Anesthesia Patient Safety Podcast

#277 Transforming Maternal Care: Faster Sepsis Recognition, Smarter Hemorrhage Response, and Safer VTE Prevention

• Anesthesia Patient Safety Foundation • Episode 277

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Welcome back to our 2025 Stoelting Conference Podcast Series. 

Fever isn’t the fail-safe it’s made out to be—especially in pregnancy. We walk through the subtle ways maternal sepsis hides in plain sight, why a quarter of those who died never had a fever, and how early warning tools, rapid antibiotics, and source control change the odds. From there, we pivot to maternal hemorrhage and show how quantifying blood loss with calibrated drapes plus a treatment bundle outperforms the old habit of visual estimation. We dig into TXA timing for high‑risk cesarean patients, the evidence gaps on transfusion strategies, and how placenta accreta spectrum demands regionalized teams and rehearsed playbooks.

The conversation then turns to venous thromboembolism, still a leading cause of maternal mortality. Risk climbs five- to six-fold and peaks postpartum, so we stress reassessment at prenatal intake, during any antepartum admission, at delivery, and before discharge. We compare heparin and low molecular weight heparin in real-world settings, highlight extremely low neuraxial hematoma risk when following ASRA guidance, and share concrete workflow tactics: pre-delivery anesthesia consults, unit-wide alerting, anticoagulant hold triggers, and pre-procedure huddles that keep patients safe while preserving neuraxial options.

Threaded through each segment is a practical theme: faster recognition, standardized bundles, and tight communication save mothers’ lives. If you’re building a safer unit, start with tools that measure what matters, empower nurses to escalate, and remove delays between suspicion and action. Subscribe, share with your team, and leave a review with one change you’ll make this week—what will you implement first?

For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/277-transforming-maternal-care-faster-sepsis-recognition-smarter-hemorrhage-response-and-safer-vte-prevention/

© 2025, The Anesthesia Patient Safety Foundation

SPEAKER_01:

Delayed recognition of maternal sepsis has been associated with increased mortality with every hour that passes without treatment. In this report of women who died from sepsis in the state of Michigan, less than one out of five were febrile when they presented to the hospital. And a quarter of these women never had a fever.

SPEAKER_00:

Hello and welcome back to the Anesthesia Patient Safety Podcast. My name is Allie Bechtel, and I'm your host. Thank you for joining us for another show. This is the second episode in our Stolting Conference series, and we are continuing the conversation about transforming maternal care. We hope that you checked out last week's show for part one, and we are glad that you're back with us today for part two. Don't forget, you can also check out the recordings from the conference on our website and YouTube channel. And thank you so much to our industry sponsors for supporting the 2025 APSF Stolting Conference, BD, Medtronic, Solventum, and IntelliGuard. Check out the show notes for more information. Before we dive further into the episode today, we'd like to recognize Blink, a major corporate supporter of APSF. Blink has generously provided unrestricted support to further our vision that no one shall be harmed by anesthesia care. Thank you, Blink. We wouldn't be able to do all that we do without you. Our next Stolting Conference speaker is Emily Naum, an obstetric anesthesiologist and critical care physician at Massachusetts General Hospital to talk about maternal sepsis. Let's start with the definition. The World Health Organization defines maternal sepsis as a life-threatening condition characterized by the presence of organ dysfunction resulting from infection during pregnancy, childbirth, or the postpartum period. It is difficult to determine exactly how common maternal sepsis is since the definitions of sepsis, severe sepsis, and septic shock have changed over the past 30 years. It is estimated to occur in about 0.1% of all deliveries in the United States and contributes up to 25% of ICU admissions. This is a significant contributor to maternal morbidity and about 10 to 15% of maternal deaths. There has been no improvement in the maternal mortality rate over the past decade, despite treatment changes. The etiology for maternal sepsis often involves respiratory or urogenital systems with pneumonia and urinary tract infections common during pregnancy and genital tract or surgical site infections more common during the postpartum period. In about one-third of cases, no pathogen is detected. We also see that group A strep is particularly virulent and viral infections have increased severity in pregnancy. Obstetric risk factors for maternal sepsis include the following multiple gestation, preterm delivery, premature rupture of membranes, induction of labor, assisted vaginal delivery, cesarean delivery, stillbirth, retained products of conception, and postpartum hemorrhage. Additional risk factors include anemia, congestive heart failure, chronic liver disease, chronic kidney disease, obesity, African American race, and public health insurance in the United States. Keep in mind that it is difficult to identify maternal sepsis. Many of the SERS criteria may not be useful due to pregnancy physiology. Only about 18% of patients will present with fever, and 25% of patients who died from maternal sepsis never even had a fever. So, what can we do? There are several screening tools and early warning systems that can be used and even integrated into the electronic medical records to aid detection and allow for early action with antibiotics, source control, and ICU admission. Some of these tools include the obstetric early warning score, the modified early obstetric warning system, sepsis in obstetric score, and maternal early warning criteria. There is no perfect system at this time, but it is important to have a high index of suspicion and use the screening tools early. Remember, patients may look really good, even in early septic shock. Treatment considerations for maternal sepsis are similar to management for non-pregnant patients, with timely antibiotic administration, ideally within one hour of diagnosis, along with fluid resuscitation, source control, and vasopressors if needed. This is an area where we can and need to do better. We need better recognition of maternal sepsis and faster response. This means escalating care when needed, prescribing antibiotics sooner, and getting them into the patients faster. Emily provides some examples for how our systems can do better with multidisciplinary reviews, process mapping to identify gaps and measure improvements, and collaboration. Other opportunities include the use of simulation, cognitive aids, and patient education so that patients are empowered to know what is and what is not normal for them. Here are the big takeaways. Maternal morbidity and mortality due to sepsis remains high. Maternal sepsis can be difficult to diagnose. A high index of suspicion, the use of an early warning system with a standardized treatment algorithm and efficient delivery of care is necessary. And multidisciplinary care and review is essential. What early warning system are you using at your institution?

SPEAKER_02:

The greatest work that was showing benefit in the systematic review were our care bundles that you've heard so much of this morning. These have definitely shown that care bundles related to maternal hemorrhage do decrease morbidity and mortality.

SPEAKER_00:

Next up, we have Beth Clayton, a certified registered nurse anesthetist at the University of Cincinnati Medical Center, to talk about maternal hemorrhage. This is a leading cause of maternal morbidity and mortality, and there is room for improvement due to gaps in diagnosis and management. Delays in recognition of hemorrhage lead to worse outcomes. Often, clinicians may use visual detection to make the diagnosis, but using calibrated drapes and observation allows for real-time estimated blood loss and facilitates earlier recognition. Beth reminds us that checking a hemoglobin level can be useful for confirmation, but not detection. And the shock index may be used to detect deterioration, but not early recognition. We hope that you will check out the 2023 article in the New England Journal of Medicine, Randomized Trial of Early Detection and Treatment of Postpartum Hemorrhage by Gallows and colleagues that evaluated the use of calibrated drapes for determination of postpartum hemorrhage, followed by using a treatment bundle, which led to a lower risk of severe postpartum hemorrhage, laparotomy for bleeding, or death from bleeding. You can find the citation in the show notes. Now, what about the role for administration of tranexamic acid? There may be no benefit for prophylactic administration to patients who are low risk, while high-risk patients undergoing C-section will benefit from prophylactic administration. For high-risk patients, it makes sense to give the TXA at skin incision without waiting to give it later. We still need more research when it comes to blood and product transfusion for patients with postpartum hemorrhage. As the 2025 Cochrane Database of Systemic Reviews concluded that the current evidence is uncertain for the effects of blood and blood product transfusion on maternal outcomes. There is also not a lot of evidence related to interoperative cell salvage at this time, but this might be best to use for patients who refuse blood transfusion. There is an intervention that does move the needle on morbidity and mortality following postpartum hemorrhage. These involve multiple coordinated interventions and promote earlier intervention by clinicians. The California Maternal Quality Care Collaborative has toolkits available, including the Improving Healthcare Response to Obstetric Hemorrhage Toolkit version 3.0. We hope that you will check it out, and I will include a link in the show notes as well. You can download the toolkit, and there is a lot of information and tools available. Another important consideration related to maternal hemorrhage is placenta ocrita spectrum. There is an increased incidence due to the increase in C-section deliveries. Patients with placenta occreta have a higher risk for hemorrhage and worse outcomes. There are hospitals that are placenta acrita centers with multidisciplinary teams and plans in place to treat patients and keep them safe. For anesthesia professionals, it is important to have a role on the multidisciplinary team. At this time, the optimal anesthesia for delivery remains unclear. We are moving on to our next speaker, Lisa Lafert, who is a professor and chair of anesthesiology at Yale Medical School to talk about maternal venous thromboembolism. Let's start with the scope of the problem. Venous thromboembolism is a leading cause of maternal mortality, and patients have a five to six-fold overall risk, with the greatest risk occurring in the weeks after delivery. Risk factors include high BMI, immobility, preeclampsia, and infection. Keep in mind that patients' risk assessment should not be static. All patients should be assessed for VTE risk multiple times in pregnancy, including upon presentation for prenatal care, during any hospitalization for an antipartum indication, at delivery hospitalization, and prior to discharge from the delivery hospitalization. So what can we do to keep patients safe? This is where prophylactic treatment with anticoagulants can help. The choice for anticoagulant may be heparin, which has a short half-life and may be reversed with protamine, or with low molecular weight heparin, which is easy to administer with better bioavailability and safety profile, more predictable dosing, lower incidence of HIT, fewer bleeding episodes, and lower incidence of osteoporosis. What are you using at your institution? There are many different protocols, which makes it hard to determine what is working and what isn't working. Unfortunately, the mortality rate has gone up again between 2020 and 2022, and we still have insufficient evidence or sample size to base recommendations for thromboprophylaxis during pregnancy. So more work is needed in this area. Another consideration for patients receiving anticoagulants is the risk for bleeding complications and spinal or epidural hematoma. The good news is that OB patients are at incredibly low risk for this complication of about 1 in 200,000 to 1 in 250,000. If you review the literature, there are no cases of spinal epidural hematoma following noraxial anesthesia in OB patients receiving thromboprophylaxis. There is likely underreporting, and it is important to consider the ASVRA guidelines when it comes to timing for noraxial anesthesia procedures and anticoagulant administration. LISA provides several strategies to help facilitate noraxial anesthesia for patients at risk for VTE, including the following advanced planning and structured communication, clear understanding of unit-based protocols, system-wide alert systems, pre-delivery anesthesia consultation, prompt communication of changes in pregnant status, trigger to hold anticoagulant, pre-procedural huddles, and timeouts. There is a call to action to address the knowledge gaps in this area with validation of clinical prediction tools for evaluating the absolute risk for patients, the optimal risk threshold, the optimal dose, the optimal duration, and the absolute bleeding risk. What a great first morning at the Stolting Conference. We had some wonderful questions and comments from audience members, including some additional considerations for patients with heart failure. Here is a mini algorithm that may be useful. For patients who present with oxygen saturation less than 95%, it is important to rule out heart failure. Once patients start desaturating or if they require supplemental oxygen, immediate action is necessary. Consider checking a BNP. If this is normal, then it can help rule out heart failure. Can your patient lie flat? If not, consider diuresis until they can lie flat. For patients who are unable to lie flat and require a C-section, this is when a general anesthetic may be needed. There is a wellness bias for pregnant patients. Many people, including healthcare professionals, still think that all pregnant patients are young and healthy. But it is so important to understand the physiologic changes of pregnancy, important vital signs, and what is abnormal for pregnant patients so that we don't miss these early signs. We still have more to talk about when it comes to the 2025 APSF Stolting Conference. And we hope that you will continue to tune in for this podcast series. If you have any questions or comments from today's show, please email us at podcast at apf.org. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit apSF.org for detailed information and check out the show notes for links to all the topics we discussed today. Have you checked out the other APSF Patient Safety Resources initiatives? Head over to APSF.org and click on the Patient Safety Resources heading. The first one down, right above this podcast, is initiatives. From here, you can check out the following look-alike drug vials, continuous blood pressure monitoring, surgical fires, a preventable problem, workplace violence prevention, drug-drug interactions, and the COVID perioperative resource center. So many great initiatives to help improve anesthesia patient safety. Until next time, stay vigilant so that no one shall be harmed by anesthesia care.