INSTRUMENTS TO DETECT EARLY WARNING

SIGNS (EWS) FOR MATERNAL AND NEONATAL

Pratuma Rithpho
Assistant Professor
(PhD.(Nursing), MSN(Women’s Health Nursing ), RN)
rpratuma@yahoo.com; FB: Pratuma Rithpho
TOPICS
 Introduction and Background of Maternal
Motility Rate and Infant Mortality Rate
 Important Early Warning Signs

 Maternal Early Warning Signs

 Neonatal Early Warning Signs

 Researches to Support Effective Early Warning

Signs
 Case Study
INTRODUCTION AND BACKGROUND
OF MATERNAL MOTILITY RATE
SOURCE: WHO, SYSTEMATIC REVIEW OF CAUSES OF MATERNAL DEATH (PRELIMINARY DATA), 2010

REFERENCE: HTTP://WWW.CHILDINFO.ORG/MATERNAL_MORTALITY.HTML
KEY FACTS FROM WORLD HEALTH ORGANIZATION

 Every day, approximately 830 women die from

preventable causes related to pregnancy and
childbirth.
 99% of all maternal deaths occur in developing
countries.
 Maternal mortality is higher in women living in rural
areas and among poorer communities.
 Young adolescents face a higher risk of complications
and death as a result of pregnancy than other women.
 Skilled care before, during and after childbirth can
save the lives of women and newborn babies.
 Between 1990 and 2015, maternal mortality worldwide
dropped by about 2.3% per year.
 Between 2016 and 2030, as part of the Sustainable
Development Goals, the target is to reduce the global
maternal mortality ratio to less than 70 cases per 100
000 live births.
MATERNAL MORTALITY RATE (DEATHS/100,000 LIVE
BIRTHS)
Country 2010 2015
Thailand 48 20
Malaysia 29 40
Vietnam 59 54
Philippines 99 114
Laos 470 197
Indonesia 220 126
Cambodia 250 161

https://www.cia.gov/library/publications/the-
world-factbook/rankorder/2223rank.html
STRATEGY TO MANAGE MMR: LESSONS
LEARNED FROM THAILAND
 • Global Policy of Maternal and Child Health
 • Labor room quality : Objective and Stakeholder

 • Safe childbirth

 • MMR monitoring

 • Component of labor room quality

 • Health care system for labor room quality

 • Role of Maternal and Child Health Board on

Reduction of Maternal Mortality Ratio
THE OPTIMAL ENHANCING STANDARD:
QUALITY IS OUR PRIORITY

LR – Labor Room
 Reduction of MMR (Prevention & Rx MMR)

 Detection of Early Warning Signs

Breastfeeding Policy
 Promotion of Breastfeeding

 Initiate Breastfeeding

PPH
 Reduction of PPH (Prevention & Rx PPH)

 Excellent teamwork and equipment, blood bank

and OR team
THREE DELAYS MODEL


 KNOW THE INTERVENTION TO PREVENT
AND TREAT
Post-partum AMTSL, PPH
hemorrhage (PPH) management
Pre- BP and urinalysis
eclampsis/eclampsia screening, Magnesium
(PE/E) sulphate use
Prolonged/Obstructed Correct partograph use
labour and appropriate action

PP sepsis Infection prevention

Newborn asphyxia Essential newborn care
and resuscitation
Source: Lancet, Neonatal Series, 2005
COMMON BARRIERS TO DELIVERY OF QUALITY
ESSENTIAL OBSTETRIC AND NEWBORN CARE:

 Weak local leadership

 Lack of formal essential obstetric and newborn care
(EONC) standards
 Inaccessible EONC services—financially,
geographically, and culturally
 Inadequate EONC inputs/infrastructure
 Poorly organized patient care processes
 Non-functioning referral/counter-referral mechanism
 Inadequate supervision/lack of continuous training
 Poor staff motivation
 Poor provider competence
IMPORTANT EARLY WARNING SIGNS
DETECTION
LESSONS LEARNED FROM REVIEWS
Hemorrhagic death
 93% of all deaths were potentially preventable
 Lack of appropriate attention to clinical signs of
hemorrhage
 Failure to restore blood volume, to act decisively with
life saving interventions
Severe Hypertension
• 60% of maternal deaths were potentially preventable
• Failure to control blood pressure, to recognize HELLP
syndrome, to diagnosis and treat pulmonary edema
Pulmonary Embolism
• ―single cause of death that is most amendable to
reduction by systematic change in practice‖
• Failure to use adequate prophylaxis
 MATERNAL EARLY WARNING SIGN

Respond Monitor

Identify Trigger
Diagnosis

Evaluate Alert
MATERNAL EARLY WARNING CRITERIA
 • Systolic BP; mmHg <90 or >160
 • Diastolic BP; mmHg >100
 • Heart rate; beats per min <50 or >120
 • Respiratory rate; <10 or >30 breaths per min
 • Oxygen saturation; % <95 room air, sea level
 • Oliguria; <30 mL/hr for 2 hours

Maternal agitation, confusion, or unresponsiveness

Patient with hypertension reporting a non-remitting
headache or shortness of breath

 Documentation system with yellow and red highlights

EFFECTIVE ESCALATION POLICY
An abnormal parameter would require:

 1. Prompt reporting to a physician or other qualified

clinician
 2. Prompt bedside evaluation by a physician or other
qualified clinician with the ability to activate
resources in order to initiate emergency diagnostic
and therapeutic interventions as needed
 3. Plan for and implementation of diagnostic work-up
4. Close follow up by senior provider of patient‘s
status until: Abnormality resolves, or Parameter
judged to be of benign etiology, or Patient is
determined to be potentially critically ill and care is
escalated (rapid response, higher acuity setting)
KEY POINTS
 Delays in diagnosis contribute to a large
portion of preventable maternal deaths
 Maternal Early Warning Systems—3
Components
1. Early Warning Criteria
2. Prompt reporting
3. Bedside evaluation
 Local implementation details
 Cut-points, measurement artifact, trends
 Who to notify, how to notify them
 Back-up systems to ensure timely evaluation
MODIFIED EARLY WARNING SCORING
ASSESSMENT TOOL
 WHEN TO USE THE MEOWS
 All women in active labor and all women following delivery.
 Routine intrapartum observations should also be performed as per the
intrapartum care guideline.
 All antenatal admissions to hospital
 All postnatal admissions to hospital
 All in-patients to have ongoing MEOWS assessments, regardless of the
reason for admission / stay (see below)
 All non-routine and / or non-scheduled contacts, either antenatal or
postnatal
 If any health problem is suspected at any time
 If the mother ever reports feeling ‗unwell‘
 NB: Oxygen saturation should be assessed BD but does not form part of
the numerical MEOWS score. However it is a red indicator that requires
a medical review when the reading is ≤ 94%
MATERNAL EARLY WARNING SCORES
(MEWS)
 Physiology commonly deteriorates progressively in
critically ill obstetric patients
 Identification of abnormal physiological parameters
and early intervention may prevent further
deterioration and reduce maternal morbidity and
mortality
 Obstetric Warning Scores may help identify
pregnant women at risk of deterioration
 The Maternal Early Warning Score (MEWS) is a
commonly used example of a bedside screening tool
that enables tracking of physiological parameters,
and when a predefined threshold is reached, triggers
bedside assessment by a healthcare professional
Physiological Normal values Yellow Alert Red Alert
parameters (White)

Respiratory 10-20 breaths per 21-30 breaths per <10 or > 30 breaths
minute minute per minutes

Oxygen saturation 96-100% <95%

Temperature 36.0-37.4 0C 35.0-36.0 or 37.5-38 <35 or >38 0C

0C

Systolic blood 100-139 mmHg 150-180 or 90-100 >180 or < 90mmHg

pressure mmHg

Diastolic blood 50-89 mmHg 90-100 mmHg >100 mmHg

pressure

Heart rate 50-99 beats per 100-120 0r 40-50 >120 0r < 40 beats
minute beats per minute per minute

Neurological Alert Voice Unresponsive, pain

response
OBSTETRIC EARLY WARNING SCORE ESCALATION PROTOCOL
THE IRISH MATERNAL EARLY WARNING
SYSTEM (IMEWS)
ANY FALL IN THE LEVEL OF CONSCIOUSNESS (AVPU SCALE)
SHOULD ALWAYS BE CONSIDERED SIGNIFICANT AND ACTED ON
IMMEDIATELY.

 Assessment of Neurological Response

 - A – Alert and orientated to person, place, time and
event.
 o V – Responds to voice/verbal stimuli (e.g. post
operative recovery).
 o P – Responds to painful stimuli with a purposeful or
non-purposeful movement.
 o U – Unresponsive - The patient does not respond to
any stimuli. •

 o Alert (A): white box (accepted neurological response

parameter)
 o Responds to Voice (V): Pink box
 o Responds to Pain (P): Pink box
 o Unresponsive (U): Pink box.
RECURRENT MATERNAL EARLY WARNING
CRITERIA

 Increase the intensity and frequency of

monitoring
 Increase the frequency of evaluation

 Initiate resuscitative and diagnostic

interventions
 Carefully consider the appropriate
differential until a diagnosis is confirmed,
or until the criteria is resolved
DIAGNOSED AS CRITICALLY ILL OR A HIGH
LIKELIHOOD OF DEVELOPING CRITICAL ILLNESS

 Initiateappropriate resuscitative,
diagnostic and therapeutic
interventions
 Escalate level of care
 Obstetric emergency response teams
 Rapid response team
 Transfer to a higher acuity setting
NEONATAL EARLY WARNING SIGN
 NORMAL RANGES FOR NEWBORN INFANT‘S
HEART RATE AND RESPIRATORY RATE AS
PUBLISHED IN STANDARD PEDIATRIC TEXTS.
Source Heart rate bpm Respiratory rate

Examination of the Newborn and 110-160: 80-90 if asleep, 160 if 40-60 if non-distressed
Neonatal Health. A multidimensional distressed
approach. Ed Lorna Davies, Sharon
McDonald8

Examination of the Newborn. A 90-140 - resting 40-60 breaths/min

Practical Guide. Helen Baston,
Heather Durward9

Roberton‘s Textbook of Neonatology. 120-160 usually 35-45

Ed Janet M Rennie10

Avery's Diseases of the Newborn., 40-50 newborn

Taesch, Ballard, Gleason11 35-60 thereafter

Advanced Paediatric Life Support – 110-160 30-40

manual12
 AT-RISK NEWBORN INFANT (ARNI)
CRITERIA

Prenatal Perinatal Postnatal

Pathological Thick meconium Grunting

Cadiotocograph Venous cord pH<7.1 Abnormal movements
Scalp ph<7 Ventilatory support Any ongoing concerns
Group B Streptococcus >3 At the request of
risk Minutes reviewing medical or
neonatal staff
Premature rupture of Five minute
membrane (PROM) APGAR<8
NEWBORN EARLY WARNING OBSERVATION CHART
NEWBORN EARLY WARNING TRIGGER AND
TRACK (NEWTT)

The NEWTT tool seeks to;

 Identify those babies at risk of clinical deterioration
following birth
 Provide a standardized observation for monitoring
clinical progress
 Provide a visual prompt to aid identification of
abnormal parameters by color coding e.g. red, amber,
green
 Reduce admission to neonatal units (NNUs)
 Reduce/limit separation of mother and baby by early
identification of and intervention for at risk infants
 Through early identification and intervention, reduce
the severity of illness for some infants who will
require admission to neonatal units.
NEWTT

Infants of any gestation at risk of sepsis

 Infants at risk of hypoglycemia

 Infants of hypertensive mothers who have

received beta blockers
 Late preterm infants

 Small for gestational age infants

 Infants demonstrating intrapartum compromise

evidenced by need for newborn resuscitation, low
APGAR score or low cord Ph
 ―Other‖ categories
RESEARCHES TO SUPPORT
EFFECTIVE EARLY WARNING
SIGN
USE OF MATERNAL EARLY WARNING TRIGGER
TOOL REDUCES MATERNAL MORBIDITY BY
LAURENCE ET AL.
Objective
 to determine if maternal morbidity could
be reduced with the implementation of a
clinical pathway-specific Maternal Early
Warning Trigger (MEWT) tool
The tool addressed the 4 most common
areas of maternal morbidity
 sepsis,
 cardiopulmonary dysfunction,
 preeclampsia-hypertension,
 hemorrhage.
 USE OF MATERNAL EARLY WARNING TRIGGER
TOOL REDUCES MATERNAL MORBIDITY BY
LAURENCE ET AL.
 Results
 There were 36,832 deliveries at the pilot sites (24,221 pre-
and 12,611 post-MEWT testing) and 146,359 at the
nonpilot sites (95,718 pre- and 50,641 post-MEWT testing)
during the 2 study time periods. Use of the MEWT tool
resulted in significant reductions in CDC severe maternal
morbidity (P < 0.01) and composite morbidity (P < 0.01).
ICU admissions were unchanged. At nonpilot sites CDC
severe maternal morbidity, composite morbidity, and ICU
admissions were unchanged between baseline and the post-
MEWT testing time period
 Evaluation of maternal early obstetric warning
system (MEOWS chart) as a predictor of obstetric
morbidity: a prospective observational study: Singh A,
Guleria K, Vaid NB, et al.

 Modified obstetric early warning scoring systems

(MOEWS): validating the diagnostic performance for
severe sepsis in women with chorioamnionitis:
Edwards SE, Grobman WA, Lappen JR et al.

 Design and internal validation of an obstetric early

warning score: Secondary analysis of the Intensive
Care National Audit and Research Centre Case Mix
Programme database: Carle C, Alexander P, Columb
M, et al.

 Use of Maternal Early Warning Trigger tool reduces

maternal morbidity: Shields LE, Wiesner S, Klein C
et al.
IN THAILAND: TRAINING SETTING
 The
efficacy of the Pediatric Early
Warning Score:PEWS in the pediatric
ward at Kamphaeng Phet Hospital by
Tanaree (2017)

 Results:Assessment of pediatric patients

by PEWS could statistically significantly
decrease, unplanned refer, morbidity rate
(p<.05) and the length of stay (p<.001)
Case Study
ACTION PROTOCOL
 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 contact 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 Immediately contact 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 contact 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)
 > 2 Red Consider calling other specialties or Emergency Obstetric Team
as appropriate
BARRIERS TO IMPLEMENT MEWS
 Leadership
 Governance arrangements in the organisation
 Clearly identified roles and responsibilities
 Communication processes
 Resources for the Emergency Response System,
such as staff and equipment suitable for IMEWS
recording and transfer of information
 Education, training and information for clinical
staff on the early detection and management of
the deteriorating patient
 Technological supports for evaluation, audit and
feedback processes.
ENABLERS FOR IMPLEMENTATION
 Good leadership
 Good governance arrangements

 Clearly identified roles and responsibilities

 Multi-disciplinary team working

 Good communication processes

 Effective education and training of staff

 Good arrangements for safely transferring

patients to higher levels of care.
LITTLE FIRE IS QUICKLY TRODDEN OUT
WHICH BEING SUFFERED, RIVERS CANNOT
QUENCH‖
INSTRUMENTS TO DETECT EARLY WARNING
SIGN (EWS) FOR MATERNAL AND NEONATAL

Pratuma Rithpho
Assistant Professor
(PhD.(Nursing), MSN(Women’s Health Nursing ), RN)
rpratuma@yahoo.com; FB: Pratuma Rithpho