L&D Triage Orientation
Triage derived from French verb trier:
To separate, sort, select
Lori Van Zoeren BS, RN
Ferris State University
Objectives
 Identify skills and qualifications necessary for LD Triage
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Success
Describe EMTALA and how it applies to the LD triage role
Practice scoring patients for Medical Exam Screen and
identify patients who require immediate provider evaluation
Discuss supplies needed to assist providers in triage
evaluation
Assess and accurately interpret real life scenarios through
case studies
Evaluate the effectiveness of the orientation program
ED triage skills for success
 Diverse knowledge base
 Multi-tasker under stress
 Strong interpersonal skills
 Ability to provide on-going
 Independent
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 Effectively communicate
 Strong critical thinking
 Ability to perform a brief,
focused interview and
physical assessment
 Ability to make quick
accurate decisions
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ENA, 2009
education
Ability to work
collaboratively
Delegation ability
Adaptability to fluctuations
in workflow
Understanding of the
cultural diversity of not
just patient but family
L&D Triage Nurse Qualifications
 Successful L&D unit orientation
 At least two years of labor and delivery
experience
 At least one year of labor and delivery
experience at Bronson
Emergency Triage VS OB Triage
Prioritizing Case Study
 Patient presents with complaint of passing a plum sized clot
at 37 weeks. Baby is active and there are no other risk factors
communicated initially.
 Patient presents with complaint of a MVA two days ago and
just wanted to make sure baby was alright. She is 28 weeks
gestation and no other risk factors noted initially.
 Patient presents to triage at 18 weeks with complaint of
lower back pain and cramping for 4 hours which has gotten
progressively worse over the last hour. Patient states she is
scared as she has lost a baby at 20 weeks due to incompetent
cervix.
What is EMTALA ?
 Emergency Medical Treatment and Active
Labor Act
 Medical Exam Screen
 250 foot rule
 Capability & Capacity
Austin, 2011
EMTALA Violation Example
 Patient was evaluated and deemed in active labor at a
hospital that did not deliver babies. Patient was allowed
to be transported in friend’s car to the delivering
hospital. The patient was delivered a few minutes after
arrival and both mom and baby were fine.
 The hospital paid $40,000 dollars in civil monetary
penalties for allegations that they failed to provide
appropriate medical exam screening and stabilizing
treatment as well as not providing appropriate transfer
vehicle.
Austin, 2011
Initial Documentation
 EMR requirements include the triage portion of the
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triage/admission tab in the EPIC chart
Medical exam screen within 20 minutes
Complex physical assessment
PTA medications (prior to admission)
Labor flow sheet with fetal monitor tracing interpretation
and any interventions if indicated
Consent for treatment signed upon arrival
Allergies documented
Medical Exam Screen Policy
 Screening within 20 minutes of arrival and again
prior to discharge
 Patients scoring 10 or greater must be seen by a
provider in a timely fashion
 Emergency Medical Condition
 Acute pain vs. regular contractions
 10 minute fetal heart rate monitor
Medical Exam Screen Scoring
 Patient presents to LD triage. SVE reveals: 2cm,
70% effaced, and -2 station. Membranes intact.
Contractions are every 4 min, lasting 30-40
seconds, palpate mild, regular, no urge to push.
Vital signs are: Temp 98.8, BP is 138/88, Resp
20. There is no edema of extremities but facial
edema is present. Is having normal bloody show
and FHT stable and reactive. Baby is vertex.
Medical Exam Screen Scoring
 Patient presents to triage who is 38 weeks
gestation with bright red bleeding like her
normal periods. SVE deferred due to
bleeding initially. She is having an occasional
contraction, no urge to push, VS are stable,
no edema. FHR is normal and reactive.
Baby was vertex by Leopold's.
Medical Exam Screen Scoring
 Patient presents to triage with complaint of
abdominal pain that rates a 10 on the pain scale.
She is writhing around in the bed to the point it is
difficult to palpate for contractions. SVE reveals
cervix that is 0 cm, 40% effaced, and 0 station.
She states no leaking of fluid or bleeding, she is
holding her breath like she is bearing down. BP
stable, pulse is 110, Temp 100. No edema. FHR
110 with moderate variability and accelerations.
Baby is vertex.
Re-evaluation guidelines
 Pre-eclampsia-B/P every 15 if elevated,
FHR every hour
 Labor evaluation- FHR every hour, VS every
4 hours
 Preterm labor- FHR every hour, VS every 4
hours
 Any abnormalities would indicate increased
surveillance
Med exam screen: Not always
 Non-emergency situations such as:
Patients admitted directly into the hospital,
bypassing triage.
Betamethasone Injections or NSTs
Austin, 2011
Success in L & D Triage
 Resources readily available
 Know your parameters
 Do you always have the backing to place orders?
OB section/More to follow
 Order to do an SVE
 Do not be fooled
 Communication & Situation Background
Assessment Recommendation (SBAR)
Chain of Command
 Charge Nurse
 Unit Coordinator
 Manager
 Director
 CNO
 PAUL BERKOWITZ, MD (OB/GYN)
 CAMELIA MERATI, MD (Hospitalist)
 STEVEN POLLENS, MD (Family Practice)
 JOHN SIKORA, DO (Anesthesia)
Stryker Gynnie Carts
Know the supplies needed to assist
providers in specimen collection
Amnisure
 Review policy if not familiar
 Explain procedure (insert 2-3 inches into vagina and
leave for 60 seconds)
 Insert swab into solvent and rotate swab for 60 seconds
 Properly label specimen and collect in Epic for the lab
requisition
 Tube to lab as a stat and call 6440 to notify an Amnisure
is coming for evaluation
Amnisure Collection
 Inaccurate results can
occur in the presence of:
Meconium, antifungal
creams, lubricating jelly,
baby oil, Replens, expired
solution, gross presence of
blood, digital exams prior
to swabbing, sample is
collected greater than 12
hours after ruptured
membranes
Fetal Fibronectin
No Prenatal Care
“Abdominal” Pain
 Preterm Labor
 Term labor
 Epigastric
 Round ligament
 Kidney
 Ovarian Torsion
 Appendix
 Abruption
Devarajan & Chandraharan, 2011
Underlying Pathology
Area of Pain
Organs to consider
Possible causes
Left Hypochondrial
Spleen, pancreas, colon
Splenic infarc, colitis
Epigastric
Stomach, pancreas, aorta,
heart
Gastritis, pancr, aortic
dissection/mayocarditis/MI
Right Hypochondrial
Liver, Kidney, hepatic flex
colon, gall bladder
Liver issues, Fatty Liver of
preg, HELLP, Pre-eclamp
Right Lumbar
Kidney, ascending colon
Pyleo, renal calc, IBS
Umbilical
Trans colon, appendix,
uterus
Appy, gastro, pancreatitis,
abruption, uterine rupture
Left Lumbar
Kidney, descending colon
Pyelo, renal calc, IBS
Left Iliac
Sigmoid, Lt tube/ovary
IBS, Ectopic, tube abscess or
rupture, ovarian torsion
Right Iliac
Appendix, rt tube/ovary
Appy, diverticulistis, above
Supra-pubic
Bladder, Uterus
Cystitis,abrup, Scar rupt
Devarajan & Chandraharan, 2011
Which of the following is not associated
with abruptio placenta?
 Cocaine
 Heroin
 HTN
 Smoking
 Advanced Maternal Age
 Women under 20 years of age
 Abdominal trauma
 Alcohol Use
 Male fetus
 Chorioamnionitis
Triage Imminent Delivery
 The infant warmer is in
triage in the corner by the
blanket warmer. Supplies
are covered but is stocked
with needed emergency
supplies to deliver a baby in
the triage area.
Discharge Process
Social Work Resources
 Coverage
 Cab passes
 Phone cards
 Child Life
 Domestic violence
Drug Seeking Behavior
 Never chart that a patient is drug seeking
 Describe patient’s perception of her pain
 Document assessment of patient’s observable
symptoms
 BE OBJECTIVE!
 MAPS report
Case Study 1
 41 year old G2 P1 30 week pregnant patient
presents via ambulance to L&D triage. She
was shopping and collapsed. She has no
known medical conditions. She had an oral
airway but spit out in route to hospital. Her
VS are HR of 130, BP 190/110, Temp 97.3,
Oxygen sat 93%, Glascow Coma scale
10/15.
Case Study 2
 25 y/o G2 P1 presents to triage with
painless vaginal bleeding at 24 weeks.
She had a previous cesarean section
delivery. VS BP 130/78, Pulse 92, Resp
20, Temp 98.4.
Case Study 3
 Patient is 40 weeks gestation and presents to L&D
triage in active labor. Fetal heart tones are 145.
After asking if any bleeding or leakage of fluid
you perform a SVE. Cervix is dilated 5 cm, 100%
effaced, and -3 station. Patient rolled to left side
and spontaneous ruptured membranes occurred.
Fetal heart tones were then noted and verified at
70 bpm as patient’s pulse is 96.
Case Study 4
 Pt is a 20 year-old G3-P1 pregnant patient
who complains of vaginal discharge which is
especially prominent after intercourse. She
states that it has a fishy odor. There is no
bleeding and no regular contractions. VS are
stable. She does complain of left lower
quadrant pain that is constant.
Case Study 5
 Call from the ER received with report
to expect an ambulance bringing in a
G3, P2 patient who is 32 weeks
pregnant involved in a multivehicle pile
up. Patient is alert and oriented, her VS
are stable, fetal heart tones are 150
with positive fetal movement.
Case Study 6
 A 31 year-old G4 P3 patient with twin
gestation at 36 weeks presents to triage.
When placed on cart she spontaneously
ruptures membranes and there is a
moderate amount of bleeding noted.
Twin A now has fetal tachycardia and a
sinusoidal heart rate pattern.
Vasa Previa
Case Study 7
 Patient presents to L&D Triage with
complaints of dizziness, headache,
difficulty concentrating, pounding
heart, tingling of the mouth, and feeling
irritable. She is sweaty and pale.
In Summary
References
 Austin, S. (2011, June). What does EMTALA mean for you?
Nursing, 41(6), 55-59.
http://dx.doi.org/10.1097/01.NURSE.0000398175.36147.bc
 Bronson Methodist Hospital website .(2014).
https://inside.bronsonhg.org/
 Devarajan, S., & Chandraharan, E. (2011). Abdominal pain in
pregnancy: A rational approach to management. Obstetrics,
Gynaecology, and Reproductive Medicine, 21(7), 198-206.
http://dx.doi.org/10.1016/j.ogrm.2011.04.001
 Emergency Nurses Association. (2011). Triage qualifications.
Retrieved from
http://www.ena.org/SiteCollectionDocuments/Position%20Stat
ements/TriageQualifications.pdf
Project Goals and Objectives
 Goal: To develop an orientation program for labor and delivery
triage nurses at Bronson Methodist Hospital in Kalamazoo, MI
 Objectives: 1.1 Identify recommended LD triage nurse
competencies required to care for the obstetrical patient
population. 1.2 Provide an educational program for nurses who
work in LD triage on skills needed for competency that are unique
to triaging obstetrical patients. 1.3 Evaluate the effectiveness of
the orientation program for staff. 1.4 Preceptor evaluation of the
attainment of the proposed goals of the scholarly project. 1.4 Selfevaluation of the attainment of the proposed goals of the scholarly
project. 1.5 Revise orientation program based on evaluation
results.
Personal & Professional Accountability
 Adherence to NLN Nurse Educator Competencies
 Performed a comprehensive literature search
 Assimilated knowledge from lit review
 Applied new knowledge to the triage orientation
program
 Followed project plan utilizing time management skills
Project Outcomes
 Increased knowledge of EMTALA and the legal
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ramifications
Increased knowledge of the differences between ER
triage and LD triage
BMH standards discussions for triage competency
Collaboration discussions with area hospitals
Hands on activities provided new knowledge of assisting
providers with obtaining cultures
Project Evaluation
 Do you have a better understanding of EMTALA?
 Was the PPT beneficial to learning about LD triage role?
 Did the PPT provide new knowledge?
 Do you feel the importance of the Medical Exam Screen was
thoroughly explained?
 Do you believe you can correctly prioritize patients listed in
case studies?
 Do you believe the objectives of the LD orientation and
competency validation program were met?