1. Common Triage Problems

2. Overview Labor Evaulation Prodromal Labor SROM
Decreased Fetal Movement
Bleeding
Abdominal Trauma/Falls
Pre-eclampsia
Abdominal Pain
Preterm Labor
Preterm Premature Rupture of Membranes

3. Labor Evaluation
Always get a history, don’t rely only on prenatal record!!!
Review prenatal, and ask the patient as well
Take HPI
Timing of Contractions
Any 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)

4. Labor Evaluation What is Labor? Do SVE (unless contraindicated)
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 clinic
Labor evaluations take TIME! You need to prove there is change

5. 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 hours
If no change, consider walking the patient. If on recheck there is cervical change  Admit
If no change  Home after Reactive NST

6. Prodromal Labor Patient is miserable
Contractions seem painful and frequent but NO cervical change
Main problem= patient exhaustion
Treat like a labor evaluation
If 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

7. SROM/PROM
Spontaneous 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

8. Sterile Speculum Exam(SSE)
Graves Speculum
Pederson Speculum

9. Amniotic Fluid Ferning

10. SROM
Verify 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.

11. Decreased Fetal Movement
Get 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)

12. Fetal Demise If 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

13. Fetal Demise Keep in mind
The 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)

14. Fetal Demise Keep in Mind
There are patients who will come into triage who are NOT pregnant but say they are (pseudopsychiasis)
These patients may often need psychiatric assistance
You 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

15. Bleeding Always consider gestational age and nature of bleeding
2nd vs 3rd trimester
Painful vs. Painless Bleeding
Almost always perform SSE
Almost never check patient before SSE.
Only exception is placenta previa
Check 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

16. 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

17. Bleeding
Common Etiologies: Abruption, Placenta Previa, Bloody Show, Laceration, Friable Cervix
Verify mothers Rh status, T&S
On 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 hold
If mother Rh-, ad KB shows >15cc fetal cells need to give Rhogam(300mcg full dose)
Bleeding often associated with preterm labor / PPROM

18. Bleeding
Placenta Previa
Placenta Abruption

19. Abdominal Trauma/Falls
Was there abdominal trauma or not?
This may dictate the length of monitoring
If 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.

20. Abdominal Trauma/Falls
Physical exam to look for fractures/abrasions
Verify Rh status
If Rh-, obtain KB
Sometimes 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.

21. High Blood Pressure History is important Have RN take serial BP’s
Timing of blood pressures
Gestational age
Is it Gestational HTN, pre-eclampsia, or just an isolated elevated BP?
Have RN take serial BP’s

22. High Blood Pressure Characterize symptoms Send Labs if indicated
Get a good history (Is there an echo in here?)
Headache
N/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 indicated
Pro/Cr Ratio
Pre-Eclampsia Panel

23. Pre-eclampsia Consider pre-eclampsia panel and CBC:
AST, ALT, BUN, Cr, Uric Acid, LDH
Look at prenatal for baseline BP’s
If prior than 20wkssuspect CHTN
Work-Up Options
Inpatient Monitoring with 24hr urine protein or Pro/Cr ratio, formal US
Send home with precautions and a 24hr urine jug, close f/u plan with primary OB.

24. Abdominal Pain Have 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 HELLP
Normal pains and discomfort of pregnancy

25. Abdominal Pain Work Up Imaging Admission Labs
UA, CBC, lytes, LFT’s, amylase, lipase?
Imaging
US to evaluate upper abdomen, renal US
CT scan acceptable if necessary and indicated
MRI safe
Admission
Be open to the need to admit for 23hr obs, pain meds, further workup.

26. Preterm Labor Symptoms can be very subtle “Spec before you check”
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.

27. Preterm Labor OK to perform SVE after SSE Place patient on the monitor
Consider US for position, fluid and growth
Main question: Are they changing their cervix, do they need tocolytics to get through the steroid window.
Same examiner checking over 1-2hrs

28. Preterm Premature Rupture of Membranes (PPROM)
SROM<37wks confirmed
Admit
Get GBS
Ultrasound for position and EFW
If <34wks, give steroids
Start Amp/Erythro IVx48hrs then Amox/Erythro POx5days for latency.
Daily NST
Deliver at 34 0/7

29. Golden Rules of Triage If in doubt, ask for help and guidance
The Labor and Delivery RN’s know more than you do (Seriously)
If SCE feels funny, it’s probably breech
Ask for help
Signs and symptoms of both pre-eclampsia/HELLP and PTL can be very subtle
Resist pressure to move patients out quickly.
Think through your assessment and plan before calling the attending
We all make mistakes, learn from them