Recognition, High Dependency Care, and Transfer of

Author: L Williams, R Smith Date: March 2021

Job Title: Consultant Anaesthetist, Delivery Suite Manager Review Date: December 2022

Policy Lead: Group Director Urgent Care Version: V3.1

Location: Policy hub/ Clinical/ Maternity/ Lifesaving guidelines/ CG489

This document is valid only on date last printed Page 1 of 18

Recognition, High Dependency Care, and Transfer of Critically Ill Maternity Patients

Protocol (CG489)

Approval and Authorisation

Approved by Job Title or Chair of Committee Date

Maternity Clinical Governance Committee

Chair, Maternity Clinical Governance Committee

4th December 2020

Change History

Version Date Author Reason

1.0 December 2012 G Jackson, J Shorthouse

Amalgamation of 2 existing documents (see below) to provide single policy document

2.0 May 2015 G Jackson Reviewed – minor changes converted to protocol status

2.1 July 2017 G Jackson, R Smith Reviewed and agreed as fit for purpose until new HMA guidance is published

2.2 May 2019 A Mansfield, Maternity Information Officer

Pg 10 – 3rd deg tear guideline title changed Pg 17 – MOWs updated

3.0 August 2020 L Williams, R Smith, C Harding

Review and overhaul to reflect current situation

3.1 March 2021 C Bell QI&A Midwife Live changes against NG121 benchmarking pg 7 (5.7.2)






Recognition, High Dependency Care, and Transfer of Critically Ill Maternity Patients (CG489) March 2021

Contents

1.0 Purpose ............................................................................................................... 3

2.0 Protocol Function and Scope .............................................................................. 3

3.0 Content ................................................................................................................ 3

4.0 Alerts ................................................................................................................... 4

5.0 Abnormal physiological parameters .................................................................... 5

6.0 Seeking Help and Immediate Measures .............................................................. 7

7.0 Escalation from low risk to consultant care antenatally or in labour .................... 9

8.0 Higher dependency (Level 1) care on Delivery Suite ........................................ 10

9.0 Criteria for ITU Admission ................................................................................. 12

10.0 Management of transfer between Care settings ................................................ 12

11.0 Duties of staff disciplines during transfer of critically ill maternity patients within the Royal Berkshire Hospital ............................................................................. 13

12.0 Monitoring standards ......................................................................................... 15

13.0 References ........................................................................................................ 15

Appendix 1 - Modified Early Obstetric Warning System (MEOWS) ............................ 16

Appendix 2 – Hypothermia Algorithm ......................................................................... 17

Appendix 3 – Delivery Suite High Dependency Chart................................................. 18







1.0 Purpose

To offer guidance to midwives and other health care staff in recognising abnormal physiological observations (vital signs) in maternity patients.

To highlight use of the MEOWS scoring system and clinical judgement in initiating an alert and utilizing appropriate resources, including immediate measures.

To outline criteria for escalation of care to maternity patients.

To determine frequency of observations in relation to MEOWS scoring.

To offer guidance for transfer of critically ill maternity patients, including resource management, record-keeping, and staff duties.

2.0 Protocol Function and Scope

This guidance applies to all antenatal, intrapartum, postoperative, and postnatal

women with the potential to clinically deteriorate, or who have been identified as

requiring higher levels of care by MEOWS scoring and/or clinical review.

3.0 Content

3.1 There is potential for any maternity patient to be at risk of physiological deterioration and we have a duty of care to protect women.

3.2 Not all deterioration can be predicted so therefore all women require close observation which includes the taking and recording of vital signs.

3.3 There is evidence that there is poor recognition of physiological deterioration and even if abnormal vital signs are recorded, appropriate action is not always taken1. Regular recording and documentation of vital signs will aid recognition of any change in a woman’s condition.

3.4 The Saving Mothers’ Lives review in 2011(CEMACE) recommended that all Trusts should use an early warning scoring system for all obstetric women. In the most recent version it acknowledges that early warning systems provide a framework to recognise abnormalities and to escalate concerns. (The Confidential Enquiry Saving Lives, Improving Mothers’ Care review in 2014) (MBBRACE)2

3.5 The use of the maternity Modified Early Obstetric Warning System (MEOWS) will highlight any changes in a woman’s condition, however, MEOWS should not be the only parameters used for assessment of a woman’s condition.

3.6 Accurate fluid balance recording is vital in the safe management of acutely ill patients and in the timely detection of deterioration.







3.7 There are a number of staff training and support resources that can be used to support ward staff in obtaining the skills, knowledge and expertise in the physiological assessment of women, MEOWS scoring, and initial first hand management of high dependency women.

Clinical experts (e.g. anaesthetist, obstetricians, senior ward staff, medical teams, maternity clinical skills facilitator and outreach).

Annual mandatory training programme for midwives

Care of the Critically Ill Pregnant Woman Module (UWL).

3.8 High dependency care (level), as opposed to full intensive care, is recommended as a valid option in terms of efficacy for critically ill women. Improving the outcome for the critically-ill obstetric patient is a goal set out in each confidential enquiry into maternal mortality. There should be adequate provision of appropriate critical care support for the management of a pregnant woman who becomes unwell. Plans should be in place for provision of critical care on delivery units or maternity care on critical care units, depending on most appropriate setting for a woman to receive care. (MBRRACE 2014)2

3.9 The management plan of unwell maternity patients should have consultant multi-specialty input into its development, particularly around timing and mode of delivery (obstetrician and neonatologist), analgesia and fluid balance (anaesthetist):

The plan should be clearly documented in the maternity record, and be reviewed at each shift change on delivery suite by those undertaking the ward round.

The care plan should be modified in the light of observations and investigations.

If the maternal condition deteriorates at any time, relevant senior input should be sought promptly by the midwife caring for the woman directly to the Delivery Suite Co-ordinator who should contact the specialty trainee initially. The trainees in obstetrics and anaesthetics should keep their relevant consultants informed of any developments.

Involvement of the intensive care team should occur with the knowledge of both the obstetricians and anaesthetists.

All channels of communication between different disciplines and levels must remain open. No one should be criticised for seeking help from alternative sources if necessary.

4.0 Alerts

4.1 Abnormal observations should initiate an “alert” (). Abnormal ranges are provided by the MEOWS scoring (Appendix 1). Any score > than 1 is considered an abnormal range.







4.2 An alert should cause the practitioner to stop and think about the implications for the woman. An alert should prompt one or more of the following depending on the severity of the woman’s condition. See MEOWS chart:

extra vigilance (additional observation parameters being measured)

further assessment and intervention by a competent practitioner

referral to the obstetric team

referral to obstetric anaesthetist (bleep 142 or 149)

urgent referral to consultant obstetric and or anaesthetic staff

referral to outreach or intensive care consultant

cardiac arrest call

5.0 Abnormal physiological parameters

5.1 Temperature

5.1.1 Temperature is one of the “vital signs” and should be regularly measured using an appropriate device. It is especially important in neutropenic patients, and for detecting sepsis.

5.1.2 Low temperature is as significant as high temperature. The Sepsis Six campaign3 defines a temperature of < 36°C as an amber flag.

5.1.3 Hypothermia is defined as a core temperature < 35°C, with significant mortality risk at < 32°C. Hypothermic patients should be warmed slowly using blankets, warm fluids and a Bair Hugger. A hypothermia algorithm can be found in Appendix 2. Although unusual in a maternity setting, extra vigilance is needed for women with a significant PPH or sepsis.

5.2 Pulse

5.2.1 A pulse rate of greater or equal to100bpm or less than 50bpm should initiate an alert. The rate and regularity of a manual pulse should be checked and recorded if previously using an automated machine. Red flag sign: sustained tachycardia >120bpm.2

5.2.3 Any woman receiving β-blocker medication will not be able to increase their heart rate to compensate for hypoperfusion conditions, and therefore other abnormal signs e.g. high respiratory rate and low urine output may have extra significance.

5.3 Respiration rate

5.3.1 Respiratory rate is the most sensitive indicator of deteriorating physiology and must be recorded in all patients5

5.3.2 A respiratory rate of < 10/min or > 20/min should initiate an alert. .2







5.3.3 Depth, symmetry and pattern of respiration should also be noted and recorded if abnormal.

5.4 Blood pressure

5.4.1 A rising blood pressure or diastolic blood pressure >90 mmHg will give an amber alert

5.4.2 If the heart rate increases above the SBP it should initiate an alert. Falling blood pressure should be regarded as late sign of deterioration.

5.5 Oxygen saturation

5.5.1 Oxygen saturations should be monitored and recorded regularly in any women with abnormal respiratory rates, shortness of breath, chest pain or cough, and for everyone on the high dependency pathway of care.

5.5.2 If the woman has an oxygen saturation reading less than 95%, with or without supplemental oxygen, anaesthetic advice must be sought (bleep 142/149).

5.5.3 Consider arterial blood gas measurement in all women with abnormal SpO2, respiratory symptoms, or unexplained low levels of consciousness.

5.6 Conscious level

5.6.1 Deterioration in conscious level can be caused by many factors, and the ACVPU score should be recorded within the MEOWS system. Any deterioration in conscious level should be followed by a more in depth assessment of GCS by a relevant clinician, including pupil reaction to light and blood sugar measurements.

5.6.2 Patients having seizures are at significant risk and should have a senior medical review.

5.6.3 A response only to pain (trapezium ‘squeeze’) or unresponsive, correlates to a GCS of ≤ 8 and should be treated as a medical emergency. Anaesthetic help should be sought urgently as the patient’s airway may become compromised.

ACVPU scale

A Alert 0

C Confusion No alert

V Responds to voice Amber alert

P Responds to pain Red alert

U Unresponsive Red alert







5.7 Urine Output & Fluid Balance

5.7.1 Health care professionals are responsible for documenting and recording correct fluid input and output, and for seeking help if the patient shows signs of deterioration e.g. if minimum hourly urine output < 0.5mls / kg / hr.

5.7.2 Urinary catheter insertion and measurement of urine output should be considered in the following instances:

Women who are clinically deteriorating (MEOWS score rising).

Women who have experienced excessive blood loss e.g. APH, PPH

Women with abnormal fluid losses e.g. vomiting, drains, or diarrhoea.

Women with severe pre-eclampsia or eclampsia, alongside this these women should also have their chest auscultated every 4 hours by the obstetrician.

Patients with restricted fluids or who are nil by mouth

Patients receiving enteral feeding or intra-venous infusions (IVI), including blood transfusions

Patients with signs and symptoms of sepsis

5.7.3 Women whose MEOWS is >3, and/or those with an IVI in progress, should have hourly fluid balance (input and output) measurements. Less acutely ill women should have fluid balance measured 4 hourly

5.7.4 Staff should be aware that insensible losses can greatly increase when a patient has a high temperatures or rapid respiratory rate.

6.0 Seeking Help and Immediate Measures

6.1 The additional importance of “midwife/nurse concern” as a factor in predicting deterioration should not be underestimated, and any member of staff who is concerned about a patient should not hesitate to call for help.

6.2 Vital signs and MEOW scoring will give an indication of the woman’s condition. Help must be sought as soon as possible if any practitioner feels unable to adequately deal with the situation, or feels that the woman could deteriorate further and warrants a more comprehensive assessment.

6.3 Responsibilities of relevant staff groups and actions to be taken in response to MEOWS scoring are detailed below:

MEOWS score 0: Repeat observations when appropriate for clinical scenario – at least daily







MEOWS score 1 (1 x amber alert): Minimum of 4 hourly observations as there is potential for deterioration

MEOWS score 2: (2 x amber alerts) Inform midwife in charge, obstetric registrar. Minimum 1 hourly observations

MEOWS score 3: (3 x amber alerts or 1 x red alert) Inform senior midwife, obstetric and anaesthetic staff. Minimum observations every 30 minutes.

MEOWS score greater than 3: (amber and red alerts) As above but the consultant obstetrician consultant anaesthetist should be informed. Minimum observations every 15 minutes. If no one is available to review the patient, inform the Outreach Team. Consider Intensive Care referral.

6.3 Any concerns about the woman must be relayed to the clinician responsible for the care of the woman, and recorded in her records.

6.4 The following procedure is a guide to calling for help (SBAR):

Before bleeping a clinician, make sure you have all the information you need to hand.

When bleeping a clinician, ensure someone is able to stay by the phone to receive the call back.

State who you are and where you are located.

State the patients name, diagnosis and whether antenatal or postnatal.

State the current problem, giving observation and assessment findings.

Be clear about what you are expecting the clinician to do.

Do not hesitate to call the cardiac arrest team on 2222, if the patient has collapsed, the patient is rapidly deteriorating or you have any major concerns

6.5 Simple early measures can often prevent further deterioration of the patient and avoid the need to admit to higher levels of care.

6.6 Interventions will depend on the patients’ vital signs and initial assessment but include some of the following:

Appropriate positioning of the patient

Checking that the optimum amount of oxygen is being delivered.

Checking that vital medications have been given

Checking that infusions are running and up to date







7.0 Escalation from low risk to consultant care antenatally or in labour

Any APH (that is not merely bloodstained show)

Any degree of PIH or PET (diastolic blood pressure > 90 mmHg or >

20 mmHg above booking diastolic on 2 occasions)

Known placenta praevia

Multiple pregnancy

Intrauterine death

Road traffic accident whether in labour or not

Women previously unbooked at RBFT

Intra-uterine transfers arriving from elsewhere

Proven UTI’s and pyelonephritis

IUGR confirmed on ultrasound

Preterm labour

Abnormal and non-reassuring FHR

Delay in 1st Stage of labour when progress has fallen four hours behind that expected (see Active Management of Labour guideline GL865). Delay in 2nd stage of labour after pushing has commenced (30 minutes for a multiparous woman and 60 minutes for a nulliparous woman).

Retained placenta (see Retained Placenta in all care settings GL904)

Post partum haemorrhage > 1000ml (see Obstetric Haemorrhage GL775)

Induction and augmentation of labour (see Oxytocin regime for augmentation or induction of labour GL925)

3rd or 4th degree tear (see Perineal Trauma guideline GL836)

Psychiatric problems or women with deteriorating mental health during labour and the postnatal period.

Post-natal readmissions

Unexplained maternal illness: MEOWS score > 2







8.0 Higher dependency (Level 1) care on Delivery Suite

8.1 Criteria for escalation of care to Level 1

Severe pre-eclampsia:

o DBP > 105 mmHg

o SBP > 165 mmHg

o And 2+ proteinurea on 2 separate occasions

Or

o DBP > 95 mmHg

o SBP > 145 mmHg

o And 2+ proteinurea on 2 occasions

Plus

o 2 signs or symptoms of imminent eclampsia e.g. epigastric tenderness, hyper-reflexia, or deteriorating renal function (creatinine > 80mmol/l, urea > 4.5mmol/l).

Major Haemorrhage: antepartum > 1000ml, postpartum > 2000 ml, or sufficient to cause a MEOWS score >3)

Cardiac disease (stenotic lesions, significant regurgitation but not ‘floppy’ mitral valves)

Respiratory disease (cystic fibrosis, pneumonia, brittle asthma)

Pulmonary embolism (acute thrombolic events or those with pleuritic chest pain until PE excluded)

Placental abruption (significant with fetal or maternal sequelae)

Acute abdomen i.e. unexplained severe abdominal pain

Ruptured uterus (postnatal)

Trauma with significant injuries

Post-maternal collapse (witnessed loss of consciousness)

MEOWS score > 3

8.2 Frequency of review

8.2.1 The woman should be reviewed by the senior team on each ward round. Between ward rounds the senior midwife should receive an update each hour. Any change in MEOWS score should be relayed to the on call anaesthetist and obstetrician who should review the woman as soon as possible, preferably together.

8.2.2 Women who have been admitted to other departments (names and departments recorded on Delivery Suite log) should be reviewed on







each ward round and by the consultant obstetrician at least once per day.

8.3 Standard of monitoring

8.3.1 Observations should be performed at least hourly or more often as required. A monitor with continuous pulse plethysmography, oxygen saturation, ECG and non-invasive blood pressure measurement should be available.

8.3.2 All observations should be recorded in the electronic records. An assessment of Waterlow score should be performed each day and appropriate equipment obtained.

8.4 Equipment

8.4.1 Some equipment is single use, disposable items. These are stored on a clearly labelled trolley which is kept in the pack room.

8.4.2 Some equipment, such as the Edan maternal and fetal monitoring equipment is kept on Delivery Suite. This is maintained by the hospital clinical engineering service.

8.4.3 Other equipment may be brought in from other sources. For example, intravenous syringe drivers may come from the equipment library. Special pressure relieving mattresses may need to be hired from the relevant manufacturers.

8.5 Training of staff

8.5.1 Where possible women requiring higher levels of care should be looked after by midwives from delivery suite or specialised nurses if woman is postnatal. It is inappropriate for women at risk of developing serious medical complications to be looked after by midwives whose customary working environment is the community and whose expertise is in the normal parturient.

8.5.2 Emergency scenario based training (PROMPT) is mandatory for all staff to attend

8.6 Discharge criteria from Higher Dependency Care (level 1)

MEOWS score should be consistently < 2.

The trigger condition should be identified and be resolving.

CVP and arterial lines must have been removed.

Oxygen therapy should no longer be required.







9.0 Criteria for ITU Admission

9.1 A MEOWS score of ≥ 4 should trigger a consultation with the Outreach team and the intensive care consultant. The consultant obstetrician and an anaesthetist should be informed.

9.2 Admission to ITU will always depend partly upon availability of beds.

9.3 Conditions requiring invasive ventilatory support are an absolute requirement that might involve transfer to another hospital.

10.0 Management of transfer between Care settings

Transfer of any sick patient either within the hospital or between hospitals is potentially hazardous. Careful multidisciplinary co-ordination to ensure the necessary resources is essential to reduce the hazards.

10.1 Indications for transfer

In-utero transfer from RBH to another hospital protocol (CG508)

Homebirth transfer from home to hospital protocol (CG507)

Postnatal transfer of mother to another hospital (CG510)

Postnatal transfer of mother to X-ray department for embolisation

Neonatal transfer to a specialist unit

Transfer of women in labour from Rushey Birth Centre to main Delivery Suite protocol (CG501)

10.2 Co-ordination

10.2.1 The following should be involved in the decision to transfer a patient:

Consultant and SpR OR Staff Grade obstetrician

Senior midwife for Delivery Suite at the RBFT and receiving unit

Delivery Suite anaesthetist who will liaise with the consultant anaesthetist and the consultant intensivist if necessary.

Relevant consultants in receiving unit (including obstetricians, anaesthetists, neonatologists as well as any other specialties).

10.2.2 If a baby is being transferred to another unit arrangements should be made for the mother to be transferred unless her condition makes this inappropriate

10.3 Resources for Transfer

10.3.1 The skill mix required for a transfer will depend on the clinical scenario. A paramedic ambulance should always be requested.







10.3.2 The Delivery Suite anaesthetist and obstetrician should review the patient to decide whether a medical escort is required. If there are serious concerns that deterioration of any system could develop during transfer, then the intensive care consultant must be consulted. The anaesthetic and intensive care consultant will then decide who the most appropriate escort is.

10.3.3 The need for midwifery escort will depend upon the level of risk to the mother and the risk of delivery occurring whilst en-route. If the woman is post-natal and in need of ventilation, the anaesthetist should be accompanied by an ODP or intensive care nurse.

10.3.4 The intensive care unit has a policy on transfer of sick patients within the hospital and to other hospitals. Women who need intensive care should be managed according to these policies. See ICU Transfers in Intensive Care Clinical handbook

10.3.5 Monitoring during transfer should continue according to the standards of the Intensive Care Society/AAGBI. As a minimum, critically ill patients require ECG, SpO2, NIBP and frequently Invasive Arterial Pressure Monitoring. Ventilated patients also require end-tidal Carbon Dioxide monitoring. 6,7,8

10.4 Communication and Record-keeping

The receiving unit should be contacted by telephone before leaving the RBFT Delivery Suite.

Records of observations made en-route should be kept on an appropriate chart.

An adverse incident form must be completed

The appropriate transfer form must be completed and a copy must be scanned into the maternal health care record on EPR.

11.0 Duties of staff disciplines during transfer of critically ill maternity patients within the Royal Berkshire Hospital

11.1 Porters

Retrieve bed or transfer trolley from ICU

Obtain a portable monitor, ventilator and ambubag with an oxygen cylinder

Obtain the transfer bag if required

11.2 Midwives

Ensure appropriate guidelines available to staff in receiving unit e.g. Bakri Balloon, preeclampsia/eclampsia

ftp://iis0/eicu/CPG/index.html

ftp://iis0/eicu/CPG/index.html







Ensure that ongoing midwifery care arranged – if pregnant fetal monitoring, if delivered that post partum checks in place

Ensure that the patient/partner are aware of plan for baby care

Ensure that notes are collated or copied as necessary and that they accompany patient

Complete Trust transfer form

Assist with transfer if appropriate

11.3 Anaesthetists

Ensure that airway is secure before transfer

Ensure appropriate ventilation and that there is a back up system available

Ensure that patient is cardiovascularly stable prior to transfer or that appropriate support is available – inotropes, iv fluids and blood

If intubated ensure that there is appropriate sedation and analgesia in place

Record observations during transfer or procedures

11.4 ODP/Anaesthetic nurse

Assist anaesthetist

Ensure adequate IV fluids, blood/blood products available during transfer and returned if not required and correctly stored

Collect extra equipment and drugs as necessary

11.5 Obstetricians

Assist with transfer

Ensure appropriate assessment of fetal wellbeing is available

Ensure that any obstetric plans are communicated to the receiving team.

11.6 Receiving team

Document ongoing care plan

Establish on appropriate ventilation

Establish on monitor

Check all infusions







12.0 Monitoring standards

Auditable Standard Monitoring method

Frequency of monitoring

Review Group / Committee

Following the calculation of the MEOWS score an action will be taken according to the score (as per guideline). When an action is taken, this will be documented in maternal health record.

Review of 1% of records of women delivered

Annual audit report

Maternity Audit Forum

13.0 References

13.1 Healthcare Commission 2006 Investigation report into 10 maternal deaths at Northwick Park Hospital

13.2 The Confidential Enquiry Saving Lives, Improving Mothers’ Care review in 2015-2017 (MBBRACE) https://www.npeu.ox.ac.uk/mbrrace-uk/presentations/saving-lives-improving-mothers-care#saving-lives-improving-mothers-care-lessons-learned-to-inform-maternity-care-from-the-uk-and-ireland-confidential-enquiries-into-maternal-deaths-and-morbidity-2015%E2%80%9317

13.3 Sepsis six Campaign https://sepsistrust.org/wp-content/uploads/2018/06/ED-adult-NICE-Final-1107.pdf

13.4 National Institute for Health and Clinical Excellence. Clinical guideline 50: Acutely ill patients in hospital (2007). NICE London

13.5 Goldhill, D. R., S. A. White, et al. (1999). "Physiological values and procedures in the 24h before ICU admission from the ward." Anaesthesia. 54: 529-534.

13.6 Transport of critically Ill Adults. Intensive Care Society Standards, Safety, and Quality. 2011

13.7 Recommendations for standards of Monitoring during anaesthesia and recovery. Association of Anaesthetists of Great Britain and Ireland (AAGBI) 4th edition. (revised March 2007). London

13.8 Transfer of patients with Brain Injury AAGBI May 2006 London

13.9 MEOWS https://www.rcoa.ac.uk/sites/default/files/documents/2019-09/EMC-Guidelines2018.pdf

https://www.npeu.ox.ac.uk/mbrrace-uk/presentations/saving-lives-improving-mothers-care#saving-lives-improving-mothers-care-lessons-learned-to-inform-maternity-care-from-the-uk-and-ireland-confidential-enquiries-into-maternal-deaths-and-morbidity-2015%E2%80%9317





https://sepsistrust.org/wp-content/uploads/2018/06/ED-adult-NICE-Final-1107.pdf

https://sepsistrust.org/wp-content/uploads/2018/06/ED-adult-NICE-Final-1107.pdf

https://www.rcoa.ac.uk/sites/default/files/documents/2019-09/EMC-Guidelines2018.pdf

https://www.rcoa.ac.uk/sites/default/files/documents/2019-09/EMC-Guidelines2018.pdf







Appendix 1 - Modified Early Obstetric Warning System (MEOWS)

Each parameter is scored and action taken according to the total.







Appendix 2 – Hypothermia Algorithm Actions for all patients: Remove wet garments

Protect from heat loss and wind chill (use blankets, turn off fans, close windows) Maintain horizontal position

Avoid rough movement and excess activity Monitor tympanic temperature Monitor cardiac rhythm

Airway Airway Breathing Breathing Circulation MAINTAIN THE AIRWAY Circulation Present Absent

Move Woman to The most Appropriate Area

Assess Airway, Breathing, Circulation

34-36C mild hypothermia Apply blankets Offer warm drinks (if not nil by mouth) Document BP/HR/RR/ Temperature at least hourly. Inform anaesthetist if MOWS 3 or above Consider checking BM Inform obstetric team if no improvement

30-34C Moderate hypothermia Inform obstetric and anaesthetic team. Apply Bair Hugger Cover head with a towel Commence warmed IV fluids via a fluid warmer Continuous cardiac monitoring. Document HR/RR/SpO2/fluid balance/MOWS and AVPUI at least every 15 minutes, inform anaesthetist if MOWS 3 or above

Temperature 34-35C apply bed sheet to

the patient, then apply a space blanket

and cover with normal blankets cover the

top of the head with a towel.

Apply the Bair Hugger full body adult blanket paper side to the patient.

The patient should have minimal clothing on and NO sheet next to them. Lay the blanket flat against the patient; do not tuck it in and only ONE SHEET over the Bair Hugger blanket. If the blanket is punctured it will still work.

TEMPERATURE SETTINGS:

BODY TEMP BAIR HUGGER SETTING

32-36C MEDIUM BELOW 32C HIGH

Do not place the hose directly on the skin

One blanket per person, they are not re-useable.

Bair Hugger and blankets are stocked by maternity theatres.

<30C severe hypothermia IMMEDIATE medical attention. Bair Hugger. Continuous cardiac monitor Warmed IV fluids. ¼ hourly BP/HR/RR/SpO2/temperature/BM SEVERE DANGER OF CARDIAC ARREST

What is the tympanic temperature? Start CPR

Call CRASH team

Developed by Leah McCarthy






Appendix 3 – Delivery Suite High Dependency Chart

Documents

Recognition, High Dependency Care, and Transfer of