Table 1 The Risk identification (RI) and Modified Early Obstetric Warning Score (MEOWS) tool. Risk identification (RI) tool
Criteria | High risk | Moderate risk | Low risk |
|---|---|---|---|
Hemorrhage | Recognition: -On admission: 1. Placenta previa, low lying placenta 2. Suspected Placenta accreta or percreta 3. Hematocrit < 30, refusal of transfusion, AND other risk factors: 4. Platelets < 100,000 5. Active bleeding (greater than show) 6. Known coagulopathy | Recognition: -On admission: 1. Prior cesarean birth(s) or uterine surgery 2. Multiple gestation 3. > 4 previous vaginal births 4. Chorioamnionitis 5. History of previous PPH 6. Large uterine fibroids | Recognition: -On admission 1. No previous uterine incision 2. Singleton pregnancy 3. < 4 previous vaginal births 4. No known bleeding disorder |
-Evaluate for development of additional risk factors in labor and postpartum: • Prolonged 2nd Stage labor • Prolonged oxytocin use • Active bleeding •Chorioamnionitis • Magnesium sulfate treatment | -Evaluate for development of additional risk factors in labor and postpartum: • Prolonged 2nd Stage labor: • Prolonged oxytocin use • Active bleeding • Magnesium sulfate treatment | -Evaluate for development of additional risk factors in labor and postpartum: • Prolonged 2nd Stage labor • Prolonged oxytocin use: • Active bleeding •Chorioamnionitis • Magnesium sulfate treatment | |
−1 or more high risk criteria: High risk of hemorrhage | −1 or more moderate risk criteria: Moderate risk of hemorrhage | No moderate or high risk of hemorrhage: Low risk of hemorrhage | |
Conclusion | Response: -Consider referral if not in labor -If in labor close monitoring, type and screen, order 2 units of blood, delivery | Response: -Consider referral if not in labor (clinical judgment) -If in labor close monitoring, type and screen, book 2 units of blood, delivery | Response: -Standard of care |
Preeclampsia/Eclampsia | Recognition: CNS: | Recognition: CNS: | Recognition: CNS: |
Awareness: unresponsive | Awareness: •Agitated/confused • Drowsy • Difficulty speaking | Awareness: Alert/oriented | |
Headache: Unrelieved headache | Headache: • Mild headache • Nausea, vomiting | Headache: None | |
Vision: Temporary blindness | Vision: Blurred or impaired | Vision impairment: None | |
CVS: SBP: ≥160 DBP: 50–89 HR: 61–110 Chest pain RS: RR: < 10 or > 30 GIT: Nausea and vomiting Abdominal pain Renal: u.o in mls: ≤30 (in 2 h) Proteinuria: Not relevant Platelet: < 50 ASAT/ALAT: > 70 Cr: > 1.2 MgSO4 toxicity: Respiration < 12 | CVS: SBP: 140–159 DBP: 50–89 HR: 111–129 Chest pain RS: RR: 25–30 GIT: Nausea and vomiting Abdominal pain Renal: u.o: 30–49 Proteinuria: • > + 1, • 300 mg/24 h Platelet: 50–100 ASAT/ALAT: > 70 Cr: 0.9–1.1 MgSO4 toxicity: Depression of patellar reflexes | CVS: SBP: 100–139 DBP: ≥105 HR: > 130 No chest pain RS: RR:11–24 GIT: None None Renal: u.o: ≥50 Proteinuria: Trace Platelet: > 100 ASAT/ALAT: < 70 Cr: < 0.8 MgSO4 toxicity: • DTR + 1 • Respiration 16–20 | |
1 or more high risk criteria: High risk of preelampsia/eclampsia | 1 or more moderate risk criteria: Moderate risk of preeclampsia/eclampsia | No moderate or high risk criteria: No risk of preeclampsia /eclampsia | |
Conclusion | Response: Immediate evaluation (ABCDE approach) • Transfer to higher acuity level • 1:1 staff ratio • Labetalol/hydralazine in 30 min • In-person evaluation • Magnesium sulfate loading or maintenance infusion O2 at 10 L per rebreather mask • R/O pulmonary edema • Chest x-ray •Safe referral to tertiary center | Response: •Notify In charge RN or Midwife •In-person evaluation •Order labs/tests •Anesthesia consult •Consider magnesium sulfate •Supplemental oxygen •Physician should be made aware of worsening or new-onset proteinuria | Response: Proceed with protocol for normal pregnancy |
Sepsis | Recognition for every woman (on admission): Risk factors: 1.gestational diabetes, diabetes or other comorbidities | Recognition for every woman (on admission): Risk factors: 1.gestational diabetes, diabetes or other comorbidities | Recognition for every woman (on admission): Risk factors: 1.gestational diabetes, diabetes or other comorbidities |
2.needed invasive procedure such as caesarean section, forceps delivery, removal of retained products of conception within 6 weeks | 2.needed invasive procedure such as caesarean section, forceps delivery, removal of retained products of conception within 6 weeks | 2.needed invasive procedure such as caesarean section, forceps delivery, removal of retained products of conception within 6 weeks | |
3.prolonged rupture of membranes | 3.prolonged rupture of membranes | 3.prolonged rupture of membranes | |
4.continued vaginal bleeding or an offensive vaginal discharge | 4.continued vaginal bleeding or an offensive vaginal discharge | 4.continued vaginal bleeding or an offensive vaginal discharge | |
Diagnosis criteria 1.CNS: new altered mental state on examination | Diagnosis criteria 1.CNS: History of new altered mental state: ---------- | Diagnosis criteria No high risk or moderate risk criteria met: -------------- | |
2.RS: RR > 25: --------- or need of FiO2 > 40% to keep Sat > 92%: --------- | 2.RS: RR > 21–24: ---------- | ||
3. CVS: SBP < 90 mmHg: ------ or HR > 130: ----------- | 3.CVS: SBP:91–100 mmHg: -----or HR: 100–130: --------- | ||
4.Renal: No urine in 18 h: ------- or if foley catheter U.O < 0.5 ml/kg/h: ---------- | 4.Renal: No urine in 12–18 h: ----------- or if foley catheter U.O: 0.5–1 ml/kg/h: -------------- | ||
5.Temperature > 39 °C: -------------- 6.Skin: Mottled appearance, Cyanosis of skin, lips or tongue, Non-blanching rash of skin: ---------------- | 5.Temperature < 36 °C: -------- 6.Skin: Signs of potential infection, including redness, swelling or discharge at surgical site or breakdown of wound: -------- | ||
−1 or more high risk criteria: High risk of sepsis | −1 or more moderate risk criteria: Moderate risk of sepsis | -no high or moderate risk criteria: Low risk of sepsis | |
Conclusion | Response: -Immediate review by senior clinical decision maker (ABCDE approach) -Blood test: -Blood gas for glucose and lactate. -Blood culture· -Full blood count· -C-reactive protein· -Urea and electrolytes· -Creatinine· -Clotting screen | Response: -Blood test: -Blood gas for glucose and lactate· -Blood culture· -Full blood count· -C-reactive protein· -Urea and electrolytes· -Creatinine· -Clotting screen -Review by senior clinical decision maker within 1 h -IV antibiotics within 1 h − 500 ml bolus every 15 min, repeat up to 3 times -If no definitive condition identified, repeat structured assessment at least hourly | Response: -Clinical assessment and manage according to clinical judgement |
- MEOWS -IV antibiotics within 1 h − 500 ml bolus every 15 min, repeat up to 3 times, if SBP < 90 mmHg give adrenaline 1 mg/500 ml NS to keep MAP> 65 or SBP > 90 -Refer to a tertiary hospital | - MEOWS -Source control within 6 h, if deep infection refer to a tertiary hospital |