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Chapter 7: SepsisLaparotomy for suspected intra-abdominal infectionshould involve a general surgeon as well as an obstetrician,as surgeons have a fundamentally differentapproach to laparotomy and are more likely to make amid-line incision to allow full exploration of theabdominal cavity.Leadership and continuity of careWhen managing complex cases, it must be clear who is incharge of the woman’s care. This is particularly importantwhen an unwell pregnant woman presents to the EmergencyDepartment rather than the Maternity or GynaecologyDepartments, as there may be a tendency for everyone toassume that someone else is looking after her. In one case,although several doctors were involved in one woman’s earlycare, no consultant took overall responsibility, nor were antibioticsgiven, until she collapsed over 24 hours after admission,by which time the outcome was inevitable.Documentation and communicationMany different medical, nursing and midwifery staff maybe involved in the ongoing care of an unwell woman andeach may see her only once or twice. This makes the assessmentof any changes in the woman’s condition very difficult.In some of the cases already discussed in this Chapter,the mother’s vital signs were either not recorded routinelyor their significance was not recognised. One of the ‘Topten’ recommendations in the last Report was for routineuse of a MEOWS chart to help in the more timely recognition,treatment and referral of women who have, or aredeveloping, a critical illness. A MEOWS chart is the easiestway to see trends in a woman’s condition and to alert staffto take appropriate action or call for help. For example:A woman in late pregnancy with a short history of sorethroat, vomiting, diarrhoea and abdominal pain was tachycardicand hypotensive on admission. Sepsis was not diagnosedfor some hours.The severity of her condition might have been recognisedsooner if a MEOWS chart had been used, and earlier antibiotictreatment and multidisciplinary care in a high-dependencysetting might possibly have changed the outcome.Involvement of other staffAnaesthetic and critical-care staff play a vital part in theeffective management of sepsis and should be involved asearly as possible, particularly when there is circulatory orrespiratory failure. For six women, also discussed in Chapter8, there were significant delays in seeking help from anaesthetistsand critical-care specialists.In some cases, hospital departments seemed to be verybusy and staff were said to be overstretched, although it isnot clear if this was directly related to the outcome. Forexample, it took several hours for two ill women to be seenby a doctor or obstetric team because they were said to bevery busy elsewhere. The husband of another very sickwoman complained about the wait in a busy maternity unitand was told that, as his wife was not seriously ill, the doctorwas seeing other more urgent patients. She died shortly after.Apart from the women whose rapidly fulminating diseasemeant they died at home or shortly after admission inthe Emergency Department, most other women died incritical care or operating theatres, reflecting the gravity oftheir condition. However, a few died in hospital wards,illustrating that seriously ill women were sometimes managedin inappropriate settings with inexperienced stafflooking after them.Sometimes there was a lack of co-ordinated care and littleor no support from senior staff when requested, butthere were also many examples of excellent teamwork. Forexample, as the assessors noted:This woman was extremely ill on admission and could nothave been saved. Her care could not have been better.Everyone, including consultants, was called and attendedextremely promptly, even though it was the middle of thenight. The teamwork was excellent.For most cases, there was a critical review by the Trust,and some also invited external assessment. Some of thesereviews were excellent, but, as with other cases counted inother chapters, many focused on irrelevant issues and failedto identify major elements of substandard care or to learnanything from the event. Recitfying this is an overall recommendationin this Report.Disclosure of interestsNone.FundingThis work was undertaken by the Centre for Maternal andChild Enquiries (CMACE) as part of the CEMACH programme.The work was funded by the National PatientSafety Agency; the Department of Health, Social Servicesand Public Safety of Northern Ireland; NHS QualityImprovement Scotland (NHS QIS); and the ChannelIslands and Isle of Man.References1 Health Protection Agency. Interim UK guidelines for management ofclose community contacts of invasive group A streptococcal disease.Health Protection Agency, Group A Streptococcus Working Group.Commun Dis Public Health 2004;7:354–61.ª 2011 Centre for Maternal and Child Enquiries (CMACE), BJOG 118 (Suppl. 1), 1–203 95