Different tools may look different and use slightly different criteria. The tool will have categories into which the patient should be classified (Ruhl, 2015). These categories will also determine when the woman should be treated.
The obstetric triage acuity scale is a 5-category system that determines when women should be admitted and the times within an assessment should occur. This system does not have good data to support its use, but it has been adapted and used to determine patients' acuity (CO, 2016).
The AWHONN maternal fetal triage index has 5 categories. The nurse who sees the patient first (or triages them) would use this tool to determine which category the patient belongs in. For example, a woman who comes to the unit via stretcher and has a seizure would be placed into the first category or stat. A woman with decreased fetal movement or a recent trauma would be placed in the second category, or urgent. A woman ≥ 34 weeks in active labor would be placed in the third category, or prompt. A woman ≥ 37 weeks in early labor would be placed in the fourth category, or non-urgent. A woman scheduled for a non-stress test with no complaints would be placed in the fifth category or scheduled (CO, 2016). Currently, this is the only triage assessment tool that has been validated.
The categories should guide the nurses and providers when the woman will receive treatment. Each case needs to be evaluated using critical thinking, but these are basic criteria to help guide the nurse and provider. A woman brought in after a motor vehicle accident with abdominal trauma should take precedence over a woman who is 37 weeks gestation and comes in because her water broke.
Each hospital should choose a maternal fetal triage assessment tool to guide the care of the woman who arrives at labor and delivery for triage.
