What Are the Recommended Nursing Protocols for Sepsis Care?
When a pregnant or postpartum patient begins to deteriorate and sepsis moves onto the differential, nurses need more than a list of warning signs. We need to know what happens next. So, what are the recommended nursing protocols for sepsis care?
No single universal sepsis nursing protocol is used by every hospital. Facility policies, order sets, escalation pathways, and available resources differ. In obstetric care, protocols also need to account for the physiologic changes of pregnancy rather than simply applying a general adult sepsis pathway without modification.
The Society for Maternal-Fetal Medicine recommends that hospitals develop their own procedures and protocols for detecting and managing maternal sepsis while avoiding reliance on a single screening tool. SMFM also considers sepsis and septic shock during pregnancy and the postpartum period medical emergencies that require immediate treatment and resuscitation. The Alliance for Innovation on Maternal Health similarly recommends facility-wide, interdepartmental protocols for assessing, treating, escalating, and managing obstetric sepsis post-stabilization.
In practical terms, the recommended nursing protocols for sepsis care should help the bedside nurse move efficiently from concern to action. That includes activating the appropriate pathway, supporting rapid diagnostic evaluation and antimicrobial treatment, assisting with maternal-specific resuscitation, identifying when source control is needed, monitoring for shock, communicating changes, and repeatedly reassessing whether the patient is responding.
1. Activate the Maternal Sepsis Protocol and Escalate Early
Once maternal sepsis or septic shock is suspected, treatment should not wait for the patient to meet every possible criterion. SMFM recommends that sepsis and septic shock in pregnancy be treated as medical emergencies and that resuscitation begin immediately.
At the bedside, the maternal sepsis protocol may include notifying the appropriate provider, activating a sepsis alert or rapid-response pathway, initiating facility-approved standing orders, increasing monitoring, establishing or expanding vascular access, and mobilizing additional clinical resources. The exact sequence depends on facility policy, but the protocol aims to reduce unnecessary delays once concern is identified.
Nursing communication is particularly important during escalation. Rather than reporting a single abnormal number, the nurse should communicate the trend when possible. A rising heart rate combined with decreasing blood pressure, falling urine output, increasing respiratory rate, or a new oxygen requirement presents a more useful clinical picture than any of those findings alone. The protocol creates the pathway for escalation, while nursing assessment provides the context that explains why escalation is necessary.
2. Use Obstetric-Specific Sepsis Assessment Rather Than One Score Alone
A strong obstetric sepsis protocol should account for the physiologic changes of pregnancy and the early postpartum period. Normal changes in heart rate, blood pressure, white blood cell count, respiratory physiology, and metabolism can overlap with criteria used in general adult sepsis screening. (I explored this overlap in Maternal Sepsis in OB: 5 Clinical Clues Nurses Should Never Miss.)
For that reason, SMFM recommends that institutions develop procedures for maternal sepsis detection and avoid relying on a single screening tool. AIM also recommends evidence-based assessment criteria that incorporate obstetric-specific considerations when appropriate.
The 2025 CMQCC Improving Diagnosis and Treatment of Obstetric Sepsis, V2.0 Toolkit provides one example of an obstetric-specific approach. Its updated resources include a two-step screening and confirmation process, an Obstetric Serious Infection/Sepsis Evaluation Flow Chart, antimicrobial resources, sample nursing order sets, and other tools designed specifically for obstetric care.
For nurses, a screening tool should trigger the next stage of assessment, not replace clinical judgment. When the score and bedside picture do not agree, the patient’s changing condition still needs evaluation and communication.
3. Obtain Cultures and Lactate Without Delaying Treatment
Diagnostic evaluation is another major component of the nursing management of sepsis. SMFM recommends obtaining appropriate microbiologic cultures, including blood cultures, before antimicrobial therapy when possible, provided that obtaining cultures does not substantially delay antibiotic administration. SMFM also recommends a serum lactate level when maternal sepsis is suspected or identified.
Nursing workflow can significantly affect how efficiently the protocol moves. IV access, blood cultures, lactate, additional laboratory studies, urine specimens, and other ordered testing may all need to occur while maternal monitoring, medications, fluids, pharmacy communication, and interdisciplinary coordination are happening simultaneously. Fetal assessment may also be occurring when clinically appropriate.
The goal is not to finish every diagnostic task before treatment can begin. The goal is coordinated care in which evaluation and treatment move forward together, without one part of the protocol creating unnecessary delays in another. (For more on the diagnostic side, see How Are Postpartum Infections Diagnosed?)
4. Support Timely Antimicrobial Therapy and Source Identification
Antimicrobial therapy is one of the most time-sensitive nursing interventions for sepsis. For pregnant or postpartum patients with septic shock or a high likelihood of sepsis, SMFM recommends empiric broad-spectrum antimicrobial therapy ideally within one hour of recognition.
The nurse’s responsibilities may include confirming allergy history, obtaining ordered cultures, ensuring adequate vascular access, communicating medication delays, obtaining antimicrobial therapy from pharmacy, administering ordered medications, and accurately documenting when treatment begins. The antimicrobial regimen depends on factors such as the suspected source of infection, local resistance patterns, medication allergies, pregnancy or lactation status, and other patient-specific factors.
The protocol should also keep source identification ongoing, as antimicrobial therapy alone may not be sufficient. Potential sources include:
Urinary tract or kidneys
Respiratory system
Intraamniotic infection
Uterine infection
Cesarean or other surgical sites
Skin and soft tissue
Abdominal or pelvic sources
Another source unrelated to pregnancy or birth
Identifying the source at this stage is not simply diagnostic. It helps determine whether antimicrobial therapy is adequate or whether the patient requires an additional intervention for source control.
5. Use Maternal-Specific Fluid Resuscitation and Reassess the Response
Fluid resuscitation is an area where maternal-specific guidance matters most. SMFM recommends early IV administration of 1 to 2 liters of balanced crystalloid within the first three hours for pregnant or postpartum patients with sepsis complicated by hypotension or suspected organ hypoperfusion. Balanced crystalloid is the recommended first-line resuscitation fluid.
The recommendation does not stop with administering fluid. SMFM also recommends ongoing detailed evaluation of the patient’s response to resuscitation, guided by dynamic measures rather than assuming that an initial fluid volume has corrected the problem.
For nurses, this makes reassessment part of the intervention itself. After giving fluids, continue to evaluate blood pressure, heart rate, urine output, mental status, oxygen requirements, respiratory findings, perfusion, and the overall clinical trajectory. Pregnancy-related conditions and comorbidities, including preeclampsia, cardiac disease, and pulmonary concerns, may alter fluid tolerance and reinforce the need for individualized reassessment.
The 2026 Surviving Sepsis Campaign guidelines also continue to emphasize hemodynamic resuscitation and reassessment in adult sepsis care. These guidelines provide important broader sepsis guidance, while obstetric-specific recommendations remain necessary for pregnant and postpartum patients.
6. Monitor for Septic Shock and Escalate When Perfusion Is Not Improving
If hypotension or hypoperfusion persists despite initial resuscitation, the protocol needs to move beyond fluid administration. SMFM recommends norepinephrine as the first-line vasopressor for septic shock during pregnancy and the postpartum period.
Assess perfusion more broadly than blood pressure or mean arterial pressure alone. Mental status, urine output, skin findings, capillary refill, respiratory status, oxygen needs, lactate trends, and the overall trajectory can all indicate whether resuscitation is working.
Persistent deterioration should also trigger evaluation of whether the patient is in the appropriate level of care. Depending on the clinical situation, the protocol may require critical-care consultation, additional vascular access, more frequent laboratory monitoring, continuous hemodynamic monitoring, respiratory support, or transfer to a higher-acuity setting.
For patients with ongoing septic shock, SMFM also includes several additional recommendations relevant to advanced protocol development. IV corticosteroids may be considered when vasopressor support remains necessary, pharmacologic venous thromboembolism prophylaxis is recommended for pregnant and postpartum patients in septic shock, and insulin therapy may be initiated when glucose exceeds 180 mg/dL in critically ill pregnant patients. These interventions are provider-directed, but nurses play an important role in administration, monitoring, and identifying complications.
7. Keep Source Control Moving
One of the most important distinctions in a comprehensive sepsis protocol for nurses is recognizing that antimicrobial therapy cannot eliminate every source of infection. SMFM recommends rapid identification or exclusion of an anatomic source of infection and emergency source control when indicated.
If the uterus is the suspected or confirmed source of maternal sepsis, SMFM recommends prompt delivery or evacuation of uterine contents for source control regardless of gestational age. Other infections may require drainage, surgical intervention, removal of an infected device, or another procedure depending on the source.
At this point, the bedside nursing role is often highly operational. Nurses may prepare the patient for a procedure, anticipate transport, maintain resuscitation measures, communicate changes to multiple teams, and continue assessment while source-control plans are made.
Maternal sepsis can rapidly require coordination among obstetrics, anesthesia, critical care, infectious disease, surgery, pharmacy, laboratory services, respiratory therapy, and nursing. One purpose of an effective protocol is to prevent teams from operating in silos during a time-sensitive emergency.
8. Communicate, Document, and Reassess the Clinical Trend
Sepsis care is not a checklist that ends after antibiotics and fluids are administered. Treatment begins, and the team must determine whether it is working. Ongoing reassessment is therefore one of the most important components of any sepsis nursing protocol.
Nursing documentation should clearly show the clinical changes that prompted concern, when interventions were implemented, and how the patient responded. During transfer or handoff, communicating the trajectory is often more useful than reporting only the latest value.
For example, “Her heart rate has increased from the 90s to 118 over the last two hours despite treatment, her urine output has decreased, and she now requires supplemental oxygen” communicates considerably more than “Her heart rate is 118.” The first statement shows the team that multiple indicators are changing despite intervention.
AIM specifically recommends facility-wide protocols and communication across care settings because patients with obstetric sepsis may be managed in labor and delivery, emergency departments, ICUs, or other areas. AIM also recommends standardized post-stabilization management and coordinated follow-up after sepsis.
In other words, maternal sepsis does not belong to one unit, and the protocol should not stop at the doors of the OB department.
What Should a Maternal Sepsis Nursing Protocol Include?
Although every healthcare organization develops its own policies and workflows, an evidence-informed maternal sepsis nursing protocol should address recognition, treatment, resuscitation, reassessment, escalation, source control, and interdisciplinary coordination. Core components may include:
Obstetric-specific sepsis screening and reassessment
Rapid provider notification and escalation
Appropriate cultures and laboratory evaluation
Lactate measurement
Timely antimicrobial administration
IV access and ordered fluid resuscitation
Ongoing hemodynamic and perfusion assessment
Identification and management of the infection source
Escalation to critical care when needed
Clear documentation and interdisciplinary handoff
Patient and family communication
Follow-up and support after severe illness
A well-designed protocol should also clarify who is responsible for each action, what can begin under standing orders or institutional pathways, what findings require escalation, how treatment delays are communicated, and how the patient’s response will be reassessed.
The important question is not whether every hospital uses exactly the same form or order set. It is whether the system enables clinicians to recognize deterioration, carry out the appropriate nursing interventions for sepsis, and escalate care without unnecessary delay.
What Is New in Obstetric Sepsis Protocols?
Obstetric sepsis protocols continue to evolve as new evidence and quality-improvement work become available. CMQCC published its Improving Diagnosis and Treatment of Obstetric Sepsis, V2.0 Toolkit in September 2025. The revised toolkit includes an updated two-step screening and confirmation process, obstetric serious-infection and sepsis evaluation resources, antimicrobial guidance, sample nursing order sets, patient advocacy materials, and post-discharge resources.
AIM continues to emphasize standardized facility-wide protocols for obstetric sepsis, interdepartmental communication, timely treatment and escalation, patient education, and post-sepsis care. Its current resources reinforce that obstetric sepsis preparedness needs to extend beyond maternity units because pregnant and recently pregnant patients receive care throughout the healthcare system.
The Surviving Sepsis Campaign published updated adult sepsis and septic shock guidelines in March 2026. The new guidance updates the 2021 recommendations and addresses antimicrobial therapy, diagnostic strategies, hemodynamic resuscitation, and post-hospital care. For OB nurses, these updates are most useful when interpreted alongside maternal-specific guidance from organizations such as SMFM, AIM, and CMQCC, not as a substitute for obstetric guidance.
These updates reinforce an important point: an obstetric sepsis protocol should not remain unchanged in a policy manual for years. Maternal safety requires current pathways, interdisciplinary education, simulation, quality review, and nurses who understand not only what the protocol says but why each step matters.
The Bottom Line: What Are the Recommended Nursing Protocols for Sepsis Care?
No single universal nursing protocol exists for sepsis care, particularly in obstetrics. Evidence-based maternal sepsis protocols generally combine immediate escalation, obstetric-specific assessment, timely cultures and lactate measurement, prompt antimicrobial therapy, individualized fluid resuscitation, monitoring for shock, source identification and control, continued reassessment, and clear interdisciplinary communication.
For nurses, responsibility does not end after the pathway is activated or the first treatments are administered. We continue to assess whether perfusion is improving, whether urine output is changing, whether oxygen needs are increasing, whether we have addressed the suspected source of infection, and whether the patient’s overall response matches what we expect.
A protocol gives us the pathway. Nursing judgment helps us recognize when the patient is no longer responding as expected.
Start With the Free Maternal Sepsis Guide
If you care for pregnant or postpartum patients, my FREE Maternal Sepsis Quick Reference Guide provides practical reminders for recognition, reassessment, clinical concerns, and escalation.
For a deeper look at maternal sepsis recognition and response, explore my Maternal Sepsis CE Course for OB Nurses.
