Antenatal Care: Maternal Sepsis
A Critical Threat to Maternal and Newborn Health
The World Health Organization (WHO) defines maternal sepsis as a life-threatening condition caused by organ dysfunction resulting from infection during pregnancy, childbirth, post-abortion, or the postpartum period. Infections during pregnancy are a major threat to both maternal and neonatal health, often leading to complications such as preterm birth, stillbirth, maternal and neonatal sepsis, and increased morbidity and mortality.
Globally, maternal sepsis accounts for 11% of maternal deaths, with an estimated 261,000 cases annually, disproportionately affecting women in low-resource settings. In sub-Saharan Africa and South Asia, infections acquired during labor and after delivery contribute to 15% of maternal deaths. Maternal infections are also linked to approximately one million neonatal deaths each year. Neonatal sepsis, frequently stemming from maternal infections, is responsible for 21% of neonatal deaths worldwide.
Common sources of infection include genital tract infections (e.g., chorioamnionitis), urinary tract infections, pneumonia, surgical site infections (especially post-cesarean), and bloodstream infections like group B Streptococcus. Maternal sepsis arises when an infection causes a systemic inflammatory response, leading to organ dysfunction, multi-organ failure, and potentially death. This cascade involves pathogen invasion, immune response dysregulation, endothelial damage, and coagulopathy.
Several factors increase the risk of maternal infections, including pre-existing conditions such as malnutrition, anemia, diabetes, and obesity, and obstetric risk factors like prolonged rupture of membranes, repeated vaginal examinations, and cesarean deliveries.
Early recognition and timely administration of antibiotics could reduce deaths from maternal sepsis by up to 50%. However, inappropriate use of antibiotics is a growing concern, contributing to the global crisis of antimicrobial resistance (AMR). The WHO emphasizes rational antibiotic use to preserve treatment efficacy.
In addition to the risk of death, maternal infections can cause long-term complications including chronic pelvic pain, tubal infertility, and reproductive health issues.
This section of the toolkit provides evidence-based guidance for healthcare providers and policymakers on the prevention, early detection, and management of maternal infections, aligning with WHO’s global efforts to reduce maternal mortality and improve care quality.
What Are the Benefits of Preventing Maternal Sepsis?
Reduces Maternal Morbidity and Mortality
Prompt diagnosis and treatment of infections can significantly decrease the risk of severe complications like sepsis, which is a leading cause of maternal death.
Enhances Quality of Life
Early detection and management of infections can prevent long-term health consequences for both mother and child.
Strengthens Healthcare Systems
Effective infection management protocols improve the overall efficiency and effectiveness of maternal and child health services.
Reduces Healthcare Costs
Prevention and early intervention are more cost-effective than managing severe complications.
Note: Use of prophylactic antibiotics for maternal sepsis has not shown any impact on neonatal outcomes.
How to Implement
1. Conduct Routine Screening for Infections in ANC
- Screen all pregnant women during ANC visits for common infections, including:
- Urinary tract infections (UTIs)
- Sexually transmitted infections (STIs) such as syphilis, chlamydia, and gonorrhea
- HIV, Hepatitis B and C
- Tuberculosis (TB) in high-risk areas
- Group B Streptococcus (GBS)
- Use point-of-care tests where available to support rapid diagnosis and treatment.
2. Promote Hygiene and Sanitation
- Educate pregnant women on proper hand hygiene, food safety, and safe water practices.
- Encourage the use of clean, safe sanitation facilities at home and in health facilities.
3. Ensure Vaccination During Pregnancy
- Administer recommended vaccines, including influenza and tetanus toxoid.
- Stay informed about other vaccines (e.g., COVID-19) based on national and local guidelines.
4. Apply Infection Prevention and Control (IPC) Measures in Facilities
- Enforce WHO's IPC Standards – hand hygiene, use of personal protective equipment (PPE), Respiratory hygiene and cough etiquette, safe injection practices, environmental cleaning and disinfection, waste management, patient placement and assessment - in all health settings.
- Maintain clean and disinfected medical equipment and surfaces to reduce infection risk.
5. Manage Peripartum Infections
- Follow clinical protocols to prevent and treat infections during labor and delivery:
- Provide prophylactic antibiotics for conditions like prolonged rupture of membranes or cesarean delivery.
- Use intrapartum azithromycin, where appropriate.
- Use the Maternal Early Warning Systems (MEWS) tool to identify sepsis early.
- Regularly monitor and record vital signs, including temperature, respiratory rate, pulse, BP, and oxygen saturation.
- Look for altered mental state or other signs of systemic infection.
- Perform relevant lab investigations:
- Full blood count, electrolytes, clotting screen, liver/kidney function tests, CRP, lactate (if available), and cultures from wounds or discharge.
6. Provide Postpartum Infection Monitoring and Care
- Monitor women for fever, abnormal discharge, severe pain, low oxygen saturation, or altered mental status.
- Offer timely treatment, follow-up, and referral for suspected or confirmed infections.
7. Engage the Community
- Train and involve community health workers and local leaders to raise awareness about infection prevention.
- Strengthen referral systems to ensure pregnant women can access care without delay.
8. Supportive Actions for Local Government Health Leaders
- Secure funding for infection prevention and maternal health services.
- Train healthcare workers on updated infection prevention and treatment protocols.
- Enhance surveillance systems to track infections and outbreaks.
- Ensure a steady supply of essential medicines, diagnostics, and equipment for maternal infection control.
Management of Maternal Sepsis
- Administration of intravenous broad-spectrum antibiotics is recommended within one hour in women at high risk of sepsis, with or without septic shock.
- Empirical antimicrobials should be reviewed with culture results and targeted oral agents used as soon as clinically appropriate.
- If a change in antibiotic regimen is considered because of deterioration despite first-line treatment, consider the addition of IV aciclovir 500mg 8 hourly (or appropriate anti-viral drug) as part of the second-line regimen.
- Use of a sepsis bundle may improve compliance with urgent management in women at high risk of sepsis.
- Measure lactate level and repeat within an hour if levels elevated >2mmol/L- where available
- Obtain blood cultures before administering antibiotics (but do not delay giving antibiotics)
- Administer broad-spectrum antibiotics
- Begin rapid administration of 30ml/kg crystalloid for hypotension or lactate level ≥ 4 mmol/L
- Apply vasopressors if hypotensive during or after fluid resuscitation to maintain mean arterial pressure (MAP) ≥ 65 mm Hg
- Early fluid resuscitation of crystalloid should be administered with an immediate 500ml fluid bolus in women with hypotension or elevated lactate above 4mmol/L. This may need repeating. When indicated, urine output should be measured hourly.
- Initiate referral to a secondary or tertiary level facility for advanced care in severe sepsis/ septic shock after stabilization of the patient
Key Indicators
- Percentage of pregnant women screened for common infections during ANC.
- Percentage of women screened and treated for parasitic infections.
- Percentage of pregnant women receiving recommended vaccinations.
- Incidence of maternal sepsis.
- Neonatal sepsis rates.
- Preterm birth rates.
- Maternal mortality ratio - sepsis case fatality rates.
- Percentage of healthcare facilities with functional IPC protocols.
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Tips
- Maintain a high index of suspicion for infections in pregnant women, especially those with risk factors.
- Introduce and support the use of maternal early warning system tools
- Provide culturally sensitive and respectful care.
- Ensure clear communication between healthcare providers and pregnant women.
- Document all findings and interventions thoroughly.
- Utilize local data to target interventions to the most at-risk populations.
Challenges
- Limited access to healthcare services, especially in rural and underserved areas.
- Shortage of trained healthcare workers.
- Unusual presentation of sepsis in pregnant women.
- Inadequate infrastructure and resources.
- Cultural beliefs and practices that may hinder access to care.
- Antimicrobial resistance.
- Gaps in record keeping and data collection.
Key Resources
- Recommendations on antenatal care for a positive pregnancy experience. WHO 2016
- Identification and Management of Maternal Sepsis During and Following Pregnancy. BJOG: IJOG 2024
- Intrapartum azithromycin to prevent maternal and neonatal sepsis and deaths: A systematic review with meta-analysis. BJOG: IJOG 2023
- Statement on Maternal Sepsis. WHO 2017
- Recommendations for prevention and treatment of maternal peripartum infections. WHO 2015
- Maternal Early Warning Scores (MEWS). Obstetrics, Anaesthesia and Critical Care 2018