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CNE The Importance of Interdepartmental

Continuing Nursing Education
(CNE) Credit
Collaboration and Safe Triage for
A total of 1.2 contact hours may be
earned as CNE credit for reading
“The Importance of Interdepartmental
Pregnant Women in the Emergency
Collaboration and in Safe Triage for
Pregnant Women in the Emergency
Department” and for completing an
online posttest and evaluation.
Department
AWHONN is accredited as a
Brenda A. Chagolla, John P. Keats, and Janet M. Fulton
provider of continuing nursing
education by the American Nurses
Credentialing Center’s
Commission on Accreditation.
ABSTRACT
AWHONN holds a California BRN
number, California CNE Provider Pregnant women who present to the emergency department can present challenges that range from the diagnoses of
#CEP580
unsuspected pregnancies to the determination of where evaluations should occur. In this review we identify literature
http://JournalsCNE.awhonn.org associated with the triage of pregnant women in the emergency department and propose a model for triage and
evaluation of pregnant women in the emergency department. Strategies are described to facilitate interdepartmental
communication to optimize safe maternal/fetal care.
JOGNN, 42, 595-605; 2013. DOI: 10.1111/1552-6909.12238
Accepted June 2013
Keywords
obstetric triage
interdepartmental
collaboration
riage, interdepartmental collaboration, and One key to ensuring optimal maternal/fetal care
T
emergency department
patient safety communication should be high priorities when lies in early, frequent, interdepartmental collabora-
interprofessional care
a pregnant woman presents to the emergency de- tion, and communication among members of the
partment (ED), regardless of her presenting chief health care team. Inadequate interdepartmental
Correspondence
Brenda A. Chagolla, RN, complaint. When a pregnant woman arrives in communication and collaboration may result in an
MSN, CNS, Birthing the ED, fetal health must be assessed, and op- increased risk of adverse events to the mother and
Suites/Woman’s timal care for the woman involves a systematic fetus. In addition, the adaption of two core princi-
Pavilion/Nursery, 2315
Stockton Blvd. Sacramento,
and an efficient approach to determine whether ples of patient safety, simplification, and standard-
CA 95817, pregnancy-related complications are present. The ization of clinical care, promises to enhance pa-
Brenda.Chagolla@ presence or absence of pregnancy-related com- tient safety (Knox & Simpson, 2011; Knox, Simp-
ucdmc.ucdavis.edu plications dictates the location of where the son, & Garite, 1999). The purpose of this article
woman’s health care needs will be most safely is to describe a collaborative model of practice
The authors and planners
for this activity report no met: the ED or in the perinatal department. To designed to optimize the care of the woman pre-
conflict of interest or best protect the woman and fetus, the woman senting to the ED equal to or greater than 20 weeks
relevant financial needs to be cared for by appropriately educated gestation for a nonobstetric complaint.
relationships. The article
caregivers who have access to the proper re-
includes no discussion of
off-label drug or device use. sources (Emergency Nurses Association [ENA],
No commercial support was 2011). Maternal and fetal health concerns are of- Background
received for this ten complex, and these concerns may need to be To safely triage pregnant women presenting to
educational activity. the ED, multiple factors must be considered such
balanced for optimum outcomes. When the ges-
Brenda A. Chagolla, RN, tational age of the pregnancy suggests the fetus as gestational age, the physiologic changes as-
MSN, CNS, is a manager at may be viable, the fetus should be considered a sociated with pregnancy, and social and psy-
the University of California hidden second patient and fetal wellbeing ascer- chological factors affecting women. Known and
Davis Medical Center,
Sacramento CA. tained. In the Guidelines for Professional Regis- unknown common medical and lifestyle risks
tered Nurse Staffing for Perinatal Units published during pregnancy can complicate the status of
by the Association of Women’s Health, Obstetric, the mother or fetus. The National Center for
(Continued) and Neonatal Nurse’s (AWHONN; 2010) emphasis Health Statistics reported that common medical
is given to the assessment of maternal and fetal complications during pregnancy increased be-
wellbeing. tween 2000 and 2010 (Martin, Hamilton, Ventura,

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C 2013 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses 595
IN FOCUS
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When a pregnant woman arrives in the ED, her well-being and
the well-being of her fetus must be evaluated.
John P. Keats, MD, is a
market medical executive
for Cigna Health Plan of
Arizona, Phoenix, AZ.
Janet M. Fulton, PhD,
MPA, RNC-OB, is the
Manager Patient Safety and
Clinical Risk, Dignity
Health, Rancho Cordova,
CA.
596
Interdepartmental Collaboration and Safe Triage for Pregnant Women in the Emergency Department
Menacker, & Park, 2002; Martin et al., 2012). The
rate of diabetes during pregnancy increased from
2.9% of births in 2000 to 5.1% in 2010 (Martin et al.;
Martin et al., 2002, 2012). Pregnancy-associated
hypertension increased from 3.9% in 2000 to 4.4%
of all births in the United States in 2010 (Martin et
al.; Martin et al., 2002, 2012). In addition, 3.8%
of infants are born to women receiving late or no
prenatal care (Menacker, Martin, MacDorman, &
Ventura, 2004). The Centers for Disease Control
and Prevention (2000, 2010) reported an increase
in obesity in women, defined as a body mass index
of greater than 30, from 19.9% in 2000 to 26.8%
in 2010. Over a 15-year study period, the number
of women categorized as obese (greater than or
equal to 90 kg) increased from 3.2% in 1988 to
10.2% in 2002 in Nova Scotia, Canada (Robinson,
O’Connell, Joseph, & McLeod, 2005). In a Cana-
dian study that reviewed a 10-year span between
1991 and 2001, researchers found that the pres-
ence of major preexisting conditions increased the
risk of severe maternal morbidity 6-fold (Wen et al.,
2005). Taken together, these data suggest a press-
ing need for hospitals to have simple, structured,
systematic protocols for the triage and care of ob-
stetric patients presenting to the ED.
To improve triage of pregnant women presenting
to the ED, we initiated an inquiry of professional
standards and published literature related to the
care of pregnant women in the ED. The limited
search results validated our concern regarding the
need to improve care processes, particularly the
interface between the ED and perinatal units.
Nursing and Physician Professional
Organizations
Prior to developing a standardized model of prac-
tice, we conducted a review of materials from nurs-
ing and physician professional organizations that
support obstetric and emergency areas to deter-
mine recommended best practices and guide-
lines. Professional standards addressing this is-
sue were extremely limited. Guidelines from the
Association of Emergency Physicians, AWHONN,
American College of Nurse Midwives, and the
American College of Obstetricians and Gynecolo-
gists totaled 191 active practice, policy, and posi-
tion statements. The Society of Obstetricians and
Gynaecologists of Canada had the largest num-
JOGNN, 42, 595-605; 2013. DOI: 10.1111/1552-6909.12238
ber of practice guidelines including 248 total and
62 related to maternal/fetal medicine and obstet-
rics. No published guidelines were found that ad-
dressed pregnant women who present to the ED
by these five organizations. Of the 55 position
statements issued by the Emergency Nurses As-
sociation (ENA), one addressed the care of preg-
nant women who present to the ED (ENA, 2011).
The ENA position statement addresses care of
women presenting to the ED for active labor or
obstetric complaints but does not address poten-
tial obstetric or fetal complications in women who
present for nonobstetric complaints. A frequently
used ED triage tool known as the Emergency
Severity Index (ESI) (Gilboy, Tanabe, Travers, &
Rosenau, 2011) and published by the Agency for
Healthcare Research and Quality was identified.
The ESI is a validated five-level triage tool for ED
patients recognized by the Association of Emer-
gency Physicians and the ENA. The ESI levels
range from 1 to 5, with 1 indicating the most ur-
gent patient needing immediate resuscitation and
5 indicating a patient who needs the fewest re-
sources. The validity of the ESI has been evaluated
based on outcomes for several thousand patients.
Researchers found consistent, strong correlations
of the ESI with hospitalization, ED length of stay,
and mortality (Gilboy et al.). In the fourth edition of
the ESI, the section addressing Level 2 discusses
obstetric and gynecologic patients but only de-
scribes triage of women with vaginal bleeding
during pregnancy and postpartum. Perinatal sit-
uations described in the ESI as Level 2 include
abdominal pain, vaginal bleeding, or vaginal dis-
charge of a pregnant woman 14 to 20 weeks ges-
tation as well as a postpartum patient with a chief
complaint of heavy vaginal bleeding. Assessment
for signs and symptoms of abruptio placentae and
placenta previa by the triage nurse is the only dis-
cussion of evaluating obstetric complaints in the
context of late pregnancy.
Literature Review
We conducted a search of PubMed and CIN-
HAL Plus to identify any relevant literature on the
triage of pregnant a woman in the emergency de-
partment that should inform the proposed model.
The search terms used included obstetrical triage
& emergency department, obstetrical triage, ob-
stetric triage & emergency department, obstet-
ric care & emergency department, pregnancy &
emergency department & disposition, and obstet-
ric triage. These searches yielded 37 manuscripts
related to triage of a pregnant woman in the
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perinatal unit, but no articles specifically focused

on the triage of a pregnant woman in the ED after Obstetric complications may be subtle in nature or not
20 weeks gestation for a nonobstetric complaint. recognized as abnormal by personnel who are not familiar with
Some literature was identified on triage of preg- the physiologic changes of pregnancy.
nant women with trauma in the ED.

We found related literature from the Pennsylva-
nia Patient Safety Authority (PPSA). Since June
2004, 20 reports have been submitted to the PPSA
group indicating ineffective interactions between
the ED and obstetric departments during the man-
agement of obstetric patients (PPSA, 2008). Two
issues identified by the PPSA group from these
20 reports include delay in fetal monitoring for pa-
tients in the ED and pregnant women without an
obstetric complaint sent to the perinatal unit with-
out an ED assessment. Three of the 20 reports
from the safety advisory were summarized by the
PPSA group (see Table 1). However, little other
published information addresses the challenges
associated with the care of pregnant women pre-
senting to the ED. This lack of literature points to
the need for further investigation as well as the
development of simple, standardized, systematic
guidelines for the management of these women.
Systems must be in place to ensure open commu-
nication and collaboration between obstetric and
ED providers.
Issues in the Triage of Pregnant
Women Presenting for Emergency
Care
An ED visit by a pregnant woman presents po-
tential challenges and opportunities. Clinicians
should not assume that the woman is receiving
prenatal care or that potential pregnancy compli-
cations are known. If the woman is 20 weeks ges-
tation or greater, providers need to ensure that no
obstetric or fetal emergencies are present regard-
less of the chief presenting complaint. Examples
of the types of cases experienced with women who
present to the ED in which early obstetric consulta-
tion would be beneficial but that are not described
in the literature are presented in Table 2.
Challenges
A pregnant woman who presents to the ED can
pose challenges due to the physiologic, social,
and psychological changes associated with preg-
nancy. Optimal evaluation of a pregnant woman
requires an understanding of the physiology of
pregnancy and possible pregnancy-related con-
ditions (Pearlman & Desmond, 2005). All women
of reproductive age who present to the ED must be
assessed for the possibility of pregnancy; some-
times a woman may be unaware or unwilling to
admit that she’s pregnant. Once pregnancy is es-
tablished (usually by the patient’s own statement),
gestational age needs to be determined or con-
firmed. Triage management of the women should
differ according to whether the gestational age has
reached the potential point of fetal viability.
Obstetric complications may be subtle in nature
or not recognized as abnormal by providers who
are not familiar with physiologic changes of preg-
nancy. A systolic blood pressure greater than
140 millimeters of mercury (mmHg) or a diastolic

Table 1: Pennsylvania Patient Safety Advisory-Events

Type Description
Fetal Monitoring A pregnant woman at 32 weeks gestation presented to the emergency department (ED) as a trauma
patient. An initial ultrasound and fetal heart tones indicated a viable fetus. The patient underwent a
series of imaging studies and treatment of superficial injuries, after which she was transferred to the
labor and delivery (L&D) department where fetal heart tones were not detected. A nonviable fetus
was delivered. Continuous fetal monitoring had not been initiated in the ED.

Maternal A pregnant patient arrived in the ED with complaints of chest pain and shortness of breath. The ED staff
Complication instructed her to ambulate to the obstetric (OB) department. She was transferred back to the ED via
wheelchair for evaluation, resulting in a delay in treatment.

Near Miss A pregnant (trauma) patient was transported to L&D from the ED for continuous fetal monitoring. The
patient’s cervical spine X-rays had not been done and her cervical collar had been removed. In
L&D, an ED nurse replaced the cervical collar, and portable cervical spine X-rays were performed.

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Table 2: Case Studies

Type Description

Hypertension A pregnant woman at 29 weeks gestation presents with a nonobstetric complaint such as a broken arm.
Because the chief complaint is viewed as nonobstetric (OB) related, the woman does not have an
OB/fetal evaluation. The patient is treated for her broken arm and discharged. It is not recognized
that her triage blood pressure is 146/92, which is not normal for pregnancy, and the blood pressure
is not rechecked. The patient presents several hours later to the perinatal unit with abdominal pain
and a placental abruption.

Fetal Complication A pregnant woman presents at 34 weeks gestation with a severe upper respiratory infection. The
woman meets the criteria for sepsis. Blood cultures are collected and antibiotics are initiated.
Several hours later, the perinatal unit is called to place the baby on the fetal monitor. The baby has a
category 3 fetal heart rate tracing; an emergency cesarean is performed with Apgar scores of 2 at 1
minute, 4 at 5 minutes, and 7 at 10 minutes.

Treatment Delay A pregnant woman at 32 weeks gestation presents with a headache for the last 10 hours. The
emergency department (ED) sends the patient for a computed tomography (CT) scan to evaluate
for neurologic complications. While in the CT scanner, the woman has an eclamptic seizure.

blood pressure greater than 90 mmHg may not
be identified as abnormal but is concerning and
requires further evaluation in a pregnant woman
(National Institute of Health, 2000). The finding of
hypertension may be incidental and not related to
the presenting complaint. Many significant obstet-
ric complications, particularly preeclampsia, may
not manifest until after 20 weeks gestation, and in
these situations, appropriate care may be delayed
while other diagnoses are evaluated. Pregnant
women who present with headache or other signs
or symptoms of preeclampsia after 20 weeks ges-
tation or within the first 6 weeks postpartum should
be quickly evaluated and treated, if indicated.
In pregnancies equal to or greater than 20 weeks
gestation, fetal well-being and uterine activity
should be evaluated. The use of electronic fetal
cardiac and uterine activity monitoring in pregnant
trauma victims greater than 20 weeks gestation is
recommended (American Academy of Pediatrics
& American College of Obstetricians and Gynecol-
ogists, 2012). Generally, the most qualified person
to evaluate fetal well-being is a provider from the
obstetric team. Initiation and ongoing clinical eval-
uation of the fetus using electronic fetal monitoring
should be performed only by health care profes-
sionals who have education and skills validation
in fetal heart monitoring and in the care of the la-
boring woman (AWHONN, 2008).
Configuration of Services
Although we found no literature or data on the
configuration of emergency services for pregnant
women, hospital personnel typically provide eval-
uation and treatment for pregnant women equal to
or greater than 20 weeks gestation who present
to the ED for nonobstetric complaints using one
of three methods, each of which has potential
strengths and limitations. For the purposes of this
article, the definition of a nonobstetric complaint is
any complaint not including contractions, vaginal
bleeding, decreased fetal movement, or rupture of
membranes.
The first method requires all pregnant women re-
gardless of gestational age and chief complaint to
be evaluated in the perinatal unit, as long as they
are medically stable. This model requires several
resources to be in operation to ensure success. A
provider who is qualified to evaluate non-obstetric-
related chief complaints should be immediately
available to the perinatal unit at all times. Evaluat-
ing all patients in obstetric triage without ED con-
sultation introduces the potential to miss important
nonobstetric problems. Additional bed space
and/or nursing resources may be needed in the
obstetric triage area to accommodate the poten-
tial increase in volume.
The second method requires a woman with an ob-
vious pregnancy-related complaint to be triaged in
the perinatal unit. These complaints may include
uterine contractions, decreased fetal movement,
vaginal bleeding, or rupture of membranes. In ef-
fect, the default method would be to screen and
diagnose a pregnant woman in the ED unless a
specific reason is identified requiring transfer to
the perinatal unit. This model of practice could

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Chagolla, B. A., Keats, J. P., and Fulton, J. M.
allow for a woman with a maternal/fetal compli-
cation that is not evident or related to the chief
complaint to be missed.
The third method requires a pregnant women at
a predetermined gestational age or greater to be
evaluated by a member of the obstetric team for
obstetric/fetal complications as an adjunct eval-
uation to the chief or presenting complaint. An
obstetrician, midwife, or perinatal nurse with ex-
perience providing obstetric medical screening
exams may perform this obstetric/fetal evaluation.
The obstetric/fetal evaluation may occur in the ED
or obstetric unit dependent on the needs of the
patient and availability of hospital resources. This
model of practice could present logistical chal-
lenges if the perinatal staff has to leave their unit
to evaluate women in ED. Evaluations could be
suboptimal if the process for determining who will
conduct the evaluation and where it will be con-
ducted is unclear.
All of the previous models described are based
on practices that evolved over time. Any of these
methods have inherent patient safety risks due to
issues such as communication between depart-
ments and knowledge gaps among providers. For
instance, providers could be skilled in general
emergency care delivery but not specifically in
care of a pregnant woman. The reverse scenario
may exist with a provider skilled in pregnancy care
but not in the care of non-pregnancy-related emer-
gency conditions.
Proposed Model for Triage
In response to the absence of peer-reviewed liter-
ature and professional guidelines relevant to this
patient safety initiative, we sought to develop a
best-practice model for triage care in the ED. A
group of interdisciplinary experts assembled to
develop this model over a period of 3 months. The
goal of the model was to standardize care and
develop a simple process to ensure that a preg-
nant woman who presents to the ED is evaluated
for maternal/fetal complications regardless of the
presenting complaint. The algorithm and policy in
Figures 1 & 2 were developed by and utilized in the
30 hospitals in the Dignity Health Hospital system
(California) that provides perinatal services. This
model is likely to be feasible for most hospitals with
perinatal services and can ensure a high level of
safety for the mother and fetus without requiring
a provider to be in the perinatal unit to evaluate
nonobstetric complaints. This model depends on
timely triage in the ED to establish pregnancy and
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to determine gestational age, chief complaint, and
ESI or other standardized acuity level. To ensure
safety, pregnant women with major trauma, res-
piratory distress, cardiac symptoms, seizures, or
other potentially life-threatening conditions should
remain in the ED for urgent evaluation, including
immediate obstetric and fetal consultations.
Interdepartmental Communication
Ongoing multidisciplinary and interdepartmental
communication is essential to provide optimal care
to the pregnant woman, her fetus, and the family.
A standardized policy for the disposition and care
of obstetric patients who present to the ED should
be developed by an interdepartmental team of
nurses, providers, and support staff from the peri-
natal department and the ED in conjunction with
leadership. It should be reviewed periodically with
the entire team in each department. Because not
all situations can be covered by a policy or al-
gorithm, early and frequent discussions should
be initiated by the obstetric and ED departments
to determine the best practices in maternal/fetal
care. Policies and procedures should address the
following issues.
Standardization of Triage
Determination of Pregnancy by the Emergency
Department. It is important to determine whether
ED triage staff routinely ask if women are preg-
nant or have been pregnant within the last 6 weeks
to trigger an evaluation for preeclampsia or other
complications related to the postpartum period.
During the triage process, all women of childbear-
ing age who present to the ED should be asked
if they are pregnant or recently gave birth. Emer-
gency room personnel should be educated that
women, regardless of presenting symptoms, may
be pregnant or may have recently been pregnant
(The Joint Commission, 2010).
Pregnancy tests are performed routinely in the ED
for women of childbearing age to check for preg-
nancy at any stage of gestation (Strote & Chen,
2006). The policy should specifically define child-
bearing age depending on the population served
and the experience of the facility. One sugges-
tion is to ask all female patients between ages 13
and 50 who present to the ED for care if they are
pregnant or if they have been pregnant in the last
6 weeks (Matthys, Coppage, Lambers, Barton,
& Sibai, 2004). Women in their first trimesters of
pregnancy should be evaluated for ectopic preg-
nancy (Hahn, Lavonas, Mace, Napoli, & Fesmire,
2012).
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Early consultation with

obstetric provider

Yes

Is patient having
vaginal bleeding,
abdominal pain,
Routine care in emergency or syncope?
department

No
No
Female patient
aged 13-50
Is the Is gestational age
presents to
Yes patient Yes 20 weeks or
emergency
pregnant? greater?
department

Yes

Emergency Severity
Communicate to perinatal personnel the Index level 1 or 2?
immediate need come to emergency Having Seizures?
Yes Imminently delivering?
department to evaluate fetus. Having major trauma?

No

Transport or accompany patient to perinatal department or have

qualified perinatal nurse and/or provider come to emergency
department to conduct obstetric evaluation.

Figure 1. Algorithm for disposition of the obstetric patient who presents to the emergency department. Reprinted from Dignity
Health, 2012. Reprinted with permission.

Timely Triage. Expeditious evaluation of the chief
complaint and triage via ESI score or another stan-
dardized tool is optimal. Obstetric patients pre-
senting with critical conditions should remain in
the ED with concurrent evaluation by the obstet-
ric team. Situations that will require management
in the ED with immediate consultation include im-
minent birth, cardiac symptoms, respiratory com-
promise, seizures, or major trauma (ESI Level 1
or 2). The perinatal team should understand which
triage tool is used in the ED and how triage levels
are determined.
Gestational Age–Based Triage. For women who
present to the ED with nonobstetric complaints,
policies should indicate the gestational age at
which an obstetric evaluation is needed. The use
of 20 weeks gestation as the defining age for ob-
stetric evaluation allows for the 2-week variation
in early ultrasound dating (American Academy
of Pediatrics & American College of Obstetri-
cians and Gynecologists [AAP & ACOG], 2012)
and ensures that potentially viable fetuses are
properly evaluated. A first-trimester ultrasound is
the most accurate and ideal method to verify

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POLICIES & PROCEDURES

TITLE: TRIAGE OF OB PATIENT IN THE EMERGENCY DEPARTMENT
(TEMPLATE)
Departments: Perinatal Department, Emergency Department
Division: Nursing

PERFORMED BY: Registered Nurse, Certified Nurse Midwife, Physician, Nurse Practitioner
POLICY:
1. It is the policy of Hospital to provide a medical screening exam and
stabilizing care to all obstetric patients in need of emergency care.
2. Quality care is provided in compliance with Emergency Medical Treatment and Labor
Act (EMTALA) guidelines.
3. All female patients between the ages of 13 and 50 who present to the emergency
department (ED) for care will be asked if they are pregnant or have been pregnant within
the last six weeks.
PROCEDURE:
1. When women who state they are or were recently pregnant present to the ED, the ED
triage Registered Nurse (RN) will determine the following:
a. The chief complaint
b. Date of last menstrual period and/or due date, if known
i. If due date is known, calculate weeks of gestation.
ii. If due date is unknown, palpate top of uterine fundus. At or above the
umbilicus equates to 20 or more weeks gestation.
2. Obstetric patients are assessed as outpatients in the perinatal department or the ED.
a. Women less than 20 weeks gestation will be assessed in the ED. When patients
under 20 weeks gestation present with complaints of vaginal bleeding, abdominal
pain, or syncope, early consultation with an obstetrical provider is appropriate.
i. Those patients who present to the ED with symptoms that do not
appear to be pregnancy related are screened, and care is provided for
in the ED.
ii. Women between 14 and 20 weeks gestation with a chief complaint of
vaginal bleeding and/or abdominal pain should have a consultation
with an appropriate OB provider. The OB provider can determine
whether to evaluate the patient in the ED or to request a transfer to the
perinatal department.
b. All pregnant patients 20 weeks gestation and greater, with or without a primary
care provider on staff, who present to the facility requesting care must have an
OB and fetal evaluation, regardless of the presenting chief complaint, by a
qualified perinatal Registered Nurse, Nurse Practitioner, Certified Nurse
Midwife, or Obstetric provider. This person is frequently the perinatal nurse.
c. Patients 20 weeks gestation or greater with a life-threatening condition or who
are medically unstable (in association with or independent of their pregnancy)
will remain in the ED, and the perinatal department will be notified immediately.
i. A perinatal RN will come to the ED.
ii. The patient will be placed on a fetal monitor, and if warranted, a
vaginal examination may be performed.

Figure 2. Template policy for obstetric patients presenting to the emergency department. Reprinted with permission from
Dignity Health, 2012.

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iii. The perinatal RN will remain with the patient until the OB condition
is stabilized.
d. Regardless of gestation, the first priority for emergency care of pregnant women
is the CABs (circulation, airway, and breathing). There is a 5-minute window that
providers have to determine if cardiac arrest can be reversed by basic life support
(BLS) and advanced cardiac life support (ACLS) before initiating emergency
hysterotomy, and there are circumstances that support an earlier start.
2. If the patient is to be transported to the perinatal department, the ED RN will notify the
perinatal Charge Nurse by telephone of the patient’s gestational age, provider, chief
complaint, and vital signs, if done.
3. If the patient does not have a provider and/or has not received any prenatal care, the OB
provider on-call for the ED will be notified.
4. The pregnant woman presenting to the ED who is actively pushing or whose membranes
rupture in the ED should be undressed and the perineal area visually examined by the ED
RN and/or ED physician prior to transferring to the perinatal department.
a. If any part of the baby’s head can be visualized, the baby will be delivered in the
ED (as per point 5 below).
b. If the umbilical cord is visualized, the patient should be positioned to relieve cord
compression and transported immediately to the perinatal Operating Room.
c. The perinatal department will be immediately notified of the situation.
5. If the patient presents and delivery is imminent, the patient will remain in the ED for
delivery.
a. The perinatal department will be notified by telephone of the pending delivery.
b. The ED physician will deliver the baby if the obstetrician is not able to attend the
delivery and will suction the mouth and nose with a bulb syringe.
c. The cord will be clamped with 2 clamps placed 2–4 inches apart and the cord cut
between the 2 clamps.
d. If stable, the infant will be placed skin to skin with the mother after initial drying.
e. Both mother and baby will be transferred to the perinatal department if the
condition of the infant and the mother is stable.
f. If the infant appears premature or is unstable, the Neonatal Intensive Care Unit
will be notified immediately.
g. The perinatal staff will be responsible for completing a Newborn Delivery Record
and placing identification bands on both the baby and parents per banding policy.
6. If delivery occurs outside the hospital, the mother and baby will be transported to the
perinatal department as soon as possible, with the baby skin to skin on the mother’s chest
or abdomen, if stable, and all but the baby’s face covered in warm blankets.
Figure 2. Continued.

gestational age (ACOG, 2009), although point of
care ultrasonic assessments may not be immedi-
ately available in the ED. In the meantime, gesta-
tional age can be determined by patient report of
last menstrual period and use of a gestational age
wheel or web-based application and fundal height
measurements. Verification of appropriate use by
triage personnel and availability of supplies for
the selected method should be available. A stan-
dard regarding estimation of gestational age (e.g.,

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Chagolla, B. A., Keats, J. P., and Fulton, J. M.
obstetric wheel application) should be established
and communicated with the ED team. If a web-
based application is used, then it should be ver-
ified that menstrual age, not conception age, is
entered into the application, as this practice con-
forms to standard obstetric nomenclature. Fundal
height measurements are often used to estimate
gestational age. In a singleton gestation, fundal
height determination is approximately at the level
of the umbilicus by 20 weeks (Vanden Hoek et al.,
2010). If the fundus is above the umbilicus, an
initial assumption can be made that the fetus is
at least 20 weeks gestation until a standard ultra-
sound can be performed to verify gestational age
and fetal number.
Most pregnant women present to the ED with-
out critical conditions. It is impossible to address
every potential clinical scenario in a policy or al-
gorithm. Therefore, it is essential that all algo-
rithms and policies for the perinatal and ED de-
partments include interdepartmental communica-
tion early in the evaluation of the pregnant woman
to jointly determine the best location for patient
care.
Obstetric Evaluation. Women who are equal to or
greater than 20 weeks gestation should receive an
obstetric evaluation by a qualified perinatal nurse
or obstetric provider, either in the perinatal unit
or in the ED. Policies and procedures for assess-
ment of pregnant women should be clearly out-
lined by the medical staff (AAP & ACOG, 2012).
The skill level of persons providing obstetric eval-
uations and care for pregnant women presenting
to the ED should be outlined in policies and stan-
dardized whenever possible. Labor, medical com-
plications of pregnancy, or an abnormal fetal heart
rate pattern diagnosed through the obstetric eval-
uation should be treated directly by the obstetrics
team.
Escorting Women During Transport. Pregnant
women who are transferred between departments
for evaluation of obstetric and nonobstetric com-
plaints should be escorted. Women who are left
to find their way from one department to another
may be delayed or not able to find the right lo-
cation. Hospitals should determine how stable,
routine patients are transported between depart-
ments. Acutely ill patients should be transported
by a registered nurse and possibly by a medical
team with advanced skills. Emergency birth kits
should accompany the women.
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Evaluation of Obstetric Patients
Presenting for Emergency Care in
Hospitals Without Obstetric
Services
Hospitals with EDs but no perinatal departments
should have defined, predetermined processes
for triage and evaluation of pregnant women that
are clearly communicated to and understood by
the health care team. The triage process for preg-
nant women who are fewer than 20 weeks ges-
tation and present to the ED with a nonobstet-
ric complaint or with trauma should be managed
as usual. The evaluation of pregnant women with
non-obstetric-related complaint who are equal to
or greater than 20 weeks gestation should be the
same as for all ED patients with similar chief com-
plaints but should also assessment of fetal heart
tones by handheld Doppler or ultrasound, and
assessment of urine for protein by urinalysis or
dipstick.
The patient’s primary obstetric provider (during of-
fice hours) or the on-call obstetric provider (af-
ter hours or for unassigned patients) should be
notified to determine if the woman can be man-
aged in the ED or if she requires further evalua-
tion. Transfer to a facility with obstetric services
is indicated if any of the following conditions ex-
ist and the woman’s condition allows: (a) labor,
(b) rupture of membranes, (c) vaginal bleeding,
(d) systolic blood pressure above 140 mmHg, (e)
diastolic blood pressure above 90 mmHg, (f) fe-
tal heart rate greater than 160 beats per minutes
(bpm), (g) fetal heart rate below 110 bpm, (h) need
for electronic fetal monitoring, or (i) urine protein
1+ which is equal to 30 milligrams per deciliter or
greater (National Institute of Health, 2000).
Recommendations
Each facility should adopt a policy for its ED
that facilitates rapid triage of pregnant women,
determination of gestational age, and identifica-
tion of pregnancy in women of childbearing age.
Depending on the facility’s approach to emer-
gency care for pregnant women, women under
20 weeks gestation may receive their formal eval-
uation in the ED as usual. When patients fewer
than 20 weeks gestation present with complaints
of vaginal bleeding, abdominal pain, or syncope,
early consultation with an obstetrics provider is
appropriate to rule out ectopic pregnancy. The
prevalence of ectopic pregnancy in symptomatic
women in the ED has been reported as high as
13% by some researchers, which is much higher
603
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A standardized policy for triage, evaluation, and care of
pregnant women who present to the emergency department
should be developed by an interdepartmental team.
than the prevalence in the general population
(Hahn et al., 2012).
Patients who are equal to or greater than 20 weeks
gestation should have an obstetric evaluation per-
formed by a perinatal nurse or obstetric practi-
tioner. In cases when a potentially life-threatening
condition is present, it is safer to keep women
in the ED and have qualified personnel from the
perinatal department go to the ED to evaluate
the mother/fetus dyads. When pregnant women
present in active labor and birth is imminent, per-
sonnel from the perinatal department should pro-
ceed to the ED to attend to the women in that
location. When the perinatal nurse or other qual-
ified provider attends to the pregnant woman in
the ED to conduct an obstetric evaluation, he or
she will need to bring a portable fetal monitor to
assess the fetus if a monitor for that purpose is not
already there.
Conclusion
The proposed model of triage for pregnant women
who are equal to or greater than 20 weeks
gestation and present to the ED for nonobstet-
ric complaints includes obstetric evaluation for
maternal/fetal complications. Research is clearly
needed to determine evidence-based practices
for triage and evaluation of pregnant women who
present to the ED for nonobstetric complaints.
Early and frequent communication between the
ED and perinatal departments is needed to pro-
vide optimal care for pregnant women and their fe-
tuses. Ongoing collaboration with all departments
and disciplines that care for pregnant women is
an essential element in the care of these women.
When pregnant women present to the ED for care,
clinicians have an opportunity and responsibility
to ensure that these women do not have maternal
or fetal complications requiring treatment.
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