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Chapter 10: Maternal Early Warning System

Philip E. Hess

INTRODUCTION

The rate of maternal mortality has been increasing in the United States. The maternal mortality rate for 2020 was 23.8/100,000 live births compared with a rate of 17.4 in 2018.1

Severe maternal morbidity (SMM) is considered a near miss for maternal mortality if some conditions are not identified and treated. CDC has a consensus list of 21 SMM indicators.2

The development of maternal early warning system (MEWS) is to increase the early recognition of changes in the mother’s vital signs and clinical conditions leading to prompt evaluation and escalation in the response with the goal of reducing the numbers of women experiencing SMM.2 A validation cohort study revealed that MEWS showed high specificity, more clinically relevant but with lower sensitivity.3

MEWS at Beth Israel Deaconess Medical Center features multidisciplinary collaboration, prompt response with defined actions and guidelines (Fig. 10-1).4

FIGURE 10-1

Beth Israel Deaconess Medical Center© Maternal Early Warning System. October 2016. (Reproduced with permission from Beth Israel Deaconess Medical Center© Maternal Early Warning System. October 2016.)

A chart shows the Maternal Early Warning Systems (MEWS). The chart consists of four sections. The first section is titled ‘Early warning signs.’ Vital signs: HR lesser than 45 or greater than 120; RR lesser than 8 or greater than 30; SBP is lesser than 90 millimeters of mercury; SPO2 lesser than 94 percent; Temperature lesser than 35 degrees Celsius (95 degrees Fahrenheit) or greater than 38.9 degrees Celsius (102 degrees Fahrenheit); SBP greater than 160 millimeters of mercury; DBP greater than 110 millimeters of mercury; Urine output lesser than 30 milliliters for 2 consecutive hours. OB events: Retained placenta, Use of 2nd uterotonics; Opening second 10-pack of laps (vaginal delivery). New lab availability: Hematocrit: Lesser than 25 percent, Platelets lesser than 100,000 per cubic millimeters, Fibrinogen lesser than 200 milligrams per deciliter. Other: provider or family concern, Shortness of breath, Maternal confusion or agitation, Non-remitting headache; Right upper quadrant pain. The second section is titled ‘Early warning response.’ The data given in the second section are as follows: Primary nurse: Action: Activates OB MEWS by calling Resource nurse and stating: ‘Patient X meets MEWS criteria of black space.’ Resource nurse: Action: Calls or pages to contact MEWS response team: Attending obstetrician, OB and anesthesia resident, Anesthesia attending. MEWS response team: Meets at the patient’s bedside. The third section is titled ‘MEWS team response.’ Hemorrhage: Follow OB hemorrhage protocol; HTN or preeclampsia: Follow preeclampsia protocol; Embolism: Follow embolism protocol; Sepsis: Follow sepsis protocol; Other: Appropriate consult service. The fourth section of the chart is titled ‘**Follow up for all MEWS.’ 1, MEWS response team reconvene no later than 1 hour to re-evaluate. 2, If unresolved after 1 hour, consideration for other interventions, ICU admission, and other consult-services.
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REFERENCES

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1. +
Hoyert  DL. Maternal mortality rates in the United States, 2020. National Center for Health Statistics. Centers for Disease Control and Prevention. https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2020/maternal-mortality-rates-2020.htm. Accessed April 2022.
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2. +
Centers for Disease Control and Prevention. How does CDC identify severe maternal morbidity? https://www.cdc.gov/reproductivehealth/maternalinfanthealth/smm/severe-morbidity-ICD.htm. Accessed April 2022.
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3. +
Blumenthal  E, Hooshvar  N, McQuade  M,  et al. A validation study of maternal early warning systems: a retrospective cohort study. Am J Perinatol. 2019;36(11):1106–1114.  [PubMed: 30856674]
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4. +
Beth Israel Deaconess Medical Center© Maternal Early Warning System. October 2016. Accessed April 2022.

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