Affix patient’s identification label here

MATERNITY EARLY WARNING SCORE

MIDWIFERY AND NURSING ACTIONSFOR PATIENTS WITH A MEWS SCORE

Score 0

Score 2

Score 1

ANY PATIENT VITAL SIGNS IN THE YELLOW SCORES 1

Calculate the Total MEWS Score1. Inform Midwife/Nurse in charge2. Increase frequency of vital signs one hourly or more frequently if required.3. Treat Pain

ANY PATIENT VITAL SIGNS IN THE PURPLE SCORES 5 OR MORE OR IF YOU ARE CONCERNED ABOUT THE PATIENT CALL

888

OBSTETRIC EMERGENCY TEAM or WOMENS HEALTH CARDIAC ARREST or STAT CAESAREAN SECTION Stay with the patient.

ANY PATIENT VITAL SIGNS IN THE ORANGE SCORES 2 - 4

Calculate the Total MEWS Score1. Inform Midwife/Nurse in charge2. Repeat vital signs within 1/2 hour.3. If MEWS score unchanged contact Obstetric Registrar, notify PAR Team.4. Continue 1/2 hourly vital signs until Obstetric Registrar arrives.5. If Obstetric Registrar not available call Obstetric Consultant.

Score 5+ 888

Score 0 0-499mls OBSERVE

Score 2 1000-1500mls

Score 1 500-1000mls

Score 5+ 1500mls+

VARIATION TO BLOOD LOSS THRESHOLDMeasuring Blood Loss estimate.Soaked Pad = 150mlsSoaked Blue inco sheet = 450mlsSoaked Towel = 600mls1ml blood = 1 gm weight

*Standard vital signs: q4H, Respiratory rate, Saturation, Heart rate, BP, Blood Loss,Temp, Level of consciousness, Urine output and Pain

PAD 150ml

INCO SHEET 450ml

TOWEL 600ml

Date

Time

Pain at Rest 0-10

Pain On Movement 0-10

Respiratory Rate

Saturations

Heart Rate

Systolic BP

Diastolic BP

Blood Loss

Temperature

Level of Consciousness

Urine Output

TOTAL SCORE

Respiratory Rate

Saturations

Heart Rate

Systolic BP

Diastolic BP

Blood Loss

Temperature

Conscious Level

Urine Output

TOTAL SCORE

Runn

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Tota

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Runn

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Tota

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lood

Pre

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mHg

Sy

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lood

Pre

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mHg

He

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ate

bpm

Sa

tura

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Urin

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Co

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Bl

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Loss

(ml)

Glucose

O2 litres/min

Counties Manukau District Health Board

MEWS SCORE - Calculate total score. Add each vital sign to reach TOTAL MEWS SCORE

Reorder No. OBST56 July 14

Est bld loss on arrival

Copyright © CMHealth 2014. All Rights Reserved. No part of this document may be reproduced without CMHealth’s express consent.

>40 >40

30-39 30-39

25-29 25-29

20 20

15 15

10 10

<8 <8

98-100 98-100

94-98 94-98

91-93 91-93

<90 <90

>140 >140

130 130

120 120

110 110

100 100

90 90

80 80

70 70

60 60

50 50

40 40

30 30

>200 >200

190 189-199

180 180

170 170

160 160

150 150

140 140

130 130

120 120

110 110

100 100

90 90

80 80

70 70

60 60

50 50

140 140

130 130

120 120

110 110

100 100

90 90

80 80

70 70

60 60

50 50

1500+ 1500+

1000-1499 1000-1499

751-999 751-999

500-750 500-750

0-499 0-499

>38.5 >38.5

38.1-38.4 38.1-38.4

38 38

37 37

36 36

<35 <35

Alert Alert

Voice Voice

Pain Pain

Unresponsive Unresponsive

New Confusion New Confusion

>30ml/hr >30ml/hr

16-29 ml/hr 16-29 ml/hr

<15 ml/hr <15 ml/hr

Modified Parameters for

Childbirth

New Parameter

Running Total Blood Loss

Visual Aid for Blood Loss

Actions

Total Mews Score

Went LIVE 17 March 2014

MEWS - Maternity Early Warning Score Conny Krebs, Clinical Midwife Educator - Ko Awatea, Auckland, New Zealand

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

One woman too many Development Implementation

Major Haemorrhage After Birth Have Tripled

Multiprofessional Team

In 2010 the Women’s Health Quality Specialist Midwife brought together a multiprofessional team with the idea to develop a modified EWS for Maternity Services.

Midwives, nurses, managers, members of the Patient At Risk team, Clinical Training & Education Centre, Acute Pain team, obstetricians, anaesthetists and midwife and nurse educators formed a group and worked together over three years to develop and implement a modified early warning score for women during childbirth.

New ParameterA new parameter – blood loss – has been added to the MEWS score. Blood loss is one of the most common causes of preventable severe maternal morbidity, and is often exacerbated by delayed or inappropriate treatment. It can be one of the critical indicators of deterioration, and the amount of blood lost is frequently underestimated.

Modification for Birthing UnitsMEWS has also been introduced to the three primary birthing units. As these units operate in the community setting, have no medical staff onsite and rely on the ambulance service for transfer, the action plan has been modified to their needs. An easy peel-off sticker, with the action algorithm appropriate for the birthing units, is applied and makes it instantly functional.

Trial MEWS was trialled over 5 days for usability in Middlemore Hospital Delivery Suite and Maternity Ward, as well as tested retrospectively on Serious and Sentinel Event cases. All retrospectively reviewed cases would have triggered and received early intervention if this chart had been available and used.

Audits Currently we are in the process of evaluating the chart and refining our measurable aim.

ConclusionPPH cannot be prevented. It is axiomatic that PPH occurs unpredictably and no patient is immune from it.

What can be changed is how we react to and manage PPH. The introduction of a specific EWS for obstetrics combined with an evidence-based management model can potentially reduce the practice variability and improve the quality of care.

MEWS

Managers

Midwives

Nurses

Obstetricians

AnaesthetistsPatient at Risk Team

Clinical Training & Education

Centre

Midwife & Nurse

Educators

Acute Pain Team

IntroductionCM Health is introducing a systematic scoring chart for maternity patients to Women’s Health Service. The MEWS (Maternity Early Warning Score) chart will assist staff to identify antenatal and postnatal women at risk of deteriorating in condition and improve the response to the acutely deteriorating woman.

SettingCM Health serves the Counties Manukau region in Auckland, New Zealand. It has a birthing unit at Middlemore Hospital, one of the largest tertiary hospitals in New Zealand, and primary birthing units at satellite sites in Botany Downs, Papakura and Pukekohe. All primary birthing units offer pregnancy clinics, labour and birthing facilities and provide postnatal care.

• The estimated Counties Manukau population for 2013 is 512,130, 11.5% of the total New Zealand population.

• Counties Manukau has high numbers of Maaori, Pacific and Asian peoples and a relatively youthful population.

• Counties Manukau has a high birth rate compared with many other areas – 7282 babies were delivered in 2013 at CM Health. This contributes to relatively high demand on our maternity and child health services.(1)

MEWS Team Gail McIver, Quality Specialist Midwife, Delivery Suite Manager / Lesley Ansell, Associate Clinical Charge Midwife / Karen Clarke, Nurse Educator / Kathy Ogilvy, Nurse / Midwife Educator / Clare Kirby, Clinical Midwife Educator / David Ansell, Obstetric SMO / Sarah Wadsworth, Obstetric SMO / Louise Sherman, Obstetric Anaesthetist / Karla Masson, Acute Pain Nurse / Jenny Hunt, Acute Pain Nurse / Dwan Lee, Acute Pain Nurse / Susan Tareki, PAR Team / Tracey Cooper, CTEC / Tanya Wilson, Associate Clinical Charge Midwife / Tish Taihia, Associate Clinical Charge Midwife / Conny Krebs, Clinical Midwife Educator

References

(1) CMDHB website; (2) Robb & Sebbon (2010) A multi-faceted approach to the physiologically unstable patient. Qual Saf Health Care; 2010; 19; e47; (3) Carle, C., Alexander, P., Columb, M. et al (2013) Design and internal validation of an obstetric early warning score: secondary analysis of the Intensive Care National Audit and Research Centre Case Mix Programme database. Anaesthesia; 2013; 68; pp. 354-367

Research Research indicates that warning signs precede virtually every critical inpatient event. There are well-established early warning score (EWS) charts in existence for use with general patients. A general EWS physiologically unstable patient chart was introduced at CM Health in 2007. (2)

However, EWS charts designed for general patients are unsuitable for use in obstetrics due to the physiological changes and modified responses that occur during pregnancy.

Although the importance of early warning scores for obstetric patients is widely recognised, there are no national or international ‘gold standards’ obstetric warning scores currently in use. (3)

Over the last four years midwives in the delivery suite observed an increase in major haemorrhages after birth, also known as postpartum haemorrhage(PPH), particularly major PPH over 1500mls. In too many cases, PPH was not managed in a timely manner to prevent women going down the continuum of deterioration, and patients became unstable.

Time to do something about it!

2010 2011 2012

148120

51

Maj

or H

aem

orrh

age

>

1500

mls

8171 8135 8103Birth Rate

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