During labour

Guidelines at both Trusts recommended that midwives on the AMU and OUs monitored women's vital signs during labour and birth with the partogram rather than the MEOWS. The partogram provided an alert and action line to enable monitoring of labour progress and prompt detection of complications. This included recordings of contractions, fetal observations, cervical dilatation and descent of the fetus.

In practice, variable use of the partogram and documentation of maternal observations were reported at both Trusts and confirmed by audit data at Westward (Westward, Audit data of women in labour, unpublished data, 2009/2010). Some midwives believed the alert line promoted unnecessary interventions rather than enabling use of their clinical judgement and professional skills to manage variations in women's labour patterns.

Box 2 provides examples of staff's mixed opinions regarding the value of the MEOWS for monitoring purposes during labour. A few obstetricians and some midwives from both Trusts considered that one-to-one care during labour enabled those midwives looking after a woman to spot changes in her condition without the need for a partogram or MEOWS chart. In contrast, a few queried why the MEOWS was not used during the intrapartum period. Junior midwives were observed to be confused at times about which chart to use.

Some women assessed as being at high risk of complications during labour were monitored using the partogram and the MEOWS chart. Vital signs were recorded by midwives in four places: notes, partogram, MEOWS chart and cardiocotograph (which monitored the baby's heart rate together with the mother's uterine contractions). Guidelines at the two Trusts did not require routine use of either the partogram or the MEOWS for women labouring at home so, when women transferred from home to hospital, handover of changes in a woman's condition was organised around verbal handover and narrative text recorded in the notes rather than the partogram chart.

High dependency care

Both Trusts had designated high dependency beds on their OUs for women with established critical illness such as eclampsia and sickle cell disease where specially designed high dependency unit charts (HDU charts) were used rather than MEOWS charts to monitor women's vital signs. These HDU charts did not include trigger points or specify response actions. At Westward, a few staff noted tensions between physicians (such as respiratory specialists who were external to the maternity units) and obstetricians with regard to their management decisions concerning the care of these women. When calling for help, midwives struggled at times to elicit a response from some of the medical physicians. Trust guidelines for escalation at Westward directed junior midwifery and medical staff to consult with the woman's obstetric consultant before calling for help from a physician. This hierarchy of command created difficulties when consultants were occupied elsewhere and midwives were required to raise the alarm, as this midwife explains: ‘We have a lot of medical patients in HDU; when they're here it is like getting blood out of a stone to get physicians to come and review them. They don't listen to midwives. I've been told by an obstetric registrar, “You need to get the medics over here,” but when you ring the medics they won't listen to you because I'm a midwife. So what do you do when all our obsetricians are busy in theatre? You've got a sick woman that needs to be seen, but the medics won't see her, radiology won't do a portable chest x-ray because it's not the doctor that's speaking to them. I've held phones up to surgeons in theatre when they're scrubbed to give verbal orders over the phone.’ (Westward, Midwife OU, 9).

Hierarchical boundaries resulted in avoidable delays in escalation of care.

Postnatal period

At Eastward, guidelines directed midwifery staff to use the MEOWS on all women in the postnatal period. Audit data showed that there was 22% usage of the MEOWS on the postnatal ward. Monitoring of respiratory rate, in particular, was poor. In the cases where a MEOWS chart was used, few had required referral or escalation of care. Most women whose case notes were reviewed were well, had their observations documented in the notes and were discharged within 24 h (Eastward MEOWS audit, unpublished data, July 2010).

Decisions by Eastward's midwives not to use the chart were made on account of the fact that most of these postnatal women were not ‘patients’ but healthy women recovering from a natural event. The chart was perceived to inappropriately medicalise childbearing. Senior midwifery staff and obstetricians saw a role for the chart to monitor women either after a caesarean section or following establishment of complications in the antenatal or postnatal period. There was resistance to its routine use for all women in the postnatal period given the large numbers of healthy women within the system. The potential gain in detecting morbidity early was perceived to be small, while the workload involved in follow-up vital sign recordings and false positive referrals was significantly greater.

At Westward, guidelines directed midwifery staff to use the MEOWS charts routinely on women staying longer than 12 h, as delayed discharge was assumed to be due to maternal or neonatal complications. Compliance with standards was also variable at this Trust, particularly with regard to documentation of a full set of observations and score. Midwifery staff from both organisations were observed to assess the need for an early warning chart postnatally on an individual case-by-case basis. The midwives used their professional judgement to decide when vital sign monitoring for some women was lower priority than other postnatal activities (box 3). In these instances, midwives chose to privilege women's breastfeeding or psychological needs, or at-risk babies’ monitoring needs, or system demands, ensuring women assessed as healthy moved quickly through the maternity system without delays imposed by the additional workload associated with the MEOWS (see box 3).

Observation of risk management meetings across both sites highlighted very few case reviews which concluded that there was a delay to the detection and management of women with postnatal complications because of a lack of observations or early warning score. Other cases were discussed which highlighted the limited use of the MEOWS in facilitating early detection of maternal collapse. These case reviews contributed to staff's mixed sense of the need for and effectiveness of the MEOWS chart.

However, anaesthetists from both organisations noted the limitation of the case-by-case approach as it was unlikely to increase detection of those women whose deterioration in condition might otherwise go unnoticed by midwives administering routine postnatal care. A midwife at Westward noted a case where colleagues failed to recognise subtle signs of the complications developing in a woman. Routine use of the MEOWS chart including measurement of her respiratory rate in the postnatal period could have facilitated earlier intervention. ‘We had a woman that was showing signs that something was slightly out but it was a very grey thing. She was a bit out of breath. We thought, “Oh well, she is a very large lady anyway, she's got crutches, she can't walk properly. That's why she's a bit puffed out.” But that's not what she was like all the time. She went into cardiac arrest.’ (Westward, Midwife OU, 7)

This anaesthetist explained his argument for extending use of the chart to all women in order to ‘catch’ those one or two who otherwise would slip through the existing safety net because of its reliance on the professional judgement of an individual practitioner. ‘It's deciding where to draw that line, that's the million dollar question because you can't predict who's going to go off and who isn't [..] We have to throw the net a little bit wider than we are now if we're going to pick up the ones [that are missed].’ (Eastward, Anaesthetist, 8)

Leadership and governance

A centrally governed safety committee to improve the management of the acutely ill had been established at both Trusts. However, neither committee concerned themselves with maternity. There was consensus from inside and outside the maternity unit that it was culturally distinct from acute care (box 4).

A service manager from Eastward explained the implications of this: ‘The general EWS doesn't fit maternity or children's services, so those areas have developed their own [tools], but perhaps not with support from the rest of the organisation to make sure they're really robust, and that's the bit that I feel is a bit difficult [..] I think sometimes [..] we're just a little bit in that too difficult box, [laughs] so you just do your own thing!’. (Eastward, Manager, 12)

Maternity-based clinical governance services monitored use of the MEOWS in each organisation. Maternity was excluded from the support and oversight provided by each Trust's central safety committee. Similarly, although Westward's critical care outreach team was designed to facilitate escalation of care processes across the Trust, in practice a clear boundary existed between its remit within acute care and maternity. Midwifery and obstetric staff were observed to be reluctant to ask for help from the outreach team even when midwives experienced difficulties getting physicians to listen or attend to calls for help.

At both Trusts, implementation of MEOWS had been driven largely by national pressure to meet the risk management standards of the NHS Litigation Authority. Demonstration of compliance with these standards provided both Trusts with the opportunity to acquire financial benefits via the clinical negligence scheme for trusts (CNST). At Westward, this led to tensions between managers keen to secure these benefits and clinicians who lacked faith in the system.

At Westward, strong clinical leadership, a learning culture, respectful interprofessional relations and a formalised strategy for driving forward quality and safety improvements were observed to help facilitate implementation of the MEOWS. At Eastward, standardised processes (including the MEOWS and partogram) were perceived by the majority of midwives interviewed to challenge their professional autonomy and jurisdiction. Case-by-case use of the MEOWS was sanctioned by some senior managers, midwives and obstetricians (see box 5).

Supervision and support

On both OUs there was a strong obstetric consultant presence, providing supervision and support for junior medical and midwifery staff. However, medical and midwifery staff reported variability in the performance of midwifery coordinators on the OUs with some concerns regarding their provision of support for junior midwifery staff. At Eastward, a ‘coping culture’ norm meant midwives felt pressured to demonstrate competence at managing the unit and at times delayed asking seniors for help, as this obstetrician illustrates: ‘There is still this old macho thing that you don't want to call in your consultant. It's there amongst the midwives as well, [..] There's this huge reluctance to ask for help, it's seen as a sign of weakness’. (Eastward, Interview, 1, Consultant Obstetrician)

This cultural norm also made it difficult for coordinators to speak up when they felt that workload levels on the unit were unsafe. ‘Through the years people … have just managed … and there's this bravado that, “Yes I can do it, I can do it,” and I think actually we should just say every now and then, “Actually we can't”. Because you're looking forward, you're looking backwards, you're looking at what's going on the ward, who's needing to be induced, it's too much’. (Eastward, Interview, 17, Senior Midwife).

Audit monitoring and feedback

Audit data on the recording of observations and the use of MEOWS were collected by both sites. Adherence to standards was fed back regularly to the units and wards at Westward, prompting managerial scrutiny, the development of action plans and further monitoring. The auditing element was reported to help encourage staff to use the MEOWS over the research period. At Eastward there was less managerial focus on monitoring and feedback on chart utilisation.