Consider these recent cases of women who were sent home after an obstetrical triage evaluation, none of whom were actually stable for discharge. A nulliparous woman at term presented with contractions q 10 minutes lasting 50 seconds and a normal fetal heart rate (FHR) pattern. After 2 hours, contractions were q 6 minutes, lasting 70 seconds, the FHR pattern was normal, and there was no cervical change. The nurse told the patient to come back when contractions were q 5 minutes and her pain was worse. The woman was reluctant to leave as she lived 40 minutes away. The nurse also told the patient that she had seen many other women this evening complaining of false labor and this was likely the result of a change in barometric pressure due to a "storm system coming through" rather than "true" labor. A telephone order for discharge was obtained from the physician. As the woman and her husband were driving home (in the middle of a thunderstorm), she felt intense pelvic pressure, her husband pulled to the roadside and the baby was born. The woman and baby returned to the hospital via ambulance.

A woman at 37 weeks with a history of a prior cesarean birth presented with contractions q 8 to 12 minutes and right-sided abdominal pain. The FHR pattern was normal and the cervix was closed. After a 90-minute evaluation, the FHR pattern was normal, contraction frequency was the same, and there was no cervical change; however, the pain continued intermittently. The physician told her what she was feeling was most likely broad ligament pain and it would subside with a warm bath and rest. Zolpidem (Ambien) was prescribed. She returned 2 hours later with unrelenting sharp pain and fetal bradycardia. Emergent cesarean birth revealed uterine rupture.

A multiparous woman at 36 weeks presented with contractions q 2 to 3 minutes and decreased fetal movement. The cervix was 1 centimeter and the FHR pattern was normal with no accelerations. Over 3 hours, the FHR pattern remained normal with no accelerations, and contraction frequency was noted to irregular with a "uterine irritability" pattern. The patient reported "cramping." A resident physician and an experienced labor nurse examined the patient and concluded she was having "Braxton-Hicks" contractions and had a reactive FHR pattern. She was discharged with instructions to lie on her left side and drink plenty of fluids. The woman was admitted 2 hours later with tachycardia, painful contractions q 1 minute lasting 30 second and fetal tachycardia with recurrent late decelerations. A 50% placental abruption was noted during emergent cesarean birth.

Many pregnant women present for evaluation prior to their admission for labor and birth. The perinatal nurse plays a key role in obstetrical triage and discharge; in some hospitals nurses conduct medical screening examinations in the absence of direct evaluation by a physician, consistent with federal regulations as per the Emergency Medical Treatment and Labor Act (EMTALA). Mother and baby should be stable for discharge as per EMTALA criteria. A thorough evaluation to rule out labor and potential complications as well as to confirm maternal-fetal well-being is critical prior to discharge (see box).

Guidelines for Obstetrical Triage

* A pregnant woman presenting to the labor and delivery area should be evaluated in a timely fashion. Initial evaluation should minimally include assessment of maternal vital signs (VS), FHR pattern, and uterine contractions

* The responsible perinatal healthcare provider should be informed promptly if any of the following are present or suspected: vaginal bleeding, acute abdominal pain, temperature of >=100.4 [degrees]F, preterm labor, preterm rupture of membranes (PROM), hypertension, and/or an abnormal/indeterminate FHR pattern.

* A labor evaluation should include assessment of the following: maternal VS, uterine activity, fetal wellbeing, urinary protein concentration, cervical examination unless contraindicated (e.g., placenta previa, PROM), fetal presentation and station, and membrane status.

* Onset of true labor is established by observing progressive cervical change in the context of regular contractions; this may require two or more cervical exams separated by an adequate period to observe change. When false labor or early labor is diagnosed, the woman should be given adequate verbal and written instructions (at appropriate literacy level and in the woman's language if non-English speaking [use interpreter as needed]) regarding when to return to the hospital.

* Fetal wellbeing should be determined prior to discharge, ideally by obtaining a reactive nonstress test if appropriate based on gestational age.

Note: Adapted from American Academy of Pediatrics (AAP) & American College of Obstetricians and Gynecologists (ACOG), 2007.

Reference