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

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

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

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

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)

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.

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

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

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)

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

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

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.

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..

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   

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

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

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

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

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

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

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

Any Questions ?

References CMACE (2011) Saving Mothers’ Lives. Reviewing maternal deaths to make motherhood safer: 2006-2008 NICE (CG50) (2007) Acutely ill patients in hospital Royal College of Physicians (2012) National Early Warning Score (NEWS) Report of a Working Party