Obstetric Early Warning Score Chart

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.

“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

Recommendations for midwifery practice as set out inChapter 13 of Saving Mothers’ Lives

Carry out, record and act upon basic observations for Both women at low and higher risk of complication.

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.

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

Completing the Obstetric EWS Chart

NA – Not applicable

Please tick below

Early Pregnancy

A/N

P/N

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 detailsDateFrequency of ObsTime (24 hr clock)

Completing the Obstetric EWS Chart

ALL relevant sections must be completed

Top section to include woman’s detailsDateFrequency of ObsTime (24 hr clock)Signature at bottom section – to correlate with signature list in maternity case notes

Respiratory RateYou must document the number. For example, you would write ‘22’ in the yellow column

Oxygen SaturationYou 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

TemperatureA ● should be inserted to aid viewing and connect dots with straight lines (not illegible comma shapes)

Heart rateThis 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 lineYou 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.

Completing the Obstetric EWS Chart

Changes to Regional Chart

Changes

Urine Output if Catheterised

Proteinuria

Wound (now incorporated in blue P/N section)

IV site

Drain site

A/N – P/N – Early Pregnancy Loss

Early Pregnancy 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

LochiaNormal

Trickle

Heavy or Foul

P/N Uterine ToneContracted

High Fundus

Relaxed/Atonic

Wound – ooze/red/swollen/pain

Yes

No

NA

Please tick below

Early Pregnancy

A/N

P/N

Neuro ResponseTick 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 ResponseTick the appropriate box that applies to the woman

Pain ScoreTick the appropriate box which applies to the woman. The pain score is explained on the back of the EWS chart

NauseaTick 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 ResponseTick the appropriate box that applies to the woman

Pain ScoreTick the appropriate box which applies to the woman. The pain score is explained on the back of the EWS chart

NauseaTick the appropriate box which applies to the woman. The nausea score is explained on the back of the EWS chart

Looks unwellUse your clinical judgement and tick the appropriate box

Completing the Obstetric EWS Chart

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.

1

2

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

≥ 2 Yellow or 1 Red

Single Yellow

White Only • Continue observations as before

• Inform Midwife/Nurse in Charge• Recheck observations in 1 hour (or

more frequently if clinically indicated)

• 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 Red

> 2 Red

• 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)

• 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

Action Protocol

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