Obstetric Triage: The Realm of the Midwife Part 2


The midwife's ability to screen, prioritize, and expedite obstetric conditions stems from a strong primary care background and a broadening knowledge base. This ability also lends itself to the emergent care skills needed in an obstetric triage unit as well as effective triaging of complaints by telephone.

With this sequence to the September/October 1999 issue of the Journal of Nurse-Midwifery, the midwife's role in obstetric (OB) triage is expanded. Topics focus on more clinically directed issues and encompass key areas such as management of acute, nonobstetric abdominal pain in pregnancy, triaging of patients during the latent phase of labor, triage do's and don'ts of ectopic pregnancy, midwifery triage of first trimester bleeding, triage and management of hypertension in pregnancy, and quality management within an OB triage unit.

Management of acute, nonobstetric abdominal pain in pregnancy focuses on clinical entities encountered by practitioners in triaging more severe abdominal complaints. Nonobstetric complaints primarily include appendicitis, gallbladder disease, pancreatitis, bowel obstruction, liver disorders, pyelonephritis, and inflammatory bowel disease. Acute, nonobstetric abdominal pain is commonly seen in pregnancy. Variations in pregnancy, both physiologic and anatomic, distort the presenting clinical picture when women present over the telephone or to OB triage. Case reviews and key triage points are offered to reinforce the clinical management of these disorders.

Latent phase labor is a common clinical condition managed by providers in the OB triage setting or over the telephone. A separate triage area aids in both the assessment and disposition of women in latent phase, either to therapeutic rest or to labor stimulation. Prolonged latent phase labor has been defined as longer than 20 hours in the nullipara and longer than 14 hours in the multipara. Understanding the range of normal latent phase labor, as well as appropriate triage assessment strategies, improves clinical decision making for these patients.

Triage do's and don'ts of ectopic pregnancy provide salient points for practitioners when evaluating a woman with possible ectopic pregnancy. No matter what the clinical setting, be it office, telephone, or OB triage/ER unit, there are triaging tips that can aid in the clinical assessment process. The role of the midwife/practitioner in the care of these patients, as well as referral and consultation sources, is discussed.

Approximately one out of five pregnant women will present or complain of bleeding during the first trimester of pregnancy. About half of these women will proceed to have a spontaneous abortion. The triaging of first trimester bleeding is a commonly encountered complaint for most OB practitioners. Management of first trimester bleeding focuses on strategies to differentiate between causes. It also identifies emergent and nonemergent issues in the triaging of this commonly managed complaint, in the office setting, triage setting, or over the telephone.

Triaging decisions in the management of hypertension in pregnancy are reviewed in depth. All clinical entities are explored. Telephone triaging and in-house triaging aspects are discussed, including questions to ask, laboratory work to order, and key criteria to review.

Components of an effective quality management program within an obstetric triage unit are also described. The functions of a quality management program vis-à-vis OB triage and the specific guidelines that make such a quality management program unique to OB triage are put forth. These functions are then related to risk-management and, specifically, how quality management affects the concept of telephone triage.

As the scope of midwifery broadens, the ability to review primary care data and to handle emergent OB complaints is expanding. The midwife now provides emergent care in the assessment of most OB complaints in myriad triage settings as well as over the telephone. To that end, midwives have emerged as key players in this realm of ever-expanding OB triage.