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The American College of

Obstetricians and Gynecologists


WOMEN’S HEALTH CARE PHYSICIANS

COMMITTEE OPINION
Number 667 • July 2016

Committee on Obstetric Practice


This Committee Opinion was developed by the American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice
in collaboration with committee members George A. Macones, MD; Christian M. Pettker, MD; Maria A. Mascola, MD, MPH; and
R. Phillips Heine, MD.
This document reflects emerging clinical and scientific advances as of the date issued and is subject to change. The information should
not be construed as dictating an exclusive course of treatment or procedure to be followed.

Hospital-Based Triage of Obstetric Patients


ABSTRACT: Emergency departments typically have structured triage guidelines for health care providers
encountering the diverse cases that may present to their units. Such guidelines aid in determining which patients
must be evaluated promptly and which may wait safely, and aid in determining anticipated use of resources.
Although labor and delivery units frequently serve as emergency units for pregnant women, the appropriate
structure, location, timing, and timeliness for hospital-based triage evaluations of obstetric patients are not always
clear. Hospital-based obstetric units are urged to collaborate with emergency departments and hospital ancillary
services, as well as emergency response systems outside of the hospital, to establish guidelines for triage of
pregnant women. Recently developed, validated obstetric triage acuity tools may improve quality and efficiency
of care and guide resource use, and they could serve as a template for use in individual hospital obstetric units.

Recommendations typically have structured triage guidelines for health care


providers encountering the diverse cases that may pres-
• Hospital-based obstetric units are urged to collabo- ent to their units. Such guidelines aid in determining
rate with emergency departments and hospital ancil- which patients must be evaluated promptly and which
lary services, as well as emergency response systems may wait safely, and aid in determining anticipated use of
outside of the hospital, to establish guidelines for resources. Although labor and delivery units frequently
triage of pregnant women. serve as emergency units for pregnant women, the appro-
• Recently developed, validated obstetric triage acuity priate structure, location, timing, and timeliness for
tools may improve quality and efficiency of care and hospital-based triage evaluations of obstetric patients are
guide resource use, and they could serve as a template not always clear.
for use in individual hospital obstetric units.
Obstetric Triage
Introduction Obstetric triage volume typically exceeds the overall birth
This Committee Opinion focuses on hospital-based tri- volume of a hospital by 20–50% (1). In a study of one
age of obstetric patients and attempts to offer approaches large center, up to one third of evaluated women did not
and frameworks for triage that are applicable to any give birth at that time and were sent home or to another
center providing obstetric care. The concept of triage unit at the completion of their evaluation and manage-
comes from the military, where workers in field hospitals ment (2). Pregnant women most commonly present for
use systematic principles to evaluate and prioritize how evaluation for labor at term. However, preterm labor,
quickly wounded soldiers are fully evaluated and treated. signs and symptoms of preeclampsia, decreased fetal
Triage in hospitals typically is associated with emergency movement, preterm premature rupture of membranes,
departments that aim to categorize and prioritize patients vaginal bleeding, and acute abdominal pain also are
who present for emergent or urgent care before detailed reported frequently. Acute and critical conditions, such
evaluation and management. Emergency departments as motor vehicle collision injury, large abruptio placentae,
or seizure, are less common, but they demand immediate for transfer or release. In the situation of preterm labor
attention and management. or preterm premature rupture of membranes, transport
Pregnant patients could present for care to any of the woman in labor is recommended if time allows (4).
institution providing urgent or emergent care. However, Antenatal transfer is associated with improved neonatal
obstetric patients are best served if local emergency ser- outcomes compared with neonatal transfer.
vices develop protocols whereby pregnant patients are Typical triage protocols involve an initial assessment
taken to the most appropriate facility, which may be a des- and decision about the priority level for evaluation. In
ignated obstetric care center, with pregnancy status, level the case of the pregnant patient, this assessment may
of acuity, and distance travelled all being important factors be conducted by a registered nurse, certified nurse–
(3). Guidelines from local and national regulatory organi- midwife or certified midwife, nurse practitioner, physi-
zations (eg, state Department of Public Health, the Joint cian assistant, or physician as designated by hospital
Commission) should be followed. The federal Emergency policy. The health care provider performing triage should
Medical Treatment and Labor Act (EMTALA) requires assign the patient’s acuity during the first encounter.
an initial medical screening examination to determine if Triage is followed by the complete evaluation of the
a true medical emergency exists; in the case of a pregnant woman and the fetus by a health care provider with skills
woman, this includes evaluation of the woman and the and training appropriate to evaluate the issues identified
fetus. The medical condition of a woman having contrac- during triage. The American College of Obstetricians
tions is not considered an emergency if there is adequate and Gynecologists’ Guidelines for Perinatal Care, Seventh
time for her safe transfer before delivery or if the transfer Edition, provides further information on what is neces-
will not pose a threat to the health or safety of the woman sary in this evaluation (4). These elements will vary based
or the fetus (4). Elaborating on key principles outlined in on the issue at hand, and a full review or listing is beyond
Guidelines for Perinatal Care, Seventh Edition (4), and in the scope of this document. Although a separate triage
Liability in Triage: Management of EMTALA Regulations area and standing orders may facilitate care for obstetric
and Common Obstetric Risks (5), the essential legal require- triage patients, having an available health care provider
ments under EMTALA related to obstetric care include appears to best optimize patient flow and reduce length
the following: of stay (6). The use of certified nurse–midwives or certi-
fied midwives who provide obstetric emergency care tri-
• An individual or individuals determined qualified age services, for example, may improve efficiency, reduce
as designated by hospital policy must perform an length of stay, and improve screening and evaluation (7).
appropriate medical screening examination to deter- For a given center, the obstetrics department, in con-
mine whether the patient has an emergency medi- junction with the other appropriate departments, should
cal condition. This determination should take into establish written guidelines defining the appropriate unit
account the health of the woman and the fetus. to evaluate obstetric patients based upon criteria such as
• If an emergency medical condition is determined to gestational age and delivery status, symptoms, medical
exist, stabilize the patient or transfer her if the obstet- condition, and available medical staff. For instance, some
ric care provider certifies that the benefits of transfer nonobstetric conditions (eg, highly transmissible infec-
outweigh the risks. In the case of the latter, a written tious diseases like influenza or varicella, critical traumas,
certification is required. and acute chest pain) may be better treated in another area
• When necessary, arrange for transfer to another of the hospital, regardless of gestational age. Conversely,
appropriate facility if the patient is stabilized or if many postpartum conditions may be best addressed
the benefits of transfer outweigh the risks. Transfer by labor and delivery staff. Disaster preparedness plans
should be carried out by qualified personnel and should include care of pregnant women (3). For all of
transportation equipment. Patients can decline these reasons, coordination and communication between
transfer after being informed of the risks and benefits obstetric and emergency departments, as well as hospital
of transfer. ancillary services, is critical (3). Emergency departments
• Appropriate medical screening cannot be delayed to should consider early consultation with obstetric care
inquire about payment method or insurance status. providers when triaging and managing pregnant patients,
especially for patients beyond the first and early second
A woman in labor is considered unstable from the latent trimesters. To be considered an appropriate location to
phase through delivery of the placenta if there is inad- evaluate and care for pregnant patients, a unit should
equate time to safely transfer her to another hospital have the ability to perform basic ultrasonography and
before delivery or if that transfer may pose a threat to her fetal monitoring. In cases that involve a woman with a
or her fetus’s health or safety. According to EMTALA, viable pregnancy who is evaluated outside of an obstetric
if a qualified medical professional is able to determine unit, it may be necessary to bring these resources from the
that a woman with contractions is in “false labor” after a obstetric unit to the location of the patient.
reasonable period of observation, then the patient’s con- Triage algorithms for obstetric acuity to assess
dition can be considered stable, and she would be eligible and assign priority to obstetric patients may be useful.

2 Committee Opinion No. 667


Women should be cared for according to triage acuity Several of these tools have been tested for content validity
rather than by time of arrival. The Emergency Severity (10) and interrater reliability (11, 12) and may be used to
Index was designed by the Agency for Healthcare improve quality and efficiency of care and guide alloca-
Research and Quality to triage nonpregnant adults and tion of resources. Hospital obstetric units are encouraged
has been adopted by many emergency departments (8). to develop triage protocols based on local conditions but
Several obstetric triage acuity tools have been developed informed by evidence-based decision making. Recently
based on this model. These tools typically classify patients developed, validated algorithms such as the Association
based on the urgency of the patient’s condition, often of Women’s Health, Obstetric and Neonatal Nurses’
using a five-level system, and can increase the propor- Maternal–Fetal Triage Index (Fig. 1) could serve as tem-
tion of high-acuity patients seen in an urgent fashion (9). plates for use in individual hospital units.

Maternal Fetal Triage Index (MFTI) Implement appropriate


infectious disease control
processes for triage
YES and evaluation.
Is the woman presenting for a scheduled procedure and has no complaint?

NO
1

PRIORITY
STaT
Abnormal Vital Signs
Maternal HR <40 or >130, apneic, Sp02 <93%, SBP ≥160 or
Does the woman or fetus DBP ≥110 or <60/palpable, No FHR detected by doppler
have STAT/PRIORITY 1 vital (unless previously diagnosed fetal demise), FHR <110 bpm for >60 seconds
signs? Immediate lifesaving intervention required, such as:
OR YES Maternal
STAT/ • Cardiac compromise • Acute mental status change or
Does the woman or fetus
PRIORITY 1 • Severe respiratory distress unresponsive (cannot follow verbal
require immediate lifesaving • Seizing commands)
intervention? • Hemorrhaging • Signs of placental abruption
OR • Signs of uterine rupture
Fetal
Is birth imminent? • Prolapsed cord
Imminent Birth
• Fetal parts visible on the perineum • Active maternal bearing-down efforts

NO

PRIORITY
uRgenT
Abnormal Vital Signs
Maternal HR >120 or <501,
Temperature ≥101.0°F, 38.3°C, RR >26 or <12, Sp02 <95%1, SBP ≥140 or DBP ≥90 symptomatic1
or <80/40, repeated; FHR >160 bpm for >60 seconds; decelerations
Does the woman or fetus
have URGENT/PRIORITY 2 Severe Pain: (unrelated to ctx) ≥7 on a 0–10 pain scale
vital signs?
OR
Examples of High-Risk Situations
• Unstable, high risk medical conditions • <34 wks c/o of SROM/leaking or
Is the woman in severe pain spotting
• Difficulty breathing
without complaint of YES
• Altered mental status • Active vaginal bleeding (not
contractions? URGENT/ spotting or show)
OR PRIORITY 2 • Suicidal or homicidal
• c/o of decreased fetal movement
Is this a high-risk situation? • <34 wks c/o of, or detectable,
uterine ctx • Recent trauma2
OR
Will this woman and/or new- ≥34 wks with regular contractions or SROM/leaking with any of the following
born require a higher level of • HIV+ • Multiple gestation
care than institution provides? • Planned, medically-indicated cesarean • Placenta previa
(maternal or fetal indications)
• Breech or other malpresentation

Transfer of Care Needed


NO • Clinical needs of woman and/or newborn indicate transfer of care,
per hospital policy

3
PRIORITY

PROmPT
Abnormal Vital Signs
Does the woman or fetus Temperature >100.4°F, 38.0°C1, SBP ≥140 or DBP ≥90, asymptomatic1
have PROMPT/PRIORITY 3 YES
vital signs?
Prompt Attention, such as:
PROMPT/
• Signs of active labor ≥34 weeks
OR PRIORITY 3
• c/o early labor signs and/or c/o SROM/leaking 34–36 6/7 weeks
Does the woman require • ≥34 weeks with regular contractions and HSV lesion
prompt attention? • ≥34 weeks planned, elective, repeat cesarean with regular contractions
• ≥34 weeks multiple gestation pregnancy with irregular contractions
• Woman is not coping with labor per the Coping with Labor Algorithm V23

NO

4
PRIORITY

nOn-uRgenT
YES NON-
Non-urgent Attention, such as:
Does the woman have a • ≥37 weeks early labor signs and/or c/o SROM/leaking
URGENT/
complaint that is non-urgent? PRIORITY 4 • Non-urgent symptoms may include: common discomforts of pregnancy,
vaginal discharge, constipation, ligament pain, nausea, anxiety.

NO

5
PRIORITY

Scheduled OR
Is the woman requesting Woman Requesting A Service, such as: RequeSTIng
a service and she has no • Prescription refill
complaint? YES • Outpatient service that was missed
SCHEDULED/
OR REQUESTING Scheduled Procedure
PRIORITY 5
Does the woman have a Any event or procedure scheduled formally or informally with the unit before
scheduled procedure with the patient’s arrival, when the patient has no complaint.
no complaint?

1
High Risk and Critical 1
Care Obstetrics, 2013
High Risk and Critical Care Obstetrics, 2013
Trauma may or may not include a direct assault on the abdomen. Examples are trauma from motor vehicle accidents, falls, and intimate partner violence.
2
15001
2
Trauma may or may not include a direct assault on the abdomen. Examples are trauma from motor vehicle accidents, falls, and intimate partner violence.
Coping with Labor Algorithm V2 used with permission
3

The MFTI is exemplary and does not include all possible patient complaints or conditions. The MFTI is designed to guide clinical decision-making but does not replace clinical judgement. Vital signs in the MFTI are suggested values. Values appropriate for the population and geographic region should be determined
3
Coping with Labor Algorithm
by each V2into
clinical team, taking used
accountwith
variablespermission
such as altitude. ©2015 Association of Women’s Health, Obstetric and Neonatal Nurses. For permission to use MFTI or integrate the MFTI into the Electronic Medical Record contact permissions@awhonn.org.

The MFTI is exemplary and does not include all possible patient complaints or conditions. The MFTI is designed to guide clinical decision-making but does not replace clinical judgment. Vital signs in the
MFTI are suggested values. Values appropriate for the population and geographic region should be determined by each clinical team, taking into account variables such as altitude.
Copyright 2015 Association of Women’s Health, Obstetric and Neonatal Nurses. For permission to use MFTI or integrate the MFTI into the Electronic Medical Record contact permissions@awhonn.org.

Figure 1. Maternal–fetal triage index. (Reprinted from Ruhl C, Scheich B, Onokpise B, Bingham D. Content validity testing of the
maternal fetal triage index. J Obstet Gynecol Neonatal Nurs 2015;44:701–9.) ^

Committee Opinion No. 667 3


Conclusion 6. Zocco J, Williams MJ, Longobucco DB, Bernstein B. A
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For More Information lable at: http://www.ahrq.gov/sites/default/files/wysiwyg/
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does not imply the American College of Obstetricians validity testing of the maternal fetal triage index. J Obstet
and Gynecologists’ endorsement of the organization, the Gynecol Neonatal Nurs 2015;44:701–9. [PubMed] ^
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or transmitted, in any form or by any means, electronic, mechanical,
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The American College of Obstetricians and Gynecologists
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4 Committee Opinion No. 667