OB Triage Patients

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OB Triage Patients

NW family medicine hospitalists are called when any EGA pregnancy of >20 weeks gestation presents to be seen in OB triage for any reason. If it is a non-pregnancy-related complaint that can be better dealt with in the ED, the patient may be directed there following a normal prenatal screening evaluation. The prenatal screening eval must rule out any obstetrical issues before the patient is sent back to the ER. Let the ER doctor know that you’re sending the patient down to the ER for further evaluation and that they are stable from an OB standpoint.

There are a few standing orders which the OB Triage nurse has available to begin a patient evaluation pending Triage Orders.

Common OB Triage Scenarios

Active term labor-primigravida:

See YKHC Clinical Guidelines On presentation, all aspects of the prenatal history are reviewed and confirmed (especially for gestational RISK FACTORS). Prenatal dating is important and how dates were confirmed can usually be found on the problem list. If it’s not there already, please add it after reviewing first prenatal ultrasound and LMP. Also review media manager to see if a patient has had OB care at ANMC – the OB notes can usually be found there. Any prenatal tests lacking at this time can then be ordered. Active labor is assessed by cervical change over time and is especially important in the patient with an unproven pelvis.

Active term labor-multiparous:

See YKHC Clinical Guidelines Same as above with labor progression generally faster. If this patient has had a previous C-section and is not in Anchorage already, a C-section will be considered (a VABC might also be considered with HROB consultation).

VBAC (vaginal birth after C-section) patient in active labor:

See YKHC Clinical Guidelines

These pre-screened low risk patients are appropriate for labor management on OB. If any fetal heart tracing other than a Category 1 is appreciated, the HROB consultant must be in-house (It should be stated that properly screened VBAC patients have a lower maternal mortality rate than the average prenatal active labor patient).

Preterm contractions and/or labor:

See YKHC Clinical Guidelines

This is an urgent OB Triage situation. Patients (EGA <36 weeks) with contractions (>4/min) should be actively treated to stop while searching for their cause, keeping in mind that tocolysis in general should be reserved for gestational ages 24-34 weeks and fetal fibronectin can only be used in 24-34 weeks. If contractions resolve, fetal fibronectin (see YKHC Clinical Guidelines-p24) can be employed to give reassurance especially prior to allowing this patient to return home to her village if prior to BIB (Be-In-Bethel) date (or 30 days prior to EDC). If uterine contractions do not stop and especially if labor is present, discussion of a preterm delivery verses transfer to Anchorage should occur with HROB with Peds alerted. If later in the day and you want an ultrasound (after contractions have stopped), keep patient overnight at prematernal home and order an ultrasound for the following morning.

Preterm and term vaginal bleeding evaluation

Multiple etiologies including miscarriage, abruption, trauma and placenta previa should be ruled out and especially the latter prior to a digital exam.

Preterm and term spontaneous rupture of membranes evaluation:

Consider a sterile speculum exam for “ferning” and Amnisure® is available (and a nursing standing order). Term premature rupture of membranes (PROM) and preterm PROM (PPROM) are admitted and observed. Nothing special needs to be done for term patients who hopefully will spontaneously transition into active labor. These patients, however, should be cervical ripened/induced or augmented to promote labor by at least 12 hours if they at not progressing. If labor is augmented/induced, huddle with HROB and labor RN to confirm plan. PPROM patients are observed and prevented from labor if at all possible in consultation with HROB, Peds and ANMC Perinatology and should be considered for transfer to ANMC. Consider steroids before transfer.

Pre-eclampsia (PEC) evaluation:

See YKHC Clinical Guidelines

The prenatal patient with elevated blood pressure and proteinuria should have PEC blood work done including a urine protein/creatinine ratio. A 24 hour urine collection for protein is no longer considered necessary for this diagnosis. Consult with HROB to determine when delivery (or transfer) is recommended.

Induction assessment for post-dates, pre-eclampsia (PEC), gestational DM, cholestasis of pregnancy:

A new Induction Policy exists for all such cases and is kept in the “Induction Book” in the NWing Doc’s Office (YKHC Clinical Guidelines Induction and for each condition of pregnancy may be out-of-date <2011>for these situations). In accordance with this new policy, “HUDDLE” as necessary with HROB and the OB Nursing Staff to develop a plan for delivery.

Vaginal discharge:

This requires a sterile-speculum exam (SVE) and appropriate lab studies as part of the evaluation.

Non-pregnancy-related urgent care complaints:

As stated above in the introduction, these patients may be treated either in OB Triage if greater >20wks or the ED (following OB screening exam).

BIB ~36 wk assessment prior to residence at Pre-Maternal Home:

These patients are seen in the prenatal clinic unless it is after hours. Any missing labs or other tests (e.g. PPD) can be done in OB Triage. If needed, an OB US can be ordered for the following Monday-Friday morning.

Antepartum Care

This is best done in the village and/or Bethel clinic and follows a specific schedule of tests and evaluations (always assessing for HIGH RISK situations) at any point durin