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862 British Journal of Midwifery • December 2014 • Vol 22, No 12

Professional

A modiﬁed early obstetric

warning system

For the majority of women childbearing

is a normal life event. Physiological

adaptations usually ensure a woman has

a healthy pregnancy, childbirth and postnatal

recovery. However, the increased cardiovascular

reserves and other physiological changes in

childbearing women can mask the sometimes

inconspicuous signs of severe maternal illness.

This can make recognition of impending maternal

collapse difficult. ‘Women with serious illness,

especially sepsis, may appear deceptively well

before suddenly collapsing, often with little or no

warning’ (Centre for Maternal and Child Enquiries

(CMACE), 2011: 86). In addition, maternal

wellbeing may be compromised in women of

increased maternal age, obese women or women

with complex medical conditions (Lee, 2014).

An early warning tool

It is important that midwives have the necessary

effective tools available to aid clinical assessment

and judgement when managing potentially life-

changing complications in childbearing women.

Early warning scoring systems have been

developed nationally following recognition and

evidence that physiological abnormalities precede

critical illness (Cullinane et al, 2005).

The use of an Early Warning Score (EWS) that

is modified for use in pregnant and postpartum

women will help in the early recognition, treatment

and referral of women who have, or are developing, a

critical illness, and is recommended. The rationale is

that in many cases, early warning signs of impending

maternal collapse go unrecognised (CMACE, 2011).

There is no national validated obstetric EWS

system; however, there are a number of existing

obstetric early warning charts in use across the

UK and work is ongoing to develop a national

obstetrics EWS (Royal College of Obstetricians

and Gynaecologists (RCOG), 2011).

A national early warning score

The Royal College of Physicians (RCP) have

recently recommended the use of a standardised

national early warning score (NEWS) throughout

the NHS for all adult patients (Royal College of

Physicians (RCP), 2012). The report emphasises the

importance of standardising clinical assessment of

all adult patients across the NHS using a scoring

sheet and standard physiological parameters. It is,

however, clearly stated in the report that NEWS

is not designed for use in pregnancy. The reason

given is that the normal baseline for physiological

parameters and the magnitude and character of

the physiological response to acute illness differs

in this group of patients (RCP, 2012). However, the

RCP did not identify any specific gestation from

which NEWS does not apply. In addition, there

is no mention of the relevance of NEWS in the

postpartum period.

A modified EWS tool for use in

childbearing women

In Kettering General Hospital, a modified early

obstetric warning system (MEOWS) chart is used

from 20 weeks gestation when the woman is

admitted to maternity wards. Many pregnancy-

specific conditions occur after the 20th week, e.g.

pregnancy induced hypertension and gestational

diabetes (Stables and Rankin, 2005). In addition,

physiological adaptations are likely to be more

significant: ‘The changes in physiology seen in

normal pregnancy mean that any scoring system

may need to be modified for this group of patients

as pregnancy progresses’ (Lewis, 2007: 241).

The MEOWS chart is used in the postnatal

period up to the 6th week following childbirth.

It is likely that physiological changes will have

returned to a pre-pregnant state at this stage and

most pregnancy-related illness will be resolved

(Stables and Rankin, 2005).

Abstract

Early warning scoring tools are embedded in the routine care of most

hospitalised patients in the NHS. The underlying principles are that

patients who develop serious illness will usually display abnormalities

in simple physiological parameters and that if these early signs

are recognised and appropriate escalation and intervention occurs,

patient outcomes will be improved. Constructing a system for use in

childbearing women presents a unique set of challenges. This article

details how the national early warning scoring system can be adapted

and used in the routine care of hospitalised pregnant and postnatal

women.

Keywords: Postpartum period, Assessment, Severity of illness index,

Vital signs, Pregnancy complications

Melanie F Cole

Midwife and Perinatal

Resuscitation Officer

Kettering General

Hospital NHS Trust

863

British Journal of Midwifery • December 2014 • Vol 22, No 12

Professional

pressure, heart rate and conscious level. These form

the minimum standard for routine monitoring of

physiological observations set by the NICE (2007b).

Blood sugar can be recorded on the chart. The

value is not mandatory and does not form part of

the formal assessment; however, the result may

be valuable to clinicians in some circumstances.

Hyperglycaemia is one of the parameters included

in the diagnostic criteria for sepsis (Dellinger et al,

2012). Urine output is relevant in some obstetric

conditions and the inclusion in the chart may at least

serve as a prompt to consider this feature.

Specific maternal observations that are recorded

on the MEOWS chart are diastolic blood pressure,

severity of pain, antenatal discharge and/or postnatal

lochia and proteinurea.

The implementation of NEWS in the hospital

for all adult non-obstetric patients prompted

the urgent review of the modified obstetric tool.

The RCP have highlighted the importance of a

standardised approach when using an EWS system;

the rationale being that a uniform approach to

training and clinical use of the tool will ultimately

improve patient safety (RCP, 2012). For this reason

the Kettering General Hospital obstetric chart

is modelled on the NEWS. Midwives will only

encounter the MEOWS chart when caring for

antenatal and postnatal women on maternity

wards. Nurses, however, may be challenged with

caring for obstetric patients on non-maternity

wards, some of whom may be significantly at risk

of deterioration. CMACE (2011: 11) state that: ‘It is

equally important that these charts are also used

for pregnant or postpartum women who are unwell

and are being cared for outside obstetric and

gynaecology services’.

Kettering General Hospital’s MEOWS chart is

contained within a booklet and is commenced

on admission to hospital. The same booklet is

used during subsequent admissions to hospital

during the relevant pregnant and postnatal period.

The booklet is maintained in the women’s base

notes folder. This enables midwives to see baseline

observations and observe trends over time more

easily at a glance. Tracking patient’s clinical

responses may indicate potential deterioration

providing a trigger for escalation of clinical care.

It will also provide guidance about the patient’s

recovery and return to stability thus facilitating

a reduction in frequency and intensity of clinical

monitoring and intervention (RCP, 2012).

The MEOWS chart should not be completed

during established labour as a partogram should

be used and clear guidelines already exist

regarding frequency of observations and normal

physiological parameters in labour (National

Institute for Health and Care Excellence (NICE),

2007a). In Kettering General Hospital, the MEOWS

score is documented on commencement of the

partogram and then re-commenced following

completion of the partogram.

Physiological parameters included

in our MEOWS chart

The physiological parameters included in the

MEOWS chart have been carefully selected to

encompass all the standard observations required in

a NEWS chart with the addition of those parameters

specifically relevant to pregnant and postnatal

women (Carle et al, 2013). The physiological

parameters recorded on a NEWS chart are respiratory

rate, oxygen saturation, temperature, systolic blood

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MEOWS front page

864 British Journal of Midwifery • December 2014 • Vol 22, No 12

Professional

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Date

Time

Date

Time

>25

21-25

12-20

<12

>25

21-25

12-20

<12

>95

92-95

<92

>37.7°

37.3-37.7

36.1-37.2

<36

Respiratory

rate

>95

92-95

<92

SpO

Inspired O

>37.7°

37.3-37.7

36.1-37.2

<36

Temperature

180

170

160

150

140

130

120

110

100

120

110

100

140

130

120

110

100

Systolic

Blood

Pressure

Diastolic

Blood

Pressure

Heart

rate

180

170

160

150

140

130

120

110

100

120

110

100

Conscious level

Pain

Discharge/Lochia

TOTAL MEOWS SCORE

Alert

V/P/U

Normal

Abnormal

Normal

Abnormal

++ >

Alert

V/P/U

Normal

Abnormal

Normal

Abnormal

++ >

140

130

120

110

100

TOTAL SCORE

Blood Sugar

Urine output

Monitor freq

Escal Plan

Initials

Blood Sugar

Urine output

Monitoring frequency

Escalation plan Yes/No/NA

Initials

MEOWS key

0 1 2 3

BOOKING BP

Proteinuria

(min daily)

First of four observation charts in booklet

865

British Journal of Midwifery • December 2014 • Vol 22, No 12

Professional

Diastolic blood pressure

Diastolic blood pressure is an important additional

parameter used in the screening for and diagnosis

of pre-eclampsia (NICE, 2008). There is reference

in the MEOWS booklet to lowering the threshold

for escalation where pre-eclampsia is suspected.

The first clinical observation recorded on the

MEOWS chart is the booking blood pressure with

the other physiological observations blocked. This

enables clinicians to observe the booking blood

pressure easily and monitor how it correlates with

further readings.

Severity of pain

Pain is recognised as an important risk factor for

severe maternal illness and mortality. Women

who have unexplained pain severe enough to

require opiate analgesia may have a severe problem

and must be referred for specialist investigation

and diagnosis. CMACE (2011) found that cardiac

disease and other causes of death were missed

when this sign was not identified. In the presence

of pelvic sepsis, severe lower abdominal pain and

severe ‘after pains’ that require frequent analgesia

or do not respond to the usual analgesia are

important symptoms. Severe pain just below the

ribs is described as an important symptom of

pre-eclampsia (NICE, 2010).

Antenatal discharge and/or postnatal

lochia

Abnormal antenatal discharge is a symptom

that may indicate an infection (CMACE, 2011).

Abnormal and heavy postnatal bleeding is a

significant cause of maternal morbidity and is

likely to be linked to an infection (Marchant et

al, 2002). Combined with other symptoms these

findings may lead to a diagnosis of sepsis. The

inclusion of this physiological parameter should

encourage midwives and other clinicians to

think about sepsis. There are frequent reminders

throughout the MEOWS booklet to consider

sepsis in all maternal cases where physiological

parameters deviate from the norm.

Proteinurea

Urinalysis assessment of protein is included, the

expectation being that urinalysis is performed

as a minimum once daily when appropriate.

The rationale is that midwives will consider

pre-eclampsia (Milne et al, 2009).

Scoring physiological observations

The scoring system used on the Kettering General

Hospital’s MEOWS form is the same as NEWS.

Physiological parameters which deviate from the

norm are allocated a score. The score increases

as deviation from the norm escalates. The final

score then falls into one of three categories: a low,

medium, or high score. Colour coding is used

as it is in NEWS to give additional visual

prompts to aid identification of abnormal

physiological parameters.

The scores attributed to the standard

physiological observations (respiratory rate,

oxygen saturation, temperature, systolic blood

pressure, heart rate and conscious level) differ from

NEWS; with the exception of the conscious level

assessment. The aim is to ensure the thresholds take

into account not only the physiological differences

between childbearing women and the general

population but also given consideration to the

specific areas of concern for this group of patients.

Diastolic blood pressure is scored taking into

account the definitions of mild, moderate and

severe hypertension outlined in NICE clinical

guidance (NICE, 2010).

When assessing the level of pain a woman

is experiencing, midwives use their clinical

judgement and take into account the level of

pain expected giving consideration to the full

clinical picture. Where the level of pain is

deemed to be abnormal or unexpected, the score

attributed is high and should in itself prompt

further investigation.

A similar theory applies when the midwife

assesses the vaginal loss; clinical judgement is

expected when determining if the vaginal loss is

considered normal and expected or not.

Proteinurea is scored with an increase in score

correlating to the level of protein detected on

dipstick urinalysis.

Blood sugar and urine output do not contribute

towards the final MEOWS score.

The recording of each necessary physiological

parameter will not give specific readings but will

give midwives a quick, clear indication of whether

that observation is within normal limits. Midwives

will record the exact physiological measurements

in maternal notes when there is deviation from

the norm.

Triggers for escalation

The trigger levels in the escalation algorithm

contained within the MEOWS booklet are the

same as NEWS. A low score is 1–4, a medium score

is 5–6 and a high score is 7 or more. Any single

score of 3 indicates an extreme variation from the

normal, which is considered at least a medium

score. The colour prompts are green for a low

score, amber for medium and red for high scores

(Figure 1).

866 British Journal of Midwifery • December 2014 • Vol 22, No 12

Professional

Escalation pathways

Identifying women who are at risk of, or who are

developing, life threatening problems will only

serve to improve outcome if early and appropriate

intervention occurs. The escalation pathway in

this MEOWS provides a guide to clinicians on

the urgency of their response, the suggested

level of support from the obstetric, medical,

anaesthetic and midwifery team, the appropriate

clinical location for the patient and the frequency

of monitoring.

Kettering General Hospital has adopted

a minimum standard of 4 hourly observations

for all adult inpatients. To enable consistency,

standardisation and for educational reasons our

MEOWS adopts the same minimum frequency;

however, there is scope for a reduction in frequency

of observations to 12 hourly for obstetric patients

who are deemed medically fit for discharge

but may remain in hospital. Examples of these

situations include the mother who remains in

hospital for feeding support or whose infant

requires hospitalisation. Midwives who exclude

women from the minimum 4 hourly observations

will document this decision on the front of the

booklet. If the woman’s clinical condition changes

this exclusion can be cancelled and again recorded

on the front of the booklet.

The associated local MEOWS guideline

highlights the importance of compliance with

other local policies which may require specific

modifications to frequency of observations.

Examples of this include women who are receiving

a blood transfusion or who are post-obstetric

anaesthesia. Kettering General Hospital’s pathway

contains additional prompts and guidance for

clinicians suspecting sepsis or pre-eclampsia.

The MEOWS chart is a tool to aid clinical

judgement and as with any EWS, midwives are

expected to escalate concern when deemed

necessary, sometimes irrespective of the guidance

contained within the escalation pathway

(Carle et al, 2013).

Kettering General Hospital’s MEOWS booklet

includes a locally agreed sepsis pathway, which

follows recommendations from the Surviving Sepsis

Campaign Care Bundles (Dellinger et al, 2012).

Midwives and other clinicians are reminded to

Deteriorating Obstetric Patient Escalation Algorithm

Continue routine 4 hourly

observations

Repeat observation if patient

condition changes

Total MEOWS = 1  4

Inform midwife/nurse in charge

who must assess the patient

immediately.

Midwife/nurse to decide if

increased frequency of monitoring

and/or escalation of clinical care

are required.

If concerned about patient contact

If symptoms of pre eclampsia

Document all actions

(headache, visual disturbance,

abdominal pain) lower threshold

for escalation

** CONSIDER SEPSIS **

(SEE PAGE 6)

OHS

Green

Pathway

Green

Pathway

Total MEOWS = 0

Inform midwife/nurse in charge

(consider critical care outreach)

Midwife/nurse to immediately

review the patient

Contact middle grade doctor

obstetric

and consider early consultant

Care to be provided in

appropriately monitored

environment

Increase the frequency of

observations to 1 hourly

** CONSIDER SEPSIS **

involvement

Inform obstetric anaesthetist

If symptoms of pre eclampsia

(headache, visual disturbance,

abdominal pain) lower threshold

for escalation

Document all actions

(SEE PAGE 6)

(ST/Reg/Trust Grade)

Amber

Pathway

Amber

Pathway

Total MEOWS = 5 - 6

If Any individual

parameter = 3

Consider 2222 for obstetric

emergency team

Commence continuous

monitoring of vital signs

Consider immediate referral to

ICU or HDU 

Document all actions

Contact middle grade doctor

obstetric

and obstetric anaesthetist

immediately

Inform midwife/nurse in charge

(SEE PAGE 6)

(ST/Reg/Trust Grade)

Red Pathway

MEOWS > 7

Acutely concerned

regarding sudden

deterioration

,A<>?9C=D8=?@?8B:D8B=CDA7@=CB86

@CB;D"/:CC5D!

** CONSIDER SEPSIS **

Figure 1. Escalation algorithm

867

British Journal of Midwifery • December 2014 • Vol 22, No 12

Professional

think about sepsis when referring to the escalation

pathways. It is appropriate to incorporate sepsis

guidelines in early warning tools as patients with

severe sepsis can be significantly more unwell

than they might appear (Parliamentary and Health

Service Ombudsman, 2013).

The competent and effective use of

communication skills will be necessary when

managing the unwell obstetric patient to ensure

timely escalation of care and intervention. The

Department of Health (DH, 2009: 7) state:

‘Organisations must ensure that their team have

the necessary communication skills to convey the

urgency of the situation and get immediate help

from clinicians with appropriate knowledge and

skills to ensure the patient receives optimum care’.

Therefore, Kettering General Hospital adopted

the communication tool, Situation Background

Assessment Recommendation; SBAR. Guidance

on how to use this tool in obstetrics is included

within the MEOWS booklet.

Education

Midwives and other users of MEOWS will require

robust training to ensure effective use of the system

and clear, legible documentation of observations

and interventions. The training needs of users at

Kettering General Hospital are addressed using

a variety of avenues. These include: vital signs

skills assessment tools; inclusion in mandatory

resuscitation training; cascade training; and online

plus hard copy user guides. In addition, there are

clear documentation standards attached to the

MEOWS guideline. Staff caring for patients in

any acute hospital setting should be competent in

monitoring, measurement and interpretation of

vital signs, equipping them with the knowledge

to recognise deteriorating health and respond

effectively to acutely ill patients (DH, 2009).

The skills of the team caring for the unwell

obstetric patient will have an impact on patient

outcome. Medical management and team work

are important in the management of obstetric

emergencies as if either are absent or lacking,

morbidity and mortality may result (Dresang et

al, 2010). In Kettering General Hospital, midwives

along with other trained clinical obstetric

practitioners such as doctors and theatre staff,

can and do access the UK Resuscitation Council

Immediate Life Support Course. The skills acquired

during delivery of presentations, discussions,

demonstrations, workshops and simulations are

all related to the obstetric patient making it highly

relevant. It is important that teaching is modified

to reflect the practice area and educative needs of

the target audience (Jennings, 2012).

When devising any MEOWS chart it is

important to ensure that abnormal parameters

do lead to a trigger prompting escalation. Ideally,

the chart is highly sensitive to alerting the user

when signs of impending illness are present.

The number of precipitate alerts must be kept

to a minimum however to ensure unnecessary

escalation and intervention is not promoted. The

Kettering General Hospital’s MEOWS chart will be

subject to scrutiny through internal audit.

Conclusion

Childbirth is a major life event and the physiological

and psychological implications of serious illness

on the woman and her family cannot be dismissed.

While midwives strive to encourage and support

normality for pregnant and postnatal women,

equal importance must be assigned to identifying

and acting on physiological changes occurring in

women, which may indicate illness that without



Patient status not improving or deteriorating:

Inform Relevant Senior Specialty Team Dr (ST/Reg/Trust Grade) - Team to inform the patients consultant

Inform Obstetric Anaesthetist

Inform Delivery Suite Co-ordinator

Confirmed or impending cardio-respiratory arrest: Dial 2222 ask for Cardiac Arrest AND Obstetric Emergency Team

Or adverse signs:

Rapid deterioration

Reduced conscious level or seizures/fits

Extreme pallor, sweating, distress

Obvious massive bleeding

Additional prompts in MEOWS booklet

868 British Journal of Midwifery • December 2014 • Vol 22, No 12

Professional

Key points

lA modified obstetric early warning tool will assist midwives when

identifying childbearing women who may be at risk of developing

serious illness

lAn obstetric early warning tool should model the national early

warning tool for standardisation and educational reasons

lWhen formulating an early warning scoring system for use on

childbearing women specific physiological parameters relevant in

pregnancy and the puerperium will need to be included

lThe clinical response to recognition of illness or deterioration in

childbearing women will affect patient outcome

timely intervention can lead to significant maternal

morbidity. A modified early obstetric warning

tool provides a useful aid to clinical judgement

during the assessment process and a structure to

follow which should ensure timely and appropriate

intervention when required. A locally devised tool

can be modelled on the NEWS. The space available

must be utilised effectively and enable clear and

legible documentation.

The MEOWS booklet in Kettering General

Hospital is commenced at 20 weeks gestation;

however, it is possible that a modified EWS

is applicable for all hospital admissions from

pregnancy booking. Some physiological

adaptations will be apparent early in pregnancy

and may therefore warrant the use of a modified

obstetric tool on admission to gynaecology wards.

There may be a place for adapting the principles

of early warning scoring for use by community

midwives. Childbearing women may develop illness

outside hospital and a structure for assessment,

intervention, escalation and appropriate referral is

equally relevant in the community setting.

A validated national obstetric early warning tool

would enable consistency and a necessary uniform

approach to the assessment and management of

potentially deteriorating childbearing women. BJM

Acknowledgements: I would like to acknowledge the

following for their input in the construction of the MEOWS

booklet: Dr Duncan Baines, Consultant Anaesthetist,

Kettering General Hospital NHS; Dr Clare Cuckson,

Consultant Obstetrician, Kettering General Hospital NHS,

Dr Elizabeth Farah, FY1, Kettering General Hospital NHS.

Artwork produced and provided with thanks by CSP Printers

www.collectorsetprinters.co.uk

Carle C, Alexander P, Columb M, Johal J (2013) Design and

internal validation of an obstetric early warning score:

secondary analysis of the Intensive Care National Audit

and Research Centre Case Mix Programme database.

Anaesthesia 68: 354–67 doi: 10.1111/anae.12180

Centre for Maternal and Child Enquiries (2011) Saving

Mothers’ Lives: Reviewing maternal deaths to make

motherhood safer: 2006-08. The Eighth Report on

Confidential Enquiries into Maternal Deaths in the

United Kingdom. BJOG 118(Suppl 1): 1–203

Cullinane M, Findlay G, Hargreaves C, Lucas S (2005) An

Acute Problem? National Confidential Enquiry into

Patient Outcome and Death, London

Dellinger RP, Levy MM, Rhodes A et al (2012) Surviving

Sepsis Campaign: International Guidelines for

Management of Severe Sepsis and Septic Shock.

Crit Care Med 41(2): 580–637. doi: 10.1097/

CCM.0b013e31827e83af

Department of Health (2009) Competencies for

Recognising and Responding to Acutely Ill Patients in

Hospital. DH, London

Dresang LT, Davis S, Miller K, Olden C, Atwood L (2010)

Safety in Maternity Care-The ALSO Provider Manual

Revised. 5th edn. American Academy of Family

Physicians.

Jennings J (2012) An evaluation of the effects of teaching

and learning styles on the delivery of components of

the Immediate Life Support Course. British Journal of

Resuscitation Spring: 23

Lee S (2014) Risk perception in women with high-risk

pregnancies. British Journal of Midwifery 22(1): 8–13

Lewis G (2007) Saving Mothers Lives: Reviewing maternal

deaths to make motherhood safer (2003-2005). The

Seventh Report on Confidential Enquiries into Maternal

Deaths in the United Kingdom. CEMACH, London

Marchant S, Alexander J, Garcia J (2002) Postnatal vaginal

bleeding problems and General Practice. Midwifery 18: 21–4

Milne F, Redman C, Walker J et al (2009) Assessing the onset

of pre-eclampsia in the hospital day unit: summary of

the pre-eclampsia guideline. BMJ 339: b3129

National Institute for Health and Care Excellence (2007a)

Intrapartum Care. Care of healthy women and their

babies during childbirth NICE clinical guideline 55.

NICE, London

National Institute for Health and Care Excellence (2007b)

Acutely Ill Patients in Hospital: recognition of and

response to acute illness in adults in hospital NICE

clinical guideline 50. NICE, London

National Institute for Health and Care Excellence (NICE)

(2008) Antenatal Care: routine care for the healthy

pregnant woman NICE clinical guideline 62. NICE,

London

National Institute for Health and Care Excellence (2010)

Hypertension in pregnancy. The management of

hypertensive disorders during pregnancy NICE clinical

guideline 107. NICE, London

Parliamentary and Health Service Ombudsman (2013)

Time To Act. Severe sepsis: rapid diagnosis and

treatment saves lives. PHSO, London

Royal College of Obstetricians and Gynaecologists (2011)

Maternal Collapse in Pregnancy and the Puerperium

Green-top Guideline No 56. RCOG, London

Royal College of Physicians (2012) National Early Warning

Score (NEWS): Standardising the assessment of acute

illness severity in the NHS. Report of a working party.

RCP, London

Stables D, Rankin J (2005) Physiology in Childbearing with

Anatomy and Related Biosciences. 2nd edn. Elsevier,

Oxford

A Modified Early Obstetric Warning System ://perigen.com/wp Content/uploads/2017/05/2014 BJM Meows 2014

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