European Journal of Obstetrics & Gynecology and Reproductive Biology 207 (2016) 11–17

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European Journal of Obstetrics & Gynecology and

Reproductive Biology
journal homepage: www.elsevier.com/locate/ejogrb

Evaluation of maternal early obstetric warning system (MEOWS chart)

as a predictor of obstetric morbidity: a prospective observational study
Anju Singh* , Kiran Guleria, Neelam B. Vaid, Sandhya Jain
Department of Obstetric & Gynaecology, University College of Medical Sciences & Guru Teg Bahadur Hospital, Delhi, India

A R T I C L E I N F O A B S T R A C T

Article history: Objectives: Maternal Early Obstetric Warning System (MEOWS) chart adopted from CEMACH 2003–
Received 15 March 2016 2005 report is based on the principle that abnormalities in physiological parameters precede critical
Received in revised form 9 September 2016 illness. The ‘track and trigger’ of physiological parameters on this chart can aid in recognition of maternal
Accepted 13 September 2016
morbidity at an early stage, ultimately halting the cascade of severe maternal morbidity and mortality.
Available online xxx
The objectives of our study were to evaluate MEOWS chart as a bedside screening tool for predicting
obstetric morbidity and to correlate each physiological parameter individually with obstetric morbidity.
Keywords:
Study design: It was a prospective observational study conducted in labour wards of Guru Teg Bahadur
MEOWS chart
CEMACH report
Hospital, Delhi, India from October 2012 to April 2014. Physiological parameters of 1065 study subjects
Trigger (including pregnant women in labour >28 weeks of gestation and postpartum women up to 6 weeks after
Obstetric morbidity delivery) were recorded on MEOWS chart. A trigger was defined as a single markedly abnormal
observation (red trigger) or the combination of two simultaneously mildly abnormal observation (two
yellow triggers). Based on outcome at time of discharge, Category 1 (normal and recovered without
morbidity) and Category 2 (recovered with morbidity or mortality) were defined. Chi-square and
Fischer’s exact test were used for comparison between two groups. Performance of MEOWS chart was
evaluated using Exact’s method. Relative risk of morbidity (odd’s ratio) and 95% confidence interval was
calculated for individual parameter. p < 0.05 was considered as significant.
Results: Two-hundred and eighty-four (26.6%) women triggered to abnormal zones on these charts. One-
hundred and seventy-seven (16.61%) fulfilled the criteria for obstetric morbidity. MEOWS chart was 86.4%
sensitive, 85.2% specific with a positive and negative predictive value of 53.8% and 96.9% respectively for
prediction of obstetric morbidity. Individual parameters of MEOWS chart also had a significant
correlation (p < 0.05) with obstetric morbidity.
Conclusions: MEOWS chart emerged as a useful bedside screening tool for prediction of obstetric
morbidity and should be used routinely in every obstetric unit. Strict monitoring and documentation of
all the vital parameters should be fundamental part of any patient’s assessment to pick up acute illness at
very early stage and to make a difference in final outcome.
ã 2016 Elsevier Ireland Ltd. All rights reserved.

Introduction deteriorating condition at an early stage may result in timely

The development of early warning system charts started from
the knowledge that abnormalities in physiological parameters
precede critical illness in general as well as obstetric population
[1,2]. These systems involve periodic measurement of basic vital
parameters to track patient’s clinical condition over the time to
gauze the risk of catastrophic event and prompt response if patient
triggers to predefined abnormal values. Recognition of patient’s
* Corresponding author.
E-mail address: docanju.singh691@gmail.com (A. Singh).
intervention and improved outcome.
An adverse pregnancy outcome can be seen as continuum of
deteriorating event from normal/healthy pregnancy ! morbidity
! severe morbidity ! near miss ! death. The ‘track & trigger’ of
physiological parameters on a chart can aid in early recognition
and treatment of maternal morbidity, thus halting this cascade of
severe maternal morbidity and mortality [3].
The 2003–2005 triennial Confidential Enquiry into Maternal
and Child Health (CEMACH) report recommended routine use of
Maternal Early Obstetric Warning System (MEOWS) chart [3].
Although studies in medical and surgical patients have shown
good performance of Early Warning System (EWS) but there are

http://dx.doi.org/10.1016/j.ejogrb.2016.09.014
0301-2115/ã 2016 Elsevier Ireland Ltd. All rights reserved.
12 A. Singh et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 207 (2016) 11–17
not enough studies on MEOWS chart to validate its use in obstetric
population.
The aim of our study was to evaluate MEOWS chart as a bedside
screening tool in prediction of maternal morbidity by measuring its
sensitivity, specificity and predictive values.
Materials & methods
Ethical approval was obtained from institutional ethical
committee. This study was conducted in the Department of
Obstetric & Gynaecology of University College of Medical Sciences
(UCMS) and Guru Teg Bahadur Hospital (GTBH), Delhi from
October 2012 to April 2014.
MEOWS chart recommended in CEMACH 2003–2005 report
was used for this study [3]. A total of 1065 women which included
pregnant women in labour beyond 28 weeks gestation and up to
6 weeks postpartum were recruited as study subjects. All
consecutive admissions to clean and septic labour wards were
recruited into study depending upon duties of principal investiga-
tor. Measurement of temperature (oral), heart rate, blood pressure,
respiratory rate, oxygen saturation (pulse oximeter), conscious
level (AVPU: alert, responds to voice or pain and unresponsive),
proteinuria (urine dipstick test), colour of liquor and lochia
characteristics were documented (Appendix A of Supplementary
material). The physiological parameters were recorded on the
chart at admission and subsequently monitored according to the
frequency given below:
Women in labour ! 4 hourly till 24 h after delivery and then
once a day till discharge.
Postpartum hemorrhage ! 1 hourly for 4 h, then 4 hourly for
next 24 h and thereafter once a day till discharge.
Caesarean section or other procedure under anesthesia ! 1 hourly
for 6 h, then 4 hourly for next 48 h and then once a day till
discharge.
Blood transfusion ! Immediately prior to start of transfusion
and then 15 min into transfusion.
Once a daily frequency of monitoring was reached, the study
subjects were followed till the time of discharge from hospital.
A trigger was defined as a single markedly abnormal observa-
tion (red trigger) or the combination of two simultaneously mildly
abnormal observations (two yellow triggers) (Table 1). However,
no intervention was done based on trigger and patients were
managed according to hospital protocol.
According to maternal outcome at time of discharge, study
subjects were divided into Category 1 (Normal and those recovered
without morbidity) and Category 2 (recovered with morbidity or
mortality).
Morbidity was defined according to Table 2.
Microsoft Excel (version 2010) and statistical software SPSS
(version 20.0) were used for data presentation and statistical
analysis. Chi-square test and Fisher’s exact test were used to
Table 1
Cut-off limits of trigger zones for individual parameters.
Parameter Red trigger Yellow trigger
Respiratory rate; breaths/min <10 or >30 21–30
Oxygen saturation; % <90 – chart
Heart rate; beats/min <30 or >120 100–120 or 30–40
Systolic BP; mmHg <80 or >160 80–90 or 150–160
Diastolic BP; mmHg >90 80–90
Lochia Heavy/foul smell – trigger was high diastolic blood pressure (33%). This was followed
Proteinuria >2+ – by heart rate (19.3%), abnormal liquor (7.23%), high systolic blood
Colour of liquor Green – pressure (5.19%) and respiratory rate (2.06%) respectively (Table 5).
Neuroresponse Unresponsive, pain Voice
General condition – Looks unwell
compare socio-demographic features and interventions between
triggered versus non-triggered group. Performance of MEOWS
chart as a screening tool was evaluated by calculating its
sensitivity, specificity and predictive values using Exact’s method.
Relative risk of morbidity (odd’s ratio) and 95% confidence interval
was calculated for individual parameter. We used the Poisson
regression with log link with robust’s variance method to find the
relative risk after adjusting potential confounders [9]. p-value
<0.05 was considered as significant.
Results
Description of study population
Completed MEOWS chart of 1065 study subjects was analysed.
Study population was largely comprised of antenatal (98%), young
females between 20–30 years of age belonging to either lower or
middle socio-economic status. About two-third of the women had
regular antenatal visits and 85% of the admissions were direct.
Associated obstetric condition was present in 22% of cases with
hypertensive disorders (9.8%) being most commonest followed
closely by previous caesarean section (7.7%). Associated medical
condition was present in 5% of cases; severe anaemia (2.4%) being
the commonest (Fig. 1).
Two hundred and eighty four (26.60%) women triggered to
abnormal zones after admission (Fig. 2).
One hundred and seventy seven (16.61%) fitted our criteria for
morbidity (Fig. 3).
The most common morbidity was hypertensive disorders
(69.4%) followed by anaemia (14.12%) and haemorrhage (9.6%).
Only one patient died due to complications of hypertensive
disorder. The pattern of morbidity distribution in category 2
patients is shown in Fig. 4.
A. Socio-demographic characteristics
The significant factors contributing to trigger included age
>30 years, muslim religion, rural background, lower socio-eco-
nomic class, referred cases. The risk of being triggered was
increased for primigravidae (45.7% vs 41.2%) and for postpartum
women (4.2% vs 0.2%). Although the number of women who had
not received antenatal care triggered more (38.7% vs 34.4%) but
this was not statistically significant (Table 3).
B. Need for intervention
Significantly higher proportion of interventions i.e. instrumen-
tal delivery (3.2% vs 2.0%), caesarean section (28.9% vs 14.3%) and
blood transfusion (20.4% vs 3.8%) was required in the women
whose MEOWS charts triggered (Fig. 5).
C. Neonatal outcome
The composite neonatal outcome was worse in triggered group
as they had significantly more number of patients with intrauter-
ine fetal deaths (Table 4).
Performance of individual physiological parameters of MEOWS
Among individual physiological parameters, the most frequent
Abnormal value in either yellow or red zone leads to significant
increase in morbidity.
 A. Singh et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 207 (2016) 11–17 13

Table 2
Diagnostic criteria of obstetric morbidity.

Obstetric morbidity Diagnostic criteria

Hypertensive disorder of Diastolic blood pressure of 90 mmHg or a systolic blood pressure level of 140 mmHg or higher after 20 weeks of gestation on two occasions
pregnancy atleast 4–6 h apart with or without proteinuria [4]
Eclampsia Severe variety of preeclampsia characterized by sudden onset of generalized tonic-clonic seizures [4]
Obstetric haemorrhage Documented estimated blood loss >1500 ml, drop in hemoglobin concentration 3 g/dl or need for blood transfusion [5]
Suspected infection Clinically suspected focus of infection  positive laboratory cultures, treated with antibiotics [6]
Pulmonary oedema Breathlessness, crepitation requiring diuretics [7]
Shock Persistent severe hypotension defined as systolic blood pressure <90 mmHg for 60 min with a pulse rate atleast 120 despite aggressive
fluid replacement [8]
Gestational diabetes Carbohydrate intolerance of varied severity with onset or first recognition during present pregnancy
Diabetic ketoacidosis Hyperglycemia, metabolic acidosis, ketones in urine [7]
Intracranial bleed CT/MRI confirmed
Acute asthma History of asthma and audible expiratory wheeze, with reduced peak expiratory flow rate [7]
Status epilepticus History of epilepsy, prolonged multiple seizures [7]

100

90

80

70

60
Percentage

50

40

30

20

10

0
Not received
Received
Urban

>37 week
Direct

28-37 week
<20

20-30

>30

Hindu

1-4

>4
Rural

Referred

Zero
Middle

Postpartum
Muslim

Lower

Absent

Absent
Present

Present
Age (yrs) Religion Residence SE Status Admission Antenatal Period of Parity Obs Medical
care Gestaon Condion Condion

Fig. 1. Characteristics of study population.

The risk of morbidity was assessed based on abnormality of morbidity. Thus, derangement in value of any vital parameter may
individual parameter of MEOWS chart (Table 6). Once, triggered be an early indicator of impending morbidity.
into abnormal zone (yellow/red); the parameters like diastolic After adjusting for confounding factors i.e. age and underlying
blood and systolic blood pressure, respiratory rate, neuroresponse, obstetric or medical condition at time of admission, the individual
general condition (looks well or unwell), proteinuria increased the parameter trigger (i.e. abnormality in heart rate, systolic and
risk of maternal morbidity or mortality by 6–7 times. Abnormality diastolic blood pressure, temperature, neuroresponse) remained
in heart rate and temperature lead to increase in risk by 2–3 folds. statistically significant (p < 0.001) for predicting risk of obstetric
However, colour of the liquor did not lead to significant increase in morbidity (Table 7).

Performance of MEOWS chart as a screening tool

Out of 284 patients who triggered on MEOWS charts, only

153 could meet the criteria of obstetric morbidity. There were
24 patients who had morbidity but did not trigger on MEOWS chart
(Fig. 6).
The MEOWS chart was found to be 86.4% sensitive, 85.2%
specific and had a positive and negative predictive value of 53.87%
and 96.9% respectively for predicting obstetric morbidity.

Comment

Early Warning System (EWS) was first developed in UK by

Fig. 2. Triggered versus non-triggered group in study population. Morgan, Williams and Wright in 1997 [10]. The fact that
14 A. Singh et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 207 (2016) 11–17

abnormalities in physiological parameters is a preceding event in

patients who suffer a cardiopulmonary arrest has already been
highlighted in a number of studies and served as a basis of these
systems [1,2,11]. Maternal mortality case reviews and CEMACH
2003–05 report have mentioned that even professionals failed to
recognise early signs of maternal collapse [3]. Hence, a need is
perceived for use of EWS for obstetric population also to predict
maternal morbidity at an early stage [3,12,13]. The intercollegiate
maternal critical care group has produced an obstetric early
warning system (ObsEWS) to detect early deterioration and
improve outcome in obstetrics [14].
Fig. 3. Two categories based on final outcome. Maternal Early Obstetric Warning System (MEOWS) chart
recommended by CEMACH is specifically designed for obstetric
population with some modifications in already existing early

80
69.49
70

60

50
Percentage

40

30

20 14.12
9.6
10 3.96
2.26 0.56
0
Hypertensive Anaemia Haemorrhage Suspected Others Mortality
disorder infection

Fig. 4. Pattern of obstetric morbidity.

Table 3
Comparison of socio-demographic characteristics between triggered and non-triggered group.

Characteristic Triggered group (n = 284) Non–triggered group (n = 781) p value

No. (%) No. (%)
Age (years)
<20 9 (3.16) 16 (2.04) <0.001*
20–30 241 (84.85) 748 (95.7)
>30 34 (11.97) 37 (4.7)
Religion
Hindu 213 (75) 643 (82.33) 0.008*
Muslim 71 (25) 138 (17.66)
Residence
Rural 25 (8.80) 27 (3.45) <0.001*
Urban 259 (91.19) 754 (96.54)
Socio-economic status
Lower 41 (14.43) 72 (9.21) 0.100
Upper lower 103 (36.26) 295 (37.77)
Lower middle 107 (37.67) 308 (39.43)
Upper middle 33 (11.61) 106 (13.57)
Parity
0 130 (45.77) 322 (41.24) 0.010*
1–4 152 (53.52) 457 (58.51)
>4 2 (0.70) 2 (0.25)
POG (weeks)
28–37 72 (25.35) 166 (21.25) <0.001*
>37 200 (70.42) 613 (78.48)
Postpartum 12 (4.22) 2 (0.25)
Antenatal care
Received 174 (61.26) 511 (65.42) 0.210
Not received 110 (38.73) 270 (34.57)
Mode of admission
Direct 215 (75.70) 705 (90.26) <0.001*
Referred 69 (24.29) 76 (9.73)
*
p value <0.05 was considered significant.
 A. Singh et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 207 (2016) 11–17 15

100 96.2
Non-triggered Triggered
90 83.2
79.6
80
70 64.4
60
50
40
28.9
30
20.4
20 14.3
10 2 3.2 3.2 3.84
0 0.4 0.4
0
Normal delivery Instrumental Ceasarean Hysterectomy Conservative Received Not received
delivery section
Inte rventi on Transfusion

Fig. 5. Comparison of interventions between triggered and non-triggered group.

included age >30 years, muslim religion, rural background, lower

Table 4 socio-economic class, primigravidae, grand-multiparity, postpar-
Comparison of neonatal outcome between triggered and non-triggered group.
tum status, absence of antenatal care, referral from other health
Neonatal outcome Triggered group Non-triggered group p value facility and presence of obstetric or medical condition.
No. (%) No. (%) As there is no availability of data on socio-demographic and
Healthy 265 (93.3) 750 (96.0) 0.053 antecedent factors in literature on validation study of MEOWS, the
Neonatal deaths 8 (2.8) 20 (2.6) association of these factors with trigger could not be compared.
Intrauterine fetal deaths 11 (3.9) 10 (1.3)
Being a developing country, low level of awareness, social taboos
Referred 0 (0.0) 1 (0.1)
and tradition, difficult accessibility to health services in rural areas
P-value <0.05 was considered significant. might be some of the causes for these associations in our study
population. Though literature does support that most of afore-
mentioned features such as elderly age, multiparity and low socio-
warning system (EWS). The present study was carried out on 1065
economic class can lead to increased obstetric morbidity [16,17].
obstetric admissions mainly comprising of young (20–30 years),
Baskett et al. have reported that delay in seeking care and transfer
antenatal (98%) females, mostly urban belonging to lower or
as one of the main factors leading to morbidity [18]. Bajwa et al. in
middle socio-economic class. The validation study for MEOWS in
Banur, India also found poor transport facility, poor rural health
literature by Singh et al. was done on 676 obstetric inpatients
infrastructure, custom and traditions to be contributing factors
(between 20 weeks of gestation till 6 weeks postpartum) in UK
towards increase morbidity and mortality [19].
[15]. Though their socio-demographic characteristics are not
There was a significantly higher proportion of interventions in
available for comparison but some differences due to different
triggered population in our study. It was also reported by Singh
geographical areas, high economy, better literacy and better
et al. (caesarean, ventouse or forceps delivery: p < 0.0001) [15].
nutrition are expected.
The composite neonatal outcome was found to be poorer in
In present study, 26.6% of the study population triggered which
triggered group but no comparison could be made due to lack of
is almost similar (30%) to the population who triggered in study by
such data in available literature on MEOWS.
Singh et al. 86% of triggered population had obstetric illness. The
In our study, hypertensive disorders of pregnancy (69%) ranked
significant factors which were responsible for women to trigger
first among the causes of obstetric morbidity followed by anaemia

Table 5
Frequency of trigger of individual physiological parameters of MEOWS chart for study population.

Parameters White trigger Yellow trigger Red trigger Total trigger

No. (%) No. (%) No. (%) No. (%)
Respiratory rate 1043 (97.9) 20 (1.9) 2 (0.2) 1065 (100)
Saturation 1065 (100.0) – 0 (0.0) 1065 (100)
Temperature 1059 (99.4) – 6 (0.6) 1065 (100)
Heart rate 859 (80.7) 200 (18.8) 6 (0.6) 1065 (100)
Systolic blood pressure 1002 (94.1) 42 (3.9) 21 (2.0) 1065 (100)
Diastolic blood pressure 731 (68.6) 248 (23.3) 866 (8.1) 1065 (100)
Lochia 1063 (99.8) – 2 (0.2) 1065 (100)
Proteinuria 1059 (99.4) – 6 (0.6) 1065 (100)
Liquor 988 (92.8) – 77 (7.2) 1065 (100)
Neuroresponse 1061 (99.6) 2 (0.2) 2 (0.2) 1065 (100)
Looks well/unwell 1055 (99.1) – 10 (0.9) 1065 (100)
16 A. Singh et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 207 (2016) 11–17

Table 6
Relative risk of morbidity with individual parameter trigger of MEOWS chart.

Individual parameter as trigger Relative risk of morbidity (odds ratio) p value

Respiratory rate 6.382 (5.379–7.573) <0.001
Oxygen saturation – –
Temperature 3.043 (1.352–6.852) 0.028
Heart rate 2.996 (2.317–3.874) <0.001
Systolic blood pressure 6.798 (5.585–8.275) <0.001
Diastolic blood pressure 7.496 (5.402–10.402) <0.001
Lochia 6.069 (5.300–6.949) 0.002
Proteinuria 6.224 (5.423–7.142) <0.001
Liquor 0.615 (0.315–1.202) 0.301
Neuroresponse 6.133 (5.351–7.029) 0.001
Looks well/unwell 6.317 (5.497–7.260) <0.001

p < 0.05 was taken as significant.

Bold value signified statistically significant parameter as p value is <0.05.

Table 7
correctly identified as having morbidity and number of misleading
Adjusted risk of morbidity for individual parameter trigger.
triggers should be very less. Though in practice, it is rarely the case.
Individual parameter as trigger Relative risk of morbidity p value So a good balance between sensitivity and specificity is desirable.
Odds ratio (95% Cl)
Since these charts are aimed at detection of maternal morbidity,
Respiratory rate 5.39 (4.27–6.81)a <0.001 the number of false positive (sensitivity) would increase burden on
Oxygen saturation – –
resources and create unnecessary anxiety but still is favoured over
Temperature 2.45 (1.12–5.39)a 0.025
Heart rate 2.33 (1.77–3.06)a <0.001
false negative. The reason being, false negative could have
Systolic blood pressure 2.57 (1.99–3.32)b <0.001 catastrophic consequences for the patients. Therefore, this chart
Diastolic blood pressure 4.06 (2.95–5.60)b <0.001 as a good screening tool should be more sensitive with acceptable
Neuroresponse 7.66 (6.54–8.96)a 0.001 specificity. No national or international ‘Gold standard’ obstetric
p < 0.05 was taken as significant. early warning scoring system exists. Although number of studies
a
Adjusted for age and medical condition. on pregnant patients are very few, a number of hospitals in UK
b
Adjusted for age, medical condition and obstetrical condition.
already use them. Swanton et al. on his survey on UK maternity
units in 2007 found that 30 (19%) maternity units were regularly
(14.12%), obstetric haemorrhage (9.6%) and sepsis (2.26%); which is using an EWS in obstetric population yet only 9 (6%) were using a
similar to the studies from developing countries where haemor- system modified for parturients [22]. In published literature by
rhage and hypertensive disorders have been shown to be major Singh et al. 2012, MEOWS chart in UK population has been found to
contributors of morbidity and mortality with variation across and be 89% sensitive, 79% specific with a positive and negative
within geographic areas [20,21]. predictive value of 39% and 98% respectively [15]. Though results of
our study 86.4% sensitive and 85.2% specific are comparable to the
MEOWS as a screening tool study by Singh et al. the few minor differences could be explained
by difference in prevalence of obstetric morbidity for Indian
For a screening tool to be of value, it should be cost effective, subcontinent. In a retrospective study done on 364 women with
safe to use, easily acceptable by community, accurate and clinically diagnosed chorioamnionitis for prediction of sepsis,
validated. Sensitivity and specificity are two components to 6 different MEOWS had variable performance with 40–100%
determine validity. The accuracy is indicated by positive and sensitivity, 4–97% specificity with a low positive predictive value of
negative predictive values which are dependent on prevalence of <2–15% for all and this study also found MEOWS with simpler
morbidity in the population. The MEOWS chart as an ideal designs to be more sensitive and useful [23]. Ethnographic analysis
screening tool should have a sensitivity and specificity close to has also concluded that complexity of managing triggers and
100% that means, most if not all of the triggered patients will be increase in overall workload can lead to loss of potential benefit of
EWS as a safety tool [24]. Considering the drawbacks and to

Category 1 Category 2
100
90 86.4 85.2
80
70
60
50
40
30
20 14.8 13.6
10
0
Triggered Non-triggered

Fig. 6. Comparison of final outcome between triggered and non-triggered group.

 A. Singh et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 207 (2016) 11–17
Table 8
Comparison of relative risk of morbidity for individual parameters.
Character Study by Singh et al. Present study
Type of study Prospective Prospective
Number of patients 676 1065
Parameter Relative risk of morbidity Relative risk of morbidity
OR (95% Cl) OR (95% Cl)
Heart rate 7.0 (4.9–10.1) 2.9 (2.3–3.8)
Diastolic blood pressure 6.6 (4.7–9.4) 7.4 (5.4–10.4)
Systolic blood pressure 5.4 (3.8–7.8) 6.7 (5.5–8.2)
Respiratory rate 4.5 (2.9–8.0) 6.3 (5.3–7.5)
Temperature 3.4 (2.0–5.6) 3.0 (1.3–6.8)
Neuroresponse 0.0 6.1 (5.3–7.0)
increase the effectiveness, the National Partnership for Maternal
Safety have proposed a Maternal Early Warning Criteria which
needs further evaluation [13].
Both in present study as well as in study by Singh et al.
sensitivity of the MEOWS was much higher as compared to non-
obstetric early warning systems. This can be attributed to use of
morbidity as a final outcome rather than death or ICU admission
which are relatively rare events in obstetric population.
Individual parameters of MEOWS chart
The most common parameter to have abnormal value in either
yellow or red trigger zone as well as for the morbidity was high
diastolic blood pressure followed by heart rate, systolic blood
pressure, respiratory rate, proteinuria, general condition, neuro-
response in decreasing order of frequency. The reason for blood
pressure being commonest could be that the value at which trigger
was set is close to the value that defined morbidity. Secondly,
hypertensive disorders were commonest in our study population.
Literature has enough evidence regarding recognizable changes
in vital parameters like heart rate, respiratory rate, blood pressure,
level of consciousness etc. prior to any life threatening event.
Swanton et al. have reported that diastolic blood pressure was
included in all 9 obstetric specific EWS that they reviewed [22].
Goldhill et al. noted the most common abnormalities to be
tachypnoea and altered level of consciousness in patients admitted
to ICU [1]. Kause et al. also revealed hypotension and fall in
consciousness level to be most common antecedent to cardiac
arrest, death or emergency obstetric admissions [25].
Comparison of the relative risk of morbidity for individual
parameter trigger showed that most of the parameters are
predicting similar risk except heart rate (tachycardia) which had
relatively higher risk and neuroresponse had no risk in study by
Singh et al. as compared to present study (Table 8). This could be
attributed to high prevalence of conditions like eclampsia, anaemia
etc. in our study population. Hodgetts et al. and Duckitts et al. also
reported contribution of vital signs on morbidity [26,27].
So, strict monitoring of all the parameters should be
fundamental part of any patient’s assessment to pick up acute
illness at very early stage and to make a difference in final outcome.
Thus, MEOWS chart emerged as an useful bedside screening
tool for predicting obstetric morbidity, meeting most of the criteria
of ideal screening tool in our North-Indian obstetric population. It
should be used routinely as bedside screening tool in every
obstetric unit as recommended by CEMACH report for early
recognition of any critical illness and periodic documentation of
physiological parameters.
We recommend further studies for validation of MEOWS chart
in different clinical settings.
17
Appendix A. Supplementary data
Supplementary data associated with this article can be
found, in the online version, at http://dx.doi.org/10.1016/j.
ejogrb.2016.09.014.
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