Professional Documents
Culture Documents
Obtain pt name/DOB
Have pt change into gown
Obtain clean catch urine sample
Arrive pt into Epic (O2)
Device select monitor
Admit pt into Obix
Place OB Triage Order
Obtain/Review Prenatal Records
Print/Place ID bands (pt and allergy)
Print labels
Complete urine dipstick
Complete Patient Profile: Important to first ask
about ROM, fetal movement, contractions, and
bleeding.
Assessment (w/in 10 min of arrival)
Assess heart tones w/in 10 min of arrival
Notify doctor
New pt education assessment/teaching
Care plan
Triage Charting
Profile
Assessment
Confirm vitals (must have vitals w/in 30 min of
DC)
Heart tones
Care Plan (Discharge care plan)
Education
D/C tab under L&D (ask when follow up appt.)
Assess FHR w/in 10 min of pt arrival to unit. Follow guidelines for gestational age:
< 20 weeks - doppler FHR upon presentation
20-24 weeks - attempt to obtain 20 min of continuous monitoring. If unable, notify physician
and doppler FHR upon presentation is this
right? 20-24 weeks?
> 24 weeks - obtain 20 min of continuous fetal
monitoring
If we have never seen the pt, obtain 40 min of continuous fetal monitoring
If pt has category I strip, absent vaginal bleeding,
and apparent latent phase of labor, switch to intermittent monitoring or auscultation. Allow pt to
walk as appropriate between sessions.
Category II Strip: Notify Physician and obtain order for auscultation , continuous or intermittent
fetal monitoring
Category III Strip: Notify physician immediately
and prepare patient for possible expedited delivery
Triage Notes:
Make sure to place OB Triage order - Indicate Pregnancy as reason for admission
Triage
Common Triage Pt complaints:
R/O Labor
R/O PTL
R/O ROM
R/O Preeclampsia
Decrease Fetal Movement
Pelvic Pain
Special Notes for consideration
If you are unsure of pt history, have no prenatal
records, or are suspicious, ask for order to send
a UDS. However, you must get permission
from the pt to send the UDS, and you need to
document that the pt gave you permission in a
note.
Always remember OB Triage Order.
Urine dipsticks are very important. Please
document urine dipstick results on all patients.
This could help us identify a preeclamptic pt
early on.
Triage Cont.
Special Notes for consideration Cont.
Dont be afraid to make suggestions to the residents about sending labs. Better to suggest
sending them early, rather than waiting until
the pt has been here for two hours, then sending labs.
**Call and alert lab that the swab is coming. The test
must run w/in 15 min of collection for accurate results**
*Results are not affected by blood, semen, or urine
Swab around the vagina and then down to the rectum. Place swab into container and snap the lid in
place. Label and Send
**Gonorrhea and Chlamydia are two separate orders make sure you put in both orders when sending down
this specimen
R/O Labor
What is gestational age? How were dates determined? Does she have a prenatal care provider?
Assess FHR and contraction pattern
Is she high risk?
Does she look uncomfortable?
Is she ruptured?
Is there vaginal bleeding?
Have resident examine pt, or ask if they want you
to check pt
Follow orders given
Probable cultures
GBS (if not available)
Wet prep if any signs of infection/abnormal
discharge
Nitrazine if any report of loss of fluid
R/O Rupture
R/O Preeclampsia
Triage:
Pt w/ abdominal trauma
Initiate peripheral IV
Saline lock IV
Notify physician
Triage:
Pt w/ BP above SBP>140 or DBP>90
Initiate peripheral IV
Obtain the following labs
CBC w/ diff
CMP
Uric Acid
LDH
ALT (in CMP)
AST (in CMP)
UA - straight cath sample
Spot CheckUrine Protein/Creatinine Ratio
Saline lock IV
Notify physician
Triage:
Pt w/ dysuria
Notify physician
Triage:
Pt w/ large vaginal bleeding
Initiate peripheral IV
Obtain the following labs:
Protime (PT)
INR
PTT (APTT)
Fibrinogen
FDPFibrin Deg. Productions
Kleihauer Betke Fetal HGB ST (KB) purple
top tube
Type and Screen
Urine drug screen
Saline lock IV
Notify physician
Possibly an H&H and CMP, also but these 2 labs
are not included under the triage protocol.