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.
http://dx.doi.org/10.1016/j.ejogrb.2016.09.014
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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 compare socio-demographic features and interventions between
population. triggered versus non-triggered group. Performance of MEOWS
The aim of our study was to evaluate MEOWS chart as a bedside chart as a screening tool was evaluated by calculating its
screening tool in prediction of maternal morbidity by measuring its sensitivity, specificity and predictive values using Exact’s method.
sensitivity, specificity and predictive values. Relative risk of morbidity (odd’s ratio) and 95% confidence interval
was calculated for individual parameter. We used the Poisson
Materials & methods regression with log link with robust’s variance method to find the
relative risk after adjusting potential confounders [9]. p-value
Ethical approval was obtained from institutional ethical <0.05 was considered as significant.
committee. This study was conducted in the Department of
Obstetric & Gynaecology of University College of Medical Sciences Results
(UCMS) and Guru Teg Bahadur Hospital (GTBH), Delhi from
October 2012 to April 2014. Description of study population
MEOWS chart recommended in CEMACH 2003–2005 report
was used for this study [3]. A total of 1065 women which included Completed MEOWS chart of 1065 study subjects was analysed.
pregnant women in labour beyond 28 weeks gestation and up to Study population was largely comprised of antenatal (98%), young
6 weeks postpartum were recruited as study subjects. All females between 20–30 years of age belonging to either lower or
consecutive admissions to clean and septic labour wards were middle socio-economic status. About two-third of the women had
recruited into study depending upon duties of principal investiga- regular antenatal visits and 85% of the admissions were direct.
tor. Measurement of temperature (oral), heart rate, blood pressure, Associated obstetric condition was present in 22% of cases with
respiratory rate, oxygen saturation (pulse oximeter), conscious hypertensive disorders (9.8%) being most commonest followed
level (AVPU: alert, responds to voice or pain and unresponsive), closely by previous caesarean section (7.7%). Associated medical
proteinuria (urine dipstick test), colour of liquor and lochia condition was present in 5% of cases; severe anaemia (2.4%) being
characteristics were documented (Appendix A of Supplementary the commonest (Fig. 1).
material). The physiological parameters were recorded on the Two hundred and eighty four (26.60%) women triggered to
chart at admission and subsequently monitored according to the abnormal zones after admission (Fig. 2).
frequency given below: One hundred and seventy seven (16.61%) fitted our criteria for
Women in labour ! 4 hourly till 24 h after delivery and then morbidity (Fig. 3).
once a day till discharge. The most common morbidity was hypertensive disorders
Postpartum hemorrhage ! 1 hourly for 4 h, then 4 hourly for (69.4%) followed by anaemia (14.12%) and haemorrhage (9.6%).
next 24 h and thereafter once a day till discharge. Only one patient died due to complications of hypertensive
Caesarean section or other procedure under anesthesia ! 1 hourly disorder. The pattern of morbidity distribution in category 2
for 6 h, then 4 hourly for next 48 h and then once a day till patients is shown in Fig. 4.
discharge.
Blood transfusion ! Immediately prior to start of transfusion A. Socio-demographic characteristics
and then 15 min into transfusion.
Once a daily frequency of monitoring was reached, the study The significant factors contributing to trigger included age
subjects were followed till the time of discharge from hospital. >30 years, muslim religion, rural background, lower socio-eco-
A trigger was defined as a single markedly abnormal observa- nomic class, referred cases. The risk of being triggered was
tion (red trigger) or the combination of two simultaneously mildly increased for primigravidae (45.7% vs 41.2%) and for postpartum
abnormal observations (two yellow triggers) (Table 1). However, women (4.2% vs 0.2%). Although the number of women who had
no intervention was done based on trigger and patients were not received antenatal care triggered more (38.7% vs 34.4%) but
managed according to hospital protocol. this was not statistically significant (Table 3).
According to maternal outcome at time of discharge, study
subjects were divided into Category 1 (Normal and those recovered B. Need for intervention
without morbidity) and Category 2 (recovered with morbidity or
mortality). Significantly higher proportion of interventions i.e. instrumen-
Morbidity was defined according to Table 2. tal delivery (3.2% vs 2.0%), caesarean section (28.9% vs 14.3%) and
Microsoft Excel (version 2010) and statistical software SPSS blood transfusion (20.4% vs 3.8%) was required in the women
(version 20.0) were used for data presentation and statistical whose MEOWS charts triggered (Fig. 5).
analysis. Chi-square test and Fisher’s exact test were used to
C. Neonatal outcome
Table 2
Diagnostic criteria of obstetric morbidity.
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
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).
Comment
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
Table 3
Comparison of socio-demographic characteristics between triggered and non-triggered group.
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
Table 5
Frequency of trigger of individual physiological parameters of MEOWS chart for study population.
Table 6
Relative risk of morbidity with individual parameter trigger of MEOWS chart.
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
Character Study by Singh et al. Present study Supplementary data associated with this article can be
Type of study Prospective Prospective found, in the online version, at http://dx.doi.org/10.1016/j.
Number of patients 676 1065 ejogrb.2016.09.014.