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Rapid response teams (RRT) and early warning score (EWS) systems have been successfully used in the United Kingdom and the North America for several years.  The overall purpose is to assist health care providers in very early recognition and treatment of patients who may be experiencing deterioration in their conditions.  Catastrophic deterioration of patients has been shown to be preceded by changes in several physiological parameters, frequently many hours before cardiac and/or respiratory arrest occurs.  Our hospital had adopted a rapid response team system in 2007.  Adult Modified Early Warning Score (MEWS) and Pediatric Early Warning Score (PEWS) protocols with management algorithms soon followed.

Obstetrical patients are also at risk for pregnancy-related and medical/surgical complications.  Hypertensive disorders, hemorrhage, and infection are examples of conditions that increase morbidity and mortality during the antenatal, intrapartal, and postpartal periods.  Obstetric –related disease and maternal co morbidities create complex challenges.  Yet the MEWS and PEWS tools did not reflect  physiological  changes and other parameters relevant to obstetrical patients.  There were no published examples of pregnancy early warning tools in the literature.

So in 2008, we created our own Obstetrical Early Warning Score (OB-EWS) tool, adding a layer of early detection to our rapid response team system. Our goals for the tool were simplicity and ease of use which could be incorporated into established nursing workflow.

The perinatal CNS and OB educator examined the adult MEWS tool in use, and adapted the six parameters (respiratory rate, heart rate, systolic and diastolic blood pressure, level of consciousness, urine output)  to reflect the physiologic changes specific to the obstetrical population.  Ranges in vital signs considered normal in adult patients may not be normal in pregnant women.  We then added four additional parameters-  fetal heart tracing, uterine activity, bleeding, and deep tendon reflexes.   Each item scores 0, 1, 2, or 3, depending on the deviation above or below “normal”.  Patients are scored on these additional parameters depending on their status (antenatal or postpartal). Total scores trigger specific responses outlined on a flow algorithm. The algorithm clearly outlines that when specific trigger scores are reached, the charge nurse, midwife and/or physician should be notified of patient’s status.  A rapid response team call can be made at any time, with or without trigger scores, if the nurse feels that the patient appears unwell or he/she is concerned about fetal or patient status.

The draft tool was reviewed by anesthesia and medical staff, followed by educational sessions for the nurses.  A paper and pencil OB-EWS tool was piloted on the mother baby and antepartum units.  The tool is currently used upon transfer from labor and delivery, and at a minimum every 8 hours on the mother baby and antepartum units. Nursing is working with clinical informatics to adapt the tool for the electronic medical record. This will enable us to further validate the OB-EWS tool, capture data more accurately, monitor compliance, and evaluate patient outcomes more effectively.