Septic shock -This is a distributive form of shock, where an overwhelming infection develops. -Certain organisms produce toxins that cause fluid to be lost from the circulation into the tissues. -The commonest form of sepsis causing death in childbearing in the UK is reported to be that caused by beta haemolytic Streptococcus pyrogenes (Lancefield Group A)

-This is a Gram-positive organism, responding to intravenous antibiotics, specifically those that are penicillin based. - In the general population, infections from Gram- negative organisms such as Escherichia coli, Proteus or Pseudomonas pyocyaneus are predominant, which are common pathogens in the female genital tract. -The placental site is the main point of entry for an infection associated with pregnancy and childbirth.

-This may occur following prolonged rupture of fetal membranes, obstetric trauma, septic abortion or in the presence of retained placental tissue. -A total of 22 women died over 3 years as a result of genital tract sepsis in the last Confidential Enquiry -Of these, 18 were counted as Direct deaths, one as early pregnancy and three late deaths, i.e. >6 weeks postpartum.

Clinical signs -The mother may present with a sudden onset of tachycardia, pyrexia, rigors and tachypnoea. -The mother may also exhibit a change in her mental state and gastrointestinal symptoms are common in pelvic sepsis. -Signs of shock, including hypotension, develop in septic shock as the condition takes hold.

-Haemorrhage may be present. -This could be a direct result of events due to childbearing, but it occurs in septic shock because of DIC

Management -This is based on preventing further deterioration by restoring circulatory volume and then eradication of the infection. -Replacement of fluid volume will restore perfusion of the vital organs. Satisfactory oxygenation is also needed. -Measures are needed to identify the source of infection and to protect against reinfection by maintaining high standards of care in clinical procedures.

- A full infection screening should be carried out including a high vaginal swab, midstream specimen of urine and blood cultures. Infusion sites and indwelling catheters should be checked for signs of contamination and changed as appropriate. -Rigorous treatment with intravenous antibiotics, after blood cultures have been taken, is essential to halt the illness. -Retained products of conception can be detected on ultrasound, and these can then be removed.

-In all situations where the mother requires to be transferred for critical or intensive care, relatives should be kept informed of progress. - The midwife may be the person with whom the relatives have formed a relationship and therefore is relied on to give information