1. Obstetric Early Warning Score Chart
Regional
Obstetric Early Warning Score Chart
Track and Trigger
Adapted from BHSCT EWS chart 2013
Gillian Morrow, Intrapartum Midwifery Practice Educator, BHSCT

2. Background
Despite recommendations in the most recent triennial reports, ‘Saving Mothers’ Lives’ (CMACE) and documented improvements in patient care using early warning scoring systems (EWS) in the general adult population, no validated system currently exists for the obstetric population.
Recommendations for midwifery practice as set out in
Chapter 13 of Saving Mothers’ Lives
Carry out, record and act upon basic observations for
Both women at low and higher risk of complication.
“There remains an urgent need for the routine use of a national modified early obstetric warning score(MEOWS) chart in all pregnant or postpartum women who become unwell and require either obstetric or gynaecology services. This will help in the more timely recognition, treatment and referral of women who have, or are developing, a critical illness during or after pregnancy.”
Recommendation 6: Specialist clinical care: identifying and managing very sick women

3. Obstetric Early Warning Score Chart
It is recognised that pregnancy and labour are normal physiological events. However, observation of vital signs are an integral part of care
There is a potential for any woman to be at risk of physiological deterioration and this cannot always be predicted. There is also evidence that there is poor recognition of deterioration in condition
Regular recording and documentation of vital signs will aid recognition of any change in a woman’s condition
The use of EWS chart prompts early referral to an appropriate practitioner, who can undertake a full review, order appropriate investigations, resuscitate and treat as required

4. Regional OEWS Chart 2013
Early Warning Scoring System and Action Protocol for Early Pregnancy, Antenatal and Postnatal
The colour trigger (yellow and red) is simple and visual. A numerical score is more complex
Red is the colour denoting serious patient condition requiring urgent action
Yellow is the colour suggesting that the patient condition is worsening requiring escalation of treatment
Balance between too much information on a chart causing distraction and maximising useful variables recorded

6. Who needs an Obstetric EWS Chart?
All women whose clinical condition requires close observation; admitted early pregnancy, antenatal or postnatal
All post operative cases – in recovery and following transfer from theatre
Any woman giving cause for concern (medical or obstetric causes)
During/Following APH/PPH/Eclampsia
Suspected infection e.g. Prolonged SROM
High-risk women in delivery suite (not in labour)

7. How frequently should the chart be completed?
Frequency of Observations is determined by;
Risk Status
Diagnosis / Reason for admission
Initial observations on admission
Protocol
An individual plan of care should be made by the Midwife/Nurse and Doctor which should specify the frequency of physiological observations
The minimum frequency of observations as an in-patient is 12 hourly.

8. Completing the Obstetric EWS Chart
What sections need to be completed?
All sections to be completed and include either;
A/N, P/N, or EP loss, tick the relevant
colour coded section
What if a section is not applicable?
Insert NA within box provided
Please tick below
Early Pregnancy
A/N
P/N
NA – Not applicable

9. Completing the Obstetric EWS Chart
ALL relevant sections must be completed
Top section to include woman’s details
Addressograph Label
Name_______________________
Consultant___________________
Hosp. No.___________________
Month_________________________
Year__________________________
Ward__________________________
Booking BP______________mmHg
BMI______________________Kg/m²

10. Completing the Obstetric EWS Chart
ALL relevant sections must be completed
Top section to include woman’s details
Date
Frequency of Obs
Time (24 hr clock)

11. Completing the Obstetric EWS Chart
ALL relevant sections must be completed
Top section to include woman’s details
Date
Frequency of Obs
Time (24 hr clock)
Signature at bottom section – to correlate with signature list in maternity case notes

12. Completing the Obstetric EWS Chart
Respiratory Rate
You must document the number. For example, you would write ‘22’ in the yellow column
Oxygen Saturation
You must document the number. For example, you would write ‘99’ in the white column
Oxygen
If you perform a set of observations you must document on the chart in the space provided if oxygen is delivered. This must always include the percentage oxygen
If the woman is on air you must document this instead of an oxygen percentage. Do not leave the oxygen section blank. Room Air = RA

13. Completing the Obstetric EWS Chart
Temperature
A ● should be inserted to aid viewing and connect dots with straight lines (not illegible comma shapes)
Heart rate
This should be documented as a ● Please take care to keep the chart legible and connect dots with straight lines. If concerned a numerical value may be inserted
Blood Pressure - Graphic trend using arrows & a dotted line
You document this with an upward arrow ( ˄ )at the systolic and a downward arrow ( ˅ ) at diastolic, joined by a dotted line so you have a graphic trend. Numerical value may be documented.

14. Changes to Regional Chart
Urine Output if Catheterised
Proteinuria
Wound (now incorporated in blue P/N section)
IV site
Drain site
The monitoring of urine output is important in many clinical settings. However, formal estimation of urine output is not always available at first assessment and measurement of urine output is not routine in the majority of patients in hospital.  
Urine output monitoring is essential for some patients as dictated by their clinical condition and this must be included on the fluid balance chart..

15. A/N – P/N – Early Pregnancy Loss
PV Loss No
Yes
Amniotic Fluid
if ROM
Clear
Red/Green
Offensive
Odourless
A/N PV Bleed
Pink/Brown
Red
A/N Uterine Tone
Normal
Tense
Lochia
Trickle
Heavy or Foul
P/N Uterine Tone
Contracted
High Fundus
Relaxed/Atonic
Wound –
ooze/red/swollen/pain
Please tick below
Early Pregnancy
A/N
P/N NA   

16. Completing the Obstetric EWS Chart
Neuro Response
Tick the appropriate box that applies to the woman
Pain Score
Nausea
Looks unwell
Neuro
Response
Alert
Voice
Pain
Unresponsive

17. Completing the Obstetric EWS Chart
Neuro Response
Tick the appropriate box that applies to the woman
Pain Score
Tick the appropriate box which applies to the woman. The pain score is explained on the back of the EWS chart
Nausea
Tick the appropriate box which applies to the woman. The nausea score is explained on the back of the EWS chart
Looks unwell
Neuro
Response
Alert
Voice
Pain
Unresponsive

18. Completing the Obstetric EWS Chart
Neuro Response
Tick the appropriate box that applies to the woman
Pain Score
Tick the appropriate box which applies to the woman. The pain score is explained on the back of the EWS chart
Nausea
Tick the appropriate box which applies to the woman. The nausea score is explained on the back of the EWS chart
Looks unwell
Use your clinical judgement and tick the appropriate box

19. Obstetric Early Warning SCORES
Calculate and record the total number of yellow and/or red scores, including those on the line
You must always have a score
documented
If OEWS does trigger a score document in case notes and inform midwife/nurse in charge
Follow the action protocol documented on the back page of the chart and record action in the case notes
You are expected to report if you have any clinical concerns irrespective of the OEWS score. 2 1 GM

20. Action Protocol ACTION PROTOCOL
The Early Warning Scoring System and Action Protocol are designed to help identify deterioration in the woman and ensure appropriate early intervention. All action taken must be fully documented in case notes. Staff should use their clinical judgement, and seek advice if they have concerns about any woman, regardless of the score.
If an OEWS chart is being commenced in a freestanding midwife led unit the parent obstetric unit needs to be informed and transfer protocols commenced

21. Action Protocol Continue observations as before
White Only
Continue observations as before
Inform Midwife/Nurse in Charge
Recheck observations in 1 hour (or more frequently if clinically indicated)
Single Yellow
Inform Midwife/Nurse in Charge
Immediately ontact the on-call obstetric SHO/Reg using SBAR to review the woman within 30 mins
Recheck observations in 30 minutes (or more frequently if clinically indicated)
≥ 2 Yellow or 1 Red

22. Action Protocol Inform Midwife/Nurse in Charge
Immediately ontact the on-call obstetric SHO/Reg using SBAR to review the woman within 20 mins
Recheck observations in 15 minutes (or more frequently if clinically indicated)
2 Red
Inform Midwife/Nurse in Charge
Immediately ontact the on-call obstetric Reg using SBAR to review the woman within 20 mins
Discuss with Obstetric Consultant/Tutor
Recheck observations in 15 minutes (or more frequently if clinically indicated)
Consider calling other specialties or Emergency Obstetric Team as appropriate
> 2 Red

25. Any Questions ?

26. References
CMACE (2011) Saving Mothers’ Lives. Reviewing maternal deaths to make motherhood safer: NICE (CG50) (2007) Acutely ill patients in hospital Royal College of Physicians (2012) National Early Warning Score (NEWS) Report of a Working Party