Professional Documents
Culture Documents
MEOWSS Baca PDF
MEOWSS Baca PDF
F
all adult patients across the NHS using a scoring
or the majority of women childbearing sheet and standard physiological parameters. It is,
is a normal life event. Physiological however, clearly stated in the report that NEWS
adaptations usually ensure a woman has is not designed for use in pregnancy. The reason
a healthy pregnancy, childbirth and postnatal given is that the normal baseline for physiological
recovery. However, the increased cardiovascular parameters and the magnitude and character of
reserves and other physiological changes in the physiological response to acute illness differs
childbearing women can mask the sometimes in this group of patients (RCP, 2012). However, the
inconspicuous signs of severe maternal illness. RCP did not identify any specific gestation from
This can make recognition of impending maternal which NEWS does not apply. In addition, there
collapse difficult. ‘Women with serious illness, is no mention of the relevance of NEWS in the
especially sepsis, may appear deceptively well postpartum period.
before suddenly collapsing, often with little or no
warning’ (Centre for Maternal and Child Enquiries A modified EWS tool for use in
(CMACE), 2011: 86). In addition, maternal childbearing women
wellbeing may be compromised in women of In Kettering General Hospital, a modified early
increased maternal age, obese women or women obstetric warning system (MEOWS) chart is used
with complex medical conditions (Lee, 2014). from 20 weeks gestation when the woman is
admitted to maternity wards. Many pregnancy-
An early warning tool specific conditions occur after the 20th week, e.g.
It is important that midwives have the necessary pregnancy induced hypertension and gestational
effective tools available to aid clinical assessment diabetes (Stables and Rankin, 2005). In addition,
and judgement when managing potentially life- physiological adaptations are likely to be more
changing complications in childbearing women. significant: ‘The changes in physiology seen in
Early warning scoring systems have been normal pregnancy mean that any scoring system
developed nationally following recognition and may need to be modified for this group of patients
evidence that physiological abnormalities precede as pregnancy progresses’ (Lewis, 2007: 241).
Melanie F Cole critical illness (Cullinane et al, 2005). The MEOWS chart is used in the postnatal
Midwife and Perinatal The use of an Early Warning Score (EWS) that period up to the 6th week following childbirth.
© 2014 MA Healthcare Ltd
Resuscitation Officer is modified for use in pregnant and postpartum It is likely that physiological changes will have
Kettering General women will help in the early recognition, treatment returned to a pre-pregnant state at this stage and
Hospital NHS Trust and referral of women who have, or are developing, a most pregnancy-related illness will be resolved
critical illness, and is recommended. The rationale is (Stables and Rankin, 2005).
British Journal of Midwifery.Downloaded from magonlinelibrary.com by 195.195.094.179 on December 2, 2014. For personal use only. No other uses without permission. . All rights reserved.
Professional
© KETTERING GENERAL HOSPITAL NHS FOUNDATION TRUST, 2014. ALL RIGHTS RESERVED
The implementation of NEWS in the hospital
for all adult non-obstetric patients prompted Kettering General Hospital
099=C>>A1=B56 NHS Foundation Trust
the urgent review of the modified obstetric tool.
The RCP have highlighted the importance of a
standardised approach when using an EWS system;
the rationale being that a uniform approach to Modified Early Obstetric Warning System Chart
training and clinical use of the tool will ultimately
(6?>D)A=;D>6A7:9D/CD7>C9D)A=D@6CD=C8A=9?<1DA)D562>?A:A1?8B:DA/>C= B@?A<>DB<9D +&3D38A=C.D0::DB8@?A<>8A;;7<?8B@?A<>
improve patient safety (RCP, 2012). For this reason ?<D=C:B@?A<D@ADBD9C@C=?A=B@?<1DA/>@C@=?8D5B@?C<@D;7>@D/CD9A87;C<@C9D?<D@6CD;B@C=<B:D<A@C>.
It will also provide guidance about the patient’s B@C (?;C 3?1<B@7=C B;CD"4*#(! B@C (?;C 3?1<B@7=C B;CD"4*#(!
recovery and return to stability thus facilitating
a reduction in frequency and intensity of clinical
monitoring and intervention (RCP, 2012).
The MEOWS chart should not be completed
during established labour as a partogram should
be used and clear guidelines already exist 1
specifically relevant to pregnant and postnatal Specific maternal observations that are recorded
women (Carle et al, 2013). The physiological on the MEOWS chart are diastolic blood pressure,
parameters recorded on a NEWS chart are respiratory severity of pain, antenatal discharge and/or postnatal
rate, oxygen saturation, temperature, systolic blood lochia and proteinurea.
British Journal of Midwifery.Downloaded from magonlinelibrary.com by 195.195.094.179 on December 2, 2014. For personal use only. No other uses without permission. . All rights reserved.
Professional
© KETTERING GENERAL HOSPITAL NHS FOUNDATION TRUST, 2014. ALL RIGHTS RESERVED
#<?@?B:DB9;?>>?A<D9B@C ----------- &B=9 -------------------------
Date Date
Time Time
>25 3 >25
Respiratory 21-25 2 21-25
rate 12-20 0 12-20
<12 3 <12
BOOKING BP
>95 0 >95
SpO2 92-95 2 92-95
<92 3 <92
Inspired O2% % 2 %
>37.7° 3 >37.7°
37.3-37.7 2 37.3-37.7
Temperature
36.1-37.2 0 36.1-37.2
<36 3 <36
180 180
170 3 170
160 160
2
150 150
Systolic 1
140 140
Blood 130 130
Pressure 120 120
0
110 110
100 100
90 90
80 80
3 70
70
60 60
120 120
3
110 110
Diastolic 2
100 100
1
Blood 90 90
Pressure 80 80
0
70 70
60 60
140 140
130 3 130
120 120
2
110 110
1
Heart 100 100
90 90
rate 80 0 80
70 70
60 60
2
50 50
40 3 40
BOOKING BP
Alert 0 Alert
Conscious level
V/P/U 3 V/P/U
Normal 0 Normal
Pain Abnormal 3 Abnormal
Normal 0 Normal
Discharge/Lochia Abnormal 3 Abnormal
Proteinuria + 2 +
(min daily) ++ > 3 ++ >
TOTAL MEOWS SCORE TOTAL SCORE
Blood Sugar Blood Sugar
Urine output Urine output
© 2014 MA Healthcare Ltd
British Journal of Midwifery.Downloaded from magonlinelibrary.com by 195.195.094.179 on December 2, 2014. For personal use only. No other uses without permission. . All rights reserved.
Professional
Diastolic blood pressure norm are allocated a score. The score increases
Diastolic blood pressure is an important additional as deviation from the norm escalates. The final
parameter used in the screening for and diagnosis score then falls into one of three categories: a low,
of pre-eclampsia (NICE, 2008). There is reference medium, or high score. Colour coding is used
in the MEOWS booklet to lowering the threshold as it is in NEWS to give additional visual
for escalation where pre-eclampsia is suspected. prompts to aid identification of abnormal
The first clinical observation recorded on the physiological parameters.
MEOWS chart is the booking blood pressure with The scores attributed to the standard
the other physiological observations blocked. This physiological observations (respiratory rate,
enables clinicians to observe the booking blood oxygen saturation, temperature, systolic blood
pressure easily and monitor how it correlates with pressure, heart rate and conscious level) differ from
further readings. NEWS; with the exception of the conscious level
assessment. The aim is to ensure the thresholds take
Severity of pain into account not only the physiological differences
Pain is recognised as an important risk factor for between childbearing women and the general
severe maternal illness and mortality. Women population but also given consideration to the
who have unexplained pain severe enough to specific areas of concern for this group of patients.
require opiate analgesia may have a severe problem Diastolic blood pressure is scored taking into
and must be referred for specialist investigation account the definitions of mild, moderate and
and diagnosis. CMACE (2011) found that cardiac severe hypertension outlined in NICE clinical
disease and other causes of death were missed guidance (NICE, 2010).
when this sign was not identified. In the presence When assessing the level of pain a woman
of pelvic sepsis, severe lower abdominal pain and is experiencing, midwives use their clinical
severe ‘after pains’ that require frequent analgesia judgement and take into account the level of
or do not respond to the usual analgesia are pain expected giving consideration to the full
important symptoms. Severe pain just below the clinical picture. Where the level of pain is
ribs is described as an important symptom of deemed to be abnormal or unexpected, the score
pre-eclampsia (NICE, 2010). attributed is high and should in itself prompt
further investigation.
Antenatal discharge and/or postnatal A similar theory applies when the midwife
lochia assesses the vaginal loss; clinical judgement is
Abnormal antenatal discharge is a symptom expected when determining if the vaginal loss is
that may indicate an infection (CMACE, 2011). considered normal and expected or not.
Abnormal and heavy postnatal bleeding is a Proteinurea is scored with an increase in score
significant cause of maternal morbidity and is correlating to the level of protein detected on
likely to be linked to an infection (Marchant et dipstick urinalysis.
al, 2002). Combined with other symptoms these Blood sugar and urine output do not contribute
findings may lead to a diagnosis of sepsis. The towards the final MEOWS score.
inclusion of this physiological parameter should The recording of each necessary physiological
encourage midwives and other clinicians to parameter will not give specific readings but will
think about sepsis. There are frequent reminders give midwives a quick, clear indication of whether
throughout the MEOWS booklet to consider that observation is within normal limits. Midwives
sepsis in all maternal cases where physiological will record the exact physiological measurements
parameters deviate from the norm. in maternal notes when there is deviation from
the norm.
Proteinurea
Urinalysis assessment of protein is included, the Triggers for escalation
expectation being that urinalysis is performed The trigger levels in the escalation algorithm
as a minimum once daily when appropriate. contained within the MEOWS booklet are the
The rationale is that midwives will consider same as NEWS. A low score is 1–4, a medium score
pre-eclampsia (Milne et al, 2009). is 5–6 and a high score is 7 or more. Any single
score of 3 indicates an extreme variation from the
© 2014 MA Healthcare Ltd
British Journal of Midwifery.Downloaded from magonlinelibrary.com by 195.195.094.179 on December 2, 2014. For personal use only. No other uses without permission. . All rights reserved.
Professional
but may remain in hospital. Examples of these includes a locally agreed sepsis pathway, which
situations include the mother who remains in follows recommendations from the Surviving Sepsis
hospital for feeding support or whose infant Campaign Care Bundles (Dellinger et al, 2012).
requires hospitalisation. Midwives who exclude Midwives and other clinicians are reminded to
British Journal of Midwifery.Downloaded from magonlinelibrary.com by 195.195.094.179 on December 2, 2014. For personal use only. No other uses without permission. . All rights reserved.
Professional
Inform Relevant Senior Specialty Team Dr (ST/Reg/Trust Grade) - Team to inform the patients consultant
Inform Obstetric Anaesthetist
Inform Delivery Suite Co-ordinator
Confirmed or impending cardio-respiratory arrest: Dial 2222 ask for Cardiac Arrest AND Obstetric Emergency Team
Or adverse signs:
Rapid deterioration
Reduced conscious level or seizures/fits
Extreme pallor, sweating, distress
Obvious massive bleeding
think about sepsis when referring to the escalation effectively to acutely ill patients (DH, 2009).
pathways. It is appropriate to incorporate sepsis The skills of the team caring for the unwell
guidelines in early warning tools as patients with obstetric patient will have an impact on patient
severe sepsis can be significantly more unwell outcome. Medical management and team work
than they might appear (Parliamentary and Health are important in the management of obstetric
Service Ombudsman, 2013). emergencies as if either are absent or lacking,
The competent and effective use of morbidity and mortality may result (Dresang et
communication skills will be necessary when al, 2010). In Kettering General Hospital, midwives
managing the unwell obstetric patient to ensure along with other trained clinical obstetric
timely escalation of care and intervention. The practitioners such as doctors and theatre staff,
Department of Health (DH, 2009: 7) state: can and do access the UK Resuscitation Council
‘Organisations must ensure that their team have Immediate Life Support Course. The skills acquired
the necessary communication skills to convey the during delivery of presentations, discussions,
urgency of the situation and get immediate help demonstrations, workshops and simulations are
from clinicians with appropriate knowledge and all related to the obstetric patient making it highly
skills to ensure the patient receives optimum care’. relevant. It is important that teaching is modified
Therefore, Kettering General Hospital adopted to reflect the practice area and educative needs of
the communication tool, Situation Background the target audience (Jennings, 2012).
Assessment Recommendation; SBAR. Guidance When devising any MEOWS chart it is
on how to use this tool in obstetrics is included important to ensure that abnormal parameters
within the MEOWS booklet. do lead to a trigger prompting escalation. Ideally,
the chart is highly sensitive to alerting the user
Education when signs of impending illness are present.
Midwives and other users of MEOWS will require The number of precipitate alerts must be kept
robust training to ensure effective use of the system to a minimum however to ensure unnecessary
and clear, legible documentation of observations escalation and intervention is not promoted. The
and interventions. The training needs of users at Kettering General Hospital’s MEOWS chart will be
Kettering General Hospital are addressed using subject to scrutiny through internal audit.
a variety of avenues. These include: vital signs
skills assessment tools; inclusion in mandatory Conclusion
resuscitation training; cascade training; and online Childbirth is a major life event and the physiological
plus hard copy user guides. In addition, there are and psychological implications of serious illness
clear documentation standards attached to the on the woman and her family cannot be dismissed.
MEOWS guideline. Staff caring for patients in While midwives strive to encourage and support
© 2014 MA Healthcare Ltd
any acute hospital setting should be competent in normality for pregnant and postnatal women,
monitoring, measurement and interpretation of equal importance must be assigned to identifying
vital signs, equipping them with the knowledge and acting on physiological changes occurring in
to recognise deteriorating health and respond women, which may indicate illness that without
British Journal of Midwifery.Downloaded from magonlinelibrary.com by 195.195.094.179 on December 2, 2014. For personal use only. No other uses without permission. . All rights reserved.
Professional
timely intervention can lead to significant maternal Mothers’ Lives: Reviewing maternal deaths to make
morbidity. A modified early obstetric warning motherhood safer: 2006-08. The Eighth Report on
tool provides a useful aid to clinical judgement Confidential Enquiries into Maternal Deaths in the
United Kingdom. BJOG 118(Suppl 1): 1–203
during the assessment process and a structure to
Cullinane M, Findlay G, Hargreaves C, Lucas S (2005) An
follow which should ensure timely and appropriate
Acute Problem? National Confidential Enquiry into
intervention when required. A locally devised tool Patient Outcome and Death, London
can be modelled on the NEWS. The space available Dellinger RP, Levy MM, Rhodes A et al (2012) Surviving
must be utilised effectively and enable clear and Sepsis Campaign: International Guidelines for
legible documentation. Management of Severe Sepsis and Septic Shock.
The MEOWS booklet in Kettering General Crit Care Med 41(2): 580–637. doi: 10.1097/
CCM.0b013e31827e83af
Hospital is commenced at 20 weeks gestation;
Department of Health (2009) Competencies for
however, it is possible that a modified EWS
Recognising and Responding to Acutely Ill Patients in
is applicable for all hospital admissions from Hospital. DH, London
pregnancy booking. Some physiological Dresang LT, Davis S, Miller K, Olden C, Atwood L (2010)
adaptations will be apparent early in pregnancy Safety in Maternity Care-The ALSO Provider Manual
and may therefore warrant the use of a modified Revised. 5th edn. American Academy of Family
obstetric tool on admission to gynaecology wards. Physicians.
There may be a place for adapting the principles Jennings J (2012) An evaluation of the effects of teaching
and learning styles on the delivery of components of
of early warning scoring for use by community
the Immediate Life Support Course. British Journal of
midwives. Childbearing women may develop illness Resuscitation Spring: 23
outside hospital and a structure for assessment, Lee S (2014) Risk perception in women with high-risk
intervention, escalation and appropriate referral is pregnancies. British Journal of Midwifery 22(1): 8–13
equally relevant in the community setting. Lewis G (2007) Saving Mothers Lives: Reviewing maternal
A validated national obstetric early warning tool deaths to make motherhood safer (2003-2005). The
would enable consistency and a necessary uniform Seventh Report on Confidential Enquiries into Maternal
Deaths in the United Kingdom. CEMACH, London
approach to the assessment and management of
Marchant S, Alexander J, Garcia J (2002) Postnatal vaginal
potentially deteriorating childbearing women. BJM bleeding problems and General Practice. Midwifery 18: 21–4
Milne F, Redman C, Walker J et al (2009) Assessing the onset
Acknowledgements: I would like to acknowledge the of pre-eclampsia in the hospital day unit: summary of
following for their input in the construction of the MEOWS the pre-eclampsia guideline. BMJ 339: b3129
booklet: Dr Duncan Baines, Consultant Anaesthetist, National Institute for Health and Care Excellence (2007a)
Kettering General Hospital NHS; Dr Clare Cuckson, Intrapartum Care. Care of healthy women and their
Consultant Obstetrician, Kettering General Hospital NHS, babies during childbirth NICE clinical guideline 55.
Dr Elizabeth Farah, FY1, Kettering General Hospital NHS. NICE, London
National Institute for Health and Care Excellence (2007b)
Artwork produced and provided with thanks by CSP Printers Acutely Ill Patients in Hospital: recognition of and
www.collectorsetprinters.co.uk response to acute illness in adults in hospital NICE
Carle C, Alexander P, Columb M, Johal J (2013) Design and clinical guideline 50. NICE, London
internal validation of an obstetric early warning score: National Institute for Health and Care Excellence (NICE)
secondary analysis of the Intensive Care National Audit (2008) Antenatal Care: routine care for the healthy
and Research Centre Case Mix Programme database. pregnant woman NICE clinical guideline 62. NICE,
Anaesthesia 68: 354–67 doi: 10.1111/anae.12180 London
Centre for Maternal and Child Enquiries (2011) Saving National Institute for Health and Care Excellence (2010)
Hypertension in pregnancy. The management of
hypertensive disorders during pregnancy NICE clinical
guideline 107. NICE, London
Key points Parliamentary and Health Service Ombudsman (2013)
ll A modified obstetric early warning tool will assist midwives when Time To Act. Severe sepsis: rapid diagnosis and
treatment saves lives. PHSO, London
identifying childbearing women who may be at risk of developing
Royal College of Obstetricians and Gynaecologists (2011)
serious illness
Maternal Collapse in Pregnancy and the Puerperium
ll An obstetric early warning tool should model the national early Green-top Guideline No 56. RCOG, London
warning tool for standardisation and educational reasons Royal College of Physicians (2012) National Early Warning
ll When formulating an early warning scoring system for use on Score (NEWS): Standardising the assessment of acute
childbearing women specific physiological parameters relevant in illness severity in the NHS. Report of a working party.
© 2014 MA Healthcare Ltd
British Journal of Midwifery.Downloaded from magonlinelibrary.com by 195.195.094.179 on December 2, 2014. For personal use only. No other uses without permission. . All rights reserved.