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Unchanged throughout pregnancy Full blood count Ranges altered in pregnancy: Hb (105–140 g/l) WBC (6–16 × 10⁹/l) Renal function Increased glomerular filtration rate Creatinine falls in first and second trimesters Normal urea reference range 2.5–4.0 mmol/l Normal creatinine <77 μmol/l Liver tests Raised alkaline phosphatase up to three‐ to fourfold of pre‐pregnancy level is normal during pregnancy Troponin Not elevated during normal pregnancy May be elevated in pre‐eclampsia, pulmonary embolism, myocarditis, arrhythmias and sepsis D‐dimer Not recommended for use in pregnancy Creatinine kinase Normal range 5–40 IU/l, i.e. lower in pregnancy Cholesterol Up to five times elevated in pregnancy (therefore should not be checked routinely) Thyroid function tests (TFTs) Use local gestation‐specific ranges ECG Sinus tachycardia 15° left axis deviation dueto diaphragmatic elevation T wave changes – commonlyT wave inversion in lead III and aVF Non‐specifìc ST changes, e.g. depression, small Q waves Holter monitor Supraventricular and ventricular ectopics are more common Chest X‐ray (CXR) Prominent vascular markings, raised diaphragm due to gravid uterus, flattened left hemidiaphragm Peak expiratory flow rate (PEFR) Unchanged in pregnancy Arterial blood gas Mild, fully compensated respiratory alkalosis is normal during pregnancy

5.2 Modified early‐warning systems

      It is recognised that pregnancy and labour are normal physiological events but ‘normality cannot be assumed without measurement’ (Knight et al., 2014). Maternity early warning score (MEWS) systems adapted for pregnancy are designed to detect when there is deviation from the normal. Regular observations of vital signs should be an integral part of care of all pregnant women. MEWS charts should be readily available and used in obstetric and non‐obstetric areas of the hospital where pregnant woman may present.

There is a minimum dataset of observations suggested at each assessment which should be recorded on a MEWS chart (Algorithm 5.1). The minimum recommended frequency of observations as an inpatient is 12 hourly. Frequency of observations is determined by risk status, initial observations and working diagnosis. Women should retain the same MEWS chart when moving from one clinical area to another, so that physiological trends can be detected.

MEWS scores outside the normal range for pregnancy are recorded in the coloured zones of the chart and should immediately trigger communication using the SBAR (situation, background, assessment and recommendation) communication tool with appropriate medical staff asking for urgent review (Box 5.1). The clinician should undertake a full systematic review, resuscitate and treat as required and order appropriate investigations. It must be emphasised that just recording observations however regularly or meticulously is not enough: abnormal ones must be acted upon . If the clinician who has been contacted is unable to attend within 10 minutes, options include contacting a more senior obstetrician or the anaesthetic team. Consider early obstetric consultant and anaesthetic consultant involvement. If a senior speciality trainee has deputised a more junior obstetrician to attend, then the midwife and charge midwife need to assess whether this is an appropriate level of clinician attending and consider escalation as outlined. It is important to care for the woman in the most appropriate clinical area. If this is not possible, then a delay in transfer must not delay immediate history taking, examination, investigations, treatment, note review and reassessment of ABCD. Contact the clinical manager on call for assistance if required.

      In non‐obstetric areas such as the emergency department or acute medical unit there should be clear routes for effective communication with the obstetric team for all pregnant women. Routes for escalation should be clear to all staff should the woman’s observations on the MEWS chart trigger a review or her condition clinically deteriorates. If a pregnant woman is triaged by the ambulance or emergency department staff to the emergency department resuscitation room a 2222 ‘obstetric emergency’ call (or equivalent) should be activated to ensure a full team including a neonatologist is available.

Box 5.1 SBAR

Situation	Identify yourself, identify your patient and where you are calling from
	‘I am calling because …’ be specific about your concern
Background	Set out the context of the admission, giving significant medical history, what operation/procedure has been had, any important blood results and recent observations. Outline her normal condition
Assessment	Give your assessment of the situation
	‘I think that she has suffered a …’
	‘I do not know what the problem is but I am very concerned about her deterioration …’
Recommendation	Here you need to be very specific in what you want the receiver to do
	‘I need you to come immediately …’
	‘I need you to come or in the next 10 minutes …’
	‘I would like to transfer her immediately to labour ward because …’

      Breathlessness

This common symptom can arise due to the normal respiratory adaptation to pregnancy, is gradual in onset and is usually noticed by the woman when she is talking or at rest. In normal pregnancy, there is a 40–50% increase in minute ventilation, mostly owing to an increase in tidal volume rather than respiratory rate and this leads to the subjective awareness of breathing. A mild, fully compensated respiratory alkalosis is therefore normal in pregnancy (see Table A5.1 in Appendix 5.1).

       However, in any pregnant woman complaining of breathlessness the ‘red flag’ features (Table 5.2) must be sought during history taking and acted upon.

      The differential diagnosis of breathlessness in pregnancy includes:

       Anaemia

       Respiratory causes: asthma, pneumonia, pneumothorax, pulmonary embolus, pulmonary oedema

       Cardiac causes: cardiomyopathy, pulmonary hypertension, valvular heart

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