Clinical Review

Avoiding the pitfalls of obstetric triage

Author and Disclosure Information

This process has streamlined the evaluation of labor and common complaints of pregnancy, such as diminished fetal movements and vaginal discharge. Here, a look at optimal screening, with case presentations illustrating the physician’s key role.


 

References

KEY POINTS
  • Several studies have documented the cost-effectiveness of obstetric triage, as well as patient satisfaction with the arrangement.
  • Any number of medical errors are possible during triage, the most common being incorrect assessment of the mother or fetus and incorrect diagnosis of true labor.
  • The most common task required of obstetric triage personnel is labor evaluation.
  • Several maternal symptoms require special evaluation. These include abdominal trauma, vaginal bleeding, motor vehicle accidents, decreased fetal movements, abdominal pain, and leakage of fluid.
Although nonphysician personnel provide the majority of obstetric triage services, close supervision by a doctor is required because of the considerable risks involved.1 Careful attention also is recommended because responsibility for the patient’s well-being—and that of her infant—ultimately lies with her obstetrician, even if another practitioner conducts the initial assessment. (See the example Case 1 and Case 2.

Thus, it is in the physician’s best interest to ensure that women who present to the triage unit are properly evaluated. This entails checking maternal vital signs and ascertaining the chief complaint, taking a complete history, and gauging risk based on the patient’s prenatal records. Assessment of fetal well-being includes evaluating fetal movements, performing a nonstress test, and calculating the appropriate amniotic fluid index or biophysical profile for the gestational age.

The following scenarios should receive special scrutiny: abdominal pain, abdominal trauma, vaginal bleeding, vaginal fluid leakage or discharge, decreased fetal movements, and motor vehicle accidents (TABLE 1).

Case 1: Absence of fetal movement

A 30-year-old primigravida presented to triage at 36 weeks’ gestation complaining of an absence of fetal movement for the last 12 hours.

Initial assessment. The triage nurse obtained her vital signs, confirmed gestational dating, placed a fetal monitor, and reviewed her prenatal records. Information gathered included:

  • When did the fetus last move? Had there been any change in fetal activity in the previous 24 to 48 hours?
  • Were there additional symptoms, such as vaginal bleeding or discharge, uterine contractions or cramping, or bladder- or bowel-related symptoms?
  • Had there been any changes in daily routines of work, exercise, meals, or sleep?
  • What was the history of the current pregnancy—specifically, were there any earlier complications?
  • What is the patient’s medical and social history? Has she used tobacco, alcohol, or drugs?

Observations. The fetal heart rate pattern was reactive, there were no regular uterine contractions, and a brief sonographic assessment demonstrated adequate amniotic fluid volume and fetal movement.

Patient’s course. The patient was reassured by seeing her baby moving on the ultrasound monitor, and was able to associate these movements with her perception of fetal activity.

The patient’s physician was contacted by phone and given all the information. Vaginal examination was considered but deemed unnecessary, given the lack of regular uterine activity and other signs and symptoms of labor.

The patient was discharged home, counseled about routine precautions, and advised to count fetal movements twice daily. She also was instructed to keep the appointment she had at her doctor’s office within the week.

Case 2: Back pain and a history of preterm delivery

A 21-year-old gravida presented to triage at 32 weeks’ gestation due to intermittent back pain. Her history was significant for a previous preterm vaginal delivery at 35 weeks’ gestation.

Initial assessment. The triage nurse found that the patient’s vital signs were normal; she was afebrile and normotensive. After confirming her gestational dates, the nurse initiated fetal monitoring and reviewed her prenatal records. Findings included:

  • Her “back pain” had begun the previous evening and was “cramping” in nature. She did not associate the pain with uterine contractions, and felt no significant pelvic pressure.
  • Her abdomen was not tender, and there had been no change in the fetal activity pattern.
  • She had no vaginal bleeding, excessive discharge, or leakage of fluid.
  • She had no dysuria, but complained of urinary frequency and urgency.
  • Her pregnancy was complicated by an earlier positive chlamydia culture and by tobacco use. She had been treated for the infection.
  • She had no medical problems, was taking prenatal vitamins only, and her family history was not contributory.
  • The fetal heart rate tracing was reactive.
  • Frequent uterine contractions were detected.

Patient’s course. The patient’s obstetrician was contacted and given the information. He came to the triage unit to assess her, and reviewed the findings with her. Upon examination, the physician confirmed that her abdomen was not tender. A speculum examination revealed a minimal amount of clear vaginal discharge. The cervix appeared closed, the membranes were intact, and there was no bleeding.

Fetal fibronectin was collected, and chlamydia and gonorrhea cultures were obtained. Upon digital examination, the cervix was closed, but felt soft and somewhat effaced. A urine specimen and culture were sent to the laboratory.

Ultrasound examination revealed normal amniotic fluid volume. Transvaginally, the cervical length was 28 mm, and there was no funneling.

The physician recommended continued observation in the triage unit. Over the next 2 hours, the uterine contractions subsided. The urinalysis revealed 10 to 15 white blood cells, and the leukocyte esterase was positive, while the fetal fibronectin test was negative. The patient was discharged home with a prescription for antibiotics, and was instructed to decrease her physical activity and increase fluid intake. In addition, she was counseled about preterm labor precautions and instructed to call her doctor’s office in 48 hours for follow-up and to check the results and sensitivity of her urine culture. She also was instructed to schedule a doctor’s appointment in 1 week.

At 35 weeks’ gestation, the patient again visited the triage unit reporting symptoms similar to those of her first visit. Evaluation revealed no preterm labor, and she was again discharged home. She had a spontaneous vaginal delivery at 37 weeks with good neonatal outcome.

Pages

Next Article: