Nair et al reported the Irish Maternal Early Warning Score (IMEWS). This can help to identify a pregnant woman who may require prompt evaluation. The authors are from St. Vincent's University Hospital. National Maternity Hospital Dublin, and Mater Misericordiae University Hospital in the Republic of Ireland.
Parameters:
(1) respiratory rate in breaths per minute
(2) oxygen saturation in percent
(3) body temperature in °C
(4) maternal heart rate in beats per minute
(5) systolic blood pressure in mm Hg
(6) diastolic blood pressure in mm Hg
(7) AVPU (alert, response to verbal, response to pain, unresponsive)
Color Zone
Significance
Points
white
normal
0
yellow
mild abnormality
1
pink
moderate or marked abnormality
2
Parameter
Finding
Points
respiratory rate
<= 10 breaths/min
2
11 to 19 breaths/min
0
20 to 24 breaths/min
1
>= 25 breaths/min
2
oxygen saturation
> 95 percent
0
<= 95 percent
2
temperature
<= 35°C
2
35.1 to 35.9°C
1
36.0 to 37.4°C
0
37.5 to 37.9°C
1
>= 38.0°C
2
maternal heart rate
< 50 beats/min
2
50 to 59 beats/min
1
60 to 99 beats/min
0
100 to 119 beats/min
1
>= 120 beats/min
2
systolic blood pressure
< 90 mm Hg
2
90 to 99 mm Hg
1
100 to 139 mm Hg
0
140 to 159 mm Hg
1
>= 160 mm Hg
2
diastolic blood pressure
< 40 mm Hg
2
40 to 49 mm Hg
1
50 to 89 mm Hg
0
90 to 99 mm Hg
1
>= 100 mm Hg
2
AVPU
A
0
V, P or U
2
total score =
= SUM(points for all of the parameters)
Interpretation:
• minimum score: 0 (all normal)
• maximum score: 14
• Escalation of care can also occur if the nurse has any concerns about the woman.
Total Score
Observations
Obstetrician
0
routine
routine
1
repeat in 30 minutes
routine
2
repeat in 30 minutes
call
3 or more
repeat in 15 minutes or monitor continuously
immediate evaluation
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