ob patients being evaluated in er

nursejohio, ASN, RN · Apr 15, 2009

We triage our own pts at my facility. Under 16 weeks goes to the ER, unless she gives us a reason to think she's gonna deliver. Traumas and other serious stuff go directly to the ER, we'll send a nurse over there for monitoring and whatnot if necessary. The clinic patients in triage are evaluated by the residents (but if they're swamped with deliveries we'll do all the triage stuff and then just have a doc look at the strip before we send them home) and nurses run the triage for the private docs.

I don't think I'd like an ER doc evaluating strips and stuff either. They've got enough going on over there, leave the OB problems to people who do it all the time

CEG · Apr 15, 2009

Our pts presenting with non-OB complaints are cared for in the ED then sent to OB triage to have FHT etc evaluated before going home. Pts presenting with OB complaints are triaged in ED and sent to OB triage. Pts presenting for non-OB complaints (MVA, asthma, etc) should be treated in ED IMO because I have no ability to set a broken bone or provide emergency asthma care. At our facility the ED doc may consult with OB before doing a procedure or med, but in reality ED is the best place for these patients. As always, mom must be treated or baby is out of luck, so evaluating FHT before stabilizing a mom is not really helpful or appropriate. Pts with OB concerns should be seen in OB. Generally this is not an issue with us as the ED tries to ship all pregnant pts to us as soon as possible.

bamamamacat · Apr 15, 2009

My dtr-in-law in Iowa was eval'd in ER multiple Xs during last few wks; came in again w/freq. contractions which abated & became infreq; pt c/o radiating pain in thighs as well as hip pain; when contracted, abd soft; No MD contact, only RN, who showed MD nsg. notes & monitor printouts; pt discharged home; pain increased; my son called ER, spoke w/ d/c RN, stating "My wife is in so much pain she's losing her mind"; RN instructed my son to run warm bath & give my d-i-l two XS Tylenol; he ran the bath & headed to the store for Tylenol when my d-i-l called his cell, stating "The baby is here" & indeed my d-i-l had suddenly delivered our granddaughter all by herself, somewhere between the bathroom and the living room; my son entered their home to find them both conscious & responsive; Emerg. rescue arrived quickly, & thank God all is well; They were told by EMTs that this is a "very rare" incident in their area, however there was no news coverage whatsoever - a town of 200,000 vs. a lg. powerful hospital, not a hard one to figure. BTW, this was my daughter-in-law's first pregnancy.

nursejohio, ASN, RN · Apr 15, 2009

Glad everyone is ok! As rare as precipitous deliveries are in primips, they do happen. We've had a couple moms sent home from triage and come back in complete or postpartum.... She comes in with contractions, we'll check her cervix, send her walking for a couple hours. If she hasn't changed when we recheck her, it's not active labor so she gets to go home. Once in a blue moon, it really is labor, her cervix just hadn't gotten the memo yet :anbd:

bamamamacat · Apr 15, 2009

Thank you for your response; my biggest problem w/this is that she was dilated @ 1 cm 48 hrs prior, & remained @ 1 cm when back in ER on day in question; however, there were marked changes in level and character of pain; also, she had been told at her last ofc visit that the delivery would most likely come before or by the 8th of the mo & all this occured on the 4th. With this data in place, I am trying to understand why the ER MD didn't personally take a look @ my dtr-in-law before allowing discharge.

eden · Apr 15, 2009

We triage all patients 20 weeks or over. If you are 19w6d you start off in the ER. I think it would be better if we could see all patients regardless of gestational age, as long as it was pregancy related.

Trauma Columnist · Apr 15, 2009

bamamamacat - glad your DIL and granddaughter are safe. We can't address the issue of the care in the ER. I would have your DIL contact the ER if she has concerns.

I have worked at two ERs and both triage the same way: OB complaint: 20 weeks - OB. If not OB complaint: seen in ER and if >20 weeks, then sent to OB for fetal monitoring.

CEG · Apr 15, 2009

Thank you for your response; my biggest problem w/this is that she was dilated @ 1 cm 48 hrs prior, & remained @ 1 cm when back in ER on day in question; however, there were marked changes in level and character of pain; also, she had been told at her last ofc visit that the delivery would most likely come before or by the 8th of the mo & all this occured on the 4th. With this data in place, I am trying to understand why the ER MD didn't personally take a look @ my dtr-in-law before allowing discharge.

Since medical advice can't be given here, just some general info. There is absolutely no way for anyone to predict when a woman will go into labor. A woman can be 5 cm dilated for weeks on end with no contractions or 1 cm and holding her baby an hour later. So no woman should put any credence into a provider who tells her she will give birth by a certain date/number of weeks (if this was possible there would be no pre-term births because we would be able to predict it, right?)

At most small community hospitals, patients will never see the MD before being discharged. The MDs are not in house and typically do not show up until delivery time in any case, so they certainly do not come in to evaluate labors. Many, many, many primigravidas and multiparas alike come in to rule out labor who are not in labor. I'm not saying this is okay- this is just the way OB is practiced. Nurses primarily manage the patients with standard orders until deliver unless there is a strict deviation from norm. Now with a midwife your daughter may have had more personalized care, but not 100% of the time. She may want to look into midwifery care for her next baby (or a planned homebirth since she seems to have a handle on this:)

bamamamacat · Apr 15, 2009

I found your explanation very informative and helpful toward putting things into at least a semblance of logical perspective; thank you.

HappyNurse2005, RN · Apr 16, 2009

We see patients over 20 weeks, though sometimes less if she is going to deliver.

yes, we see non-OB complaints in OB triage, without ever being seen in the ED.

A patient comes into ER registration, tells them her problem, they callus then bring her right up to OB triage. No ER triage, no ER eval.

If she's had a bad MVA (requiring anbulance), or broken a bone she'll go down there.Oh, or chest pain or severe difficulty breathing. We get all kinds of non ob complaints. Asthma. DKA. r/o DVT. minor MVA (drove self to hospital). hit in abdomen with brick. fell down stairs.rash. seizures (from seizure disorder) back pain. hemorrhoids. nausea/vomiting. and all the regular OB stuff too-r/o labor, vag bleeding, r/o SROM or PPROM, decr FM, r/o UTI, etc.

Initial eval by RN-vitals, urine dip, cervical check (if term and on a private patient), quick history of current problem. Residents do cervical checks on all clinic patients. Then MD either comes to see and eval patient (if a clinic patient or if private MD is awake and on floor) or gives orders over the phone (Private MD at home). MD MUST see the patient before discharge. Even if all they do is say hi, they MUST lay eyes on patient before discharge.

Elvish, BSN, DNP, RN, NP · Apr 16, 2009

OB trauma - straight to the ED, and OB resident plus L/D charge nurse go down to evaluate.

Pregnant pt w/ non-pregnancy-related condition - seen in ED and if needed, transferred to med/surg floor. OB consult is done to review meds etc. and write orders for FHTs etc. If floor isn't comfortable w/ doing FHTs, one of the L/D or mother/baby nurses go up/down to do it.

Pregnant pt with pregnancy related condition - if 20 weeks to L/D first. We deliver

In all cases, OB is at the very least consulted, if not managing care entirely.