Maternal Early Warning System

as proposed by the National Partnership for Maternal Safety

Mhyre, J., D’Oria, R., Hameed, A., Lappen, J., Holley, S., Hunter, S., Jones, R., King, J., & D’Alton, M. (2014). The maternal early
warning criteria: A proposal from the National Partnership for Maternal Safety. Co-published by the Journal of Obstetric,
Gynecologic, and Neonatal Nurses, 43, 771-779; and Obstetrics and Gynecology, 124, p. 782-787.

The Maternal Early Warning Criteria

Measure Value
Systolic Blood Pressure (mm Hg) <90 or >160
Diastolic Blood Pressure (mm Hg) >100
Heart rate (beats per minute) <50 or >120
Respiratory rate (breaths per min) <10 or >30
Oxygen saturation on room air, at sea level % <95
Oliguria, mL/hr for ≥2 hrs <35
Maternal agitation, confusion, or unresponsiveness
Woman with preeclampsia reporting a non-remitting headache or shortness of breath

It is important to verify isolated abnormal measurements, particularly for blood pressure, heart rate,
respiratory rate and oxygen saturation.

Urgent bedside evaluation is usually indicated if any of these values persist for more than one measurement,
present in combination with additional abnormal parameters, or recur more than once.

While awaiting the arrival of the evaluating clinician, the bedside nurse should follow basic resuscitation
principles:
 Achieve free-flowing appropriate venous access
 Increase frequency of vital signs
 If woman still pregnant – left uterine displacement
 Supplemental oxygen therapy
*Appropriate standing orders are needed to allow the bedside nurse to administer these resuscitative
measures

Please see accompanying paper for differential diagnosis information for Maternal Early Warning Criteria

CMQCC MATERNAL EARLY WARNING SYSTEM 7_17_15 1

 Differential Diagnosis for the Maternal Early Warning Criteria
Measurement
Blood pressure > 160 systolic or
> 100 diastolic
Blood pressure <90 systolic
Heart rate >120 bpm
Heart rate <50
Respiratory rate >30
Respiratory rate <10
Common Diagnoses
 Chronic hypertension
 Preeclampsia
 Sympathomimetic
medications
(methylergonovine,
Phenylephrine, other
vasopressors)
 Dehydration
 Supine hypotension
syndrome
 Regional anesthesia side
effect
 Hemorrhage
 Medication side effects (beta
blockers, calcium channel
blockers
 Vasovagal reaction (in
presence of bradycardia)
 Dehydration
 Hemorrhage
 Infection
 Medication side effects
(sympathomimetics, beta-2
agonists)
 Anxiety/pain/panic attack
 Vasovagal reaction (in
presence of hypotension)
 Medication side effects (beta
blockers)
 Hypertension (reflex
bradycardia)
 Hypoxia (asthma)
 Hemorrhage
 Infection (sepsis,
pneumonia)
 Anxiety/panic
attack/exertion
 Medication toxicity (opioids,
Rare But Life-Threatening Diagnoses
 Illicit substance abuse (cocaine, amphetamines)
 Endocrine disorders (pheochromocytoma,
hyperthyroidism, renal artery stenosis
 Hypoventilation with hypercarbia (opiate-related,
obstructive sleep apnea, respiratory muscle weakness
 Sepsis
 Cardiac (cardiomyopathy, right or left heart failure,
myocardial ischemia, pericarditis, cardiac tamponade,
arrhythmia)
 Thromboembolism (pulmonary embolism)
 Concealed hemorrhage
 Amniotic fluid embolism
 Anaphylaxis
 Diabetic ketoacidosis
 Drug toxicity (magnesium, local anesthetic)
 High spinal or epidural block
 Tension pneumothorax
 Vascular emergency
 Cardiac (see above)
 Illicit drugs (cocaine, amphetamine)
 Thromboembolism (pulmonary embolism)
 Concealed hemorrhage (retroperitoneal hemorrhage,
abruption, uterine rupture)
 Amniotic fluid embolism
 Anaphylaxis
 Endocrine disorders
 Malignant hyperthermia
 Vascular emergency (splanchnic arterial or aortic
dissection)
 Heart block from cardiac disease
 Hypoventilation or hypoxemia (obstructive sleep
apnea)
 Electrolyte disturbance
 Medication toxicity (magnesium)
 Stroke/Increased intracranial pressure
 High spinal or epidural block
 Cardiac
 Thromboembolism (pulmonary embolism)
 Aspiration
 Metabolic acidosis including diabetic ketoacidosis
 Concealed hemorrhage
 Amniotic fluid embolism
 Stroke
 Airway obstruction

Oxygen saturation <95% or
increasing oxygen requirements
to main oxygen saturation >/=
95%
Maternal confusion, agitation,
or unresponsiveness
Oligura <35mL/hr over a 2hr
period
Mhyre, J., D’Oria, R., Hameed, A., Lappen, J., Holley, S., Hunter, S., Jones, R., King, J., & D’Alton, M. (2014). The maternal early
warning criteria: A proposal from the National Partnership for Maternal Safety. Co-published by the Journal of Obstetric,
Gynecologic, and Neonatal Nurses, 43, 771-779; and Obstetrics and Gynecology 124, p. 782-787.
benzodiazepines,
magnesium
 Obstructive sleep apnea
 Atelectasis
 Bronchospasm (asthma)
 Hemorrhage
 Hypoventilation (obstructive
sleep apnea, opiate or
benzodiazepine effect)
 Infection (pneumonia)
 Hypoxemia
 Hemorrhage/hypotension
 Illicit substances
 Seizure/postictal
state/posterior reversible
encephalopathy syndrome
 Psychosis is a diagnosis of
exclusion
 Severe dehydration
 Hemorrhage
 Obstructed urinary catheter
CMQCC MATERNAL EARLY WARNING SYSTEM 7_17_15 3
 Asthma with respiratory failure
 High spinal or epidural block
 Cerebrovascular accident
 Airway obstruction (asphyxia, laryngospasm)
 Pulmonary edema
 Thromboembolic disease (pulmonary embolism)
 Cardiac disease
 Concealed hemorrhage
 Amniotic fluid embolism
 Anaphylaxis
 Aspiration
 Acute chest syndrome (sickle cell disease)
 Pneumothorax
 Venous air embolism
 Blood product reaction (TRALI, TACO)
 Diabetic ketoacidosis, hypoglycemia
 Sepsis
 Concealed hemorrhage
 Thromboembolic disease
 Amniotic fluid embolism
 Anesthesia complications
 Cardiomyopathy
 Cerebrovascular accident, cavernous sinus thrombosis
 Increased intracranial pressure
 Electrolyte abnormality (hypermagnesemia)
 Hyperthyroidism/thyroid storm, myxedema coma
 Medication toxicity
 Surgical complications
 Genitourinary tract injury
 Preeclampsia with severe features
 Sepsis
 Concealed hemorrhage
 Acute renal failure