MEWS - Maternity Early Warning Score

Conny Krebs, Clinical Midwife Educator - Ko Awatea, Auckland, New Zealand

Gail McIver, Midwife Manager - CM Health, Auckland, New Zealand
Kathy Ogilvy, Nurse/Midwife Educator - Ko Awatea, Auckland, New Zealand

One woman too many Development Implementation Went LIVE 17 March 2014
Introduction Research New Parameter
Affix patient’s identification label here
CM Health is introducing a systematic scoring chart for maternity Research indicates that warning signs precede virtually every critical A new parameter – blood loss – has been added to the MATERNITY EARLY WARNING SCORE
patients to Women’s Health Service. The MEWS (Maternity Early inpatient event. There are well-established early warning score (EWS) MEWS score. Blood loss is one of the most common causes *Standard vital signs: q4H, Respiratory rate, Saturation, Heart rate, BP, Blood Loss,Temp, Level of consciousness, Urine output and Pain

Warning Score) chart will assist staff to identify antenatal and postnatal charts in existence for use with general patients. A general EWS of preventable severe maternal morbidity, and is often Date
Time
MIDWIFERY AND NURSING ACTIONS
FOR PATIENTS WITH A MEWS SCORE
women at risk of deteriorating in condition and improve the response to physiologically unstable patient chart was introduced at CM Health in exacerbated by delayed or inappropriate treatment. It can be Pain at Rest 0-10
Pain On Movement 0-10
Score 0
the acutely deteriorating woman. 2007. (2) one of the critical indicators of deterioration, and the amount
>40 >40
30-39 30-39 Score 1

Respirations
25-29 25-29
of blood lost is frequently underestimated. 20 20 Score 2
However, EWS charts designed for general patients are unsuitable
Setting
15 15
10 10 Score 5+ 888
for use in obstetrics due to the physiological changes and modified
Modification for Birthing Units
<8 <8
98-100 98-100 ANY PATIENT VITAL SIGNS IN THE

Saturations
YELLOW SCORES 1
CM Health serves the Counties Manukau region in Auckland, New responses that occur during pregnancy. 94-98 94-98

for
91-93 91-93
Calculate the Total MEWS Score
Zealand. It has a birthing unit at Middlemore Hospital, one of the largest MEWS has also been introduced to the three primary birthing s
<90 <90

ter
1. Inform Midwife/Nurse in charge
O2 litres/min
2. Increase frequency of vital signs one hourly
tertiary hospitals in New Zealand, and primary birthing units at satellite Although the importance of early warning scores for obstetric units. As these units operate in the community setting, have
>140
e >140

ram th
or more frequently if required.
130 130
3. Treat Pain
patients is widely recognised, there are no national or international a
d P ldbir
120 120
sites in Botany Downs, Papakura and Pukekohe. All primary birthing no medical staff onsite and rely on the ambulance service for 110 110
e
ifi Chi

Heart Rate bpm

units offer pregnancy clinics, labour and birthing facilities and provide ‘gold standards’ obstetric warning scores currently in use. (3) transfer, the action plan has been modified to their needs. An
100

d
100

o ANY PATIENT VITAL SIGNS IN THE

90 90

postnatal care. easy peel-off sticker, with the action algorithm appropriate for
80
70 M 80
70
ORANGE SCORES 2 - 4

Multiprofessional Team 60 60
Calculate the Total MEWS Score

the birthing units, is applied and makes it instantly functional. 50

40
50
40
1. Inform Midwife/Nurse in charge
2. Repeat vital signs within 1/2 hour.
• The estimated Counties Manukau population for 2013 is 30 30
3. If MEWS score unchanged contact
Obstetric Registrar, notify PAR Team.
>200 >200
512,130, 11.5% of the total New Zealand population.
Trial 190 189-199
4. Continue 1/2 hourly vital signs until
180 180
Obstetric Registrar arrives.
170 170
5. If Obstetric Registrar not available
call Obstetric Consultant.

Systolic Blood Pressure mmHg

• Counties Manukau has high numbers of Maaori, Pacific and Midwives MEWS was trialled over 5 days for usability in Middlemore
160
150
160
150

Asian peoples and a relatively youthful population.

140

ctions
140

Hospital Delivery Suite and Maternity Ward, as well as 130 130 ANY PATIENT VITAL SIGNS IN THE

Acute Pain
120 A 120 PURPLE SCORES 5 OR MORE OR IF YOU ARE

Team Managers tested retrospectively on Serious and Sentinel Event cases. 110 110 CONCERNED ABOUT THE PATIENT CALL
• Counties Manukau has a high birth rate compared with many 100 100

All retrospectively reviewed cases would have triggered and 90 90 888

other areas – 7282 babies were delivered in 2013 at CM Health. 80 80

received early intervention if this chart had been available and 70 70 OBSTETRIC EMERGENCY TEAM or

r WOMENS HEALTH CARDIAC ARREST

oss
This contributes to relatively high demand on our maternity and
60 60

used. 50
ete 50 or STAT CAESAREAN SECTION
L
ram lood
Stay with the patient.
child health services.(1)
140 140

Diastolic Blood Pressure mmHg

a
130 130

Midwife & 120

w P lB 120 VARIATION TO BLOOD LOSS THRESHOLD

Audits a
Ne Tot
110 110
Nurse Nurses Measuring Blood Loss estimate.

Major Haemorrhage After Birth Have Tripled

100 100
Soaked Pad = 150mls
Educators
ing
90 90

MEWS
Soaked Blue inco sheet = 450mls
80
n n 80 Soaked Towel = 600mls
Currently we are in the process of evaluating the chart and Ru
70 70 1ml blood = 1 gm weight
60 60

Visua
Score 0 0-499mls OBSERVE
refining our measurable aim. 50 50
1500+
l Aid f 1500+

Blood Loss (ml)

Score 1 500-1000mls

Running Total
1000-1499
or Blo 1000-1499
751-999 751-999
odScore 2 1000-1500mls
Major Haemorrhage

Lo
Conclusion ss
500-750 500-750
Clinical Training 0-499 0-499 Score 5+ 1500mls+
& Education Obstetricians Est bld loss on arrival
PAD 150ml
> 1500 mls

>38.5 >38.5
148 Centre
PPH cannot be prevented. It is axiomatic that PPH occurs 38.1-38.4 38.1-38.4

Temperature
38 38
120
51
unpredictably and no patient is immune from it. 37
36
37
36
<35 <35
Patient at Risk Alert Alert
Anaesthetists

Urine Output Consciousness

Team What can be changed is how we react to and manage PPH. The Voice Voice

Level of
Pain Pain INCO SHEET 450ml

2010 2011 2012 introduction of a specific EWS for obstetrics combined with an Unresponsive
New Confusion
Unresponsive
New Confusion

evidence-based management model can potentially reduce the

Running Total
>30ml/hr >30ml/hr
Birth Rate 8171 8135 8103 16-29 ml/hr 16-29 ml/hr

practice variability and improve the quality of care. Glucose

<15 ml/hr <15 ml/hr

In 2010 the Women’s Health Quality Specialist Midwife brought Respiratory Rate
MEWS SCORE - Calculate total score. Add each vital sign to reach TOTAL MEWS SCORE
Respiratory Rate TOWEL 600ml

Over the last four years midwives in the delivery suite observed an
together a multiprofessional team with the idea to develop a modified Saturations

Sco re Saturations

s
Heart Rate Heart Rate
w
EWS for Maternity Services. l Me
Systolic BP Systolic BP

increase in major haemorrhages after birth, also known as postpartum Tota

Diastolic BP Diastolic BP
Blood Loss Blood Loss

haemorrhage(PPH), particularly major PPH over 1500mls. In too many

Temperature Temperature

Midwives, nurses, managers, members of the Patient At Risk team, Level of Consciousness
Urine Output
Conscious Level
Urine Output
cases, PPH was not managed in a timely manner to prevent women Clinical Training & Education Centre, Acute Pain team, obstetricians, TOTAL SCORE TOTAL SCORE

going down the continuum of deterioration, and patients became

Counties Manukau District Health Board Copyright © CMHealth 2014. All Rights Reserved. No part of this document may be reproduced without CMHealth’s express consent. Reorder No. OBST56 July 14

anaesthetists and midwife and nurse educators formed a group

unstable. and worked together over three years to develop and implement a
modified early warning score for women during childbirth.
Time to do something about it!

MEWS Team References

Gail McIver, Quality Specialist Midwife, Delivery Suite Manager / Lesley Ansell, Associate Clinical Charge Midwife / Karen Clarke, Nurse Educator / Kathy Ogilvy, Sponsorship and Funding: (1) CMDHB website; (2) Robb & Sebbon (2010) A multi-faceted approach to the physiologically unstable
Nurse / Midwife Educator / Clare Kirby, Clinical Midwife Educator / David Ansell, Obstetric SMO / Sarah Wadsworth, Obstetric SMO / Louise Sherman, Obstetric patient. Qual Saf Health Care; 2010; 19; e47; (3) Carle, C., Alexander, P., Columb, M. et al (2013) Design
Anaesthetist / Karla Masson, Acute Pain Nurse / Jenny Hunt, Acute Pain Nurse / Dwan Lee, Acute Pain Nurse / Susan Tareki, PAR Team / Tracey Cooper, CTEC / and internal validation of an obstetric early warning score: secondary analysis of the Intensive Care
Tanya Wilson, Associate Clinical Charge Midwife / Tish Taihia, Associate Clinical Charge Midwife / Conny Krebs, Clinical Midwife Educator National Audit and Research Centre Case Mix Programme database. Anaesthesia; 2013; 68; pp. 354-367