Obstetric Early Warning Score Chart - Maternity Use Only
Addressograph Label
Month __________________
Name _____________________________ Booking BP __________ mmHg
Year ____________________
Consultant _________________________ BMI ________________ Kg/m²
Please tick below
Ward ___________________
Hosp No. __________________________
Date: Early Pregnancy
Frequency of Obs:
A/N
Time 24hr clock:
P/N
>30
Resps >30
21-30 21-30
10-20 10-20
<10 <10
% O2 91-100% 91-100
Saturation ≤90% ≤90
Inspired O2/RA % %
39
Temp 38
37 39
38
36
37
35 36
35
150
150
140 140
Heart Rate 130
130
120
120
110
110
100 100
90
90
80
80
70
70
60
50
40 60
50
40
190
180
190
170
180
160
Systolic
150
Blood 140 170
Pressure
130 160
120 150
110 140
100
130
90 120
80
70 110
60
100
50
90
80
70
60
50
130
Diastolic
130
Blood 120
Pressure
120
110
100 110
90 100
80
90
70
80
60
50 70
40 60
50
40
Early Pregnancy No
PV blood loss
No
Yes Yes
Amniotic Clear Clear
Fluid Pink/red/green Pink/red/green
If ROM
Offensive Offensive
Odourless Odourless
A/N PV Bleed Brown Brown
Red Red
A/N Uterine Tone Normal Normal
Tense Tense
Lochia Normal Normal
Trickle Trickle
Heavy or Foul Heavy or Foul
Contracted Contracted
P/N Uterine
High Fundus High Fundus
Tone
Relaxed/Atonic Relaxed/Atonic
Wound – Yes Yes
Ooze/red/swollen
/pain No No
Neuro Alert Alert
Response Voice Voice
Pain Pain
Unresponsive Unresponsive
Pain Score 0-1 0-1
2-3 2-3
Nausea 0-1 0-1
2-3 2-3
Looks Unwell No No
Yes Yes
Total Yellow Scores:
Total Red Scores: NA – Not
Signature (initials): applicable
Adapted from the Belfast Trust OEWS Chart September 2013
Obstetric Early Warning Score Chart - Maternity Use Only
ACTION PROTOCOL
The Early Warning Scoring System and Action Protocol are designed to help identify deterioration in the woman and ensure appropriate
early intervention. All action taken must be fully documented in case notes. Staff should use their clinical judgement, and seek advice if
they have concerns about any woman, regardless of the score.
If an OEWS chart is being commenced in a freestanding midwife led unit the parent obstetric unit needs to be informed and transfer protocols commenced
Continue observations as before
White Only
Single Yellow
≥ 2 Yellow or 1 Red
2 Red
• Inform the Midwife/Nurse in Charge
• Recheck observations in 1 hour (or more frequently if clinically indicated)
• Inform Midwife/Nurse in Charge
• Immediately contact the on-call obstetric SHO/Reg, using a structured
communication approach e.g SBAR, to review the woman within 30 minutes.
• Recheck observations in 30 minutes (or more frequently if clinically indicated)
• Inform Midwife/Nurse in Charge
• Immediately contact the on-call obstetric SHO/Reg, using a structured
communication approach e.g SBAR, to review the woman within 20 minutes.
• Recheck observations in 15 minutes (or more frequently if clinically indicated)
Inform Midwife/Nurse in charge
• Immediately contact the on-call obstetric Reg, using a structured
> 2 Red communication approach e.g SBAR, to review the woman within 20 minutes.
• Discuss with Obstetric Consultant/Tutor
• Repeat observations in 15 minutes (or more frequently if clinically indicated)
Consider calling other specialties or Emergency Obstetric Team as appropriate
Interventions / Investigations P.V Loss
Airway – Breathing – Circulation A standard maternity pad:
If appropriate, sit upright and administer oxygen Partially stained = 30mls
Consider need for IV access, review observation Saturated to capacity =100mls chart, fluid balance, hourly urometer, drug
prescription chart and level of monitoring A single absorbent incontinence pad Consider need for 12 lead ECG, Chest X-ray, arterial
(75x57cms):
blood gas, CBC, U&E, Coag screen
Saturated will hold 250mls of blood.
Surgical Swabs:
Observations explanation Saturated small surgical swab (10cmsx10cms) = 60mls
Saturated large surgical swab (45cmsx45cms) =350mls
Pain Score Nausea Score
A standard kidney dish:
1 = none 0 = no nausea
Holds 500mls of blood
2 = a little 1 = mild nausea
3 = moderate 2 = severe nausea In Major cases consider weighing swabs
4 = severe 3 = vomiting
Ref: Bose P. Regan F. Paterson-Brown S. (2006) Improving the
accuracy of estimated blood loss at obstetric haemorrhage using
clinical reconstructions. British Journal of Obstetrics and Gynaecology
