Transcript Recovery Early Warning Score Scenario

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
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.
Recommendations for midwifery practice as set out in
Chapter 13 of Saving Mothers’ Lives
Carry out, record and act upon basic observations for
Both women at low and higher risk of complication.
“There remains an urgent need for the routine use of a national modified early obstetric
warning score(MEOWS) chart in all pregnant or postpartum women who become unwell and
require either obstetric or gynaecology services. This will help in the more timely
recognition, treatment and referral of women who have, or are developing, a critical illness
during or after pregnancy.”
Recommendation 6: Specialist clinical care: identifying and managing very sick women
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
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
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)
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.
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
Please tick below
Early Pregnancy
A/N
What if a section is not applicable?
 Insert NA within box provided
NA – Not
applicable
P/N
Completing the Obstetric EWS Chart
ALL relevant sections must be completed
 Top section to include woman’s details
Addressograph Label
Name_______________________
Month_________________________
Consultant___________________
Year__________________________
Hosp. No.___________________
Ward__________________________
Booking BP______________mmHg
BMI______________________Kg/m²
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)
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
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
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.
Changes to Regional Chart
Changes
 Urine Output if Catheterised
 Proteinuria
 Wound (now incorporated in blue P/N section)
 IV site
 Drain site
A/N – P/N – Early Pregnancy Loss
Early Pregnancy
PV Loss
No
Clear
Amniotic Fluid
if ROM
Please tick below
Yes
NA
A/N
Red/Green
Offensive
P/N
Odourless
A/N PV Bleed
A/N Uterine Tone
Pink/Brown
Red

Normal

Tense
Normal
Lochia
Trickle
Heavy or Foul
Contracted
P/N Uterine Tone
High Fundus
Relaxed/Atonic
Wound –
ooze/red/swollen/pain
Yes
No
Early Pregnancy

Completing the Obstetric EWS Chart
Neuro Response
 Tick the appropriate box that applies to the woman
Pain Score
Alert
Neuro
Response
Voice
Pain
Unresponsive
Nausea
Looks unwell
Completing the Obstetric EWS Chart
Neuro Response
 Tick the appropriate box that applies to the woman
Alert
Pain Score
Neuro
Voice
Response
 Tick the appropriate box which applies to the
woman. The
Pain pain score is
explained on the back of the EWS chart
Unresponsive
Nausea
 Tick the appropriate box which applies to the woman. The nausea score
is explained on the back of the EWS chart
Looks unwell
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
Obstetric Early Warning SCORES
 Calculate and record the total number of yellow and/or red
scores, including those on the line
2
 You must always have a score
documented
1
GM
 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.
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
Action Protocol
White Only
Single Yellow
≥ 2 Yellow or 1 Red
• Continue observations as before
• Inform Midwife/Nurse in Charge
• Recheck observations in 1 hour (or more
frequently if clinically indicated)
• 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)
Action Protocol
2 Red
> 2 Red
• 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)
• 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
Any Questions ?
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