Maternal Sepsis in Pregnancy — OBRx Inpatient Order Set

1. Admission / Level of Care / Team Activation

Admit / transfer patient to: ☐ ICU ☐ Step-down / high-acuity obstetric unit ☐ Labor & Delivery ☐ Emergency Department observation

Activate sepsis response / rapid response team now.

Notify OB attending / MFM now.

ICU / critical care consultation.

Anesthesia consultation.

Infectious disease consultation.

Additional consults: ☐ Surgery ☐ Urology ☐ Interventional Radiology ☐ Cardiology ☐ Neonatology ☐ Pharmacy ☐ Other: ______________________

2. Recognition / Screening / Clinical Indication

Clinical classification

Suspected serious infection without definite end-organ injury

Maternal sepsis

Septic shock

Suspected source

Urinary / pyelonephritis

Intraamniotic infection / chorioamnionitis

Postpartum endometritis

Septic abortion / retained products of conception

Cesarean / wound / pelvic abscess

Necrotizing soft tissue infection

Pneumonia / respiratory infection

Bacteremia / line infection

Unknown source

Other source: __________________________

3. Nursing Orders / Monitoring

4. IV Access / Fluids / Hemodynamics

Insert 2 large-bore peripheral IV lines.

Central venous access if needed per ICU / anesthesia.

Arterial line if indicated.

Balanced crystalloid resuscitation

Balanced crystalloid: ☐ Lactated Ringer’s ☐ Plasma-Lyte ☐ Other: __________________

Initial bolus 1000 mL IV now

Additional 500–1000 mL IV bolus based on response

Goal total first 1–3 hours: 1–2 L IV for hypotension or suspected hypoperfusion

Maintenance fluid: __________________________

Reassess after each bolus for MAP, pulse, respiratory effort, lung exam, urine output, mental status, capillary refill, and lactate trend.

Do not use starches or gelatin-based resuscitation fluids.

Vasopressors

Start norepinephrine infusion per hospital/ICU protocol if hypotension persists after adequate fluids.

Norepinephrine concentration: ____________________

Initial rate: ____________________

Titrate to MAP ≥65 mmHg or individualized goal

Consider hydrocortisone for vasopressor-dependent septic shock per ICU team.

5. Laboratory / Cultures / Imaging

6. Source-Specific Antibiotic Panels

Administer empiric broad-spectrum antibiotic therapy as soon as possible. First dose should ideally begin within 1 hour when maternal sepsis is likely or shock is present.

These are build-ready default panels for local review, not a substitute for pharmacy approval or local antibiogram. Adjust for renal function, BMI/weight policies, severe beta-lactam allergy, resistant organisms, and postpartum/lactation considerations.

Undifferentiated severe sepsis / septic shock / unclear source

Piperacillin-tazobactam 4.5 g IV q6h

OR cefepime 2 g IV q8h + metronidazole 500 mg IV q8h

Add vancomycin per pharmacy dosing if MRSA risk, line infection, severe SSTI, or hospital-acquired concern

Severe beta-lactam allergy pathway: ____________________________________________

Pharmacy to verify renal dosing and weight-based adjustments.

Infectious disease consult.

Use this panel when the patient is unstable or the source is unclear and broad abdominal/pelvic/urinary coverage is needed.

Pyelonephritis / urosepsis

Ceftriaxone 1–2 g IV q24h

OR cefepime 2 g IV q8–12h if severe illness, prior resistant organism, or healthcare exposure

Consider piperacillin-tazobactam 4.5 g IV q6h if shock or polymicrobial concern

Urine culture before antibiotics if feasible without delay

Renal ultrasound now

Consider CT / urology consult if obstruction, stone, or failure to improve

Broaden therapy for septic shock, obstruction, prior ESBL, or recent hospitalization.

Postpartum endometritis / septic abortion / retained products / uterine source

Clindamycin 900 mg IV q8h + gentamicin ______ mg/kg IV q24h (or institution-specific dosing)

OR ampicillin-sulbactam 3 g IV q6h

OR piperacillin-tazobactam 4.5 g IV q6h if severe illness / shock / broad pelvic-abdominal coverage desired

Pelvic ultrasound now

Evaluate for retained products / uterine contents requiring evacuation

Consider GAS / toxin-mediated disease if rapid progression, severe pain, or disproportionate shock

Add clindamycin if toxin suppression desired and not already included

If uterine source is confirmed or strongly suspected, prompt evacuation or delivery may be necessary for source control.

Intraamniotic infection / chorioamnionitis / labor-associated infection

Ampicillin 2 g IV q6h + gentamicin ______ mg/kg IV q24h (or institution-specific dosing)

Add anaerobic coverage per local pathway when postpartum, cesarean, severe infection, or polymicrobial concern is present: ____________________________

Delivery planning per obstetric indication and maternal status

Do not delay maternal stabilization for fetal interventions

Tailor route and continuation of therapy to delivery timing, route of delivery, and postpartum course.

Cesarean wound / pelvic abscess / severe skin-soft tissue / necrotizing infection

Piperacillin-tazobactam 4.5 g IV q6h + vancomycin per pharmacy dosing

Add clindamycin 900 mg IV q8h if necrotizing infection, streptococcal toxic shock, or clostridial process is suspected

Surgical consultation STAT

CT / ultrasound to define abscess if patient stable enough

Debridement / drainage / re-exploration now if indicated

Pain out of proportion, crepitus, rapid progression, bullae, skin anesthesia, or refractory shock should trigger immediate operative evaluation.

Pneumonia / respiratory source

Community-acquired pneumonia pathway: ____________________________________________

Hospital-acquired / ventilator-associated pathway: ____________________________________________

Add antiviral therapy if influenza is suspected: ____________________________________________

Respiratory viral testing / sputum culture / chest imaging

Escalate oxygen / ICU / anesthesia support as needed

Because CAP/HAP protocols vary, this tab is designed for local respiratory-order-set linkage.

Antibiotic administration details

First antibiotic dose STAT now

Record antibiotic start time: ______________________

Pharmacy to verify allergy history, renal dosing, IV compatibility, and local restricted-drug policy.

Narrow therapy when culture data, operative findings, or imaging identifies source and susceptibilities.

7. Source Control Orders

Evaluate immediately for drainable, removable, obstructive, necrotic, or uterine source.

OB/GYN procedure planned: ☐ D&C ☐ D&E ☐ Manual uterine evacuation ☐ Delivery ☐ Cesarean delivery ☐ Other: ______________________

Surgical procedure planned: ☐ Debridement ☐ Abscess drainage ☐ Re-exploration wound ☐ Hysterectomy ☐ Other: ______________________

Urologic source control: ☐ Nephrostomy ☐ Ureteral stent ☐ Other: ______________________

Source control target identified at: ______________________

Planned source control time: ______________________

8. Obstetric / Fetal Management

Confirm gestational age and fetal viability.

Continuous fetal monitoring if viable and feasible.

Ultrasound for fetal status / placenta / retained products as indicated.

Neonatology consult if risk of preterm delivery.

Betamethasone if preterm delivery risk and clinically appropriate.

Magnesium sulfate for fetal neuroprotection if indicated and not contraindicated.

Maternal stabilization takes priority over fetal intervention.

Delivery indicated for: ☐ Obstetric indication ☐ Uterine source control ☐ Maternal deterioration ☐ Other: ______________________

9. Respiratory / Supportive Care / VTE Prophylaxis

Respiratory support

Supplemental oxygen to maintain maternal oxygen saturation goal ______%

High-flow nasal cannula / noninvasive support per ICU team

Intubation / mechanical ventilation if indicated

Supportive care

Acetaminophen ______ mg PO/IV q______ PRN fever/pain

Insulin protocol if glucose >180 mg/dL

SCDs

Pharmacologic VTE prophylaxis if not contraindicated: ____________________________________________

Lactation / postpartum medication review if applicable

10. Escalation / Provider Notification Parameters

Notify provider immediately for SBP < ______ or MAP < ______

Notify provider immediately for HR > ______ persistent

Notify provider immediately for RR > ______ or new respiratory distress

Notify provider immediately for O₂ saturation < ______ despite support

Notify provider immediately for urine output < ______ mL/hr

Notify provider immediately for rising lactate, severe pain out of proportion, suspected necrotizing infection, altered mental status, or worsening fetal status.

11. Documentation / Quality / Disposition

Record recognition time: ______________________

Record blood culture collection time: ______________________

Record antibiotic administration time: ______________________

Record initial fluid bolus start/completion time: ______________________

Record vasopressor start time if applicable: ______________________

Record source control time if performed: ______________________

Daily review of cultures, imaging, source control, antibiotic narrowing, and level of care.

Multidisciplinary debrief if ICU admission, shock, emergency surgery, or severe maternal morbidity.

Survivorship / family support plan if prolonged ICU course or septic shock.

12. Provider Authentication

Ordering clinician signature

Date

Time

Printed name / credentials

Contact / pager

Co-sign if required

Disclaimer

This order set is an educational template for instructional purposes only. It does not replace institutional protocols, national guidelines (e.g., ACOG, RCOG), or consultation with maternal–fetal medicine, nutrition, psychiatry, and other specialists.

Medication doses, fluid rates, and monitoring schedules must be verified against current institutional policies, pharmacy guidance, and patient-specific factors (e.g., renal/hepatic function, gestational age, comorbidities, and fetal status). For EHR implementation (e.g., Cerner/Epic), each bullet should be mapped to local orderables and adjusted to match system-specific naming, dosing defaults, and routing.