Parulekar SV
Maternal
mortality and morbidity are higher than they should be, in both most of the
developed countries as well as developing countries. They need to be kept low,
because pregnant women are young women, most of them healthy, and they have a
long life ahead of them. Pregnancy and childbirth are physiological processes,
not illnesses and should not result in serious outcomes for the mother and the
baby. The mothers are the persons who look after the families, especially the
children, who grow up to form pillars of the society. Death or serious illness
of a mother leaves a deep imprint on the health of the family. A large number
of such occurrences are entirely avoidable, provided they are anticipated and
detected early. Healthcare providers have always used methods to meet this
goal.
Workers
in the developed world have recommended the use of maternal early warning tools
for this purpose. Shields et al described use of one such tool called Maternal
Early Warning Trigger (MEWT) tool. It was described as a clinical
pathway-specific tool that addressed the four most common areas of maternal
morbidity – infection, cardio-pulmonary dysfunction, hemorrhage and
hypertension. Any single value of the following, sustained for more than 20
minutes was considered positive – maternal heart rate above 130 bpm,
respiratory rate above 30/min, mean arterial pressure below 55 mm Hg, or
concern by the nurse. Other parameters were also considered to be positive if
there were two abnormal values - heart rate above 110 or below 50 bpm,
temperature above 38 or below 36° C, blood pressure above 160/110 or below
85/45 mm Hg, respiratory rate above 24 or
below 10/min, oxygen saturation below 93%, fetal heart rate above 160
bpm, altered maternal mental status, or disproportionate pain. The study was
done on a large number of pregnant women. It involved a control group too, in
which these measures were not used. Use of this tool and addressing the
condition detected resulted in significant reduction in maternal morbidity.
Other
tools have been recommended and used in the past. In Great Britain The modified
early obstetric warning system (MEOWS) has been proposed in UK and the maternal
early warning criteria (MERC) has been recommended in USA by National Council
for Patient Safety. MEOWS uses a score attributed to the parameters such as temperature,
systolic blood pressure, diastolic blood pressure, heart rate, respiratory
rate, level of consciousness using AVPU scale and urine output. AVPU is short
for A - Alert (Alert and conscious), V - Voice (Responds
to voice), P - Pain (Responds to pain),
and U - Unresponsive (No response to
voice or pain). These are charted on a graph paper. A score of 3 or higher is
an indication for initiating action based on predefined algorithm which
recommends change in monitoring pattern, referral, review, or therapeutic action.
General
opinion on the use of these tools is that they have not been tested widely
enough to prove statistically that they are effective. In the meantime, more
and more of such tools are likely to be proposed, each worker or group of
workers inspired to find a tool that would prove to be more useful that those
which have been described before. In general a scoring system is not a very
good system to detect an abnormality because the same score can be reached by
different combinations of values of different variables, all of which do not
carry the same degree of significance. Besides, on receiving an alert, the
obstetrician has to evaluate all parameters again in order to determine which one
is abnormal, so that the underlying cause can be sought. It would be a lot
easier, faster and more efficient to inform him about the abnormal parameter
itself. Nurses and doctors in the developing world have a very large number of
pregnant women to treat at any given time, and cannot afford to spend time
developing scores from charts and then evaluating the scores to find the cause.
We screen all pregnant women and decide which ones are likely to develop
particular complications during labor or any problems related to the pregnancy.
The high risk ones are monitored more intensively. We have been using the chart
of vital parameters, record of vaginal bleeding and nurse’s concern over
anything that she believes is abnormal over the last thirty six years. A woman
in labor or with an acute pregnancy complication is monitored every half hour
(more frequently if critically ill, but we are considering early warning here)
and the nurse informs the obstetrician if the temperature rises above 370
C, heat rate rises above 120/min or falls below 60/min, respiratory rate rises
above 30/min or falls below 14/min, blood pressure rises above 140 mm Hg
systolic or 90 mm Hg diastolic, or falls below 90 mm Hg systolic or 60 mm Hg
diastolic, urine output falls below 60 ml in 2 hours (in patients likely to
develop renal insufficiency), significant vaginal bleeding occurs, or any
serious event occurs that alarms or baffles the nurse. Then the obstetricians
checks the patient and finds out the cause of the abnormal parameter. Based on
the diagnosis, appropriate action is taken as per management guidelines. We
have been able to detect almost all conditions that cause maternal morbidity
and mortality (hemorrhage, hypertension, sepsis and their complications) using
this system. We cannot detect some like amniotic fluid embolism in early phase,
but then no tool described so far can do so. We appreciate that some workers
are developing tools to reduce maternal morbidity and mortality, because they
mean well. But we prefer to be practical and take clinical actions at the
earliest hint of a developing abnormality rather than spend time and energy
developing scores using cumbersome tools which do not achieve results any
better than ours.