Obstetric EWS

FRANS O H PRASETYADI
FACULTY OF MEDICINE, HANG TUAH UNIVERSITY /
DR. RAMELAN NAVAL HOSPITAL, S U R A B A Y A
Introduction

 Critical illness is uncommon, but could potentially devastating

complication during pregnancy
 At its most extreme, critical illness may lead to the death of the
woman during pregnancy or shortly afterwards
 Early identification as part of crtitical care is ultimately important 
the need of EWS
 Maternity EWS provides guidance & processes for the early
detection of life threatening illness in pregnancy and up to 42 days
postpartum period
Maternity EWS

 Intended to be used by heathcare professional staffs

 Recording of vital signs is consequently important

 MEWS is expected to improve recording of observation, especially

respiratory state, in pregnant women with proven bacteremia

 Standard (national) patient observation chart and escalation

triggers
 IMEWS-Patient-Observation-Chart.pdf
EWS vs Obstetric EWS
Critical illness in maternity care

 Unique, exacerbated by pregnancy or coincidental conditions

 Reflected to the classification of maternal death:

 Direct
 Indirect
 Coincidental deaths
Critical illness in maternity care (2)

 Unique:
 Obstetric hemorrhage
 Pre-eclampsia syndrome
 Pulmonary embolism (venous and AFE)
 Chorioamnionitis/endometritis
 Uterine rupture
 Placenta acreta
 Acute fatty liver

One maternal death ~ 9 maternal severe morbidity

Maternity EWS guideline

 Aimed at improving the management of in-patient care

 Irrespective of age, location, or reason for admission
 Designed to guide clinical judgement (complement clinical care)
but not replace it
 Clinical decisions and therapeutic options should be discussed with
a senior clinician on a case-by-case basis as necessary
Key recommendations

 Should be used for women who are clinically pregnant or within

puerperal phase
 Should be used to complement clinical care not replace clinical
judgement
 Timing of clinical observations depends on the woman’s individual
circumstances
 BP shoild be measured with the correct cuff size to avoid
unnecessary interventions
 Effective communication system should be in place
Key recommendations (2)

 Who should be the senior doctor called should be agreed by the

midwifery and medical senior management

 Depends on the acute illness, give early consideration for seeking

professional assistance of other medical specialties

 The Sepsis Six Box customised for pregnancy should be added

Definitions

 EWS (early warninng score)

 MEWS (maternity early warning system
 ISBAR
 Communication tool
 Identify, situation, background, assessment, and recommendation

Full set of vital signs (RR, temp, HR, BP, neurological response, and
pain score)
Urinalysis is required on admission
Recording physiological
observations
 Respiration
 Mandatory observation
 The earliest and most sensitive indicator of deterioration
 60 seconds (as heart rate). If regular  30 seconds and doubled
 Normal RR : 11-19 per minute

Oxygen saturation (SpO2)

 Not routinely measured, normal : 96-100%
 Only if RR abnormal, necessity of medical/obstetric condition
 Accuracy depends on adequate peripheral blood flow to the probe
(artificial nails, nail polish!!)
 Temperature
 Recorded at appropriate site
 Accepted temp 36-37.4°C
 Swinging pyrexia may indicate sepsis

Heart rate
 >> radial artery. Alternatives : brachial, carotid, femoral
 Tachycardia/bradycardia should be double checked manually
 Accepted parameter : 60-99 bpm
 Blood pressure
 Systolic and diastolic recorded seperately
 Use proper cuff size (size should be documented)
 Korotkoff I for SBP, Korotkoff V for DBP
 Should be checked manually at least once (~aneroid
sphygmomanometer)
 Acceptable parameter : 100-139 for SBP, 50-89 for DBP
 Hypotension is a late sign of deterioration  decompensation
 Urine
 Urinalysis of freshly voided urine for screening, diagnosis or assessment
 Recorded on admission, specific maternal disorders / treatment, clinical
symptoms
 Proteinuria
 Glucose
 Others (ketones, blood, nitrites
 Assessment of neurological response (AVPU scale)
 A measure of consciousness
 A : alert and orientated to person, place, time, and event
 V : responds to voice (verbal stimuli)
 P : responds to painful stimuli with a purposeful or nonpurposeful
movements
 U : unresponsive, patient does not respond to any stimuli

Any fall in AVPU scale  significant  acted on IMMIDIATELY

 Pain score
 Total yellow / pink scores
 Any yellow / pink scores should initiate escalation guideline
 If concerned about a woman, escalate care regardless of triggers

Initials
Should be clearly written in the initial box on the chart
Initial / signature bank shouold be maintained in each hospital as
per local guideline
Escalatation guideline
 Frequency of recording
 Full set of vital sign as baseline
 Frequency of subsequent observations determined by initial and
presenting clinical conditions
 Women in labor recorded on partogram