Tips From an L&D Triage Nurse: How To Get Admitted…and How Not To!

Before I became an L&D nurse, I wouldn’t have known what qualified one patient for admission over another.  Since I began working L&D, I’ve come to realize that most of our patients don’t, either, but we also have a very different population–those patients who think they do.

I’ll bet you’ve heard all kinds of things from your friends, your mom, your neighbor, your coworkers, your cousins, the cashier at the grocery store, the talkative old lady in aisle 12 (let’s face it: pregnant ladies are prime targets for unwarranted advice!).  But what are we L&D triage nurses really looking for when you come into the hospital?  What’s the difference between a patient who will stick around until delivery and one who won’t?  And why did we send your great-aunt’s cousin’s neighbor’s best friend home when she was dilated to 3 and dying of contractions?

Sometimes it’s more of an art than a science, but I’ll try to break it down for you nice and neat, show you a few tricks that people have tried to beat the system, and divulge how we L&D nurses tease out the truth from the tall tale.

1.  Dilation Does Not Equal Admission.

While cervical dilation provides nurses and physicians with an idea of where a woman is in the labor process, dilating before labor actually starts isn’t uncommon, even in first-time moms.  Now, it’s more likely that your multipara (a woman who has had 2 or more babies) is going to dilate earlier and more than your first-time mom, but that isn’t always the case, nor is it unsafe to head home when dilated to 4 or 5 or even 6 centimeters, though the higher you go, the less likely it is that you’re not in active labor.  Trust me (and anyone who’s ever given birth before), babies don’t usually just fall out, especially if it’s your first.

I’ve discharged patients who were dilated to 4 or 5–a few of them even being first-timers!–who were definitely not in labor.  Often, I’m met with shock and disgust.  “How dare you discharge me!  Do you realize how far dilated I am?  I could go at any time!”

Yes, that’s entirely true.  At the same time, however, so could the other lady I’m preparing to send home who’s only dilated to a 1 and 30% effaced, and there’s no guarantee that she won’t deliver before you do!

So think about it: when you do come in huffing and puffing and ready to push a baby out, do you want to be admitted to a room, or would you rather deliver in a cramped triage room because we’ve admitted every lady who was dilated to 3cm or more?

Point being, if we kept every woman who was dilated to a certain degree but not in labor, our L&D unit would be full to bursting all the time.

2. Contractions Do Not Equal Admission.

I know, I know.  Those contractions are painful, and you really do look uncomfortable. I don’t think you’re faking that.  But your contractions are 4 to 8 minutes apart, incredibly irregular, and they’re just not that strong.

Both of the qualifiers above–regularity and strength–are two things that L&D nurses look for in assessing patients for admission.  With regards to regularity, we can determine that by placing the patient on the toco–a monitor that indicates the length and pacing of contractions.  As far as strength, that is assessed by placing a hand on your belly and feeling it during a contraction.  (Just in case you didn’t know, the external monitor that times your contraction doesn’t actually tell me how strong they are.  Only properly placed internal monitors can do that!).

But contractions on their own don’t necessarily indicate the need for admission.  Instead, in conjunction with cervical dilation, L&D nurses often check to see if those contractions, irregular and mild or not, are changing mom’s cervix.  So when the L&D nurse tells you to get up and walk for an hour and come back for another cervical check, what she’s really trying to see is if a) your contractions will go away with walking (meaning they’re likely Braxton-Hicks, or false labor) and b) if your contractions are causing cervical change over decent stretch of time.

If at some point you get the brilliant idea to try to fake a contraction by manually depressing the toco–don’t.  We L&D nurses spend our entire shifts reading those strips.  We’re pretty good judges of what’s real and what’s not.  Also, when we enter the room to talk to/assess you and your contractions suddenly stop for 10 minutes, we’ll know.

3.  Pain Does Not Equal Admission.

I hear this one a lot, too.  Ladies in various stages of pregnancy come in complaining of pain, and while some women feel their labor entirely in their backs or butts, chances are, if you’re feeling only constant pelvic pressure and/or back pain, you’re not in labor (at least, I really hope you’re not!).

Many of our OB docs won’t give more than a Tylenol or ibuprofen for pain in the pregnant population due to the risk to the fetus.  We have some patients who come to triage in an attempt to refill narcotics and/or get narcotics prescribed to them.  If you have issues in your pregnancy that do require narcotic drug management, do not expect your triage OB to provide/modify/manage these for you as this should be addressed by your primary OB and/or pain management team.

If you’re tired of being pregnant and you think that exaggerating/creating nonexistent pain will get you admitted and induced, think again, especially if you’re preterm.  Most hospitals these days won’t even consider an elective induction unless you’re 39 weeks along or more, and it is rare that the triage OB will opt to schedule an elective induction for a patient that isn’t his or her own, especially on the spot.  Hospitals are busy places, and trying to get your triage staff to finagle you into an impromptu induction is a really, really poor bet.

If we were to keep every pregnant woman who came in complaining of pain, we wouldn’t have any room for actual laboring patients.

4.  Water and Waders: Real or Fake

One thing that will get you admitted quicker than you can say, “Let’s have a baby!” is ruptured membranes (ie, your water is broken).

If you’re really preterm (see: earlier than 34 weeks), you will have just signed yourself up for an extended stay at the L&D Inn.  Because of the infection risk and risk of other emergencies like cord prolapse with preterm premature rupture of membranes (PPROM), you will be admitted and remain in the hospital until you deliver, which is usually around 34 weeks.

If you’re 34 weeks or later, chances are we will give you some antibiotics and either let you labor or induce labor if you’re not already in it.

Now, if you’re itching for an admission/induction and you’re thinking you can fake rupture of membranes (ROM), think again.

Let’s go over a few things that do not comprise ROM:

  1. Cervical discharge (normal in pregnancy, but can also indicate a vaginal infection)
  2. Urine
  3. Apple juice/water/Mountain Dew

I’ve had patients who have honestly mistaken both of the first two items above for their water breaking, and sometimes, it really can be hard to tell what exactly is coming out of there, especially if you’re late in pregnancy and you haven’t really seen it in a few months!

However, I’ve also had patients who have intentionally urinated on themselves to make it look like their water has broken.  I’ve had patients who have told me that it had to be their water breaking because “urine just isn’t that clear!”  I’ve had patients who have used other substances (see item #3) to make it look like their water is broken.

Let me be the first to warn you: if you’re silly enough to try to fool us with pee or any other liquid in an effort to get induced/admitted/delivered, we will figure out the truth.  Don’t be the talk of the break room.  Quit while you’re ahead.

The first thing we do when you come in through triage is test your vaginal canal with a little strip of paper called nitrazine.  This tells us the pH (acidity) of your vagina.  Normally, vaginal canals are acidic.  However, amniotic fluid is basic.  Our test strip will turn blue if your water is broken.  Of note, urine will also change nitrazine paper blue..

So after we do the nitrazine test, we’ll do another test called AmniSure.  This test checks to see if there are actual proteins from amniotic fluid present in your vagina, and this test is considered diagnostic.  If it is negative, your water isn’t broken.  If it is positive, welcome to the Inn.

If you really do believe your water is broken, it is important that you come in.  If your water is broken and you neglect it, you could end up losing your baby and in serious jeopardy yourself if you should get an infection.

5.  Looking for a Lost Mucous Plug…

While losing your mucous plug typically means you’re beginning to dilate, this by no means indicates that you’re in labor and certainly isn’t a reason to visit your L&D triage unit.

If you do come in telling us that you lost your mucous plug and you aren’t having contractions and/or some other medical issue, we will put you on the monitor for the obligatory 20 minutes, make sure your baby is OK, possibly check your cervix, and (barring some other medical issue) send you home.

Mucus Plug 1Mucus Plug 2Mucus Plug 3Mucus Plug 4Mucus Plug 5Mucus Plug 6Mucus Plug 7

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Long story short, admitting in L&D is much more complicated than “Oh, you’re contracting? Let me get you a bed!”  So when you go in, expect a thorough assessment.  Be patient and honest with us.  But most of all, be patient and honest with yourself.  Doing so will likely ensure a healthy baby and a better outcome for both of you.  That’s our goal when we’re evaluating patients for admission.  Hopefully, that’s your goal, too.

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