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.