INTRODUCTION

Advancements in diagnostic and therapeutic techniques have ushered a new era in obstetrical medicine, as a result of which maternal mortality and morbidity statistics are touching the lowest ebbs in the developed countries .¹Obstetric triage has now become part of the fabric of obstetrics. As a specialty within perinatal care, it came of age in the 1980s-1990s in the United States and internationally, and flourished during the early part of the 21st century. ³Triage is one of the most important and challenging tasks of the emergency department. The word triage is derived from the French verb trier, which means to sort or to choose. ²Obstetrical triage exists to meet this same purpose.

Factors responsible for this movement toward use of obstetric triage units include: the need to improve utilization of obstetric bed capacity, provide less turnover of patients in the labor/delivery setting, allow for more immediate rapid response to obstetric emergencies, prevent unnecessary labor admissions, decrease waiting times, and provide heightened assessment of fetal and maternal well-being. Over the decades, role responsibilities within the obstetric triage setting have changed as nurses, physicians, midwives, and other providers have become part of a more collaborative model of obstetric triage care. ³

Purposes for obstetric triage.⁴

a) Provide urgent care for pregnant women.

b) Improve obstetric services.

c) Expeditiously assess patients.

d) Remove pregnant women from emergency room waits.

e) Prevent unnecessary admissions.

f) Decrease patient wait time.

g) Avoid tying up limited labour beds

h) Gate keeper to monitor room utilization and prioritization

i) Decrease workload in labour and delivery room.

j) Save time, money and improve patient flow.

Functions of obstetrics triage units. ⁵

• Referrals and transfers

• Triaging of obstetrics telephone calls

• Selected obstetrics procedures, labour assessment and evaluation

• Decompression of labour and delivery

• Fetal evaluation and assessment

• Evaluation of medical and obstetrics complaints

• Initial stabilization of obstetrics complications

• Evaluation of obstetrics

Common conditions present to the emergency department according to gestational age .⁶

Problems occurring prior to 20 weeks

Pregnant women frequently present to the emergency department with vaginal bleeding. Common causes include various types of miscarriages (i.e. threatened, inevitable, complete, incomplete and septic). Knowledge of the volume and colour of per vaginal (PV) loss will assist the triage nurse with categorising the urgency of the case.

• Bright red blood loss is usually indicative of active bleeding, while brownish red blood loss is usually old.

• Many women may also complain of associated abdominal pain that may be likened to severe period pain.

• Shoulder tip pain can be indicative of a bleeding ectopic pregnancy.

• The first and foremost diagnosis to exclude in the female of child-bearing age, including those who have undergone sterilisation procedures presenting with vaginal bleeding, is an ectopic pregnancy.

Abdominal pain is the most common symptom in ruptured ectopic pregnancy.Non-ruptured ectopic pregnancies generally present with bleeding (brown being the most common) due to low progesterone and consequent shedding of the decidua.

Regardless of the diagnosis, vital signs that deviate from normal and severe pain (such as torsion or ruptured cysts) warrant prompt medical assessment.

Problems occurring from 20 weeks onwards

Pregnant women from 20 weeks gestation may present with the following obstetric conditions:

• Ante partum haemorrhage

• Preeclampsia (including eclampsia)

• Pre-term rupture of the membranes and labour.

Hypertension (>140/90) is a particularly important sign to alert the triage nurse to a more serious problem. The presence of the associated symptoms of severe preeclampsia warrants urgent medical assessment.

These include:

• Headache, Visual disturbances, epigastria pain, right upper quadrant (RUQ) pain, non-dependent oedema.

These women are at risk of fitting and placental abruption, and the foetus has a higher risk of placental insufficiency.

There is a correlation between the degree of hypertension and complications such as cerebral haemorrhage.

• Ante partum haemorrhage is defined as >15 mL of blood loss from the vagina from 20 weeks gestation.

• Common causes include placenta praevia and placental abruption.

• In placenta praevia, blood loss is usually visible PV and is not usually accompanied by pain.

• In placental abruption, the primary symptom is abdominal pain. The associated blood loss may be concealed between the placenta and uterus.

Haemodynamic changes are only seen with big bleeds, smaller bleeds may be difficult to detect or more easily detected with an abnormal cardiotocograph (CTG).The main signs and symptoms are hemodynamic changes associated with hypovolaemic shock and abdominal pain.

Postnatal women may present with the following:

Secondary postpartum haemorrhage, puerperal sepsis, mastitis, wound infection, eclampsia, postpartum cardiomyopathy

• Postnatal depression.

Urgent threats to foetal wellbeing:

• Changes in oxygen saturations in the mother are of direct relevance to foetal wellbeing. A small reduction in maternal oxygenation can severely impact on foetal oxygenation because of the left shift in the oxyhaemoglobin dissociation curve

associated with foetal haemoglobin. Consider oxygen saturation at triage on all pregnant women.

• Major alterations in blood pressure (whether high or low) are not well tolerated by the foetus.

• Active vaginal bleeding at any gestation presents a risk to the foetus.

• Abdominal pain during pregnancy may represent a pathological process threatening the foetus.

• Pregnant women normally feel foetal movement from 18–20 weeks gestation. A regular pattern of foetal movement is a reassuring sign of foetal wellbeing. Absent or diminished foetal movements require prompt assessment

Obstetrical triage acuity scale (OTAS^)
.7

The obstetric triage and emergency department triage differ in significant ways. The most common task required of obstetric triage personnel is labor evaluation. In obstetrics triage generally refers to the initial interview and assessment as well as care in the triage unit for several hours before patient disposition. Other common presenting symptoms are possible rupture of the amniotic membranes prematurely or at term, premature uterine contractions, decreased fetal movements, vaginal discharge, urinary tract symptoms, and concerns related to the prenatal course and non-obstetric symptoms (e.g., upper respiratory complaints).¹⁰

The need for a reliable and valid obstetric triage tool is crucial to eliminate time delays, not just patient to initial nursing assessment time, but patient to provider delays. OTAS is the first standardized acuity assessment tool designed specifically for pregnancy-related problems with established reliability and validity. Introduced in 1999, revised 2008 OTAS is a five-category acuity scale (resuscitative to non-urgent) with a comprehensive set of obstetrical determinants. The implementation of a standardized assessment of acuity in the obstetrical triage unit using OTAS has enabled the assessment of the distribution of acuity, the measurement of patient flow stratified by acuity, and assessment of triage interventions to improve patient flow.

Obstetrical triage acuity scale (OTAS)

OTAS	Level 1 (resuscitative )	Level 2 (emergent )	Level 3 (urgent)	Level 4 (less urgent)	Level 5 (non-urgent)
Time to physician	Immediate	≤ 15mts	≤ 30 mts	≤ 60mts	≤ 120 mts (2 hours )
Re-assessment	Continuous nursing	Every 15 mts	Every 15 mts	Every 30 mts	Every 60 mts
Labour/fluid	-Imminent birth	-Suspected preterm la bour/ PPROM<37 weeks	-Signs of active labour 37 weeks	-Signs of early labour/ PROM>37 weeks	-Discomforts of pregnancy
Bleeding	-Active vaginal bleeding with or without abdominal pain	-Bleeding associated with cramping (>spotting )<37 weeks	-Bleeding associated with cramping (>spotting )>37 weeks	-Spotting
Hypertension	-Seizure activity	-Hypertension >160/110 and or headache ,visual disturbances,RUQ pain	-Mild hypertension >140/90 with /without associated signs and symptoms
Fetal assessment	-Abnormal FHR tracing -No fetal movement	-Atypical FHR tracing, abnormal BPP, Abnormal dopplers, Decreased fetal movement
Other	-Acute onset severe abdominal pain -Altered level of consciousness -Cord prolapsed -Severe respiratory distress -Suspected sepsis	-Major trauma -Shortness of breath -Unplanned and unattended birth	-Abdominal /back pain greater than expected in pregnancy -Flank pain /hematuria -Nausea /vomiting and /or diarrhea with suspected dehydration	-Ongoing assessment from outpatient clinic (for hypertension, blood work) -Minor trauma -Nausea /vomiting and /or diarrhea -Signs of infection (ie.dysuria,cough,fever,chills )	-Anything that does not seem to pose threat to mother or fetus -Cervical ripening -Out patient placenta previa protocol -Pre booked visits (i.e., Rh and progesterone injections, NST) -Assessment for version -Rashes

Policy regarding documentation.⁸

Documentation of the patient’s admission (including triage notes) should make reference to the following:

– Date and time of assessment

– Name of attending triage nurse

– Presenting complaints

– Relevant history

– Relevant assessment findings

– Allocated triage category

– If re-triage is necessary the re-triaged along with time and reason for this.

– Assessment and any diagnostic, first aid or other treatment measure provided

– Discharge plan if the patient is discharged from triage or emergency

– RN signature

It is important that the triage nurse document if the history was obtained from someone other than the patient. When documenting a triage assessment use as many of the patients own words in quotation as possible, in addition to the objective data that has been collected

Potential errors / issues in obstetric triage.⁹

· Incorrect assessment of maternal condition, fetal well-being, or pregnancy-related complications

· Failure to diagnose active labor

· Inappropriate discharge from the triage unit

· Incomplete or poorly documented record

· Failure to comply with the standard of care for treatment

· Safety related issues like excessive waiting time, crowding, delays in early recognition of significant events. Having a surge policy to deal with overcrowding and use of fast-track, observation, and holding rooms, equipped with monitoring capability, are all helpful in managing overcrowding

CONCLUSION:

Obstetric triage approach has been shown to reduce length of stay, increase patient satisfaction and reduce unnecessary admissions. Stabilization of the obstetric patient with any emergency condition, whether or not the condition is obstetric related is of the utmost importance otherwise the effect on the fetus may be detrimental. Policies and procedures for the care of an obstetric patient presenting to the emergency department can address a number of factors, including the nature of the complaint, the availability of consultants and testing, the gestational age of the fetus, the need for fetal evaluation, and transfer of the patient between emergency department and obstetric departments. In addition, open lines of communication between providers are necessary in order to provide optimum care for both patients when an obstetric patient presents to the Emergency department.

REFERENCES:

1. Sukhwinder Kaur Bajwa and Sukhminder Jit Singh Bajwa. Delivering obstetrical critical care in developing nations. Int J Crit Illn Inj Sci. 2012 Jan-Apr; 2(1): 32–39.

2. Sheehy. Emergency nursing principles and practice. 6^th ed . Mosby Elsevier: USA; 2 010 .59-64

3. http://nursingcenter .com /cearticle.

4. Wanda Jeavons, Shady Grove. The ARNP in ob triage. https://awhonn.confex.com/awhonn/2007/recordingredirect.cgi/id/183

5. Diane. J. Angelini, Donna La Fontaine. Obstetric triage and emergency care protocols. springer publishing company: Newyork;

6. Common Wealth Department of Health and Ageing. Emergency Triage Education Kit. Canberra, Australian Government. 2007 https://www.health.gov.au/internet/main/...nsf/.../Triage%20Workbook.pdf

7. http://www.lhsc.on.ca/About_Us/LHSC/Publications/Homepage/Obstetrical-Triage-Acuity-Scale.htm 2013.

8. Australasian College for Emergency Medicine. - Policy on the australasian triage Scale. Melbourne: Australasian College for Emergency Medicine; 2006. Available from http://www.acem.org.au/media/policies_and_guidelines/P06 Aust Triage Scale Nov 2000.pdf

9. Gary Ventolini, Mdran Neiger .Avoiding the pitfalls of obstetric triage.OBG management. July 2003 · Vol. 15, No. 7

Received on 22.01.2016 Modified on 27.01.2016

Int. J. Nur. Edu. and Research. 2016; 4(2): 227-230.

DOI: 10.5958/2454-2660.2016.00045.4