Triage Tales: Inducing Irritation

Oy ve, I had another one.

What a scene. You would’ve thought she was about to deliver right then and there.  But let me back up a bit.

There I was at the nurse’s station, enjoying an evening that could easily be described as…er, well, we don’t say that word in my profession (it starts with a “q” and if you do say it, you run the risk of being assaulted by an angry horde of RNs!).

Quiet night

But nevertheless, there we were, standing around and chatting amongst ourselves, sipping our first cups of coffee and having a splendid time.

Then, the call came in from the front desk.  I was up for triage, so the yellow sticky came directly to me.

“Ashley Smith, G1P0, ctx/pain, 18 y.o., 36.4, Dr. Adams.”

In English: my patient is Ashley Smith. She’s an 18-year-old patient of Dr. Adams expecting her first baby.  She’s here for painful contractions and she’s at 36 weeks, 4 days gestation.

I glanced up at my charge nurse, who had taken the call. “Is this one for real?”

She shrugged. “I dunno.  The receptionist sounded pretty serious when she sent me the info.  It sounds like it might be.”

“Okey dokey.  I’ll put her in 2.”  I said, heading down the hallway and out through the double doors to our reception desk.

Ashley Smith was clearly uncomfortable, breathing heavily in the chair at the receptionist’s desk.  An older woman, presumably her mother, stood behind her.

“Ashley?” I approached, taking the consent forms from the receptionist.

“Yeah.” The girl replied, standing up painfully.  Her mother took one of her arms and together, we slowly made our way back through the double doors and into the triage room.  Ashley, panting and holding her belly, was obviously holding back tears as we went.

“I’m Sophina.  I’m going to be your nurse today.  When did your contractions start?”

“They started about 4 hours ago.  I’ve been up walking, moving around, all kinds of stuff.  They aren’t stopping.”  Ashley replied.

“OK.  Where’s most of your pain?” I asked.

“Down there.” She motions toward her privates.  “And sometimes in my back.”

“Gotcha.  How far apart are your contractions and how long do they last?” I ask, starting to wonder what exactly I was dealing with.  Ashley’s “contraction”, which should’ve been letting up by now, seemed more like continuous pain, and the pressure she was describing could be indicative of advanced dilation, which was causing baby’s head to push down on her perineum.  However, most women by that point are beside themselves with the urge to push and in much more distress, both symptoms that Ashley was not exhibiting.

“They don’t really stop.” Ashley said.

“I’ve tried to time them, and they seem to let up every three to four minutes for a few seconds, and then she’s right back into them.”  Ashley’s mom piped up as we arrived in the room.

Now my mind was really going.  Was I looking at a case of uterine tetany (contractions that last much longer than they should)?  Was Ashley really having contractions?  Or was this patient, a young primigravida, after something else entirely?

In the room, I started the process of gathering the data I’d need to make a full assessment.  I put Ashley on the monitor, revealing  a very happily gestating fetus.  When I placed the toco (the monitor used to measure the length of contractions), I checked Ashley’s abdomen, noting that her uterine tone felt relaxed and normal.  The toco wasn’t picking anything up, but Ashley continued to complain of contractions.  So in the midst of getting Ashley’s vitals and asking her questions, I adjusted the toco several times, taking the opportunity to touch her abdomen to assess for contraction strength.  There was absolutely no uterine tone to be felt.

Finally, it was time for the acid test: dilation check.  Ashley was dilated to about a 1 and 40% effaced–certainly not advanced or indicative of active labor by any means.  It was when I was entering her dilation into the computer, which provides a historic view of her previous checks, that I realized this was Ashley’s fifth time through triage that week.

Now with a much clearer idea of what I was dealing with, I told Ashley I’d get ahold of the doc and be back in about 15 minutes.  Shaking my head, I did a bit of charting, made sure I had a 20-minute strip of baby’s heart rate and Ashley’s non-existent contractions, and prepared to call.

Just as I was about to call, however, Ashley’s mom stuck her head out of the triage room door. “Sophina, can you come check her again? She’s having a lot of pain!”

I hopped up and zipped into the room, where Ashley was writhing on the stretcher. Once again, the toco revealed no contraction activity, and Ashley’s uterus was relaxed.  I pulled on a sterile glove and gel and performed yet another cervical exam–absolutely no change.  Reassuring Ashley and her mother that nothing was happening, I readjusted my monitors, headed to the computer and called the doc.

Generously, the physician agreed to give some Tylenol #3 (Tylenol with codeine) for my uncomfortable soon-to-be mom, and as I headed back into the room with the drug and a glass of water, I prepared myself for what I knew was likely going to happen.

“All right, Ashley.  It looks like you’re not in labor.  Your cervix hasn’t changed since last week, the majority of your pain is down low and in your back, both of which are common in normal third-trimester pregnancies, and I’m not picking up any contractions of any kind, which is consistent with how you’ve described your pain.”

It was like flipping a switch.  Suddenly, Ashley didn’t appear to be in pain anymore.  The tears and the writhing and the look of discomfort were instantly gone.  She was glaring at me with the sullen disgust of a teenager whose bluff had been called.

“I’ve got some Tylenol #3 here, which is Tylenol with codeine, so we’ll see if that will help your pain any.  Otherwise, your baby looks nice and happy and I think we’ll be getting you on your way home soon.”  I said, scanning Ashley’s bracelet and her med.

Ashley verified her name and date of birth without looking at me.  While she took her med, it was obvious she was on the verge of breaking down.  I waited, knowing it was coming, finishing my medication documentation as her patience wore thin…

Say it 1Say it 2Say it 3

Say it 4

Finally:

“This is stupid!  I’m so sick of being pregnant!  I just want an induction.  Go out there and tell the doctor I want to be induced tonight! I just don’t wanna be pregnant anymore!!!”  Ashley exploded, looking me dead in the eye.

Say it 5

I turned to face her.  “Ashley, your baby is not yet at term.  We absolutely do not induce before 39 weeks except for medical reasons due to the higher risk of C-section and poorer outcomes for both moms and babies.  Your vitals and assessment are perfect.   Your baby looks great.  What you are experiencing are the normal pains and aches of pregnancy, and unfortunately, there is very little I can recommend for that aside from Tylenol, walking, perhaps a warm shower, and a good massage.”  I explained firmly.  Ashley once more looked away and down at the sheet, angrily staring at her belly.

“I’ll give you about thirty minutes to see if that Tylenol #3 takes your pain down a notch, but in the meantime, I’m going to get your discharge instructions together.  Do you have any questions or is there anything I can get for you right now?” I asked.

Ashley shook her head “no”, still avoiding eye contact.  Ah, the silent treatment.  It was all I could do not to flash back to my own teenage years.

“All right. Call me if you need me or if you have questions.”

I left the room with both Ashley and her mother staring me down and headed to the computer.  I quickly printed discharge instructions, found a pen and finished up my charting.  Thirty minutes later on the dot, I entered the room again and noted Ashley sitting in bed casually, playing on her phone.

“How’s your pain, Ashley?” I asked.

“No change.” She replied shortly.

“I can’t believe you’re really going to discharge her when she’s in this much pain!  This is ridiculous!” Ashley’s mother exclaimed dramatically.

I looked at Ashley, who was absorbed in a game of Solitaire and coolly ignoring me, and back at Ashley’s mother. “Ma’am, what your daughter is experiencing is clearly not labor.  We do not admit healthy moms and babies for pregnancy discomfort.  If you are truly concerned that something else is wrong, then I will call over to the main ER and let them know your daughter has been medically cleared by L&D, and she can be seen there.  Is that something you’d like?” I looked at Ashley.

Ashley shrugged, clearly out of ideas. “I’m good.”

I nodded.  “Great. Now, let’s go over your discharge instructions.”

Ten minutes later, my biggest fans were heading out the double doors back to the parking lot.

So if you’re expecting a baby and find yourself tired of being pregnant, take a walk, take a Tylenol, watch some TV, read a book, cook some dinner–but whatever you do, don’t try to trick your triage nurse!

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