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The early detection

of maternal
deterioration in
pregnancy
Philip Banfield1, Consultant Obstetrician,
Catherine Roberts2 Infection Prevention Sister
& Glan Clwyd Hospital, North Wales

Previously,
1 National Faculty Lead.
2 National Programme Manager, Welsh 1000 Lives Plus,
Transforming Maternity Services Mini-Collaborative.

March 2015 © 2015 The Health Foundation


Introduction of vital signs, using a Modified Early
Obstetric Warning System (MEOWS)
The early detection of severe illness in was a top recommendation in the UK
pregnant women is challenging because of confidential enquiries into maternal deaths
the relative rarity of such events, combined in 20073 and 2011.4
with the normal changes in physiology
associated with pregnancy and childbirth There is no fully validated early warning
that may be considered abnormal in the system for use in obstetrics and practical
non-pregnant state. Early recognition experience reported in the literature is
is essential because deterioration can mixed. Kodikara et al 5 established that
be alarmingly rapid, with catastrophic MEOWS identifies potentially sick women
consequences. The challenge is to balance but that there is a high false positive rate.
the identification of women needing The blood pressure parameters are also
intervention without ‘over-medicalisation’ reportedly set incorrectly. Carle et al 6
of an otherwise physiological process. concluded that the general early warning
system was sensitive to predict obstetric
mortality, but that the obstetric MEOWS
Background did not confer any additional benefit.
Any maternal death is a tragic event for Lappen et al 7 disagreed with this and
families and clinical staff. Advances in the concluded that the general early warning
prevention, recognition, and response to systems should not be applied to the
several leading causes of direct maternal obstetric population. They also reported
deaths - thromboembolism, hypertensive that the relative infrequency of sepsis
disorders, haemorrhage and sepsis - among pregnant women limits the positive
have seen a general downward trend in predictive value of any general scoring
maternal mortality in the United Kingdom system, precluding the development of a
(UK).1 Substandard care has been an on- clinically useful obstetric model. However,
going finding of confidential enquiries. it is agreed that most critically ill pregnant
Between 2009-12, 106 (52)% of the 203 women have early triggers, which continue
direct maternal deaths in the UK had throughout their illness.8
treatment where improvements to their A UK wide obstetric anaesthetist survey
care may have made a difference to their in 2009 revealed consensus of opinion
outcome.1 on the need for a nationally agreed early
In comparison with mortality, there are warning tool for obstetrics with the
estimated to be 8 times the number of associated training, skills and resources.9
women who suffer from severe maternal
morbidity in the UK. Critical care National Early Warning System
admissions are estimated at 26/10,000
(NEWS) – non obstetric
maternities but a definitive number is
difficult to ascertain and may be as high as Early detection, timeliness, and
12/1000.2 competency of the clinical response
are determinants of clinical outcome in
In many cases the early warning signs and
people with acute illness.10 A range of
symptoms of impending severe maternal
early warning systems are in use across the
illness or collapse go unrecognised. The
UK, for example, the all-Wales National
regular recording and documentation

The early detection of maternal deterioration in pregnancy 2


Early Warning System (NEWS) provides but the process created a range for most
a consistent approach to the recognition parameters that would need further
and response to acutely ill patients. It also testing and validation. It was recognised
provides the same language especially for that the search for validity, that may not
clinicians who work between different apply universally to all pregnant women
hospitals and it has been extensively at all times, risked missing the essential
validated within the UK and Canada.11 aims in tracking maternal condition
NEWS is surveillance based on a simple (deterioration), triggering review and
scoring system, with scores allocated to escalation to appropriate expert care in a
physiological measurements. The scores timescale that improves outcomes.
are aggregated and the clinical team is
This group concluded the focus was
alerted to any clinical deterioration and
NOT about exact figures, but more the
a triggered timely, appropriate response.
response that would provoke escalation to
The track and trigger of NEWS should be
prompt senior review by the appropriate
mirrored in the observation charts in use.
multidisciplinary team (MDT) member.
Consequently they were able to reach
Agreeing the physiological consensus based on an exemplar’ format
parameters in obstetrics - what (A Policy Exemplar Guide12). This allowed
is normal and abnormal – and local variation and adaptation, leading to
ownership and use, rather than obstacles
does it matter? and delay - tools of practical use for
It is unsurprising that there are a number practising clinical staff with an identified
of existing obstetric early warning charts need. Such ‘bottom-up’ development has
in use across the United Kingdom; been considered highly effective in Wales.13
MEOWs has been adapted to ‘work’ locally
All obstetric units should have trained
and there are also a number of numerical
obstetric anaesthetists available and
warning systems in use.
many hospitals have critical care outreach
Maternity clinical staff know there are teams. It is emphasised that ANY concern
changes to physiological parameters in about a woman should lead to escalation,
pregnancy, which leads to difficulties regardless of a score. An MEOWS
reaching agreement and consensus for example used in Wales is given in Figure
exact figures, ranges and significance of 1. Although colour-coded charts may
particular values. This creates a tension trigger review or intervention, an objective
when trying to link early warning system scoring system would allow the grading
for obstetrics to the general NEWS, of progressive responses and monitoring
because the specificities and sensitivities of progression of disease or success of
are different, un-quantified and do not treatment. Many MEOWS charts remain
map directly for either symptoms or signs. unvalidated, although some progress
towards this was made by Singh et al 14
Clinicians from all Welsh health boards who found maternal morbidity could be
at a Maternity National Learning Session predicted with a sensitivity of 89% and
(November 2011) were invited to add their a specificity of 79%. Recognising charts
knowledge and experience and suggest need to be monitored for their use and
what they thought were the appropriate value irrespective of their validity helps
scoring values. This suggested that the justify their implementation whilst waiting
development of consensus was possible, for validity studies. This surveillance can

The early detection of maternal deterioration in pregnancy 3


be achieved through existing validated streptococcal infection died within 2 hours
improvement methods such as PDSA of signs of SIRS (75% within 9 hours). The
cycles.15 United Kingdom Obstetric Surveillance
System (UKOSS) reported on 365 women
To improve the recognition and response with severe sepsis, giving a rate of 4.7
to the acutely deteriorating pregnant women / 10,000 maternities. 71 had septic
woman, robust escalation guidance (and shock (19.5%) confirming the strong
the response it provokes) is paramount, association with group A streptococcal
and this has been based on a Royal infection in those who survive also.21
College of Anaesthetists Report.2 Explicit
guidance is available about when to The diagnosis of sepsis in the non-
request appropriately skilled multi- pregnant woman has been widely agreed
disciplinary senior help (Table 1). A through work by the surviving sepsis
campaign,22 with a validated tool for
formal communication tool such as SBAR
management – the Sepsis Six Bundle.
(Figure 2) is recommended for use when
requesting assistance during escalation.16 Being unwell with, for example, an
upper respiratory tract infection (URTI)
is common in pregnancy and many
The early detection of women innocuous and self limiting infections
with sepsis occur all the time in the community.
Additional tools are available for the Mortality from severe sepsis is RARE, but
recognition and treatment of severe early warning signs may go unrecognised.
sepsis in the deteriorating pregnant Not all women with a high temperature
woman.17 Maternal sepsis rose to become or flu-like symptoms in pregnancy or
a leading cause of maternal death in the puerperium have, or are at risk of
the UK, sparking the need for urgent developing, sepsis. Many individuals and
consideration18 and it has been the specific groups would strongly wish for pregnancy
focus of the latest maternal mortality and childbirth to be promoted as a ‘natural’
report.1 Although the RCOG have event, and hence there is also a need to
published guidelines on maternal sepsis19,20 avoid over diagnosis and unnecessary
there is a need for practical tools to medicalisation of well women.It is the
implement them. presence of the systemic inflammatory
response with an actual or potential source
The importance of these tools is seen of infection that leads to the diagnosis
when one considers the 83 women in of sepsis. It is relatively straightforward
the UK and Republic of Ireland who to add to the list used in diagnosing
died of infection related causes between sepsis in adults, in order to account for
2009 and 2012.1 Twenty women died possible additional causes of pregnancy-
of genital sepsis, a significant reduction specific infection, including prolonged
from the 2006-8 figure. Infection where ruptured membranes or offensive liquor,
Group A Streptococcus is isolated is the unexplained fetal tachycardia in the
most important factor associated with absence of a maternal tachycardia (looking
progression from systemic inflammatory for chorioamnionitis), recent delivery and
disease (SIRS) to septic shock (Where / or offensive lochia and breast redness
there is refractory hypotension after fluid and / or tenderness or mastitis. It is
resuscitation). The rapidity of deterioration important to be wary that women with a
is demonstrated by the observation history of sore throat may have Group A
that half of the women with group A Streptococcal infection.1

The early detection of maternal deterioration in pregnancy 4


Although the PCO2 can reflect the they are being ‘told’ to use, compliance is
associated metabolic acidosis (with likely to be reduced.
respiratory compensation) found in sepsis
When looking to record severe sepsis in
(with a cut off of 7.34kPa) the relative
pregnancy, the United Kingdom Obstetric
hyperventilation of pregnancy, in order
Surveillance System (UKOSS) also took
to maintain a diffusion gradient of waste
a largely pragmatic approach and found
CO2 from the feto-placental unit, means
that the patients identified matched the
many normal women exhibit this relative
numbers expected at the start of the
respiratory alkalosis as part of the normal
study21 This is a strong argument for
physiological changes of pregnancy, but
consideration and recognition of severe
have a reduced buffering capacity for
sepsis, rather than precision, in its exact
metabolic acidosis when it does occur.23
diagnosis.

What does this mean in


A pragmatic approach
practice?
In drawing up a local policy or
In the absence of an adequate tool guideline, there should be an agreed set
validated for pregnancy, the two most of parameters beyond which everyone
important questions would seem to be: would agree that further investigation
Is the woman unwell? and management is required. This can be
formulated graphically (Figure 3) into an
COULD she have SEPSIS? exemplar flow chart.
In this context, track and trigger tools These parameters probably apply to
(such as MEOWS) aid the diagnosis and pregnancy AFTER the first 20 weeks and
management of the acutely deteriorating up until 48 hours after delivery. Outside
woman with sepsis. However, Edwards this period, is probably safer to use the
et al 24 found poor prediction using such non-pregnant values, especially if the
charts alone (the positive predictive values woman reports feeling unwell.
for the 6 MEOWS charts they identified
ranged from <2-15%. As so much of pregnancy care occurs
outside of the hospital setting, knowledge
Just as with MEOWS charts, there are a of the potential for sepsis and recognition
variety of tools being implemented for of potential maternal deterioration is
pregnant women, that use some or all of important. A screening tool for use in
the physiological parameters from a non- a community setting is being used in
pregnancy specific context through to tools Powys, Wales.25 Antenatal and postnatal
that attempt to modify the parameters women are asked how they are feeling at
to account for maternal physiological each contact with midwife. If they feel
changes. The pragmatic approach would unwell, observations are taken (including
be to not argue for uniformity, but temperature, pulse and respiration rate).
rather agree upon using whichever tool Early warning triggers are calculated.
will actually be used in clinical practice Signs and Symptoms of infection and
(monitoring compliance and outcomes). the Systemic Inflammatory Response
Ownership and buy-in are critical. If Syndrome are actively sought. To enable
clinical staff perceive deficiencies in what appropriate and timely escalation, an ‘aide

The early detection of maternal deterioration in pregnancy 5


memoir’ card for maternal sepsis also acts Conclusions
as a prompt for midwives. (Figure 4)
The physiological parameter least likely
Any woman who is obviously unwell to be affected by pregnancy itself, and
is referred or admitted for further acts as a marker of severity of maternal
assessment. There is an explicit mechanism condition is respiratory rate. Many
and audit trail for following up any woman women have minor illnesses with changes
NOT admitted e.g. the next day to make to physiological parameters that could
sure that the woman is getting better. be alarming outside of pregnancy. This
It should be emphasised to the woman leads to asking whether a woman feels
and her relatives that, if she is getting fundamentally ‘well’ or ‘unwell’ and being
worse, she should seek hospital attention particularly aware of maternal tachypnoea,
immediately. especially if associated with a significant
A key feature of this work was to explore rise in the lactate level. This may indicate
the application to pregnancy of the sepsis the need for rapid escalation to a
six care bundle from the Surviving Sepsis critical care environment where prompt
Campaign.22 However, pregnancy needs intervention may materially alter outcome.
further consideration in relation to the Use of track and trigger tools depend
fetus/retained products of conception on effective recognition of gradual
and the inherent thromboembolic risk of deterioration and appropriate escalation in
pregnancy and sepsis risk together. This order to mobilise the appropriate level of
culminated in the collaborative approach expertise across disciplines. This is aided
of the ‘Sepsis Six plus Two’ maternity sepsis by assessing ill pregnant women regularly
response tool. with effective clinical communication via
Measurement played an important part in objective discussion in formal handovers
the implementation of these tools. In the (a safety brief).
short term, this was around process change Early intervention by ‘thinking sepsis’
and being able to demonstrate reliable and instituting appropriate investigations
implementation. Outcome data however promptly, and the sepsis six plus two care
is long term but an example of this would bundle completes a set of tools for clinical
be a reduction in the numbers of women staff to recognise and manage deteriorating
escalated to a higher level of care. women in a structured and logical manner,
with clear pathways to requesting senior
and multidisciplinary help.

The early detection of maternal deterioration in pregnancy 6


References 7. L
 appen, J., Keene, M., Lore, M., Grobman,
W., Gossett, D. (2009). Existing predictive
1. K
 night M, Kenyon S, Brocklehurst P, Neilson models do not accurately characterize risk of
J, Shakespeare J, Kurinczuk JJ (Eds.) on behalf sepsis in obstetric patients. American Journal
of MBRRACE-UK. Saving Lives, Improving of Obstetrics and Gynaecology. Conference
Mothers’ Care - Lessons learned to inform 2010 30th Annual Meeting of the Society for
future maternity care from the UK and Ireland Maternal-Fetal Medicine, SMFM Chicago,
Confidential Enquiries into Maternal Deaths Il United States. Conference Start: 20100201
and Morbidity 2009–12. Oxford: National Conference End: 20100206 Sponsor: March of
Perinatal Epidemiology Unit, University of Dimes. Conference Publication: (var.pagings).
Oxford 2014. 201 (6 SUPPL. 1) (pp s182), Date of Publication:
December 2009.
2. Royal college of Anaesthetists (2011). Providing
equity of critical and maternity care for the 8. T
 ufail, S.R., Flavell, E.M., Collis, R.E. (2009). A
critically ill pregnant or recently pregnant retrospective audit of early warning scores in
woman. Available from: http://www.rcoa.ac.uk/ the detection of critically ill obstetric patients.
node/1857. Accessed: 30thJan 2015. International Journal of Obstetric Anaesthesia.
Conference: Annual Meeting of the obstetric
 ewis, G. (Ed) (2007) Confidential Enquiry
3. L Anaesthetists’ Association, OAA Jersey
into Maternal and Child Health, Saving United Kingdom. Conference Start: 20090521
Mothers’ Lives – Reviewing maternal deaths to Conference End: 20090522. Conference
make motherhood safer 2003-2005. London: Publication: (var.pagings). 18 (ppS20).
CEMACH.
9. S wanton, R.D.J.,Al-Rawi, S., Wee, M.Y.K.
4. C
 entre for Maternal and Child Enquiries (2009). A national survey of obstetric
(CMACE) (2011). Saving Mothers’ Lives: early warning systems in the United
reviewing maternal deaths to make motherhood Kingdom. International Journal of Obstetric
safer: 2006–08. The Eighth Report on Anaesthesia.18, 253-257.
Confidential Enquiries into Maternal Deaths in
the United Kingdom. BJOG 2011;118(Suppl. 10. National Institute for Health and Clinical
1):1–203. Excellence (2007). Recognition of and response
to acute illness in adults in hospital. [CG50].
5. K
 odickara, M., McGlennan, A.P. (2010). Study London: National Institute for Health and
to determine the incidence of triggering using Clinical Excellence.
CEMACH – recommended modified early
warning system (MEOWS). International 11. Prytherch, David R., Smith, G., Schmidt, P.,
Journal of Obstetric Anaesthesia.. Conference Featherstone, P. (2010). ViEWS—Towards
Start: 20090521 Conference End 20090522. a national early warning score for detecting
Conference Publication: ( var.pagings). 18 adult inpatient deterioration. Resuscitation. 81
(pp59), 2009. Date of Publication: May 2009. 932–937.

6. C
 arle, C., Jpohal, J., Columb, M., Alexander, P. 12. Final Obstetric EWS Paper 2 Response Doc
(2010). Evaluation of modified early warning Nov 2012 http://www.1000livesplus.wales.
scores as a predictor of outcome in obstetric nhs.uk/sitesplus/documents/1011/FINAL%20
admissions to critical care units: Secondary Obstetric%20EWS%20Paper%202%20
analysis of the Intensive Care National Audit Response%20Doc%20Nov2012.pdf. Accessed
and Research Centre (CNARC) Case Mix 30th Jan 2015
Programme (CMP) database. British Journal of
Anaesthesia. Conference: Anaesthetic Research 13. Roberts C, Banfield P. Transforming Maternity
Society Meeting Nottingham United Kingdom. Service Final Report March 2014 http://
Conference Start 20100701 Conference End: www.1000livesplus.wales.nhs.uk/sitesplus/
20100702. Conference Publication: (var. documents/1011/FINAL3%20year%20
pagings). 105 (5) (pp707P), Date of Publication: report%20mat%20programme%20MAR%20
November 2010. 141000%20lives%20i.pdf. Accessed 30th Jan
2015

The early detection of maternal deterioration in pregnancy 7


14. Singh S, McGlennan A, England A, et al. 23. Royal College of Obstetricians and
(2012). A validation study of the CEMACH Gynaecologists. Maternal collapse in Pregnancy
recommended modified early obstetric warning and the Puerperium. Green Top Guideline No.
system (MEOWS). Anaesthesia 2012; 67: 12–8 56. London: RCOG; 2011

15. Roberts C, Banfield P. Transforming Maternity 24. Edwards SE, Grobman WA, Lappen JR,
Services ‘How to’ Guide, 2nd Edition Oct Winter C, Fox R, Lenguerrand E, Draycott T.
2012. http://www.1000livesplus.wales.nhs.uk/ (2014) Modified obstetric early warning scoring
sitesplus/documents/1011/How%20to%20 systems (MOEWS): validating the diagnostic
%2817%29%20Maternity%20Services%20 performance for severe sepsis in women with
Web%202nd%20edition.pdf. Accessed 30th Jan chorioamnionitis. Am J Obstet Gynecol, doi:
2015 10.1016/j.ajog.2014.11.007

16. 1000 lives Plus (2010). How to Guide 6. Rapid 25. http://www.1000livesplus.wales.nhs.uk/
Response to Acute Illness. P19. maternity-powys. Accessed 18th Februray 2015

17. http://www.1000livesplus.wales.nhs.uk/
sitesplus/documents/1011/How%20to%20
%286%29%20Rapid%20Response%20to%20
Acknowledgements
Acute%20Illness%20%28Feb%202011%29%20 This work is the product of a large number
Web.pdf. Accessed: 10th January 2015.
of clinicians in several specialties in Wales
18. Final Sepsis Policy Exemplar Guide Nov under the auspices of the Welsh National
2012 http://www.1000livesplus.wales.nhs. 1000 Lives Campaign ‘Transforming
uk/sitesplus/documents/1011/FINAL%20
Maternity Services’ which ran from 2010-
Sepsis%20PEG%20NOV%2012.pdf. Accessed
30th Jan 2015 14.

19. CMACE (2010). EMERGENT THEME The Aneurin Bevan, Cwm Taf and BCUHB
BRIEFING #1: Genital Tract Sepsis. SAVING Teams have been extremely helpful in
MOTHERS’ LIVES 2006-08: Briefing on developing the thought processes around
genital tract sepsis. http://www.hqip.org.uk/
which this practical application of the
assets/NCAPOP-Library/CMACE-Reports/13.-
September-2010-Emergent-Theme-Briefing- original Surviving Sepsis Campaign to
Genital-Tract-Septis-2006-2008.pdf pregnancy have evolved.
20. Royal College of Obstetricians and Matt Turner, Consultant Anaesthetist at
Gynaecologists. Bacterial sepsis in pregnancy. ABHB led their work that crystallised the
Green Top Guideline No. 64a. London: RCOG;
Mini-Collaborative developing the ‘Sepsis
2012
Six** Plus Two’ for pregnancy.
21. Royal College of Obstetricians and
Gynaecologists. Bacterial sepsis following Chris Hancock, Programme Manager,
pregnancy. Green Top Guideline No. 64b. RRAILS has provided valuable advice and
London: RCOG; 2012 support throughout.
22. Acosta CD, Kurinczuk JJ, Lucas DN, Tuffnell There are many other contributors on the
DJ, Sellers, S, Knight M on behalf of the United
Kingdom Obstetric Surveillance System.
labour wards and communities of Wales
Severe Maternal Sepsis in the PLoS Medicine collectively known as the ‘Transforming
11(7): e1001672.urviving sepsis campaign. Maternity Services Mini-Collaborative’.
Sepsis care bundles http://www.survivingsepsis.
org/Bundles/Pages/default.aspx. Accessed 30th
Jan 2015

The early detection of maternal deterioration in pregnancy 8


Figure 1: Exemplar MEOWS Chart,
1000 Lives Transforming Maternity Care mini-collaborative

The early detection of maternal deterioration in pregnancy 9


Table 1: Exemplar escalation policy (with acknowledgement)

ESCALATION
Minimal
Obstetric Alert … Medical Review
Monitoring
NEWS
0- 2 12 hourly* Nil

3–5 1-4 hourly Midwife in charge and Within 30 mins: Increased frequency
Obs SHO of obs. Inform obs ST3 and obs
anaes ST3 (or equiv) & of review
outcome.

Could this woman have sepsis?

6-8 1-2 hourly Obstetric ST3 and Urgent call to team with primary
Obs anaesthetist medical responsibility for the patient
6 = SICK! (maternity).

Simultaneous call to personnel with


core competences for acute illness.
These competences can be delivered
by a variety of models at local level,
such as a critical care outreach
team, a hospital-at-night team or
a specialist trainee in anaesthesia,
obstetrics, acute medical or surgical
specialty.

>9 30 mins Team with critical Emergency call to team with


care compentencies & critical care competences and
9 = NOW maternity team. The team should
Obs ST3/Obs anaes include a medical practitioner
ST3/Consultant skilled in the assessment of the
obstetrician critically ill patient, who possesses
advanced airway management and
resuscitation skills.

* or as per local guidance

Note of Caution: Frequency of observations can be increased at the discretion of the clinical
team. Equally, concern about a patient should lead to escalation, regardless of the score.

The early detection of maternal deterioration in pregnancy 10


Figure 2: Example of SBAR communication

The early detection of maternal deterioration in pregnancy 11


Figure 3: Exemplar screening tool for sepsis in pregnancy and Sepsis Six Plus**
Two recognition and response bundle for use in pregnancy
(20 weeks to 48hrs postnatal)

The early detection of maternal deterioration in pregnancy 12


Figure 4: Exemplar aide memoire for recognition and management of
sepsis in pregnancy

The early detection of maternal deterioration in pregnancy 13