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National Clinical Guideline on the Irish Maternity Early Warning System (IMEWS)

Status: Published on

The National Clinical Effectiveness Committee (NCEC) requires inclusion of evidence on both the clinical and cost-effectiveness of health technologies in the development of all National Clinical Guidelines in Ireland. The completion of a budget impact analysis (BIA) of the implementation of a National Clinical Guideline is also a required step. The role of HRB-CICER is to independently review evidence and provide scientific support for the development, by guideline development groups, of these evidence-based National Clinical Guidelines.

In 2013, the Irish Maternity Early Warning System (IMEWS) was introduced into Irish hospitals. The IMEWS National Clinical Guideline No. 4 was developed in 2014 and was based on a systematic review of the underpinning clinical effectiveness and cost-effectiveness literature up to April 2014. As part of updating the IMEWS National Clinical Guideline, HRB-CICER conducted a systematic review of the clinical effectiveness and cost-effectiveness literature so that changes in the evidence on early warning systems for use in maternity care could inform the National Clinical Guideline update. This involved:

  1. an update of the previous systematic review of clinical effectiveness and cost-effectiveness conducted to support the development of the IMEWS guideline
  2. a new systematic review to identify clinical audits of early warning systems.

A BIA was conducted to quantify the resource implications to the Health Service Executive (HSE) following implementation of the guideline. There are two key changes to service delivery that will occur as a result of implementation of the guideline recommendations. These are:

  1. The creation of new posts, one per hospital group (excluding the Children’s Hospital Group). It is planned that these staff will assume responsibilities for providing education and training on IMEWS to staff members in the maternity and acute hospitals and oversee regular local audits of IMEWS.
  2. As part of the guideline update an e-learning module was developed, and the guideline recommends that all relevant staff complete this training.


Although most women progress through pregnancy, labour and delivery with few complications, maternal death and severe morbidity remain important public health concerns. Many cases of major maternal morbidity and mortality may be preventable; therefore, early recognition of clinically deteriorating pregnant women remains a priority for improving maternity services.

Maternity early warning systems are bedside tools that are used for monitoring the condition of hospitalised pregnant and postnatal women to facilitate early detection and management of clinical deterioration. The IMEWS chart is completed at the bedside. Vital signs (respiration rate, oxygen saturation, temperature, heart rate, blood pressure, urine and neurological response) are recorded on charts and colour coded according to their value using predefined thresholds for abnormalities. If a patient breaks or triggers these thresholds, an escalation of care should be initiated.


The systematic review of the literature to support the update of the IMEWS guideline was carried out in accordance with agreed HRB-CICER processes and following the HIQA guidelines for the retrieval and interpretation of economic literature.

The BIA was conducted in accordance with the HIQA guidelines for budget impact analysis and economic evaluation in Ireland.