Triage

Triage Checklist

Obtain pt name/DOB

Have pt change into gown

Obtain clean catch urine sample

Arrive pt into Epic (O2)

Device select monitor

Admit pt into Obix

Place OB Triage Order

Obtain/Review Prenatal Records

Print/Place ID bands (pt and allergy)

Print labels

Complete urine dipstick

Complete Patient Profile: Important to first ask

about ROM, fetal movement, contractions, and

bleeding.

Assessment (w/in 10 min of arrival)

Assess heart tones w/in 10 min of arrival

Notify doctor

New pt education assessment/teaching

Care plan

Triage Charting

Profile

Assessment

Confirm vitals (must have vitals w/in 30 min of

DC)

Heart tones

Care Plan (Discharge care plan)

Education

D/C tab under L&D (ask when follow up appt.)

Krames Teaching for D/C

Pt>37 weeks: Recognizing Labor, Kick

Counts, Benefits of Breastfeeding, Delivery

Prep sheet (add whatever other teaching pt

needs - i.e. medications, condition specific

Pt

Triage Vital Signs

Upon Admission to triage:

Assess and document routine vital signs which include

HR, BP, RR, SpO2, and pain.

Obtain temp at admission and q1hr if febrile

Assess and document Pulse, BP, SpO2, & RR q1hr

Notify physician and assess V/S q15min x1 hour if any

of the following are met:

Pulse > 120

SBP < 80, > 140

DBP < 50, > 90

RR > 20

SpO2 < 95%

Triage Fetal Heart Tone

Assessment

Assess FHR w/in 10 min of pt arrival to unit. Fol-

low guidelines for gestational age:

< 20 weeks - doppler FHR upon presentation

20-24 weeks - attempt to obtain 20 min of con-

tinuous monitoring. If unable, notify physician

and doppler FHR upon presentation is this right? 20-24 weeks?

> 24 weeks - obtain 20 min of continuous fetal

monitoring

If we have never seen the pt, obtain 40 min of con-

tinuous fetal monitoring

If pt has category I strip, absent vaginal bleeding,

and apparent latent phase of labor, switch to inter-

mittent monitoring or auscultation. Allow pt to

walk as appropriate between sessions.

Category II Strip: Notify Physician and obtain or-

der for auscultation , continuous or intermittent

fetal monitoring

Category III Strip: Notify physician immediately

and prepare patient for possible expedited delivery

Triage Notes:

Make sure to place OB Triage order - Indi-

cate Pregnancy as reason for admission

Make sure to order NST and complete NST

form, if applicable.

Have the resident sign off the NST

before pt is discharged.

If urine drug screen is necessary:

Obtain and document verbal consent

for UDS

Triage

Common Triage Pt complaints:

R/O Labor

R/O PTL

R/O ROM

R/O Preeclampsia

Decrease Fetal Movement

Pelvic Pain

Special Notes for consideration

If you are unsure of pt history, have no prenatal

records, or are suspicious, ask for order to send

a UDS. However, you must get permission

from the pt to send the UDS, and you need to

document that the pt gave you permission in a

note.

Always remember OB Triage Order.

Urine dipsticks are very important. Please

document urine dipstick results on all patients.

This could help us identify a preeclamptic pt

early on.

Triage Cont.

Special Notes for consideration Cont.

Dont be afraid to make suggestions to the resi-dents about sending labs. Better to suggest

sending them early, rather than waiting until

the pt has been here for two hours, then send-

ing labs.

For any pt complaining of vaginal bleeding: Do

NOT perform a SVE until you verify there is

not previa.

DO NOT perform SVE on preterm pts unless

you are the only person on the floor and it is

ABSOLUTELY necessary.

DO NOT perform SVE on: bleeding, preterm,

or R/O rupture

Swab and Culture Info Cont.:

Amnisure ROM

To be used if other methods of ruling out ROM are

inconclusive

Supplies: Amnisure packet

1) Physician will swab for 1 minute to collect sample

2) RN will swish swab in the solution for 1 minute

3) Remove swab and throw away

4) Label specimen and send to lab.

**Call and alert lab that the swab is coming. The test

must run w/in 15 min of collection for accurate re-

sults**

*Results are not affected by blood, semen, or urine

Swab and Cultures:

FFN - Fetal Fibronectin

MUST be collected before anything else is placed in

the vagina

Supplies: FFN packet (swab & tube)

The physician will swab under SSE for 10 seconds,

put swab in container, break off, cap tube, label,

send to lab

May have false + if anything has been in the va-

gina over the past 48 hours. May have false + with

urine, blood, or vaginal mucous

Done for 24-34 weeks gestation


GBS

Supplies: White Culture Collect Swab

Swab around the vagina and then down to the rec-

tum. Place swab into container and snap the lid in

place. Label and Send


Gonorrhea/Chlamydia

Supplies: Orange top tube Gonorrhea/Chlamydia

packet - use applicator in package

The physician will swab under SSE. They will use

1 swab and place it into the orange top vial. Make

sure the lid is screwed onto the vial tightly. Label

and send.

**Gonorrhea and Chlamydia are two separate orders -

make sure you put in both orders when sending down

this specimen

Swab and Cultures:

Nitrazine

Tests for the pH in vaginal fluids. Tests for Rupture of

Membranes

Supplies: Nitrazine swab

PH indicator on nitrazine swab will change color

with the presence of amniotic fluid

Green - Black indicates presence of amniotic fluid

Yellow - Orange indicates absence of amniotic

fluid

Equivocal is not an acceptable result per manufac-

turer

Avoid blood, urine, and cervical mucus - these

may result in a false positive reading

R/O Labor

What is gestational age? How were dates deter-

mined? Does she have a prenatal care provider?

Assess FHR and contraction pattern

Is she high risk?

Does she look uncomfortable?

Is she ruptured?

Is there vaginal bleeding?

Have resident examine pt, or ask if they want you

to check pt

Follow orders given

Probable cultures

GBS (if not available)

Wet prep if any signs of infection/abnormal

discharge

Nitrazine if any report of loss of fluid

R/O Pre-Term Labor

What is the pt gestational age? How were dates

determined? Does she have a prenatal care pro-

vider?

DO NOT check a preterm pt!! (Unless absolutely

necessary). Get DRs Assure that she has had nothing in her vagina for

24 hrs (intercourse, digital exam, etc.) Have physi-

cian perform SVE (No gel on speculum). The first

swab will be FFN.

Prepare supplies:

Speculum

Flashlight

Sterile gloves

Swabs/cultures (see below)

FFN

Wet Prep

GC/Chlamydia

GBS

Assess FHT and contraction pattern

Follow orders as given

Mag is used for CP ppx, not to stop labor

R/O Rupture

Dont check your patient Assess for visible fluid

Is she contracting? Is she bleeding? How long has

she been ruptured? What color is the fluid? Any

odor?

Assess FHR and contraction pattern

Follow orders given

Prepare for SVE

Speculum

Flashlight

Sterile gloves

Swabs/cultures (see below)

FFN

Look for Pooling

Amniswab, Smear Amniswab on slide and give

to resident to assess for ferning under micro-

scope

Amnisure needed?

GC/Chlamydia

Wet Prep

R/O Preeclampsia

Apply EFM and assess vital signs

Test for clonus and DTRs

Labs: CBC, CMP, LDH, Uric acid, Clotting Fac-

tors, U/A, Protein Creatinine Ratio

Supplies needed: Straight Cath, purple top lab

tube, mint top lab tube

If pt has treatable pressures (systolic over 160/

diastolic over 105), get IV access immediately.

Potential IV meds: Hydralazine, Labetalol,

Magnesium

Foley if starting Magnesium

Order pumps immediately if starting Mag.

NEVER start Mag w/o a pump!!!!

Decreased Fetal Movement

Place pt on monitor ASAP

If no FHR, ask resident to verify FHR via ultra-

sound

If positive FHT, obtain NST

Highly consider BPP, especially if pt is close to

term

Complaint of Pelvic Pain

Clean catch urine w/ dip. If absolutely normal,

straight cath with U/A & C&S

What is GA?

If term, contractions?

If preterm, round ligament pain? Pain with move-

ment? Pre-term labor?

UTI: Itching/Burning? Pain or burning with urina-

tion?

Other infection: abnormal discharge? Pain/

burning?

PTL: Contractions? Dehydration? Infection?

Is there any vaginal bleeding? Abruptions/previa?

Monitor FHR and contraction pattern

Cultures:

FFN if PTL is suspected

Amniswab if ANY report of fluid loss

Wet Prep

GC/Chlamydia

GBS if appropriate

Triage:

Pt w/ abdominal trauma

Initiate peripheral IV

Obtain the following labs:

FDPFibrin Deg. Products Kleihauer Betke Fetal HGB ST (KB) - purple

top tube

Saline lock IV

Notify physician

ADD that we need 4 hours CEFM after

trauma? Is that right?

Triage:

Pt w/ BP above SBP>140 or DBP>90


Obtain the following labs

CBC w/ diff

CMP

Uric Acid

LDH

ALT (in CMP)

AST (in CMP)

UA - straight cath sample

Spot CheckUrine Protein/Creatinine Ratio Saline lock IV

Notify physician

Need straight cath, purple top tube, mint top tube

Triage:

Pt w/ dysuria


U/A and urine culture/sensitivity per straight

cath

CBC w/ diff

Notify physician

Triage:

Pt w/ large vaginal bleeding



Protime (PT)

INR

PTT (APTT)

Fibrinogen

FDPFibrin Deg. Productions Kleihauer Betke Fetal HGB ST (KB) purple

top tube

Type and Screen

Urine drug screen

Saline lock IV

Notify physician

Possibly an H&H and CMP, also but these 2 labs

are not included under the triage protocol.

Documents

Triage