Pre-Hospital Maternity Decision Tool for Ambulance Clinicians
Outcomes
This learning package will provide information around the need for the Pre-hospital Maternity Decision Tool, when to use the tool and how to locate the tool on the electronic report form (EPR).
The Pre-Hospital Maternity Decision Tool is used to guide clinical decisions when assessing pregnant and recently pregnant patients. It helps clinicians to recognise the risk of deterioration in pregnant or recently pregnant women and provides a guide as to which actions to take, using the information obtained. The tool is based on the national maternity early warning score (MEWS) parameters and aligns to the JRCALC for use in ambulance services.
By the end of this learning, you will –
- Understand when to use the Pre-Hospital Maternity Decision Tool
- Understand some of the changes that occur during pregnancy which affect clinical observations
- Understand the observations required as part of the clinical assessment
- Understand the actions needed following clinical assessment and application of the tool
- Be able to locate the Pre-Hospital Maternity Tool on EPR
When should the Pre-Hospital Maternity Decision Tool be used?
This tool is for all ambulance clinicians who use JRCALC and is to be used to assess –
- All pregnant patients
- All patients suspected to be pregnant
- Up to 4 weeks post pregnancy – regardless of gestation and regardless of if the pregnancy ended in birth, pregnancy loss or termination of pregnancy
Why is the Pre-Hospital Maternity Decision Tool more suitable for this patient cohort?
Pregnant/recently pregnant women need specific assessment due to the altered physiology during pregnancy which means that they can compensate for longer, showing only marginal changes in their clinical observations which are considered normal in non-pregnant patients. The haematological status of pregnant patients is different to that of non-pregnant patients, and this difference can still be apparent for up to 4 weeks after the pregnancy has ended.
The table below demonstrates the changes that occur during pregnancy, birth and the postpartum period.
These changes mean that it can be more difficult to determine when a pregnant or recently patient is unwell, unless the correct assessment tool is used.
NEWS2 should not be used in pregnant or recently pregnant patients as it does not provide a specific enough assessment in these patients.
Which observations are recorded when using the Pre-Hospital Maternity Decision Tool?
The clinical assessment requires –
- Oxygen saturations
- Respiratory rate
- Pulse rate
- Systolic and diastolic blood pressures
- Temperature
Note: There are 2 pulse rates measured – one related to during pregnancy and within 48 hours after birth and the other from 48hours after birth, depending on the time frame the assessment is made.
The tool requires measurements relating to –
- Consciousness
- Cardiac Symptoms
- Abdominal Pain
And includes to sub categorise such as –
- Symptoms under 20 weeks of pregnancy
- Vaginal blood loss under 20 weeks pregnant
- Vaginal fluid loss over 20 weeks pregnant
- Postnatal blood loss (within 30 minutes of birth)
- Pre- eclampsia / Eclampsia over 20 weeks pregnant
- Neurological symptoms
- Patient appearance
What happens after the observations have been measured against the Pre-Hospital Maternity Decision Tool?
The table below demonstrated the actions to be taken below once the patients assessment parameters have been measured tool.
NWAS has local policies in place to support the decisions –
- Green flags only: discuss a plan of care with CIH and document on the record
- 1 Amber flag: Convey the patient to the nearest appropriate hospital, use clinical judgement and the JRCALC to decide if an emergency pre-alert is required via CIH (Stage 2 pre-alert)
- 2 or more Amber flags: Emergency conveyance to the nearest appropriate hospital with Pre-Alert via CIH (Stage 2 pre-alert)
- 1 or more Red flag – Emergency conveyance to the nearest appropriate hospital with Pre-Alert via CIH (Stage 2 pre-alert)
All Obstetric-led maternity units in the northwest have the Maternity Red Phone protocol in place. CIH are best positioned to place a pre-alert to the nearest obstetric led unit. Always confirm where the ambulance is being met to ensure timely navigation through the hospital.
Do not call maternity units directly. This has led to delays in access, de-escalation of critical need, ambulance diversion, documentation and governance challenges and patient harm.
Remember that patients undergoing resuscitation should be conveyed to the nearest Emergency Department with a Stage 1 pre-alert via despatch – this includes Maternal peri/cardiac arrest and newborns undergoing newborn life support.
Where to find the Pre-Hospital Maternity Tool on EPR
The video below will show you where to find the Pre-Hospital Maternity Tool on your EPR. There is also a text transcript of the instructions below.
Video Transcript
This video will show you where to find the Pre-Hospital Maternity Tool on your EPR.
The Pre-Hospital Maternity Tool should be used when –
- Pregnancy is confirmed
- Pregnancy is suspected
- Recently pregnancy (up to 4 weeks ago – regardless of gestation or how the pregnancy ended)
To locate the tool, go to the incident home page and swipe the iPad screen to the left to reveal more tiles.
Open the My Training tile – and select the Clinical Guidelines.
Select the Pre-Hospital Maternity Decision Tool and measure the parameters alongside the clinical assessment to guide clinical decision making.
Key points to remember –
- Use the tool in all pregnant patients and those suspected to be pregnant
- Use the tool up to 4 weeks after pregnancy – regardless of gestation or whether the pregnancy ended in birth, pregnancy loss or termination of pregnancy
- NEWS2 should not be used in this patient cohort
- Use the Pre-Hospital Maternity Decision Tool alongside the JRCALC and NWAS policies
- If birth is imminent – use the JRCALC Imminent Birth Guidelines and facilitate the birth. Any concerns highlighted by the tool should be acted on as soon as possible, following the birth.
Further Resources
A new national MEWS has been developed and is recommended for all maternity units in the UK. The Pre-Hospital Maternity Decision Tool has been developed utilising the same parameters of MEWS with modification to align with the ambulance service context. The following publication provides the work that supports this recommendation.
Gerry S, Bedford J, Redfern OC, Rutter H, Chester-Jones M, Knight M, Kelly T, Watkinson PJ. Development of a national maternity early warning score: centile-based score development and Delphi informed escalation pathways. BMJ Med. 2024 May 15;3(1):e000748. doi: 10.1136/bmjmed-2023-000748.
This MBRRACE-UK annual report of the Confidential Enquiry into Maternal Deaths and Morbidity, includes surveillance data on women who died during or up to one year after pregnancy between 2020 and 2022 in the UK. In addition, it also includes Confidential Enquiries into the care of women who died between 2020 and 2022 in the UK and Ireland from thrombosis and thromboembolism and malignancies as well as the care of women who died as a result of ectopic pregnancy between 2021 and 2022.
This guideline covers diagnosing and managing ectopic pregnancy and miscarriage in women with complications, such as pain and bleeding, in early pregnancy (that is, up to 13 completed weeks of pregnancy).
NICE [2023] Ectopic pregnancy and miscarriage: diagnosis and initial management
The Pre-Hospital Maternity & Neonatal Group represent maternity leads across the UK. The group work with JRCALC and wider system partners to develop policies and clinical guidelines for ambulance services. Further education resources around maternity care in the ambulance service can be found on this YouTube Channel: National Prehospital MatNeo Group @PreHospMatNeoUK.
Contact Information
For any additional support or information, contact the maternity team at Maternity.team@nwas.nhs.uk.
