Obstetric Early Warning Score Chart

1. 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

2. 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.

3. 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

4. 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

6. 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)

7. 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.

8. Completing the Obstetric EWS Chart 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 NA – Not applicable

9. Completing the Obstetric EWS Chart ALL relevant sections must be completed • Top section to include woman’s details

10. Completing the Obstetric EWS Chart ALL relevant sections must be completed • Top section to include woman’s details • Date • Frequency of Obs • Time (24 hr clock)

11. Completing the Obstetric EWS Chart ALL relevant sections must be completed • Top section to include woman’s details • Date • Frequency of Obs • Time (24 hr clock) • Signature at bottom section – to correlate with signature list in maternity case notes

12. Completing the Obstetric EWS Chart Respiratory Rate • You must document the number. For example, you would write ‘22’ in the yellow column Oxygen Saturation • You 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

13. Completing the Obstetric EWS Chart Temperature • A ● should be inserted to aid viewing and connect dots with straight lines (not illegible comma shapes) Heart rate • This 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 line • You 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.

14. Changes to Regional Chart Changes • Urine Output if Catheterised • Proteinuria • Wound (now incorporated in blue P/N section) • IV site • Drain site

15. A/N – P/N – Early Pregnancy Loss NA   

16. Completing the Obstetric EWS Chart Neuro Response • Tick the appropriate box that applies to the woman Pain Score Nausea Looks unwell

17. Completing the Obstetric EWS Chart Neuro Response • Tick the appropriate box that applies to the woman Pain Score • Tick the appropriate box which applies to the woman. The pain score is explained on the back of the EWS chart Nausea • Tick the appropriate box which applies to the woman. The nausea score is explained on the back of the EWS chart Looks unwell

18. Completing the Obstetric EWS Chart Neuro Response • Tick the appropriate box that applies to the woman Pain Score • Tick the appropriate box which applies to the woman. The pain score is explained on the back of the EWS chart Nausea • Tick the appropriate box which applies to the woman. The nausea score is explained on the back of the EWS chart Looks unwell • Use your clinical judgement and tick the appropriate box

19. 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. 2 1 GM

20. 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

21. Action Protocol • Continue observations as before White Only • Inform Midwife/Nurse in Charge • Recheck observations in 1 hour (or more frequently if clinically indicated) Single Yellow • 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 Yellow or 1 Red

22. Action Protocol • 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) 2 Red • 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 > 2 Red

25. Any Questions ?

26. 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