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OB Early Warning Criteria

1 Contact Hour
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This peer reviewed course is applicable for the following professions:
Advanced Practice Registered Nurse (APRN), Certified Nurse Midwife, Certified Nurse Practitioner, Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Midwife (MW), Nursing Student, Registered Nurse (RN), Registered Nurse Practitioner
This course will be updated or discontinued on or before Saturday, April 25, 2026

Nationally Accredited

CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.

Outcomes

≥ 92% of participants will know what obstetric early warning criteria is and how to respond.

Objectives

After completing this continuing education course, the participant will be able to:

  1. Define early warning criteria.
  2. Indicate why early warning criteria are essential.
  3. Choose when to activate a response based on the early warning criteria.
  4. Analyze the barriers to early warning criteria implementation.
  5. Specify how to implement the early warning criteria.
CEUFast Inc. and the course planners for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.
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Author:    Kelly LaMonica (DNP(c), MSN, RNC-OB, EFM)

Background

Monitoring, also known as clinical surveillance, is ongoing patient assessments that identify problems and trigger responses. A warning system is a process that defines observation criteria and sets a limit to trigger a response. Although non-obstetric warning systems have existed for over twenty years, there has not been a system for obstetric women until 2011, when the United Kingdom began to introduce a formal maternal early warning system (Nair et al., 2020).

Maternal morbidity and mortality are still on the rise in the United States. Severe maternal morbidity has risen by over 144% in the United States from 1987 to 2019 (Centers for Disease Control and Prevention [CDC], 2023). There are some potential reasons for this increase including (National Institute of Health [NIH], 2018):

  • Increases in maternal age
  • Pre-pregnancy obesity
  • Preexisting chronic medical conditions
  • Cesarean delivery

Additional conditions including hemorrhage, hypertension, infection, and venous thrombosis (VTE) with delays in recognition, diagnosis, and treatment can cause many preventable maternal deaths as well (Xu et al., 2022).

In 2011, The Centre for Maternal and Child Enquiries recommended that the Maternal Early Warning System (MEWS) started to be introduced into maternity units in the United Kingdom. Since then, there are variations in the MEWS that are used across the world (Nair et al., 2020). The National Partnership for Maternal Safety devised maternal early warning criteria (MEWC) for use in maternal early warning systems (Arnolds et al., 2019). Maternal early warning criteria can prevent maternal morbidity and mortality.

Current Evidence of Early Warning Criteria

Maternal mortality reviews have shown that in women who died, a disproportionate number demonstrated abnormal vital signs, suggesting that a single-parameter system should maximize specificity for patients developing a critical illness (Friedman et al., 2018; Mhyre et al., 2014). The MEWS was created to account for normal physiologic changes that occur in pregnancy. There are many variations of the MEWS, but common parameters include:

  • Heart rate
  • Respiratory rate
  • Blood pressure
  • Level of consciousness
  • Oxygen saturation

Other important parameters may include:

  • Level of pain
  • Lochia
  • Urine output

Different designs of MEWS have shown different results, leading to the need for more additional research. Please reference the following table for the specific parameters of the Maternal Early Warning Criteria.

Table 1: The Maternal Early Warning Criteria
Systolic blood pressure (mm Hg)<90 or >160
Diastolic blood pressure (mm Hg)>100
Heart rate (beats per min)<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 hours<35
Maternal agitation, confusion, or unresponsiveness
Patient with preeclampsia reporting a non-remitting headache or shortness of breath

(Friedman et al., 2018)

These triggers cannot address every potential clinical scenario that could be faced by an obstetric clinician and should not replace clinical judgment. As a core safety principle, the bedside nurse should always feel comfortable with escalating concerns at any point (Friedman et al., 2018).

Activating Early Warning Criteria

All patients who meet any of The Maternal Early Warning Criteria should receive prompt bedside evaluation by a provider with the ability to activate resources to initiate emergency diagnostic and therapeutic interventions as needed (Friedman et al., 2018).

It is important to note that one abnormal measure could have been inaccurate; therefore, it should be repeated. If the patient's provider is unavailable for a prompt evaluation, a covering provider should evaluate the patient. If a woman meets the criteria and the reason cannot be determined, a maternal-fetal medicine consult, a hospital intensivist consult, or a rapid response team action should be initiated. Some electronic medical records (EMRs) can be programmed to alert the RN and page appropriate resources (such as the attending physician) automatically when the patient meets the criteria (Friedman et al., 2018).

Barriers to Early Warning Criteria

The most significant barrier to implementing an early warning criteria system is both a physician and administration buy-in. Providers may not want to be bothered, especially when unavailable. Therefore, it is crucial to have an in-house provider to cover these circumstances. However, many providers are reluctant to respond to and treat other providers' patients. Nurses making the call to the provider may have difficulty calling a provider who will not respond appropriately. It is vital for hospital administration to support an early warning criteria policy and ensure that providers follow it. Nurses may improve the use of the criteria if they receive praise or acknowledgment for using the criteria appropriately (Friedman et al., 2018).

Implementing Early Warning Criteria

The Council on Patient Safety in Women's Healthcare, a subcommittee of the American College of Obstetrics and Gynecology (ACOG) and the Association of Women's Health, Obstetric, and Neonatal Nursing (AWHONN) both support the use of maternal early warning criteria.

Each hospital should have a policy that includes (AIM, 2022; Arnolds et al., 2019):

  • Criteria to trigger the early warning system
  • Whom to notify
  • How to notify them
  • How rapidly to expect a response
  • When and how to activate the clinical chain of command in order to ensure an appropriate response is taken

Provider Notification

The provider should be notified immediately once the patient meets criteria and should respond as soon as possible with a bedside evaluation of the patient in a timely manner, ideally within 10 minutes.If the attending physician is not immediately available, any in-house OB provider should provide a bedside evaluation of the patient.

If an in-house provider sees the patient, the attending physician or Certified Nurse Midwife (CNM) should also receive notification of the patient's status. If an in-house OB is called but not immediately available due to other responsibilities, he or she should receive a verbal report and determine what further action is necessary. There should always be a backup plan in case the OB provider is unavailable due to another cooccurring emergency, otherwise care can be delayed leading to complications (Friedman et al., 2018).

Provider Actions

Once the provider gets to the bedside and evaluates the patient, they should document their evaluation. The provider should notify the nurse of the planned frequency of monitoring and re-evaluation and the criteria for immediate physician notification. The provider should communicate the assessment and plan with the staff involved in care of the patient. This communication or huddle should include the (Alliance for Innovation on Maternal Health [AIM], 2022):

  • Primary RN
  • The Charge RN
  • The Anesthesiologist
  • The attending physician, if present
  • The in-house provider so everyone is aware of the plan for this patient

If MEWS conditions(s) persist after corrective measures are undertaken, then an maternal-fetal medicine (MFM) consult should be requested as soon as possible. If they are not available, an intensivist consult should be ordered. If necessary, a Rapid Response Team may be activated.

If the RN and the charge nurse question any part of the patient's care and no resolution is forthcoming with the attending physician, another appropriate physician and a nurse in the Nursing Chain of Command should receive a notification. Nurses must have support in this process.

Case Study

Sarah is a 42-year-old woman who delivered her first baby via c-section 3 hours ago. She had moderate to heavy bleeding during her recovery. Her estimated blood loss measured 1200 mL. Her vital signs have been stable.

Sarah is transferred to the mother-baby unit at 11:00 pm. She begins to complain of severe abdominal pain. She is given hydromorphone (Dilaudid) for her pain that she rates as a 9 out of 10 on the pain scale. Her bleeding is moderate. Her assessment includes:

  • BP 128/84
  • HR 140
  • Respirations 18
  • Temperature 98.6
  • Oxygen saturation is 98% on room air
  • Urine output is adequate

The RN assumes the elevated HR is due to her pain. The RN returns in 1 hour to check on this patient and finds her lethargic with a BP of 90/60, HR 150, and an oxygen saturation of 94%. The RN calls a rapid response. The patient ends up in the operating room with a massive hemorrhage requiring a massive transfusion and subsequent transfer to the intensive care unit.

Let's reflect on this case:

  • Were the RN's actions appropriate?
  • Should the early warning criteria have been activated?
  • Could the massive transfusion have been prevented?

At 11:00 pm, the patient's HR met early warning criteria. Her HR should have been rechecked and the provider called. The RN's actions were not appropriate. Her HR could have been elevated due to pain, but the woman had already had a hemorrhage, and her bleeding was still moderate. A massive transfusion may have been prevented if the patient had been treated with blood products sooner, but it is impossible to say it was preventable. The woman could have and should have received care sooner.

Conclusion

Maternal early warning criteria can prevent maternal morbidity and mortality. There are studies to support the effectiveness of these criteria. There are cases of complications such as preeclampsia that may not be preventable, but prompt treatment may prevent maternal morbidity or mortality. All nurses should know these criteria and have a process to activate a response.

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Implicit Bias Statement

CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.

References

  • Alliance for Innovation on Maternal Health. (AIM). (2022). Severe hypertension in pregnancy. Alliance for Innovation on Maternal Health (AIM). Visit Source.
  • Arnolds, D., Smith, A., Banayan, J., Holt, R., & Scavone, B. (2019). National partnership for maternal safety recommended maternal early warning criteria are associated with maternal morbidity. Anesthesia & Analgesia,129(6), 1621-1626. Visit Source.
  • Centers for Disease Control and Prevention. (CDC). (2023). Pregnancy mortality surveillance system. Retrieved April 1st, 2024. Visit Source.
  • Friedman, A., Campbell, M., Kline, C., Wiesner, S., DAlton, M., & Shields, L. (2018). Implementing obstetric early warning systems. American Journal of Perinatology Reports, 8(2), e79-e84. Visit Source.
  • Mhyre, J., DOria, R., Hameed, A., Lappen, J., Holley, S., Hunter, S., Jones, R., King, J., & DAlton, M. (2014). The Maternal Early Warning Criteria: A proposal from the National Partnership for Maternal Safety.Journal of Obstetric, Gynecologic & Neonatal Nursing. 2014;43(6):771-779. Visit Source.
  • Nair, S., Dockrell, L., & Colgain, S. (2018). Maternal early warning scores (MEWS). World Federation of Societies of Anesthesiologists (WFSA) Resource Library. Visit Source.
  • National Institute of Health. (NIH). (2018). What are some factors that make a pregnancy high risk? Eunice Kennedy Shriver National Institute of Child Health and Human Development, U.S. Department of Health and Human Services. Visit Source.
  • Xu, Y., Zhu, S., Song, H., Lian, X., Zeng, M., He, J., Shu, L., Xue, X., & Xiao, F. (2022). A new modified obstetric early warning score for prognostication of severe maternal morbidity. BMC Pregnancy Childbirth, 22, 901. Visit Source.