TABLE 1
Maternal symptoms requiring special evaluation
| SYMPTOM | RECOMMENDED SCREENING/INTERVENTION |
|---|---|
| Abdominal pain | Assess maternal and fetal well-being. |
| Rule out trauma, fall, abruption, preterm or term labor, domestic violence, abdominal pathology, ovarian torsion, appendicitis, acute abdomen, cholelithiasis, and nephrolithiasis. | |
| Abdominal trauma or a fall (with or without direct abdominal trauma) | Assess maternal well-being and gauge severity of trauma—mild, moderate, or severe (emergency room protocol). |
| Obtain blood type and screen, with Rhimmune globulin for Rhnegative. | |
| Employ continuous fetal monitoring for 6 hr (mild), 12 hr (moderate), or 24 hr (severe) when there is direct abdominal trauma. | |
| Rule out domestic violence. | |
| Vaginal bleeding | Assess maternal well-being and identify placental location if unknown. |
| Conduct bedside ultrasound to rule out placenta previa. | |
| Confirm bleeding by sterile speculum and quantify amount. | |
| Perform serial hematocrit and hemoglobin, Kleihauer-Betke test if Rhnegative; Rhimmune globulin may be indicated. | |
| Confirm fetal well-being (nonstress test, amniotic fluid index, biophysical profile). | |
| Monitor contractions. | |
| Rule out placental abruption, trauma, or domestic violence. | |
| Fluid leakage or vaginal discharge | Assess maternal and fetal well-being. |
| Rule out spontaneous rupture of membranes, infection (urine, vagina, uterus), and preterm or term labor. | |
| Motor vehicle accidents | Have the emergency room evaluate, stabilize, or resuscitate the mother. |
| Confirm GA and fetal well-being after above. | |
| Deliver fetus if indicated. (Fetus best resuscitated intrauterus.) | |
| Decreased fetal movements | Assess maternal well-being and confirm GA. |
| Obtain reactive nonstress test as per GA; if nonreactive, obtain a biophysical profile. | |
| Confirm fetal movements. Measure amniotic fluid index as per GA. | |
| Rule out domestic violence. | |
| GA = gestational age | |
Rationale for obstetric triage
Obstetric triage came into common use in the United States in the early 1980s as a result of increased financial constraints on hospitals, a personnel shortage, and the resultant strain on environmental services and other valuable hospital resources.2 Due to an increasing number of births at the time, the use of labor and delivery beds for patient evaluation clearly was inappropriate and led to dissatisfaction among patients and healthcare providers alike.3
The solution to this problem came with the creation of a triage area adjacent to the labor and delivery unit, where pregnant women could be evaluated for labor and nonlabor-related issues. Qualified nursing personnel, including registered obstetric nurses, nurse-midwives, and nurse-practitioners, completed staffing of the unit.
Laboring patients who presented to obstetric triage were assessed and transferred to the labor unit. Nonlaboring patients were evaluated and appropriately managed by experienced obstetric personnel. This reduced the time each woman spent in the hospital, increased patient satisfaction, and eliminated the cost of expensive labor and delivery beds by curtailing unnecessary admissions. The cost-effectiveness of this screening unit and the accompanying rise in patient satisfaction were demonstrated in several studies.4,5
Recommendation: Close communication between physician and triage personnel
When evaluating patients in the triage unit, clinicians can rely upon a wealth of well-defined criteria. The American College of Obstetricians and Gynecologists sets the standards of care through its committee opinions, educational/technical bulletins, technology assessments, and other publications. In addition, the Emergency Medical Treatment and Active Labor Act6 holds hospitals accountable for prompt screening and subsequent care of pregnant women who present in active labor.
Any number of medical errors are possible during triage, the most common being incorrect assessment of the mother or fetus and incorrect management of laboring patients (TABLE 2). Close interaction between the physician and triage personnel—which can be achieved through clear, timely, sincere, and complete exchange of clinical information—decreases the likelihood of such mistakes.
The majority of women presenting for obstetric triage at level 1 and 2 hospitals—ie, hospitals without a neonatal intensive care unit—are low-risk patients. In this setting, nonphysician providers are generally the ideal caregivers. These practitioners are able to evaluate common pregnancy symptoms, diagnose active labor, and transfer laboring patients to labor and delivery.1
In level 3 hospitals, the proportion of high-risk patients who present to triage is usually larger; as a result, physicians typically are more closely involved in their evaluation.
TABLE 2
Potential errors in obstetric triage
|
Initial screening: Overall well-being and history
The most common task required of obstetric triage personnel is labor evaluation.3 Other common presenting symptoms are possible rupture of the amniotic membranes prematurely or at term, premature uterine contractions,1 decreased fetal movements, vaginal discharge, urinary tract symptoms, and concerns related to the prenatal course and non-obstetric symptoms (eg, upper respiratory complaints).3 Less common reasons for evaluation include abdominal trauma, domestic violence, hypertensive disorders, vaginal bleeding, and a desire for prenatal care.3
Initial evaluation should include the following:
Assessment of the mother’s well-being. A triage nurse obtains the patient’s history, paying special attention to the presenting symptoms (for example, time of onset, appearance of vaginal discharge, duration and severity of vaginal bleeding), current risk factors, and pregnancy course. The prenatal chart should be available to help direct and personalize the patient’s care.