Common Triage Problems

OverviewLabor EvaulationProdromal LaborSROMDecreased Fetal MovementBleedingAbdominal Trauma/FallsPre-eclampsiaAbdominal PainPreterm LaborPreterm Premature Rupture of Membranes

Labor EvaluationAlways get a history, don’t rely only on prenatal record!!!

Review prenatal, and ask the patient as wellTake HPI

Timing of ContractionsAny vaginal bleeding? (ie: spotting, bleeding with wiping, frank bleeding)Any fluid gush/leaking?Fetal Movement? Has it changed? What was last vaginal exam in office? (Note date and dilation)

Labor Evaluation

What is Labor?Labor is painful contractions causing cervical change over time

Do SVE (unless contraindicated)You need to prove there is change, everyone should get checked if you think they are in labor. This is also why you need to know what the patient was dilated to in clinicLabor evaluations take TIME! You need to prove there is change

Labor Evaluation

You have checked the patient, now what?Give the patient a chance to change, again remember, this evaluation can take time.Re-check in 1-2 hoursIf no change, consider walking the patient. If on recheck there is cervical change à AdmitIf no change à Home after Reactive NST

Prodromal LaborPatient is miserableContractions seem painful and frequent but NOcervical changeMain problem= patient exhaustionTreat like a labor evaluationIf going home, encourage bath, offer Ambien 5-10mg or Hydroxyzine for sleep If you cannot send patient home you can admit for therapeutic rest

Morphine sleep-10-15mg IM MSO4 +/-IVF

SROM/PROMSpontaneous Rupture of Membranes /Premature Rupture of Membranes

Leaking fluid – May be the dramatic big gush or slow leak (think peeing your pants)

Do SSE and look for: Pooling,Ferning + Nitrazine AFI may help in certain circumstances

In some places you can use Amnisure

Sterile Speculum Exam(SSE)• Graves Speculum • Pederson Speculum

Amniotic Fluid Ferning

SROMVerify GBS status and if SROM confirmed, start antibiotics immediately if GBS+If still unsure of rupture after SSE, re-examine after 1 hr.If the patient is NOT in labor, but ruptured (PROM) Check with attending, some will want SVE others may not.

Decreased Fetal MovementGet a good history from patient

Length of time of no FM and find out how she has been monitoring this

Place of monitor Await reactive NST (if>32wks). Reassuring if <32wks. Doptones ok if <24wks—reassurance.

If non-reactive, may need to do BPP (call Senior)

Fetal DemiseIf no heartbeat detected

If the RN is NOT getting a heartbeat and you cannot find it by US…CALL YOUR SENIOR RESIDENT!Call attending immediately! You should not typically as an intern being delivering the diagnosis of demise

Fetal Demise

Keep in mindThe ultrasound used for FHT will pick up an adult heart rate on the strip in a demise

This looks like a FHR tracing but with bradycardia. If in doubt, take maternal pulse, do US with M-mode (Ask Senior to help)

Fetal Demise

Keep in MindThere are patients who will come into triage who are NOT pregnant but say they are (pseudopsychiasis)

These patients may often need psychiatric assistanceYou may need to consider having security on floor in this instance as this can cause significant problems with FOB and these patients are at higher risk for infant abduction

BleedingAlways consider gestational age and nature of bleeding

2nd vs 3rd trimester Painful vs. Painless Bleeding

Almost always perform SSEAlmost never check patient before SSE.

Only exception is placenta previaCheck with attending as to preference. Best to hold on SSE and admit for a formal US. Do bedside US first to look at placenta position

Bleeding

Quantify amount of VB If patient unstable or NRFHT’s she may need emergent or crash C/S

Remember, patients with abruption can deliver fast – there are times to do a SCE

Abruptions does not always equal C-Section

BleedingCommon Etiologies: Abruption, Placenta Previa, Bloody Show, Laceration, Friable CervixVerify mothers Rh status, T&SOn SSE: use rectal swabs, clean out and look all around, see if active bleeding from os vs friable cervix – may want sponge stick available.Abruption Labs: CBC, KB, fibrinogen(<200 concern) and T&S vs. draw and holdIf mother Rh-, ad KB shows >15cc fetal cells need to give Rhogam(300mcg full dose)Bleeding often associated with preterm labor / PPROM

Bleeding• Placenta Previa • Placenta Abruption

Abdominal Trauma/FallsWas there abdominal trauma or not?

This may dictate the length of monitoringIf no or limited abdominal trauma, the fetus needs to be monitored for 4 hours continuously. If contractions, or FHR abnormalities, direct abdominal trauma

24hrs of monitoring indicated.General management:

Treatment priorities directed toward injured pregnant woman as they are for non-pregnant patients. First stabilize the mother.

Abdominal Trauma/FallsPhysical exam to look for fractures/abrasionsVerify Rh status

If Rh-, obtain KBSometimes patient needs to go to ER for further evaluation ( or re-evaluation) after fetal status shown to be stable.

Remember we don’t fix fractures, gun shot wounds, etc.

High Blood PressureHistory is important

Timing of blood pressuresGestational ageIs it Gestational HTN, pre-eclampsia, or just an isolated elevated BP?

Have RN take serial BP’s

High Blood Pressure

Characterize symptomsGet a good history (Is there an echo in here?)

HeadacheN/V, Epigastric or RUQ pain, New swelling, weight changes Is HA different from normal HA? History of migraines? Does it go away with Tylenol?

Send Labs if indicatedPro/Cr RatioPre-Eclampsia Panel

Pre-eclampsiaConsider pre-eclampsia panel and CBC:

AST, ALT, BUN, Cr, Uric Acid, LDHLook at prenatal for baseline BP’sIf prior than 20wksàsuspect CHTNWork-Up Options

Inpatient Monitoring with 24hr urine protein or Pro/Cr ratio, formal USSend home with precautions and a 24hr urine jug, close f/u plan with primary OB.

Abdominal PainHave a broad DDx:

Gallstones, Kidney stones, appendicitis, Gastroenteritis, Hepatitis, Crohn’s, IBS, Cystitis or Pyelo, hydronephrosis, Pancreatitis, adnexal mass, Round Lig pain, pre-eclampsia or HELLPNormal pains and discomfort of pregnancy

Abdominal Pain

Work UpLabs

UA, CBC, lytes, LFT’s, amylase, lipase?

ImagingUS to evaluate upper abdomen, renal USCT scan acceptable if necessary and indicatedMRI safe

AdmissionBe open to the need to admit for 23hr obs, pain meds, further workup.

Preterm LaborSymptoms can be very subtle

back pain, nausea, “just don’t feel right”, menstrual-like cramps, spotting.“Spec before you check”Perform SSE first and get:

GBS (rapid), GC/Chlamydia, wet mount, nitrazine and ferning slides, UA, FFN (attending dependent) if 24-34wks and nothing per vagina x 24hrs.

Preterm LaborOK to perform SVE after SSEPlace patient on the monitorConsider US for position, fluid and growthMain question: Are they changing their cervix, do they need tocolytics to get through the steroid window.Same examiner checking over 1-2hrs

Preterm Premature Rupture of Membranes (PPROM)

SROM<37wks confirmedAdmitGet GBS Ultrasound for position and EFWIf <34wks, give steroidsStart Amp/Erythro IVx48hrs then Amox/Erythro POx5days for latency. Daily NSTDeliver at 34 0/7

Golden Rules of TriageIf in doubt, ask for help and guidanceThe Labor and Delivery RN’s know more than you do (Seriously)If SCE feels funny, it’s probably breechAsk for helpSigns and symptoms of both pre-eclampsia/HELLP and PTL can be very subtleAsk for helpResist pressure to move patients out quickly. Ask for helpThink through your assessment and plan before calling the attending Ask for helpWe all make mistakes, learn from them