What criteria should I use to determine whether a patient with suspected puerperal sepsis requires urgent referral to secondary care?

Patients with suspected puerperal sepsis require urgent referral to secondary care if they meet any of the following high risk criteria:

• Signs of organ dysfunction such as altered consciousness, hypotension (systolic blood pressure less than 90 mmHg), reduced urine output (less than 0.5 ml/kg per hour), need for ≥40% oxygen to maintain oxygen saturation above 92%, or hypothermia (temperature below 36°C).
• Elevated lactate levels, specifically lactate over 4 mmol/litre, or lactate between 2 and 4 mmol/litre, indicating severity of sepsis.
• Clinical signs of shock or hemodynamic instability.

In these cases, immediate senior clinical assessment, initiation of broad-spectrum antibiotics within 1 hour, blood tests including blood cultures and lactate measurement, and intravenous fluid resuscitation are required.
Referral to a critical care specialist or team should be made promptly for patients with lactate over 4 mmol/litre or systolic blood pressure less than 90 mmHg.
Women in labour with suspected sepsis should have a multidisciplinary review involving senior obstetric, anaesthetic, midwifery, and critical care staff.
Urgent referral is also indicated if the source of sepsis is thought to be the genital tract, to expedite birth and control infection.
These criteria ensure timely recognition and management of puerperal sepsis to reduce risk of severe illness or death.

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