Participants will understand what a maternal-fetal triage tool is and how to apply it clinically.
After completing this continuing education course, the participant will:
The Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) defines obstetric (OB) triage as “the brief, thorough, and systematic maternal and fetal assessment performed when a pregnant woman presents to care to determine priority for full evaluation.1” A maternal fetal triage assessment tool is a tool that can be used for nurses to determine the medical and nursing needs of the pregnant woman who arrives at a triage unit or labor and delivery unit. Not all hospitals have maternal fetal triage units, so this may occur in the labor and delivery unit. “OB triage is a multidisciplinary specialty within the labor and delivery unit. It is comparable to an emergency department with unpredictable census, chief complaints, and unexpected challenges.2”
Prior to 2007, a maternal fetal triage assessment tool did not exist. Since that time, 3 tools have been created.2 The newest, evidence-based tool created by the Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN) was developed in 2015.3 Not all hospitals have adopted a tool for triaging patients.
Women frequently come to labor and delivery units for triage as a non-pregnant woman would go to the Emergency Department, where triage levels are used. The American College of Obstetricians and Gynecologists (ACOG) has released a committee opinion that supports the use of maternal fetal triage guidelines.4 ACOG believes that triage guidelines could improve the quality and efficiency of care that women receive when going to labor and delivery.
Obstetric triage patients can increase the volume of a labor and delivery unit by 20-50%. As many as 1/3 of all women that present to labor and delivery go home without delivering their baby.5 These increased volumes can impact patient care and outcomes. Nurses need a way to evaluate the pregnant woman and determine the level of care needed, and the speed at which that care must be given.
According to the federal Emergency Medical Treatment and Labor Act (EMTALA), all pregnant women who present to a hospital must receive an initial medical screening exam to determine if a medical emergency exists, regardless of the patient’s ability to pay or where the woman usually received care.6 Women who are not determined to have an emergency may be transferred if appropriate.
Different tools may look different and use slightly different criteria. The tool will have categories into which the patient should be classified.7 These categories will also determine the time in which 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 has been adapted and is used to determine acuity of patients.5
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 is having 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 who is scheduled for a non-stress test with no complaints would be placed in the fifth category, or scheduled.5 Currently, this is the only triage assessment tool that has been validated.
The categories should guide the nurses and providers as to 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 who is 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.
A labor and delivery unit is like an Emergency Department, where the next patient is usually unknown. One woman or 5 women may walk in the door at any given time. Nursing units are not often staffed for the walk-in patients. Triage patients are usually not included in staffing ratios, even though they require nursing time. The number of providers and resources may also be limited depending on the size and area of the hospital. At any time, a woman or her fetus may be in a life or death situation. Having a maternal fetal triage tool in place to guide the care and timeliness of care may improve the outcome for the mother, fetus, or both. Women in labor and delivery units should not receive care in the order of arrival. They must be cared for in order of priority.5 A process to evaluate maternal and fetal status in a triage setting is important to ensure the best outcomes for the woman and her baby.
Two pregnant women arrive in a busy labor and delivery unit for triage. All nurses have patient assignments when these 2 women arrive. Both women go into evaluation rooms. A nurse goes into each room. One woman is 35 weeks with heavy bleeding. The other woman is 41 weeks in early labor. Using a triage tool, the RN knows that she must triage the bleeding woman first.
Using a maternal fetal triage tool, the RN will determine which patient needs to receive medical treatment first.
With a triage tool, the RN will see the bleeding woman first, because there is a chance of a placental abruption that could put the woman or fetus at risk.
A RN with experience may already know that a bleeding pregnant woman is at higher risk of a complication, but a new nurse may think that the 35-week woman is too early to deliver and choose to see the early labor patient first. Using this tool will also enable the nurse to determine that this patient needs care urgently.