Individual research recommendation details

Recommendation ID

NG121/4

Question

What clinical features and laboratory investigations can be used to better stratify risk for women in labour with signs of sepsis (including fever and tachycardia)?

Any explanatory notes
(if applicable)

Why the committee made the recommendations

No evidence was found on observations for women in labour with obstetric complications so the committee made recommendations based on their expertise and knowledge of good practice. They agreed that in order to understand the whole clinical picture, it is important to listen to the woman's concerns and her own account of her symptoms. The committee acknowledged that women in the following groups would only need routine maternal observations during labour if there were no other concerns:

• breech presentation

• suspected small-for-gestational-age baby

• suspected large-for-gestational-age baby

• previous caesarean section

• labour after 42 weeks of pregnancy

• no antenatal care.

The committee did not want to medicalise care for women with fever in labour and agreed that many of these women do not need additional maternal observations apart from hourly monitoring of temperature and level of consciousness (AVPU [alert, voice, pain, unresponsive]), and 4‑hourly monitoring of respiratory rate and oxygen saturation. However, if other symptoms or signs develop, the possibility of sepsis should be considered.

The committee did not want to medicalise care for women with slight concerns about possible sepsis, but they agreed that if concerns are enough to warrant antibiotic treatment, more frequent observations are needed because of the risk of sudden deterioration. The committee recommended continuous or half-hourly measurement of pulse, blood pressure and respiratory rate in line with the NICE guideline on sepsis. Hourly monitoring of temperature is sufficient, but AVPU should be monitored every half hour, with continuous or 30‑minute monitoring of oxygen saturation. Hourly recording of urine output should be performed if the woman has a catheter.

The committee agreed that for women with intrapartum haemorrhage, continuous monitoring of vaginal blood loss is important because this is often underestimated and it can be difficult to decide when more action is needed. Therefore the committee recommended more frequent observations to detect possible changes in a woman's condition. They also recommended other observations such as respiratory rate, volume of urine output, AVPU and oxygen saturation to prompt transfer to an obstetric-led unit and involvement of a senior obstetrician if needed.

Because of the increased risk of serious medical problems in women with obstetric complications or no antenatal care and the need for timely action when indicated, it is important that the woman's condition is comprehensively reviewed by an experienced healthcare professional who should be responsible for deciding if there is a need to escalate care. The committee was aware that the risk of serious medical problems for the woman or the baby depends on the whole clinical picture. They recommended that this should be taken into account when discussing options for care with the woman during the intrapartum period.

The lack of evidence on maternal observations for women in labour with suspected sepsis prompted the committee to make a research recommendation to inform future guidance.

How the recommendations might affect practice

The committee agreed that the recommendations reflect current best practice, but this may result in changing practice in some units.

Full details of the evidence and the committee's discussion are in evidence review K: risk assessment for women with obstetric complications or no antenatal care.

Source guidance details

Comes from guidance

Intrapartum care for women with existing medical conditions or obstetric complications and their babies

Number

NG121

Date issued

March 2019

Other details