Triage Senarios
Literature:
ACOG Com Opin Hospital Based Triage (2016)
Seminars in Perinatology - Obs and fetal triage (2020)
See Specific Scenario resources below
Other useful links:
Data supported tool for OB triage acuity -- AJOG article about OTAS system 2013 and JOGC OTAS system 2016 review
This is another adaptation of the OTAS above - similar 5 tier scale with different organization
Specific Scenario Resources:
Remember: Get a FFN first!! You can always not send it on but once exam done can't collect it.
Triage pathway preterm.PNGManagement of Preterm Labor:
Corticosteroids – for fetal lung maturity
Single course for singleton 24-34 weeks gestation; repeat for less than 34 weeks if previous course was >14 days ago
Single course 34-37 weeks if not previously given
Magnesium – for fetal neurologic protection
If <32 weeks gestation
Tocolysis – general goal is to get through steroid/mag windows
Ie nifedipine, terbutaline
Rule out Rupture:
Amnisure – Vaginal swab, processed in lab
Significant bleeding and recent digital exam interfere with result (The performance of AmniSure has not been established in the presence of the following contaminants: meconium, anti-fungal creams or suppositories, K-Y Jelly, Baby Powder (Starch and Talc), Replens, and Baby Oil.)
Expensive (~$500)
ROM Plus – Vaginal swab, processed in lab
Only significant bleeding interferes with the result (lubricant, semen okay)
Middle road expensive (~$100)
Ferning/pooling/nitrizine - Speculum exam with a slide and ph strip
Semen and urine can also cause ferning and nitrazine positive (so get fluid from the os if at all possible)
Very inexpensive (pennies)
Ultrasound to confirm oligohydramnios (max vertical pocket <2) though if pt has oligo this is misleading, more helpful to add to a convincing picture
Ferning on microscope
Pre-labor rupture of membranes ("PROM") Creogs over coffee - Labor episode (middle section re: PROM) 2021, see above ALSO chapter as well
It’s reasonable to wait some time for spontaneous labor, based on TERMPROM data suggesting almost 80% of patients will labor by 12 hours after PROM.
However, patients should be aware of potentially increased risk (immediate induction may decrease time to delivery by up to 10 hr, decrease risk of chorioamnionitis/endometritis, decrease early onset neonatal sepsis, decrease NICU admit)
If GBS+, patients should be started on PCN to reduce neonate GBS sepsis risk.
Oxytocin seems to be the best agent, though evidence is somewhat limited overall. Do not generally use balloon catheters with ROM.
Vaginal Bleeding
**Know where the placenta is before doing an exam**
Dangerous causes:
Placental Abruption - painful uterine bleeding and fetal distress
Most common cause of serious vaginal bleeding, occurring in 1 percent of pregnancies
Risk factors: tobacco or cocaine use, chronic hypertension, preeclampsia, thrombophilias, abdominal trauma, and abruption in a previous pregnancy
*Cannot rule out with US, but if seen on US it is an abruption*
Placenta Previa - painless vaginal bleeding, often after intercourse
Initial sentinel bleed not usually dangerous without cervical instrumentation or cervical digital examination
Risk factors: Chronic hypertension, Multiparity, Multiple gestations, Older age, Previous cesarean delivery, Tobacco use, Uterine curettage
Vasa Previa - painless bleeding generally with SROM or AROM
This is fetal blood so needs to be acted on quickly - average blood volume of a term fetus is approximately 250 mL
Risk factors: In vitro fertilization, Low-lying and second trimester placenta previa, Marginal cord insertion, Multiple gestation, Succenturiate-lobed and bilobed placentas
Common causes: recent cervical exam or membrane stripping, intercourse, cervical change ("bloody show")
Decreased Fetal Movement ("DFM")
**Remember if RN can't get doptones - bring support person (senior/attending) if possible and ultrasound. Make this eval a priority**
Creogs over coffee - Stillbirth 2020
CTG = NST (this is an Australian flowsheet)
IUFD = Intrauterine fetal demise
FMH = Fetomaternal hemorrhage
Resources for coping:
Jensi's phone number 715-379-6148
Link to madlines to find Acting Chief - please call for support!!
SMPH employee assistance information
In addition, the following resources are available:
Resident/Fellow Forum: An electronic resident-only email forum is provided where you may discuss topics and
issues with your resident colleagues from all our DFMCH-sponsored GME programs. This resident/fellow-only email
forum, hosted by the chief residents from each program, is available at resident.forum@fammed.wisc.edu. This
confidential forum permits only residents to send and receive messages—it is not accessible to faculty, staff, or
others. Contact your chief resident(s) for more details.
Program Personnel: Program directors, chief residents, education coordinators, faculty mentors, and other faculty and staff are also available to assist residents/fellows with educational, personal, or professional concerns. Professional Resources: All residents/fellows are offered, and have direct access for individual confidential support and counseling from their employing organization for work-related and personal issues in areas such as
For more information, or to arrange an appointment contact the Employee Assistance Office per your residency program:
• UW Employee Assistance Office (EAO) at eao@mailplus.wisc.edu or call (608) 263-2987 or toll free 877-260-0281
o More information is available on the website at https://eao.wisc.edu/
