September is sepsis awareness month. Sepsis is a serious condition, and one that can develop suddenly. In this article Professor Helen Cheyne, RCM (Scotland) professor of midwifery, University of Stirling, tells her powerful personal story of the condition, and points to why recognition of sepsis by midwives and health professionals is vital for pregnant and postnatal women and babies. She also shares Tiffany’s story, and the differing responses to sepsis in neighbouring Trusts.
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Sepsis: what midwives and maternity professionals need to know
One thing we have all learned from the Covid -19 pandemic is that severe infection is not a thing of the past nor a problem confined to low-income countries. Each year as World Sepsis Day and Sepsis Awareness month approach infection and its potential consequence is foremost in my mind because three years ago, I very nearly died due to sepsis. In sharing my story and the story of one of my fellow UK Sepsis Trust trustees I hope to remind midwives, students and all birth workers of the importance of knowing how to recognise the signs of sepsis and when and how to take action.
My story
All was normal at work on Thursday 3rd May 2019, in the afternoon I felt a little unwell, tired, achy limbs, sore shoulder and neck. I had a cup of tea with a colleague but felt no better so I went home and straight, to bed. Next day I felt worse, very fluey symptoms – sore muscles and limbs, headache, tired. I wandered around the flat or lay in bed, took paracetamol every four hours. A friend came round and said she would take my dog so I didn’t have to walk her. I wasn’t worried I just thought I had flu and that I’d feel better tomorrow. But early the next morning I realised that I couldn’t get out of bed, I sent a text to a friend who lived next door, asking her to come round to make me a cup of tea and thankfully she came round right away. She took one look at me and said ‘no arguments! I’m calling NHS 24’. They wanted to speak to me and when I reached out for the phone, I saw that my nailbeds were a dark blue/purple colour. When I told the call handler this, they dispatched an ambulance immediately and it arrived very quickly. I was rushed to casualty where there was a medical team waiting, they recognised that I had severe sepsis and I was admitted to ICU. Overnight my condition deteriorated rapidly and on Sunday morning (less than four days after first feeling unwell) the nurses helped me to call both my sons to tell them how much I loved them and say goodbye, before I was placed on a ventilator. I was on the ventilator for a week. This was a terrible time for my sons, family and friends. I was diagnosed as having meningococcal septicaemia. For the first few days my sons were told I was unlikely to live and that I was the sickest person in the hospital (not my favourite accolade), and as the week went on, that I was likely to lose limbs and might have brain damage. After a week however, I wasn’t dead, my condition improved a little and was able to be extubated. There followed a long process of recovery, I was on renal dialysis for around a month and in hospital for 4 months; in that time I required amputation of both legs below the knee and lost the tips of all of my fingers, I had to learn to walk again. Three years later I live every day with the impact of sepsis – but life returns to something like normal, my wee dog and I still go for our walks every day, recovery goes on I recently have been learning to run and for the first time managed a swim in the sea- the human spirit is amazingly resilient and we midwives are a tough bunch!
You will understand why sepsis is very real for me and it should be for everyone involved in healthcare. Sepsis causes 11 million deaths worldwide annually (2017)1. Almost 50,000 people in the UK die of sepsis each year, with very many more people living (like me) with its lifelong impacts. While many people affected by sepsis will be older or living with long term conditions midwives and other maternity care staff cannot be complacent. Sepsis is a leading cause of maternal deaths worldwide and is the third most common cause of death in new born babies2. However, maternal sepsis does not only affect people living in low-income countries. In the 2006/8 Saving Mother’s Lives report3 sepsis was the leading direct cause of maternal death in the United Kingdom in that reporting period. In the most recent report 37 direct or indirect deaths were due to sepsis meaning that it remains one of the leading causes of maternal death in the UK4. Recent US data found that maternal sepsis complicates between 4 and 10 per 10,000 live births with indications that rates are increasing5.
Yet sepsis is a preventable cause of maternal or neonatal death. Sepsis is not a disease in itself; it is a syndrome caused by underlying infection defined as a life-threatening organ dysfunction due to a dysregulated host response to infection.1 In other words, sepsis is the body’s response to severe infection and it develops as a result of undetected and unchecked infection (it is important to remember that infection is not in itself, sepsis) .
Pregnant and postnatal women and babies are at increased risk of developing sepsis because of the many opportunities for infection, in particular, following labour and birth and in the early postnatal period. For example, UTI, prolonged SROM, retained products, caesarean section or perineal wounds, mastitis. Babies may become infected through vertical transmission from their mother antenatally or during their birth or through postnatal environmental exposure6.
In the UK almost all women receive care from NHS maternity services from antenatal booking (around 10 weeks of pregnancy) through to around 7-10 days following birth7. Therefore, midwives and other maternity care providers have a responsibility, and must make opportunities, to identify early signs of infection in women and babies and to take appropriate action
The majority of cases of maternal and infant infection are likely to occur in the postnatal period and we know that most maternal deaths occur postnatally, yet this period of increased risk comes at the time where vigilance is least. For over 20 years, reports and surveys have highlighted the inadequacy of postnatal care and warned of the risks; yet erosion of this service persists, women are discharged from hospital quickly after giving birth, even following caesarean section. Early discharge is not in itself a problem but combined with reduction of regular routine postnatal care means that vigilance is obviously reduced and there is a risk that women can fall through the net8.
Tiffany’s story
Tiffany gave birth to her first baby by caesarean section earlier this year. She was discharged home after two days but the following day she felt unwell, she contacted the maternity hospital where she had her baby and was advised to go to A & E. After a long wait she was seen and following some tests she was discharged. She says- I asked to see an obstetrician but was refused. I was a bit frustrated that I was discharged home (after the birth) without any advice about the dressing or section recovery in general. I think I may have been one of those unfortunate people that have slipped through the gap as I live bordering two regions and after leaving hospital, they transferred my care to the midwife team from the other area who have no details about me. Even though I had a caesarean section only two days before they (midwives in the hospital where I gave birth) refused to see me. The next day Tiffany attended the maternity triage in her local hospital as she had a spiking temperature and rigors – she was admitted immediately with suspected sepsis and started on the local sepsis protocol of IV antibiotics.
Five months later she says – I think the key thing I am still struggling to understand following the episode is how two hospitals (two trusts), about 15 miles apart could have responded in such a different way to an obvious infection following c-section delivery. Upon ringing triage (maternity), and then the maternity ward of the hospital where I gave birth, they refused to see me and even stated that they had no obligation to my aftercare just days following delivery and that it was a GP matter to be dealt with. The 2nd hospital, on the other hand, following ringing triage, brought me in immediately and advised the medical team to start the sepsis treatment pathway, including IV antibiotics etc within the required timeframe. I found this disparity between the two trusts rather disturbing, especially in light of the potential to develop sepsis following delivery, especially a major op such as c-section.
In times of financial constraints and increasing workload pressures daily midwife postnatal visits seems a very distant memory. Yet midwives and maternity service providers must ensure that women and babies are safe, in particular from known risks. Elizabeth Duff in her talk for Midwifery Hour – Postnatal Care – who cares?, highlighted the mismatch between the sparse information provided to women about signs of infection following birth and the specific risk factors listed in information for professionals. Women and families must have clear information to enable them to know when to be concerned and what action they need to take. When they do seek help. they must be listened to and taken seriously.
There is a delicate balance between improving outcomes from sepsis and over prescription of antibiotics which might contribute to Anti-Microbial Resistance (AMR). The natural physiological response, particularly during the second stage of labour, can result in many of the normal signs of infection (such as tachycardia and modest fever) without any clinical evidence of infection. It’s essential that we remember that temperature alone is not a feature of sepsis definitions. Midwives should rightly have a high index of suspicion for infection, but must be aware that infection is not in itself sepsis. Prior to treating a woman as having sepsis the presence of one or more Red Flags must be confirmed. The UK Sepsis Trust has provided free online learning for health professionals and an infographic for midwives. They also provide information for members of the public about signs of sepsis in adults and children.
References
- World health Organisation. Sepsis. Sepsis (who.int) Accessed 07/09/2022
- Wang H, Naghavi M, Allen C, et al Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016;388:1459-544doi:10.1016/S0140-6736(16)31012-1.
- Reidy J, Russell R. CMACE 2006–2008. International Journal of Obstetric Anesthesia. 2011 Jul 1;20(3):208-12.
- Knight M. The findings of the MBRRACE-UK confidential enquiry into maternal deaths and morbidity. Obstetrics, Gynaecology & Reproductive Medicine. 2019 Jan 1;29(1):21-3.
- Plante LA, Pacheco LD, Louis JM, Society for Maternal-Fetal Medicine (SMFM. SMFM Consult Series# 47: Sepsis during pregnancy and the puerperium. American Journal of Obstetrics and Gynecology. 2019 Apr 1;220(4):B2-10.
- Kim F, Polin RA, Hooven TA. Neonatal sepsis. bmj. 2020 Oct 1;371.
- National Institute for Health and Care Excellence. Postnatal care. NICE guideline [NG194] Published: 20 April 2021
- Bowers J, Cheyne H. Reducing the length of postnatal hospital stay: implications for cost and quality of care. BMC health services research. 2015 Dec;16(1):1-2.
Professor Helen Cheyne
RCM (Scotland) professor of midwifery, University of Stirling
September 2022