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Maternal early warning criteria

Maternal early warning criteria
Systolic BP (mmHg) <90 or >160
Diastolic BP (mmHg) >100
Heart rate (beats per minute) <50 or >120
Respiratory rate (breaths per minute) <10 or >30
Oxygen saturation on room air, at sea level, % <95
Oliguria, mL/hour for ≥2 hours <35
Maternal agitation, confusion, or unresponsiveness; patient with preeclampsia reporting a non-remitting headache or shortness of breath
These triggers cannot address every possible clinical scenario that could be faced by an obstetric clinician and must not replace clinical judgment. As a core safety principle, bedside nurses should always feel comfortable to escalate their concerns at any point.
BP: blood pressure.
From: Mhyre JM, D'Oria R, Hameed AB, et al. The maternal early warning criteria: A proposal from the national partnership for maternal safety. Obstet Gynecol 2014; 124:782. DOI: 10.1097/AOG.0000000000000480. Copyright © 2014 American College of Obstetricians and Gynecologists. Reproduced with permission from Wolters Kluwer Health. Unauthorized reproduction of this material is prohibited.
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