Early warning systems in obstetrics: A systematic literature review

Abstract

Introduction Several versions of Early Warning Systems (EWS) are used in obstetrics to detect and treat early clinical deterioration to avert morbidity and mortality. EWS can potentially be useful to improve the quality of care and reduce the risk of maternal mortality in resource-limited settings. We conducted a systematic literature review of published obstetric early warning systems, define their predictive accuracy for morbidity and mortality, and their effectiveness in triggering corrective actions and improving health outcomes. Methods We systematically searched for primary research articles on obstetric EWS published in peer-reviewed journals between January 1997 and March 2018 in Medline, CINAHL, SCOPUS, Science Direct, and Science Citation Index. We also searched reference lists of relevant articles and websites of professional societies. We included studies that assessed the predictive accuracy of EWS to detect clinical deterioration, or/and their effectiveness in improving clinical outcomes in obstetric inpatients. We excluded studies with a paediatric or non-obstetric adult population. Cross-sectional and qualitative studies were also excluded. We performed a narrative synthesis since the outcomes reported were heterogeneous. Results A total of 381 papers were identified, 17 of which met the inclusion criteria. Eleven of the included studies evaluated the predictive accuracy of EWS for obstetric morbidity and mortality, 5 studies assessed the effectiveness of EWS in improving clinical outcomes, while one study addressed both. Sixteen published EWS versions were reviewed, 14 of which included five basic clinical observations (pulse rate, respiratory rate, temperature, blood pressure, and consciousness level). The obstetric EWS identified had very high median (inter-quartile range) sensitivity—89% (72% to 97%) and specificity—85% (67% to 98%) but low median (inter-quartile range) positive predictive values—41% (25% to 74%) for predicting morbidity or ICU admission. Obstetric EWS had a very high accuracy in predicting death (AUROC >0.80) among critically ill obstetric patients. Obstetric EWS improves the frequency of routine vital sign observation, reduces the interval between the recording of specifically defined abnormal clinical observations and corrective clinical actions, and can potentially reduce the severity of obstetric morbidity. Conclusion Obstetric EWS are effective in predicting severe morbidity (in general obstetric population) and mortality (in critically ill obstetric patients). EWS can contribute to improved quality of care, prevent progressive obstetric morbidity and improve health outcomes. There is limited evidence of the effectiveness of EWS in reducing maternal death across all settings. Clinical parameters in most obstetric EWS versions are routinely collected in resource-limited settings, therefore implementing EWS may be feasible in such settings.

Implementation and Evaluation of Obstetric Early Warning Systems in tertiary care hospitals in Nigeria

“…There was no change in the proportion of obstetric complications, ICU admission and length of hospital stay following EWS implementation. Obstetric EWS have been previously shown to prevent progressive obstetric morbidity (Shields et al, 2016;Hedriana et al, 2016;Umar A., et al, 2019). In contrast to our findings also, Shields and colleagues, in a large multicentre quasi-experimental trial, reported a significant reduction in severe and composite maternal morbidity (p<0.01) as defined by the Centre for Disease Control (CDC), but not mortality, in six intervention hospitals following EWS implementation, compared to 19 controls (Shields et al, 2016).…”

“…Obstetric EWS is recommended for monitoring the condition of hospitalised pregnant and postnatal women, based on predetermined abnormal values (warning signs) to generate a rapid medical response and facilitate early detection and management of clinical deterioration (ACOG, 2013;CEMACH, 2007;Edwards et al, 2015;Mhyre et al, 2014;Shields, 2016). A recent systematic review of EWS used in obstetrics reported that they are effective in predicting adverse obstetric outcomes and reducing obstetric morbidity (Umar A. et al, 2019).…”

Implementing the Risk Identification (RI) and Modified Early Obstetric Warning Signs (MEOWS) tool in district hospitals in Rwanda: a cross-sectional study

“…Similarly, the implementation of the Obstetric EWS has been found to be effective in predicting severe morbidity, to contribute to improved quality of care, to prevent progressive obstetric morbidity and to improve health outcomes [21]. However, there is limited evidence of the effectiveness of the Obstetric EWS in reducing maternal death across all settings [21].…”

Implementing the Risk Identification (RI) and Modified Early Obstetric Warning Signs (MEOWS) tool in district hospitals in Rwanda: A cross-sectional study

“…In addition, the Obstetric EWS tool has been found to be effective in predicting severe morbidity (in general obstetric population) and mortality (in critically ill obstetric patients) (Umar et al, 2019).…”

“…Furthermore, the implementation of the Obstetric EWS has been found to contribute to improved quality of care, prevent progressive obstetric morbidity and improve health outcomes (Umar et al, 2019). However, there is limited evidence of the effectiveness of the Obstetric EWS in reducing maternal death across all settings (Umar et al, 2019).…”