Deterioration in pregnant or recently delivered women: Recognition

and use of the modified early obstetric warning system (MEOWS)

Key Points
• All pregnant women receiving assessment and care within the trust must have a MEOWS
chart commenced regardless of the setting
• The full range of physiological observations must be taken and recorded as part of the
assessment process. It is essential that the practitioner recording these observations is able to
differentiate between normal and abnormal readings.
• Prompt action, escalation and request for urgent medical review will occur when indicated
allowing for appropriate management of women at risk of deterioration.
• All staff will receive training and instruction in the rationale and use of the MEOWS chart.
• The appropriate use of MEOWS charts will be regularly audited and outcomes reported to
the maternity service.

Version: 2.1
Pippa Clark, Lead Midwife for Practice
Guidelines Lead(s): Development and Education
Contributors:
Lead Director/ Chief of Service: Miss Anne Deans
Obstetrics and Gynaecology Clinical
Ratified at: Governance Committee, 5th March
2020
Date Issued: 18th March 2020
Review Date: March 2023
Pharmaceutical dosing advice and formulary B. Joules and D. Kriel 12.12.2019
compliance checked by:
Key words: MEOWS, modified early obstetric
warning system, deterioration, sepsis,
pregnancy
This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The
interpretation and application of clinical guidelines will remain the responsibility of the individual clinician.
If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review
date. This guideline is for use in Frimley Health Trust hospitals only. Any use outside this location will not
be supported by the Trust and will be at the risk of the individual using it.

V2 March Page 1 of
Version Control Sheet

Version Date Guideline Lead(s) Status Comment

1.0 June Melanie Woolman final First cross site version
2016
2.0 March Pippa Clark final Updated and approved
2020 at OGCGC 5th March
2020
2.1 June Pippa Clark final Addition of point 4.5,
2020 page 10, approved as
Chair’s action by A.
Deans 25.06.2020

Related Documents

Document Type Document Name

Abbreviations

MEOWS Modified Early Obstetric Warning System

NEWS National Early Warning Score
NICE National Institute for Health and Care Excellence
VDS Verbal descriptor scale
CCT holder Certificate of completion of training holder

V2 March Page 2 of
 Contents Page No

1. Introduction 4

2. Use of the modified early obstetric warning system (MEOWS) 4

3. Observation parameters 5

4. Escalations and Actions 9

5. Training 10

6. Auditable standards 10

7. Monitoring compliance 10

8. References 11

10. Appendix 1: WPH MEOWS chart 12

11. Appendix 2: FPH MEOWS chart 14

V2 March Page 3 of
1. INTRODUCTION
1.1 MBRRACE,(Mothers and Babies reducing risk through Audits and Confidential Enquiries)
Saving Lives, Improving Mothers’ Care (2014) reiterated recommendations made from
previous reports in 2007 and 2011 advocating the use of a modified early warning system
(MEOWS) in maternity care settings to facilitate the prompt recognition of acute illness
and/or rapid deterioration of a woman’s condition. MBRRACE Saving lives, improving
Mothers’ care 2018 elaborate further to say that for women who are unwell their clinical
condition is to be considered as well as the MEOWS Score.

1.2 The Royal College of Physicians (2012) has led on the development of a National Early
Warning Score (NEWS) report, which advocates standardising the use of a NEWS system
across the NHS in order to drive the step change required in the assessment and
response to acute illness. Within the Trust all non-pregnant adult patients are assessed
using NEWS. For pregnant women the use of the Modified Early Obstetric Warning
System (MEOWS) chart (see appendices), that has been specifically modified to reflect
the physiological adaptations of normal pregnancy is advocated as it is specific to the
physiological parameters of pregnancy and early postnatal period. MEOWS demonstrated
a much higher sensitivity than non-obstetric early warning systems. (Singh 2012)

1.3 It is essential that pregnant and recently delivered women with obstetric and medical
complications, who are admitted to clinical areas within and outside maternity are
assessed using the MEOWS chart.

2.0 USE OF THE MODIFIED EARLY OBSTETRIC WARNING SYSTEM (MEOWS)

2.1 All pregnant women receiving assessment and care within the trust must have a MEOWS
chart commenced. This includes any woman with a positive pregnancy test.

2.2 A full range of physiological observations (see MEOWS chart) must be recorded as part of
the assessment process. It is essential that the practitioner recording these observations
is able to differentiate between normal and abnormal readings. Colour coding is used to
aid identification of abnormal physiological parameters. If all observations are normal then
the original care plan can be followed which should specify the frequency and type of
continued MEOWS observations.

V2 March Page 4 of
2.3 Women should retain the same MEOWS chart when moving from one clinical area to
another so that physiological trends can be observed.

2.4 All MEOWS charts used must be clearly identified with the woman’s name, date of birth ,
NHS and Hospital number and secured in the womans ‘s health records.

2.5 Women in the postnatal period who have prior risk factors identified , developed
complications or undergone surgical intervention should have a MEOWS commenced. If
women are considered unwell in the postnatal period, they should be assessed utilising a
MEOWS chart regardless of the hospital setting. Most women are discharged from
maternity care on or shortly after ten days following birth of their baby. Midwives are
legally required to care for women up to 28 days following birth. For the purpose of this
guideline the postnatal period is considered to be up to 6 weeks (42 days) after the birth of
the baby irrespective of the gestation.

2.6 The MEOWS chart should not be completed during established labour as a partogram
should be used and clear guidelines already exist regarding frequency of observations and
normal physiological parameters in labour (National Institute for Health and Care
Excellence (NICE,2007a). A maternity high dependency care chart must be used for
women requiring high dependency care in labour ward or in the critical care unit.

2.7 Prompt action and urgent medical review when indicated, allows for appropriate
management of women at risk of deterioration.

3.0 OBSERVATION PARAMETERS

3.1 Respiratory rate:
Respiratory rate is the most sensitive indicator of deteriorating physiology and must be
recorded in all women every time a full set of observations are taken.
Respiratory rate is the best marker of a sick woman and is the first observation that will
indicate a problem or deterioration in condition. Therefore respiratory rate is a mandatory
observation.

V2 March Page 5 of
3.2 Oxygen saturation
Oxygen saturation monitoring should be available for high risk women, however it should
not be used as a substitute for counting respiratory rate as deterioration in oxygen
saturation is a later sign of deterioration. Oxygen saturation monitoring must be
commenced in the presence of an abnormal respiratory rate (yellow and red scores) to
optimise detection of further deterioration.

3.3 Temperature
During labour a transient raise in temperature is often observed and this may also be seen
as a response to epidural anaesthesia. However any rise in temperature observed at any
time in the pregnancy continuum must be closely observed. A marked rise in temperature
or a marked fall could indicate an impending risk of sepsis (please refer to sepsis tool). A
low temperature (below 36 degrees) is also significant and highly significant in the
presence of other abnormal parameters in the respiratory rate, pulse and blood pressure.
A temperature below 35 degrees is highly significant.
Early recognition and appropriate treatment of sepsis is essential.

3.4 Heart rate

Women with underlying heart disease may not respond/cope well with the increased
physiological demands of pregnancy. They may not be able to compensate for the
increased cardiac output required. Most women have a higher heart rate (of approximately
20 beats per minute) in pregnancy due to the increased cardiovascular output to
compensate for the increase in the circulating blood volume. As with non-pregnant
women, their heart rate will increase during periods of strenuous activity and/or stress. A
sudden rise in heart rate (tachycardia) may be in response to labour, pain, fear, anxiety,
etc. and in isolation (i.e., all other parameters are normal) should be observed. However, a
prolonged tachycardia, in conjunction with any other abnormal observations, must be
treated as potentially pathological.
For some women, a slow heart rate (bradycardia) may be normal or result from effective
pain relief such as an epidural, especially when the woman is relaxed and possibly able to
sleep. A bradycardia could be drug induced (i.e., such as epidural fluids leaking directly
into the blood stream) or with cardiac complications. If a bradycardia occurs in conjunction
with a raised blood pressure and/or a sudden loss of consciousness, it may indicate
cerebral haemorrhage.
In isolation, an annormal heart rate cannot be used as a reliable predictor of problems;
however, in conjunction with any other abnormal parameter is significant.
V2 March Page 6 of
3.5 Blood pressure
Systolic and diastolic pressures are scored separately on MEOWS charts.
Use of the correct cuff size for the woman is vital for the accuracy of recordings of blood
pressure especially in the obese woman.
In the first trimester, due to relaxation of the peripheral blood vessels, pregnant women
tend to have a lower blood pressure and the diastolic may fall by 20mmHg from non-
pregnant values. Women with underlying hypertensive problems may not exhibit this fall
and may go on to have hypertensive problems (pregnancy induced hypertension or pre-
eclampsia) later in pregnancy. Both systolic and diastolic blood pressure increase in
pregnancy but should remain within normal parameters.

The systolic pressure is sensitive to activity, stress and anxiety and transient rises up to
150mmHg are considered normal. A lower systolic reading is common in pregnancy;
however a sudden decrease in blood pressure especially with a corresponding increase in
pulse rate may indicate a late sign of haemorrhage. Pregnant women can lose up to 30-
40% of their circulating blood volume with no change to their vital signs especially blood
bressure.

If the pulse is greater than the systolic pressure this is highly significant and must
be referred immediately for obstetric review.

Caution: Electronic recordings of blood pressure can underestimate readings by up to 5%.

It is recommended good practice that if blood pressure is raised on electronic readings this
should be rechecked manually at least once using a sphygmomanometer.

3.6 Urine output / Proteinuria

Urine output should be equal or greater than 100 mL in any 4 hour period. This should be
recorded on a separate fluid balance chart along with all sources of input and output with
periodical calculation of cumulative fluid balance. If a new chart is started the balance from
the previous chart should be transferred to the next page to ensure continuity of
monitoring. Pregnant women admitted to any area of the Trust require a daily urinalysis to
exclude proteinuria.

V2 March Page 7 of
 Fluid balance charts should be employed in the following circumstances:
 Postoperative
 Administration of intravenous fluids
 Postpartum haemorrhage
 Magnesium sulphate
 Indwelling urinary catheter including first two voids following removal of the
catheter
When a fluid balance chart is in use it should be accurately filled in with both measured
input and output. Entries such as OTT [out to toilet] are not acceptable.

3.7 Amniotic fluid

Antenatallhy,abnormal vaginal discharge is a symptom that might indicate infection.
Pregnant women with unexplained vaginal wetness need to be assessed by an
obstetrician/ midwife for potential rupture of membranes.

3.8 Neurological responses

This is based on the 4 point AVPU:
A = Alert (no score)
V = responds to Voice (yellow)
P = responds to Pain (red)
U = Unresponsive (red)
Any deterioration in the level of consciousness must be reported to an obstetrician
and/or anaesthetist

3.9 Pain assessment tool

Any pain outside that expected of normal labour is abnormal, and this should be regularly
reviewed, documented and treated. Documentation should including site,type of pain
(constant, intermittent, on movement only, sharp, dull, etc) as well as the intensity.
Pain scores (chart is on the reverse of the MEOWS chart) should be assessed ideally with
the woman resting using a verbal descriptor scale (VDS) which is then transposed to a
score from 0 to 4.
In pregnant women admitted to a clinical area outside of maternity services, labour or
premature labour should be considered as a potential cause of maternal pain. Pain is
recognised as an important factor for severe maternal illness. In the presence of pelvic
sepsis, severe lower abdominal pain and severe “after pains” that require frequent

V2 March Page 8 of
 analgesia are important symptoms. Severe pain just below the ribs is described as an
important symptom of pre-eclampsia.
Pain that increases with intensity over time must be reviewed by a senior
obstetrician.

3.10 Lochia
Abnormal and heavy postnatal bleeding is a significant cause of maternal morbidity and is
likely to be linked to infection.Combined with other features of MEOWS these symptoms
may lead to a diagnosis of sepsis and prompt treatment is required.

3.11 Early Detection of Women with Sepsis – Looks unwell

Midwives and other clinicians are reminded to think about sepsis when referring to the
escalation / Action protocol. The MEOWS chart can be utilised in conjunction with the
Trust sepsis screening tool and care pathway.
If the woman reports and/or appears unwell, sepsis should always be considered in the
differential diagnosis
Maternal sepsis is a leading cause of maternal death in the UK, and has remained a
specific focus. It is important to note that women with a history of a sore throat may have
Group A Streptococcal infection.

4.0 ESCALATIONS AND ACTIONS

4.1 Total Red and Yellow Scores The total number of red and yellow boxes marked will
identify the action required as outlined on the flow chart on the rear of the chart.

4.2 Identification of woman at risk of developing life threatening problems will only serve to
improve outcomes if early and appropriate intervention occurs.

4.3 Recognition of deterioration in condition does not necessarily mean diagnosis but does
mean investigation and appropriate level referral involving a multidisciplinary approach. It
is important to note that the system will not improve outcomes in isolation; this will only
occur if interventions subsequently applied are appropriate and timely.

4.4 Always contact labour ward, Frimley site (ext: 4035), Wexham site (ext: 154521) for
midwifery and possible obstetric review for pregnant or recently delivered women newly
admitted to the Trust. Follow the escalation / action protocol found on the rear of the
MEOWS chart, specific to each hospital site.
V2 March Page 9 of
4.5 If a woman's deterioration or condition requires transfer from the oostnatal ward back to
the labour ward, the resident Obstetric Consultant or CCT Holder should be informed
immediately and review the patient as soon as possible. If there is no resident Obstetric
Consultant or CCT Holder on site, then the non-resident Obstetric Consultant at home
should be informed and should review the woman at the earliest opportunity.

5.0 Training
Training is incorporated into the local induction and preceptor programmes, the ADAM
course and Maternity mandatory training days.

6.0 Auditable Standards

All pregnant and recently delivered women will have a MEOWS chart commenced on
admission if there are risk factors present and/or abnormal observations are recorded.

Observations will be undertaken as defined within the individual care plan including
frequency.

When parameters are identified as abnormal (yellow and red) referrals for obstetric review
will be made.

7.0 Monitoring compliance

This guideline will be subject to three yearly audits. The audit midwife is responsible for
coordinating the audit. Results presented to the department clinical audit meeting.

Action plans will be monitored at the quarterly department clinical governance meeting.

V2 March Page 10 of
8. References
Centre for Maternal and Child Enquiries (CMACE) (2011). Saving Mothers’ Lives: reviewing
maternal deaths to make motherhood safer: 2006–08. The Eighth Report on Confidential
Enquiries into Maternal Deaths in the United Kingdom. BJOG 2011;118(Suppl. 1):1–203.

Knight M, Kenyon S, Brocklehurst P, Neilson J, Shakespeare J, Kurinczuk JJ (Eds.) on

behalf of MBRRACE-UK. Saving Lives, Improving Care - Lessons learned to inform future
maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and
Morbidity 2009–12. Oxford: National Perinatal Epidemiology Unit, University of Oxford 2014.

Knight M, et al (2018) of MBRRACE-UK. Saving Lives, Improving Care - Lessons learned to

inform future maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths
and Morbidity 2014-16. Oxford: National Perinatal Epidemiology Unit, University of Oxford 2018.

Lewis, G. (Ed) (2007) Confidential Enquiry into Maternal and Child Health, Saving Mothers’
Lives – Reviewing maternal deaths to make motherhood safer 2003-2005. London:
CEMACH.

National Institute of Health and Clinical Excellence, Acutely ill patients in hospital:
Recognition of and response to acute illness in hospital (Guideline 50) 2007

Royal College of Physicians (2012) National Early Warning Score (NEWS): Standardising
the assessment of acute illness severity in the NHS. Report of a working party. RCP, London
NHS Litigation Authority (NHSLA). Clinical Negligence Scheme for Trusts (CNST):
maternity clinical risk management standards. Version 1. NHSLA, 2012.

Singh S, McGlennan A, England A, et al. (2012). A validation study of the CEMACH

recommended modified early obstetric warning system (MEOWS). Anaesthesia 2012; 67: 12–

V2 March Page 11 of
 Committed to Facing the

Appendix 1: WPH MEOWS chart

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WtEXJHAIM SI JE. ES,CAl!.ATIIONI t .ArC1J'I ON P1RO'iJiOCOl

Alli pregna11t nr r,ecemfy � WIIITB1 u,p to• 42 da:,:s pooblatal must be assessed 1usiA9
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mocam about arq wmBfl.. re.!!ardlE55: ofilia store. lm mart call be ulili.:ed in conjllJcti'Ofl v;ftb the �gjs; meerm:g tool.

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V2 March Page 14 of
 Committed to Facing the

Appendix 2: FPH MEOWS chart

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V2 March Page 15 of
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V2 March Page 16 of
 Committed to Facing the

IFRIMLEY S[JIE ESCALAllON I ACTION PROTOCOIL

Atwarys ca tact labour w.3rd (exl: 134035) for midwifery and FJOSSibl:e abstetri::. re111isirar review (see box
below}
lfiami1191 Scaring System is designed ta, he identify deterio:raliori mi lhe woms:11 and ensure aipprupriate
rly intell'>!en iua, All · ion ta. must be ¥ deeumsn ad in catse nn es. Staff :smoold use their nieal jud;gmenl
Jld :seek .ad'i'ic:e · ti,ey lila!i'e ccneems abo t any 'frnman, re.oardles.s of the score. This chart ca'.111 be w'lilized in
· rnc:iio '!Ni , he .sey.sis :sere irng to .

C • e Observa11ioos..as befo1e (mimniwm 2h y)

lmtamn tfle Midi\life I urse in charge

'{ Recme.d: o'.b.senra1ions. in 1 hour (or more lraq rntly if clinically ill

lmfamn 1fle Mid1&1ife I urse in cllarge to assess 1fle women

Im media :el:;i cam tact t e on-call obste ric Regis rar {bleep 5300) ta
re1iie1.'i' ·l.\,ittlin 30 mimrles
Recme.d: o'.bsenra1ions. in 15 minutes ,(,or mo:re ifrequently if clinically - ir.ated)

lmfumn 1fle Mid1\!ife I urse in cllarge to assess 1fle woman imm ate'ly

ii
z
; lmrnedia :el:;i ca11 act· e on-call ohsta ric Regis rar {bleep 5300) ta
re11jei,'i' wittlin 30 minutes, the abstelric registrar is unaEII: n reviel\!,
esea te to tile absfetr� oorisultant (bleey 5607)
00 Recme.d: o'.bsenra1io11JS in 15 mn1Jtes {,or mo:re ire ently if clinically - icated)
lmfumn obste; rin , esti1e1ist (b!ee;p :51 · .2)

lmfumi 1fle Midi\life I urse in cllarge to assess 1fle women imm ate'ly
lmmediaj:el:;i cam act e en-call obste ric Regis rar {bleep 53 . ta r,e:r,,iel\, wrg;enfly
Discuss care ., h 1fle a -ea consul !:Int abs ett- • eep 5607)
Recme.dJ: lSeflla1io11JS. in 15 mn1Jtes (or mere frequently if clinically - icated)
Consider 2222 for obs atric emergenc:'j' arid / or rasusei afion te;mi

@
0
Mo
/1.1:R�i
On M D!lement l 4
I
Viery Severe { Wars
Pai11 Paim

Abdon," �·- Severe l,eada!Che

Pl.ei.a!.e IJ!Jofe· this. is mot an Protenm Pyrem BreatNessness
assessmen : of oomira;cilia11 PV' Loss (v: - bleedi,g or fu:I loss) Chest� -
.strellgtli &. durafina wtiic sho Ume output less 100ml over 4 /wry sudden
be documented separaitety. Any hows �a.mn
pain outside a 'nmmal abawr is
aibnannal

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