A now discontinued 'early warning' system to guide Irish maternity unit staff on the treatment of seriously ill pregnant women was flawed and could have potentially put women at risk, it has emerged.

These guidelines were in use until recently in 10 of the country's 19 maternity units, but have since April been superseded by a new and more reliable early warning guide for all units.

A HSE report on practice guidelines for the new system - The Irish Maternity Early Warning System (I-MEWS) says there were issues with the old system. Early warning systems are intended to flag danger signs for staff so that they can recognise when a patient might be deteriorating and take appropriate action.

The old warning system, called the Modified Early Obstetric Warning System (MEOWS), was recommended for use following a maternal death due to infection at Our Lady of Lourdes Hospital in Drogheda in 2008 and was also recommended by the Confidential Maternal Mortality Enquiry reports in the UK and Ireland.

However, the HSE report states that while the MEOWS initiative was well intended and aimed at improving the quality of maternity care, 'there was a serious risk that the initiative would not succeed and may potentially increase the clinical risk for pregnant women.'

This, the report says, was particularly likely to occur in circumstances where an over-reliance was placed on the MEOWS guide.

Operation of this system, when it was used in Irish units, was not standardised from unit to unit and differed from hospital to hospital. Application of the guidelines was inconsistent across the specialty of obstetrics and inadequacies in staff training with the system were identified, the report states.

It adds that the use of MEOWS in pregnancy had not been validated in any country.

Prof Michael Turner, Head of the HSE's Obstetrics and Gynaecology Clinical Programme, told irishhealth.com the issues with the MEOWS system were international and not national issues.

MEOWS was potentially a problem because the triggers to seek medical assistance may not have been sensitive enough during pregnancy, and staff were potentially over-reliant on the warning scores, he said.

"We have no information or data, however, to show that MEOWS increased or decreased risks in maternity services worldwide."

The report stresses that any early warning system is only a complementary tool and should never be used to replace clinical judgement.

It says some studies have highlighted the limitations of MEOWS with chorioamnionitis (infection of membranes and fluid surrounding the foetus) or other serious infections during pregnancy.

The MEOWS guideline was not used on the ward where Savita Halappanavar was treated at University Hospital Galway last October. She was eventually diagnosed with sepsis secondary to chorioamnionitis and died on October 28 last.

Ironically, the Arulkumaran report on the death of Ms Halappanavar last October suggested if the hospital's MEOWS guideline had been used in this case, it may have raised a 'red flag' about her deteriorating condition at an earlier stage.

The Savita report also showed that guidelines at Galway Hospital for management of suspected sepsis were not followed until late into the patient's treatment.

The Arulkumaran report noted that the MEOWS system was to be replaced nationally by the new I-MEWS early warning score.

The new HSE report stresses that the MEOWS warning system has not been well validated for use in pregnancy, particuarly for infection in pregnancy.

The new HSE I-MEWS guidelines, now published, deal with monitoring temperature, respiratory rate, urine, blood pressure and other factors and indicate danger 'triggers' in a deteriorating patient that require immediate escalation of care.

The guidelines cover issues raised in the Arulkumaran report on Savita Halappanavar's treatment, including communication issues and staff handovers.

Prof Turner said it was planned to audit the use of the the new system in the future so that its use could be optimised.

He stressed that Ireland was, to his knowledge, now the first country in the world to develop a standardised obstetric early warning system.

The guidelines on the new system say all maternity units should have effective communication systems in place to ensure there is minimal delay between the triggering of a call for review when a patient is deteriorating and the arrival of a medical doctor.

It says the designation of who should be the senior doctor called should be agreed locally by the midwifery and medical senior management

The report says while Ireland continues to have a low maternal death rate by international standards, 'there is no room for complacency and efforts to improve the quality of clinical care in the maternity services must be continually renewed'.

It stresses, however, that the new warning system should complement clinical care and is not designed to replace clinical judgement.

The new warning system has been backed up by a multidisciplinary staff education programme on its use.

The guidelines have been produced by the HSE with the Institute of Obstetricians and Gynaecologists