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The early detection

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

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

What does this mean in

A pragmatic approach
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

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19. CMACE (2010). EMERGENT THEME The Aneurin Bevan, Cwm Taf and BCUHB
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DJ, Sellers, S, Knight M on behalf of the United
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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)

Obstetric Alert … Medical Review
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

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

>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