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Monitoring, also known as clinical surveillance, is ongoing patient assessments that identify problems and trigger responses (Mhyre et al., 2014). A warning system is a process that defines observation criteria and sets a limit to trigger a response (Mhyre et al., 2014). Although non-obstetric warning systems have existed for nearly twenty years, there has not been a system for obstetric women until recently.
Maternal morbidity and mortality are still on the rise in the United States. Severe maternal morbidity has risen by over 200% in the United States from 1993 to 2014 (Severe Maternal Morbidity, 2019). There are some known reasons for this increase; increases in maternal age, pre-pregnancy obesity, preexisting chronic medical conditions, and cesarean delivery (Queenan, 2015). Hemorrhage, hypertension, infection, and venous thrombosis with delays in recognition, diagnosis, and treatment cause many preventable maternal deaths (Mhyre et al., 2014).
From 2003 to 2005, the Saving Mothers' Lives report recommended a modified early obstetric warning system. This system assessed vital signs and scored the woman based on the results. An algorithm was then used to determine what the woman needed. The score showed whether the woman was fine, needed closer monitoring, or immediate attention (Behling & Renaud, 2015).
After several studies, it was determined that a single-parameter risk assessment system that favors simplicity and specificity over complexity and sensitivity would be easier with increased patient specificity. 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 (Mhyre et al., 2014). The maternal early warning criteria were created based on these reviews.
Table 1: The Maternal Early Warning Criteria
|Systolic BP (mm Hg)||<90 or >160|
|Diastolic BP (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,%|
|Oliguria, mL/hr for ≥2 hours||<35|
|Maternal agitation, confusion, or unresponsiveness|
|Patient with preeclampsia reporting a non-remitting headache or shortness of breath|
Note. BP = blood pressure.
These triggers cannot address every possible clinical scenario that could be faced by an obstetric clinician and must not replace clinical judgment. As a core safety principal, the bedside nurse should always feel comfortable with escalating concerns at any point (Mhyre et al., 2014).
All women who meet any of The Maternal Early Warning Criteria should receive prompt bedside evaluation by a physician with the ability to activate resources to initiate emergency diagnostic and therapeutic interventions as needed (Mhyre et al., 2014). 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 is initiated. Some electronic medical records can be programmed to alert the RN and page appropriate resources (such as the attending physician) when the patient meets the criteria.
The most significant barrier to implementing an early warning criteria system is a physician and administration buy-in. Providers may not want to be bothered, especially when unavailable. 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 ensures that providers follow it. Nurses may improve the use of the criteria if they receive praise or acknowledgment for appropriately using them.
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. The findings in maternal morbidity reviews also support the use (CPSWHC, 2019).
California Pregnancy Associated Mortality Review 2002-2005
|Delayed Response to triggers|
|Amniotic fluid embolism||67%|
Each hospital should have a policy that includes the criteria to trigger the early warning system, whom to notify, how to notify them, how rapidly to expect a response, and when and how to activate the clinical chain of command in order to ensure an appropriate response (CPSWHC, 2019).
If the attending physician is immediately available, he/she will provide a bedside evaluation of the patient within 10 minutes. If the attending physician is not immediately available, the RN will call the in-house OB to provide a bedside evaluation of the patient within 10 minutes. The attending physician or CNM will also receive notification of the patient's status. If the CNM is notified, he/she will notify the attending physician. If an in-house OB is called but not immediately available, he/she will receive a verbal report and determine what further action is necessary.
When called to the bedside, the physician will document by writing a note which includes but is not limited to differential diagnosis, the planned frequency of monitoring and re-evaluation, criteria for immediate physician notification, and any diagnostic or therapeutic interventions. The physician will communicate the assessment and plan via a "huddle." Huddle participants include the Primary RN, the Charge RN, the Anesthesiologist, the attending physician, if present, and the in-house OB. If MEWS conditions(s) persist after corrective measures are undertaken, then an MFM consult should be requested. Additionally, the intensivist consult and Rapid Response Team may activate.
If the RN and the charge nurse question any aspect 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 will receive a notification. Nurses must have support in this process.
Maternal early warning criteria can prevent maternal 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.
Patient M.S. is a 42-year-old 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 1200mL. Her vital signs have been stable. She transfers to the mother-baby unit at 11 pm. She begins to complain of severe abdominal pain. She is given Dilaudid for the pain of 9 out of 10 on the pain scale. Her bleeding is moderate. Her BP is 128/84, HR 140, respirations 18, temperature 98.6. Her pulse ox is 98% on room air, and her 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 pulse ox of 94%. The RN calls a rapid response. The patient ends up in the OR with a massive hemorrhage requiring a massive transfusion and transfer to ICU.
- Were the RN's actions appropriate?
- Should the early warning criteria have been activated?
- Could the massive transfusion have been prevented?
At 11 pm, the patient's HR met early warning criteria. The HR should have been rechecked and the provider called. The RN's actions were not appropriate. HR could be 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 should have received care sooner.
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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.
- Behling DJ, Renaud M. Development of an Obstetric Vital Sign Alert to Improve Outcomes in Acute Care Obstetrics. Nursing for Women's Health. 2015;19(2):128-141. DOI:10.1111/1751-486x.12185.
- Council on Patient Safety in Women's Health Care Maternal Early Warning Criteria. Published June 11, 2019. Accessed December 5, 2019. Visit Source.
- Mhyre JM, Doria R, Hameed AB, et al. 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. DOI:10.1111/1552-6909.12504.
- Queenan JT. Protocols for High-Risk Pregnancies: An Evidence-Based Approach. Wiley-Blackwell; 2015.
- Severe Maternal Morbidity in the United States | Pregnancy. Accessed December 1, 2019. Visit Source.