OB Guideline 30: Early Warning System

Obstetrical patients may exhibit physiological changes that signify deterioration.

Triggers

• Systolic BP (< 80 or > 160 mm Hg)
• Diastolic BP (> 105 mm Hg)
• Heart rate (< 50 or > 120 beats per min)
• Respiratory rate (< 10 or > 30 breaths per min)
• Oxygen saturation % (< 95 room air, at sea level)
• Oliguria (< 30 mL for > 2 hours): for catheterized patients
• Agitation, confusion, unresponsiveness (if any present)
• Preeclampsia, with patient reporting non-remitting headache or shortness of breath (if any present)

An effective maternal early warning system with prompt bedside evaluation may facilitate timely recognition, evaluation, and treatment for obstetrical patients developing critical conditions such as hemorrhage, hypertensive crisis, and sepsis.

The initial OB provider for patient assessment should be credentialed in obstetrics and may be a physician, certified nurse midwife, nurse practitioner, or physician assistant. If no credentialed obstetrics provider is available, each institution should specify an appropriate initial bedside responder, while simultaneously contacting the obstetrical attending physician. At a minimum, a Rapid Response Team (obstetrical attending physician, anesthesiologist covering obstetrics, and charge nurse) should be readily available to assist in stabilizing the patient and determining when transfer to a higher level of care is indicated.

Institutional Responsibility

Each institution should develop an early warning system (see Appendix C). Institutional leadership should provide necessary resources for implementation, including staffing, education, a quality improvement process, and leadership from senior medical and nursing personnel.

View the entire Early Warning System Algorithm.

1. Preparing for clinical emergencies in Obstetrics and Gynecology. ACOG Committee Opinion No. 590, March 2014, Reaffirmed 2018. American College of Obstetricians and Gynecologists.
2. Mhyre JM. The maternal warning criteria. Obstetrics and Gynecology. 2014;124:782–86.