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Management of Severely Ill Pregnant or Postnatal Woman Pathway

MOEWS Calculated

Score = 0 - 2

  • Antenatal = Daily Observations
  • Postnatal = at least 12 hourly observations

Score = 3 - 5

Within 30 Minutes you must

  • Inform Senior Midwife
  • Inform Senior Obstetrician, ST3 or above

Score 6 or Above

Within 15 Minutes you must

  • Inform Shift leader
  • Inform Senior Obstetrician, ST3 or above.
  • Inform the Anaesthetist
  • Transfer to delivery suite

 

Senior Obstetrician, ST3 or above review within time frame

Yes

Senior Obstetrician, ST3 or above to ensure

  • The consultant Obstetrician is informed
  • Review and document management plan in the health record
  • Multidisciplinary team is involved as appropriate
  • Consider transfer to Delivery Suite

No

  • Call Consultant Obstetricia
  • Contact the Anaesthetic Registrar/Consultant as required
  • Depending on the MOEWS consider critical care referral as per Trust guidelines

Does the woman have any Two of the following?

  • Temperature under 36oC or Over 38.3oC
  • Heart Rate - over 100 bpm Antenatal - over 90 bpm Postnatal
  • Respiratory Rate over 24/minute
  • White Cells less than 4, more than 12 x 10 /L
  • Blood Sugar more than 7.7 in the absence of diabetes
  • Acutely altered mental state

No

  • Follow standard MOEWS protocol
  • Re-apply screening tool if situation changes
  • Consider source of infection without inflammatory response
  • Consider source of infection without inflammatory response

 

Is the History Suggestive of New infection?

  • Prolonged Spontaneous Rupture of the membranes.
  • Unexplained foetal tachycardia in the absence of a maternal tachycardia.
  • Urinary Tract Infection
  • Catheter or other line infection.
  • Meningitis
  • Pneumonia
  • Peritonitis
  • Offensive liquor.
  • Breast redness/tenderness/ mastitis
  • Intra Uterine Death/ Stillbirth
  • Cellulites / Septic Arthritis/ Fasciitis / Wound Infection
  • Endocarditis
  • Diarrhoea

No

Look for non-infective causes

  • Pancreatitis
  • Transfusion reaction
  • Trauma
  • Burns
  • Thromboembolism

Management of Sepsis Patient

Patient has Sepsis

  • Seek Senior Review
  • Consider seeking critical care opinion
  • Oxygen : High Flow 15L / min via a non-re breather mask
  • Blood Cultures: Take at least one set prior to antibiotics Plus FBC, U&E, LFT, Clotting, Glucose, Lactate,
  • Serum Lactate If more than 2 with signs of organ dysfunction inform Senior Anaesthetist.
  • Inform ITU
  • IV Antibiotics - 1st dose to be given within the first hour
  • Fluid Resuscitation
  • Continue MOEWS every 30 mins
  • Monitor fluids and record fluid balance hourly
  • Catheterise and commence HDU Chart (if not commenced)
  • VTE Prophylaxis
  • Consider Delivery or ERPC

Does the woman have any signs of Organ dysfunction?

  • Blood Pressure systolic less than 90 or MAP of less than 65
  • New need for O2 to keep SpO2above 90%
  • Urine Output less than 0.5 ml /KG for 2 hours
  • Bilirubin more than 34 μmols/l
  • Platelets less than 100 x 10 L
  • INR less than 1.5 or aPTT less than 60s
  • Lactate more than 2mmol /L
  • Creatinine more than 170 mmol/L

Yes - Patient has Severe Sepsis

No

  • Reassess patient
  • Document appropriate management plan

 

Systolic BP <90mmHg or MAP <65mmHg or a fall of >40mmHg or lactrate >4mmol from baseline after resuscitation?

Yes

Septic Shock

Refer to Critical care?

Accepted for ITU/HDU

Transfer ITU/HDU

  • Ensure patient has received adequate fluid resuscitation: boluses of 30ml/kg
    0.9% saline or Plasma-lyte
  • If still shocked (low BP/ low urine output/ high lactate) insert central venous
    catheter under USS guidance (only if competent; otherwise seek help)
  • Aim to achieve CVP 8-12mmHg with Care, Check CVP Monitor
  • Consider noradrenaline if still shocked or dobutamine if ScvO2 < 70%.
    Consider +/-blood transfusion
  • Take heparinised sample from central line (use ABG syringe): check
    ScvO2>70%
  • Consider blood transfusion if haematocrit < 30 and ScvO2 <70%.
  • Recheck Lactate if initially high >4 mmol/L
  • Review Antibiotics
  • Daily Obstetric review if antepartum

No

Severe sepsis, no shock

  • Refer to Critical Care /CCOT/Acute
    Response Team
  • Ensure management plan is documented
    in notes
  • Ensure hourly MOEWS taken, recorded
    and acted upon.
  • Monitor urine output
  • Record hourly fluid balance
  • Monitor blood test for signs of AKI
  • daily antibiotic review
  • Medical review at 6 hrs

If patient fails to respond to treatment refer to critical care