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Research Article | Volume 14 Issue: 3 (May-Jun, 2024) | Pages 169 - 178
A Study on Modified Early Obstetric Warning System (MEOWS Chart) As A Screening Tool In Prediction Of Obstetric Morbidity
 ,
 ,
1
Associate Professor (OBG Dept) , Govt Medical College, Kadapa, Andhra Pradesh, India.
Under a Creative Commons license
Open Access
PMID : 16359053
Received
March 4, 2024
Revised
March 20, 2024
Accepted
April 9, 2024
Published
May 7, 2024
Abstract

Background: To assess MEOWS Score (parameters &triggering factors) in pregnant & postpartum women. To measure outcome in terms of morbidity in MEOWS charted pregnant and postpartum women. Materials & Methods : A prospective study was conducted from May 2021- May 2022 .The study comprised of 300 pregnant women greater than 28 weeks upto 6 weeks post partum admitted to labor ward. After taking informed consent from pregnant women and postpartum mothers admitted to labour room, their name, age, occupation residence was recorded, clinical examination was done, vitals were recorded, general and specific investigations were done. MEOWS parameters were measured and an individual score was given and each parameter added to obtain a combined MEOWS score and patients were assigned to triggered and non-triggered groups. These triggered and the non-triggered women were followed and evaluated for obstetric morbidity and fetal outcome. Statistical software SPSS (version 22.0) was used for data presentation and statistical analysis. Continuous Data was presented as mean +/- standard deviation, categorical data was displayed in the form of percentage and analysed by Chi-square test. Performance of MEOWS chart as a screening tool was evaluated by calculating its sensitivity, specificity and predictive values. A p-value of<0.05 was considered as significant. Results: Hypertensive disorder of pregnancy was the most common (21.9%) obstetric morbidity followed by anemia (16.35%). The MEOWS score in this study had a sensitivity of 0.8806 and a specificity of 0.8069. The positive and negative predictive values of the MEOWS tool to predict obstetric morbidity were 0.5673 and 0.9592 respectively. Conclusion: The MEOWS is a sensitive and specific tool to predict obstetric morbidity with a high positive predictive value

Keywords
INTRODUCTION

Pregnancy and labour are considered normal physiological events in a woman’s life. Physiological changes occur to nurture the developing foetus and prepare the mother for labour and delivery. These changes include increase in to metabolic rate, increased cardiac output, Decreased blood pressure, increased levels of pregnancy hormones (progesterone and oestrogen). Pregnancy can be complicated by pre-existing medical conditions like hypertension, diabetes mellitus, anaemia etc. and conditions that develop during pregnancy like antepartum haemorrhage, eclampsia, and postpartum haemorrhage, pulmonary edema etc. Despite the fact that the global maternal death burden has decreased by nearly 50% in the last two decades, an estimated 810 deaths occur each day due to pregnancy and childbirth complications around.

 

The  world     It  is  estimated  that  a  maternal  death  occurs every minute, amounting to between 500,000 and 600,000

.

 deaths  of  women  of  reproductive  age each year. Hence there is a need for strict regular vigilance to predict beforehand the possible deteriorations in a high3.treatable   According to UNICEF, the leading causes of maternal deaths are postpartum haemorrhage, puerperal sepsis, pre-eclampsia and eclampsia, complications from delivery, and unsafe 

abortions. And treatable   According to UNICEF, the leading causes of maternal deaths are postpartum haemorrhage, puerperal sepsis, pre-eclampsia and eclampsia, complications from delivery, and unsafe abortions. Abnormalities in physiological parameters are well-known to precede critical illness. As a result, regular monitoring of physiological parameters aids in the early detection of catastrophic events, ultimately halting the cascade of severe maternal morbidity and mortality. Confidential Enquiry into Maternal and Child Health (CEMACH) 2003-2005 Saving mother’s lives Report stated that “In many   cases,   the   early   warning   signs   of   impending maternal   collapse   went   unrecognized” They   further quoted that "The increase in physiological reserve during pregnancy may mask the signs of critical illness, likely to result in a delay in diagnosis and appropriate management."4    Several   versions   of   Early   Warning

 

Systems have been used in obstetrics over the years, including Maternal Early Warning Criteria, Maternal Early Warning Trigger, and Modified Early Obstetrics Warning System. The EWS for the non-obstetrical population could not be directly transferred to the obstetric population due to normal physiological changes during pregnancy. The CEMACH report strongly advocated for the implementation of   the   MODIFIED   EARLY   OBESTETRIC   WARNING SYSTEM (MEOWS) to aid in the early detection of potentially fatal illnesses such as haemorrhage, pre-eclampsia/eclampsia, and sepsis.

 

A number of countries have implemented various strategies that have contributed to the reduction in maternal mortality over the years, ranging from a single intervention to a complex set of public health approaches such as safe motherhood strategies promoted by WHO and UNICEF. These include ANC, delivery by skilled birth

 

assistant, promoting institutional delivery, and access to emergency obstetric services by strengthening health services and addressing lacunae in social factors contributing to health. Furthermore, many countries are experimenting with demand-side financing initiatives, such as the role of conditional cash transfers in lowering financial barriers to seek maternal health services.

 

Stirling Royal Infirmary, a health care facility in Scotland, developed the MODIFIED EARLY OBESTETRIC

WARNING SYSTEM (MEOWS) chart The goal of MEOWS   was to improve recognition of pregnant women at risk of clinical deterioration and facilitate early intervention. The MEOWS chart includes the following physiological parameters (warning signs): respiratory rate (breaths/min), oxygen saturation (%), heart rate (beats/min), systolic blood pressure (mmHg), diastolic blood pressure (mmHg), lochia, proteinuria, liquor colour, neuroresponse, and general condition.

 

MEOWS charts are used to prompt health care providers to conduct a full review, order appropriate investigations, resuscitate, and treat pregnant and postnatal women based on predetermined warning signs. The current study aims to assess MEOWS Score in pregnant and postpartum women, to measure morbidity outcomes in MEOWS charted pregnant and postpartum women, and to predict obstetric morbidity using MEOWS Score.

 

MEOWS is a concise bedside screening tool for maternal morbidity. The maternal early obstetric warning system consists of three key components namely : early warning criteria, prompt reporting, and bedside evaluation. An abnormal parameter necessitates immediate intimation to a senior care provider, followed by bedside assessment by that care provider, who would mobilise resources to initiate emergency diagnostic and therapeutic interventions that are necessary. This should be followed by diagnostic.

 

work-up planning and implementation. A senior care provider must closely monitor the patient's condition until the abnormality resolves or the parameter is concluded to be benign etiology. If the patient is determined to be

7potentially  critically  ill  the  care  is  escalated     There  is

 

limited evidence linking the implementation of MEOWS charts to improved outcomes in the general pregnant population.

 

MEOWS activates a clinical response when two moderately abnormal parameters (yellow alerts) or one severely abnormal parameter (red alert) trigger an urgent assessment of the patient's status and the establishment of a follow-up surveillance plan.

 

 

Table 1: Modified Early Obstetric Warning System (MEOWS)

 

 

PARAMETER

 

 

RED TRIGGER

 

 

YELLOW TRIGGER

RESPIRATORY RATE (breath/min)

<10 OR >30

21-30

OXYGEN SATURATION (%)

<90

-

HEART RATE (beats/min)

<30 OR >120

100-120 OR 30-40

SYSTOLIC

BLOOD PRESSURE (mmhg)

<80 OR >160

80-90 OR 150-160

DIASTOLIC

BLOOD PRESSURE (mmhg)

>90

80-90

LOCHIA

HEAVY/FOUL SMELL

-

PROTEINURIA

>2+

-

COLOUR OF LIQUOR

GREEN

-

NEURORESPONSE

UNRESPONSIVE, PAIN

VOICE

GENERAL CONDITION

-

LOOKS UNWELL

TEMPERATURE

<35 OR >38

35-36

 

Each parameter in MEOWS CHART is scored according to the table given below

 

Table 2: Scoring of individual parameters of MEOWS chart

 

SCORE

3

2

1

0

1

2

3

TEMPERATU RE

 

≤34.9

35-35.

9

37-37.9

38-38.9

>39

 

 

SYSTOLI C BLOOD PRESSU RE

 

 

≤69

 

 

70-80

 

 

90-99

 

 

100-139

 

 

140-14

9

 

 

150-159

 

 

≥160

 

DIASTOLIC BLOOD   PRESSURE

 

 

 

 

<49

 

 

50-89

 

 

90-99

 

 

100-109

 

 

≥110

HEART

 

RATE

 

 

 

<39

 

 

40-59

 

 

60-99

 

 

100-10

9

 

 

110-129

 

 

≥130

RESPIRATO RY

 

RATE

 

 

≤10

 

 

 

 

11-20

 

 

21-25

 

 

26-30

 

 

≥30

 

 

NEURO RESPON SE

 

 

 

A ALER T

V RESP O NDS TO

VOICE

P RESP ON DS TO PAIN

U UNCO NS CIOUS

 

All the individual parameter scores are added to give a combined MEOWS score

 

 

 

Fig 1                             Modified Early Obstetric Warning System Chart

 

MATERIAL AND METHODS:

The study was conducted after The study was conducted after getting approval from Institutional Ethics Committee. The Institutional Ethics Committee approval number is LR No : 85/2021

 

A prospective study was done from May 2021- May 2022 on 300 pregnant and postpartum women admitted to labor room.

 

Inclusion criteria :

              1.Pregnant women beyond 28 weeks of gestationa age and upto 6 weeks of postpartum.

 

Exclusion criteria:

 

1.Women with ectopic pregnancies and abortions.

2.Women who were already diagnosed with morbidity. 3.Obstetric women admitted to ICU.

After valid written informed consent ,the following data was recorded: name, age, occupation, residence, education

 

Detailed obstetric history including gravida status, gestational age, LMP, EDD; menstrual history, marital history, medical and surgical history and family history was taken. Complete General and physical examination was done. The vital parameters -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 measured and documented. Systemic examination was done

 

Obstetric examination (P/A –fundal height, lie, presentation, position, liquor status uterine activity, FHS P/V Examination – Cervical dilatation, effacement, station, membrane status and pelvic assessment done regarding adequacy for that particular baby. The parametric values were recorded on the chart immediately after admission and monitoring ws done according to the frequency described below:

 

For labouring women every 4 hourly till 24 h then once a day until discharge. For Postpartum haemorrhage every 1 hourly for first 4 hours, then 4 hourly for next 24 hours and once a day thereafter untill discharge.

If a Caesarean section or other procedure was done under anaesthesia every hourly for first 6hours, then 4 hourly for next 48hours followed by once a day until discharge.

If Blood transfusion was planned Immediately prior to start of transfusion and then every 15 min till the end of transfusion.

Each time MEOWS parameters was measured an individual score was given to each parameter according to TABLE 2. All the individual parameter scores were added to obtain a combined MEOWS score and recorded . Accordingly, patients were assigned as triggered and non-triggered groups.

These triggered and the non-triggered women were followed and evaluated for obstetric morbidity and fetal outcome , discharged when recovered and followed till 6 weeks postpartum.

 

The data thus collected was entered into Microsoft Excel and appropriate tables and graphs were prepared. Statistical software SPSS (version 22.0) was used for data presentation and statistical analysis. Quantitative or continuous Data was represented as mean +/- standard deviation and analysed statistically by applying unpaired student's t test. Qualitative or categorical data was displayed in the form of percentage and analysed by Chi-square test. Chi-square test was used to 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. A p-value of <0.05 was considered as significant.

 

2.Women who were already diagnosed with morbidity. 3.Obstetric women admitted to ICU.

After valid written informed consent ,the following data was recorded: name, age, occupation, residence, education Detailed obstetric history including gravida status, gestational age, LMP, EDD; menstrual history, marital history, medical and surgical history and family history was taken. Complete General and physical examination was done. The vital parameters -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 measured and documented. Systemic examination was done.

Obstetric examination (P/A –fundal height, lie, presentation, position, liquor status uterine activity, FHS P/V Examination – Cervical dilatation, effacement, station, membrane status and pelvic assessment done regarding adequacy for that particular baby. The parametric values were recorded on the chart immediately after admission and monitoring ws done according to the frequency described below: For labouring women every 4 hourly till 24 h then once a day until discharge. For Postpartum haemorrhage every 1 hourly for first 4 hours, then 4 hourly for next 24 hours and once a day thereafter untill discharge. If a Caesarean section or other procedure was done under anaesthesi every hourly for first 6hours, then 4 hourly for next 48hours followed by once a day until discharge.

If Blood transfusion was planned Immediately prior to start of transfusion and then every 15 min till the end of transfusion.

 

Each time MEOWS parameters was measured an individual score was given to each parameter according to TABLE 2. All the individual parameter scores were added to obtain a combined MEOWS score and recorded . Accordingly, patients were assigned as triggered and non-triggered groups.

These triggered and the non-triggered women were followed and evaluated for obstetric morbidity and fetal outcome , discharged when recovered and followed till 6 weeks postpartum.

 

The data thus collected was entered into Microsoft Excel and appropriate tables and graphs were prepared. Statistical software SPSS (version 22.0) was used for data presentation and statistical analysis. Quantitative or continuous Data was represented as mean +/- standard deviation and analysed statistically by applying unpaired student's t test. Qualitative or categorical data was displayed in the form of percentage and analysed by Chi-square test. Chi-square test was used to compare socio- demographic features and interventions between triggered versus non-triggered group. Performance of MEOWS chart as a screening tool was evaluated by

RESULTS:

300 pregnant women beyond 28 weeks of gestational age and up to 6 weeks post delivery were admitted to the labour room of Govternment Maternity Hospital, Tirupati and were included in this prospective analytical study. 104 (35%) women belonged to trigger group and 196 (65%) belonged to non trigger group.

 

Obstetric Morbidity

Triggered group

No. (%)

Non–triggered group

No. (%)

Chi square

value

P value

Hypertensive disorder of

pregnancy

17(16.35%)

5(2.55%)

 

 

 

 

 

115.838

 

with df=9

 

 

 

 

 

<0.0001(S)

Acute Asthma

3(2.88%)

0

Obstetric

Hemorrhage

9(8.65%)

2(1.02%)

Gestational DM

7(6.73%)

0

Anemia

17(16.35%)

1(0.51%)

Heart Disease

2(1.92%)

0

Eclampsia

4(3.85%)

0

Pulmonary

Edema

1(0.96%)

0

Shock

2(1.92%)

0

Nil

45(43.27%)

188(95.92%)

TOTAL

104(100%)

196(100%)

 

 

 

Chi square test applied; S=Significant; df=degree of freedom

 

Fifty-nine patients (19.66%) fitted our criteria for obstetric morbidity. In the present study Hypertensive disorder of pregnancy was the most common 21.9% obstetric morbidity followed by anemia (16.35%), obstetric hemorrhage (8.65%) and GDM (6.73%) and acute asthma 2.88%, which were all statistically significant. (P<0.0001)

 

 

 

 

 

 

 

TABLE 4: Frequency of trigger of individual physiological parameters of MEOWS chart for study population

Parameters

Red trigger No. (%)

Yellow trigger

No. (%)

White trigger (Non Trigged)

No. (%)

Total trigger No. (%)

Respiratory

rate

1

20

279

300

Saturation

0

0

300

300

Temperature

9

0

291

300

Heart rate

13

65

222

300

Systolic blood

Pressure

9

79

212

300

Diastolic blood

pressure

9

63

228

300

Neuroresponse

0

0

300

300

Total

41

227

 

 

 

In the present study ,among the red triggers, heart rate was the most noted parameter (13%) followed by temperature, systolic and diastolic blood pressure at 9% each. Systolic blood pressure -79% , Heart Rate - 65% and Diastolic Blood Pressure- 63% were the major contributors to the yellow trigger.

 

TABLE 5 : Obstetric morbidity according to total MEOWS score

Obstetric morbidity

TOTAL MEOWS SCORE 0

TOTAL MEOW S

SCORE 1-4

TOTAL MEOWS

SCORE 5-6

TOTAL MEOWS SCORE 7

Hypertensive disorder of

pregnancy

5

6

11

0

Eclampsia

0

0

2

2

Obstetric

haemorrhage

2

5

4

0

Suspected Infection

0

0

0

0

Pulmonary Oedema

0

0

1

0

Shock

0

1

1

0

Gestational Diabetes

0

7

0

0

Diabetic

ketoacidosis

0

0

0

0

Intracranial

Bleed

0

0

0

0

Acute asthma

0

3

0

0

Status

epilepticus

0

0

0

0

Others

1

19

0

0

nil

168

65

0

0

In the present study hypertensive disorder of pregnancy in 5 subjects and obstetric hemorrhage in 2 subjects were found associated with a MEOWS score of 0. Gestational diabetes in 7 subjects, hypertensive disorder of pregnancy in 6 subjects, obstetric hemorrhage in 5 subjects, were associated with MEOWS score of 1-4. Hypertensive disorder of pregnancy in 11 subjects, obstetric hemorrhage in 4 subjects, found associated with a MEOWS score of 5-6. Eclampsia in 2 subjects were found associated with a MEOWS score of 7.

 

 

 

 

 

 

Table 6 : Sensitivity & Specificity of MEOWS chart

Studied group

Co- Morbidity

Yes

No

Triggered Group

59

45

Non Triggered

Group

8

188

Chi square value

105.57 with df=1

P value

<0.0001(S)

Sensitivity

0.8806

Specificity

0.8069

PPV

0.5673

NPV

0.9592

In the present study 59 (56.7%) subjects of triggered group had associated co-morbidities as against 8 (4%) in the non-triggered group. The MEOWS score in this study had a sensitivity of 0.8806 and a specificity of 0.8069. The positive and negative predictive values of the MEOWS tool to predict obstetric morbidity were 0.5673 and 0.9592 respectively.

DISCUSSION

The Modified Early Obstetric Warning Score (MEOWS) was

G

10developed by Lewis to allow early recognition of physical deterioration in parturient women by monitoring their physiological parameters.

In this study, Modified Early Obstetric Warning System (MEOWS chart) was applied and studied in 300 patients admitted to the Government maternity hospital Tirupati.

8

thThe subjects were between the 2 week of pregnancy up to 6 weeks post-partum. It aimed to study the modified early obstetric warning system (MEOWS) chart as a screening tool in the prediction of maternal morbidity.

 

Among the 300 study subjects in this study, 104 subjects formed the triggered group with the remaining 196 subjects forming the non-triggered group. Pulse rate, respiratory rate, systolic and diastolic blood pressure primarily contributed to triggers in the present study. 13.67% of subjects had red triggers while 75.67% had white triggers. 59 subjects (56%) in the triggered

 

group had obstetric morbidities. Hypertensive disorder of pregnancy was the most common obstetric morbidity (21.9%). The results of the present study

11are  in  concurrence  with  that  of  Singh  A  et al (2016 which showed that among individual physiological parameters, the most frequent trigger was high diastolic blood pressure (33%).

 

In the present study , among triggered group, 50% of the subjects had a MEOWS score of 2 with 25.96% having a MEOWS score 3 followed by 10.58% having MEOWS score 5. In a study by Singh S. in 2012, two hundred patients (30%) had trigger factors out of which 86 patients (13%) had obstetric including haemorrhage (43%), hypertensive disease of pregnancy  (31%)  and  suspected  infection  (20%) .The results of present study are comparable with those of Meh et al 2022            , where the leading

 

causes of maternal death were obstetric haemorrhage (47%; higher in poorer states), pregnancy-related infection (12%) and hypertensive disorders of pregnancy (7%). Abnormalities were also found in the physiological parameters of 49.8% of the women identified from MEOWS

13triggers by Schuler L et al 201

 

In the present study, admission to Intensive Care Unit (ICU), High Dependency Unit (HDU), duration of hospital stay, transfusion of blood products, necessity of ionotropes and MgSO4 and requirement of ventilator

 

support were documented as factors determining morbidity. Five subjects in the triggered group were admitted into ICU. In previous studies also there is positive correlation between high MEOWS score and ICU admission

In the present study, the Meows tool showed an overall sensitivity of 0.88 and specificity 0.80, Positive Predictive Value (PPV) of 56.73% and Negative Predictive Value (NPV) of 95.92% Our results were comparable to those of Singh A et al (2016) who assessed MEOWS parameters in an obstetric population specifically evaluating test characteristics for detecting high-risk clinical scenarios and severe maternal morbidityThey found the (PPV) to be 39% which was lower than our PPV of 56.73%. MEOWS was overall 26.89% sensitive and 79% specific with a positive predictive value of 39.104 of our study subjects belonged to the triggered group with a mean of

 

25.13±3.14 and 196 belonged to the non-triggered group with a mean of 24.33±3.85. The difference in mean was not statistically significant. Singh et al 2016 reported a 26.6% as against 35% who triggered to abnormal zones.

3by Ryan HM et al (2017 MEOWS had high sensitivity (0.96) but low specificity (0.54) for ICU admission >24 hours, whereas ≥1 one red trigger maintained sensitivity (0.96) and improved specificity (0.73). Altering MEOWS trigger parameters may improve the accuracy of MEOWS in predicting ICU admission.

Sensitivity and positive predictive value of MEOWS tool in the 15present study was higher than that of Tuyishime et a which showed a sensitivity of 28.9% and a specificity of 93.5%, a PPV of 36.1%, a NPV of 91.1%, an accuracy of 86.2%, and a relative risk of 4.1 (95% Confidential Interval (CI), 2.4–7.1).11In a study by Singh S. et a which was done to validate the MEOWS in 2012, the MEOWS score was 89% sensitive (95% CI 81–95%) and 79% specific (95% CI 76–82%). Their positive predictive value was lower at a 39% (95% CI 32–46%) and they reported a negative predictive value of 98% (95% CI 96–99%).

CONCLUSION

The MEOWS is a sensitive and specific tool to predict obstetric morbidity with a high positive predictive value. It is an objective score of obstetric morbidity and hence reliable in assessing pregnant women. The Score is easily reproducible & has a low false positivity, by using it regularly in the primary level health care facilities will help us in early identification of worsening & in providing better care to the pregnant women & also in avoiding unnecessary referring of patients to higher centres. MEOWS chart on regular usage in the hospitalized patients helps us in identifying the improvement or deterioration in patients thereby aiding us in providing appropriate health care.

MEOWS score is not influenced by regional & cultural differences of the population & it can be used in different backgrounds without altering the parameters.

REFERENCES
  1. World Health Organization. Trends in maternal mortality: 1990-2015: estimates from WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population World Health Organization; 2015.
  2. Desa UN. Transforming our world: The 2030 agenda for sustainable development
  3. Creanga AA, Berg CJ, Ko JY, Farr SL, Tong VT, Bruce FC, Callaghan WM. Maternal mortality and morbidity in the United States: where are we now?. Journal of women's health. 2014 Jan 1;23(1):3-9.
  4. Al-Foudri H, Kevelighan E, Catling CEMACH 2003–5 Saving Mothers' Lives: lessons for anaesthetists. Continuing Education in Anaesthesia, Critical Care & Pain. 2010 Jun 1;10(3):81-7.
  5. Bullough C, Meda N, Makowiecka K, Ronsmans C, Achadi EL, Hussein J. Current strategies for the reduction of maternal mortality. BJOG: An International Journal of Obstetrics & Gynaecology. 2005 Sep;112(9):1180-8.
  6. Bohren MA, Hunter EC, Munthe-Kaas HM, Souza JP, Vogel JP, Gülmezoglu AM. Facilitators and barriers to facility-based delivery in low-and middle-income countries: a qualitative evidence synthesis. Reproductive 2014 Dec;11(1):1-7.
  7. Robbins T, Shennan A, Sandall J. Modified early obstetric warning scores: A promising tool but more evidence and standardization is Acta obstetricia et gynecologica Scandinavica. 2019 Jan;98(1):7-1.
  8. Singh A, Guleria K, Vaid NB, Jain S. Evaluation of maternal early obstetric warning system (MEOWS chart) as a predictor of obstetric morbidity: a prospective observational study. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2016 Dec 1;207:11-7.
  9. Cole MF. A modified early obstetric warning system. British Journal of Midwifery. 2014 Dec 2;22(12):862-8.
  10. Lewis G. Saving Mothers' Lives: the continuing benefits for maternal health from the United Kingdom (UK) Confidential Enquires into Maternal Deaths. WB Saunders. InSeminars in perinatology 2012 Feb 1 (Vol. 36, No. 1, pp. 19-26).
  11. Shields LE, Wiesner S, Klein C, Pelletreau B, Hedriana HL. Use of maternal early warning trigger tool reduces maternal morbidity. American journal of obstetrics and gynecology. 2016 Apr 1;214(4):527-e1.
  12. Friedman AM, Campbell ML, Kline CR, Wiesner S, D'Alton ME, Shields LE. Implementing obstetric early warning systems. American Journal of Perinatology Reports. 2018 Apr;8(02):e79-84.
  13. Thomas M. Abstract No.: ABS2092: Study of perioperative modified early obstetric warning scores among pregnancy Induced hypertensive patients posted for caesarean deliveries. Indian J Anaesth. 2022 Mar;66(Suppl 1):S16– 7. doi: 10.4103/0019-5049.340735. PMCID: PMC9116870
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