action High risk: start the sepsis bundle now (within 1 hour)
Senior obstetrician review now; call the anaesthetist. Over 20 weeks: left lateral tilt or manual uterine displacement.
- IV broad-spectrum antibiotics within 1 hour (regimens below)
- Blood cultures before antibiotics, but do not delay antibiotics
- Lactate (venous gas) now; 2 mmol/L or more: senior review, IV fluids, repeat lactate within 1 hour
- Lactate 4 mmol/L or more: escalate now and discuss with critical care
- Oxygen if SpO2 below 94%: titrate to SpO2 94-98%; no routine high-flow oxygen
- Hourly urine output with catheter and urometer
- FBC, U&E, creatinine, LFT, coagulation, CRP, glucose; cultures from the likely source
04Warning If Group A strep suspected: can kill within hours
Clues: sore throat or GAS contact, diarrhoea, severe pain, early shock. Failing in ICU: consider IVIG (not if IgA deficient).
- ADD clindamycin 600 mg IV 8-hourly to switch off toxin
- Pain out of proportion, bruising or skin change: suspect necrotising fasciitis; urgent surgical review
- Single room, droplet and contact precautions; iGAS is notifiable: tell infection control and public health
05Action Empiric IV antibiotics within 1 hour (adult doses)
Follow local guidelines. Check allergy first. Gentamicin: if CrCl below 40 mL/min, give one dose only; empirical use no more than 48 h.
- Genital tract or unknown source: amoxicillin (or ampicillin) 2 g IV 6-hourly + gentamicin + metronidazole 500 mg IV 12-hourly
- Life-threatening sepsis: piperacillin-tazobactam 4.5 g IV 6-hourly or meropenem 1 g IV 8-hourly, plus clindamycin 600 mg IV 8-hourly
- Gentamicin 4-5 mg/kg IV once (up to 7 mg/kg in septic shock), on ideal or adjusted body weight; local protocol for levels
- MRSA risk: add vancomycin 25-30 mg/kg IV load (max 2.5 g), then per local protocol and levels
- Severe penicillin allergy (anaphylaxis, SJS): gentamicin + clindamycin 600 mg IV 8-hourly (+ azithromycin 500 mg IV daily if genital tract); ask infectious diseases (GBS may resist clindamycin: consider vancomycin)
- Mild delayed penicillin allergy (rash), unknown source: cefazolin 2 g IV 6-hourly + gentamicin + metronidazole 500 mg IV 12-hourly
- Mild delayed penicillin allergy, genital tract: ceftriaxone 2 g IV daily (or cefotaxime 2 g IV 8-hourly) + azithromycin 500 mg IV daily + metronidazole 500 mg IV 12-hourly
- Worse despite first-line antibiotics: add aciclovir 500 mg IV 8-hourly (HSV)
06Action Hypotension or lactate above 4 mmol/L: 500 mL crystalloid bolus
Pre-eclampsia or eclampsia: high risk of pulmonary oedema; give fluid with anaesthetic or critical care input.
- Crystalloid: 0.9% sodium chloride or Hartmann's, 500 mL fast
- Reassess BP, HR, lactate and chest after each bolus; repeat by response
- More than 2 L without better BP: critical care input now (SOMANZ: ward limit 20 mL/kg, up to 2 L)
07Action Shock after fluids: start vasopressor and call critical care now
SBP below 90 mmHg, MAP below 65 mmHg or lactate above 4 mmol/L despite fluids. Transfer to ICU.
- Noradrenaline first line to keep MAP 65 mmHg or more
- Arterial line and central venous access; senior anaesthetist plans anaesthesia and monitoring
- Other ICU triggers: pulmonary oedema, need for ventilation, falling GCS, renal replacement, acidosis, hypothermia
- Still on vasopressor (noradrenaline 0.25 mcg/kg/min or more for 4 h or more): consider IV hydrocortisone 50 mg 6-hourly (adult)
- Cardiac arrest over 20 weeks: manual uterine displacement; resuscitative hysterotomy
08Action Find the source: examine, culture and image promptly
Do not withhold imaging because of pregnancy or breastfeeding.
- Genital tract: chorioamnionitis, endometritis, retained products, septic miscarriage, wound infection
- Urinary: pyelonephritis
- Breast: mastitis, breast abscess
- Chest: pneumonia, influenza, COVID-19 (influenza: oseltamivir 75 mg orally twice daily for 5 days)
- Consider HSV even without skin lesions
- Mimics: pre-eclampsia or HELLP, haemorrhage, pulmonary embolism, amniotic fluid embolism
09Action Source control as soon as possible
A senior obstetrician leads. Do not delay source control.
- Chorioamnionitis: expedite birth at any gestation
- Retained products: evacuate the uterus
- Abscess (breast, pelvic, wound): drain
- Necrotising fasciitis: urgent surgical debridement with plastic surgery, ICU and infectious diseases
- Peritonitis: laparotomy
- Uterine sepsis not controlled: hysterectomy may be needed
10Action If still pregnant: fetal monitoring and timing of birth
Stabilise the mother first, unless the uterus is the source. Neuraxial block only after senior anaesthetic review (sepsis, coagulopathy).
- Continuous CTG in labour and during sepsis at a viable gestation; caution with fetal blood sampling
- Senior obstetrician decides timing and mode of birth with the woman
- Chorioamnionitis: birth is needed on maternal and fetal grounds
- Tell the neonatal team: organism, antibiotics, corticosteroids, magnesium
11Action If preterm birth expected: corticosteroids and magnesium sulfate
Magnesium can worsen hypotension. Oliguria or AKI: check serum magnesium. With gentamicin: risk of weakness and slow breathing.
- Before 35+0 weeks: consider antenatal corticosteroids; do not delay birth for them in chorioamnionitis
- AU, before 30+0 weeks: magnesium sulfate 4 g IV over 15-20 min, then 1 g/h until birth or per local stop time
- UK (NICE): offer magnesium at 24+0 to 29+6 weeks; consider at 30+0 to 33+6 weeks
- On magnesium: monitor RR, reflexes and urine output; calcium gluconate 1 g IV for toxicity
12Action Ongoing care: monitor and review
Reassess often; escalate any deterioration. Before LMWH: check bleeding, platelets and timing of neuraxial block or surgery.
- Maternity chart observations; escalate on any trigger
- Repeat lactate until normal; urine output 0.5 mL/kg/h or more
- Review antibiotics with cultures at 48-72 h; targeted oral agent when appropriate
- Sepsis raises VTE risk: reassess thromboprophylaxis
- iGAS: antibiotic prophylaxis for mother and baby (within 28 days after birth); tell household contacts
- Baby of a mother treated for sepsis in labour or within 24 h of birth: assess for neonatal infection
13Outcome Recovery and follow-up
Most women recover with prompt treatment.
- Complete the antibiotic course; duration by source and response
- Tell the woman the signs of genital tract infection and GAS, and about hand hygiene
- Debrief the woman and family; document and review the case
Guideline Source
RCOG Green-top Guideline No. 64: Identification and Management of Maternal Sepsis during and following Pregnancy
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Antibiotic choices must follow local guidelines and resistance patterns; doses shown are adult examples (SOMANZ 2023, eTG-based)
- Normal vital signs change in pregnancy and maternity chart thresholds differ between Australian states; use the local chart
- Neonatal assessment and treatment are out of scope
- Not for sepsis more than 6 weeks after pregnancy ends; use the adult sepsis pathway
Contraindicated Populations
Women more than 6 weeks after birth, miscarriage or termination (use the adult sepsis pathway)Neonates (use neonatal sepsis guidance)
Applicable Regions
AUNZUKUSEUGlobal
AU: SOMANZ sepsis in pregnancy position statement 2023 and eTG Antibiotic; use the state maternity observation chart; iGAS nationally notifiable since July 2021 (CDNA SoNG).
NZ: National maternity early warning chart; SOMANZ 2023 lists NZ regimens (cefuroxime-based).
UK: RCOG Green-top Guideline No. 64 (2024); magnesium for neuroprotection per NICE (24+0 to 33+6 weeks).
US: Antibiotic examples are AU/UK; follow local US protocols.
Version 2Next review: 2027-09-30
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Related Resources
Frequently Asked Questions
What is the Maternal Sepsis Management (RCOG 2024)?
The Maternal Sepsis Management (RCOG 2024) is a emergency clinical algorithm for Obstetrics & Gynecology. It provides a structured decision tree to guide clinical decision-making, based on RCOG Green-top Guideline No. 64: Identification and Management of Maternal Sepsis during and following Pregnancy.
What guideline is the Maternal Sepsis Management (RCOG 2024) based on?
This algorithm is based on RCOG Green-top Guideline No. 64: Identification and Management of Maternal Sepsis during and following Pregnancy (DOI: 10.1111/1471-0528.18009).
What are the limitations of the Maternal Sepsis Management (RCOG 2024)?
Known limitations include: Antibiotic choices must follow local guidelines and resistance patterns; doses shown are adult examples (SOMANZ 2023, eTG-based); Normal vital signs change in pregnancy and maternity chart thresholds differ between Australian states; use the local chart; Neonatal assessment and treatment are out of scope; Not for sepsis more than 6 weeks after pregnancy ends; use the adult sepsis pathway. Individual patient factors may require deviation from these recommendations.
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