On the day I was supposed to be discharged from the hospital, I began to feel sick. I began to experience fever, chills, overall feeling of weakness, became short of breath, and felt like my heart was racing. I told my doctors all of my symptoms, but was quickly brushed off and was told that I was likely “just anxious about being a new mother.” Some tests were run and my White Blood Cell (WBC) count was higher than the previous tests, but again I was brushed off and told, “An elevated WBC count is normal after child birth.” — April Chavez, in April Chavez, Survived Sepsis

In two weeks, Sepsis Survivors Week will kick off and there will be stories of women, patients, and families who have been impacted by sepsis during pregnancy and after delivery. NPIC will share some of those here, but it is important to highlight a few items before we get there that deserve our attention now.

Normalization of Deviance
About three weeks ago, I blogged about the Normalization of Deviance and it became NPICs highest viewed blog. Why? Because every healthcare provider has experienced it in one way or another. At one level or another. And we are all seeking solutions.

Symptoms brushed off as “just anxious about being a mother?” Check the Normalization of Deviance box. (And a few other boxes too, but that’s another blog).

White blood cell count elevated with symptoms? “An elevated white blood cell count is normal after childbirth.” This one should be easy…the term “normal” was tossed in there to normalize the symptoms and findings (you guessed it…check that box again).

So How Do We Un-Normalize Symptoms of Sepsis in Pregnancy?
There is a challenge to sepsis in that in many ways it can different from other risks to pregnant and postpartum patients. Postpartum Hemorrhage? You can quantify (or should quantify) blood loss. Severe hypertension? Preeclampsia? Blood pressure, swelling, edema. Sepsis is a bit more insidious. The World Health Organization defines maternal sepsis as a life-threatening condition defined as organ dysfunction resulting from infection during pregnancy, childbirth, post-abortion, or the postpartum period (up to 42 days). What I am describing above are the symptoms that lead to sepsis, and how we as healthcare providers can break the chain and halt the progression of sepsis in its tracks.

Swiss Cheese Model and Near Miss/Error


If you have ever taken a TeamSTEPPS or other course in patient safety or risk management, invariably you will be introduced to the "Swiss Cheese Model” of patient error prevention. In essence, all of the holes line up perfectly to allow for an error or event to occur. Recognition of signs and symptoms of infection that lead to sepsis is the first step. Let’s use April’s story and sepsis recognition as an example:

Hole 1: Fever, chills, weakness, racing heartbeat/Dismissed

Hole 2: Shivering from fever/Dismissed (and thermostat of room turned up to provide warmth)

Hole 3: Symptoms continued/“New mom anxiety” and prescribed an anti-anxiolytic (symptoms dismissed)

How many more holes needed to be passed through? NONE. There were too many already! How many team members did not think to signal to someone that this was not normal? That these symptoms should be addressed?

AIM Sepsis in Obstetric Care Bundle
In 2022, the Alliance for Innovation on Maternal Health (AIM) launched the Sepsis in Obstetric Care Bundle. This patient care bundle provides teams the tools and elements needed to ensure consistent, standardized communication and care to prevent the downstream effects of infection and sepsis. Every hospital should be implementing this patient care bundle and readying their teams to be aware of the signs and symptoms of infection and sepsis.

There are a few key takeaways from this bundle:

1. Readiness: Create a culture that utilizes non-hierarchical communication so that all team members, including the patient, feel empowered to speak up about a concern and know that their input is valued by the entire care team. We can educate all day long. But that education means nothing if teams will not listen to the patient and their concerns about new symptoms.


2. Recognition and prevention: Provide patient education focused on general life-threatening pregnancy and postpartum complications and early warning signs, including sepsis signs and symptoms other than fever, and instructions for whom to notify with concerns. Ditto.


3. Response: Initiate facility-wide standard protocols and policies for assessment, treatment, and escalation of care for people with suspected or confirmed obstetric sepsis. If you have only prepared your obstetric departments to respond to infection or sepsis in an obstetric patient, your chain of survival is already broken.


4. Reporting/Systems Learning: Conduct multidisciplinary reviews for systems improvement of each sepsis case to assess the screening program, the quality of care provided to patients with sepsis, and whether instances of bias may have impacted care.


5. Respectful/Equitable Care: Because maternal mortality and severe maternal morbidity related to sepsis disproportionately affect Black, Indigenous, and Hispanic people because of systemic racism, but not race itself, it is necessary to mitigate this bias by having a high index of suspicion for sepsis.

So, let’s un-normalize our response to infection and sepsis. And yes, I get it…many things may “look” like infection. In many instances, sepsis may require a differential diagnosis and other symptoms to recognize. But it is important to recognize them and not dismiss them.

Let’s ensure a culture and environment in which many more patients with sepsis survive. Better yet, let’s create an environment where sepsis is caught before the downstream impact can occur. Learn more about sepsis at https://www.sepsis.org/ and share your own experiences about sepsis and the care of patients who have survived during Sepsis Survivors Week.