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How labor and delivery nurses decide which moms need priority evaluation and care

Maternal Fetal Triage Index is a tool that help nursing staff identify the relative risk of patients

One of the challenges facing nurses in a hospital labor and delivery department is being able to identify those patients who need the most urgent evaluation and care. This is generally the role of a triage nurse, but the responsibility carries over to labor and delivery nurses providing bedside care for patients who have been admitted to the unit.

Generally, the triage nurse is the first person who will see a patient upon arrival in the labor and delivery unit. Nursing and physician input led to the development of the Maternal Fetal Triage Index, which should aid labor and delivery nurses in determining which patients need priority care. The index has five different priorities, with the first being the highest, and the fifth being the lowest.

Stat/Priority 1

This is assigned when any of these three situations is present:

• The mother or unborn baby has abnormal vital signs.

For the mom, this includes a heart rate of less than 40 or greater than 130; apnea (temporary cessation of breathing); oxygen saturation of less than 80%; systolic blood pressure (top number) greater than 160, or diastolic blood pressure (bottom number) of greater than 110 or less than 60.

For the fetus, a heart rate of less than 110 beats per minute for over one minute.

• The mom or fetus requires immediate life-saving intervention.

This includes maternal conditions such as cardiac problems, severe respiratory distress, seizures, hemorrhages, acute change in mental status, unresponsiveness, and signs of placental abruption or uterine rupture.

For the unborn baby, prolapsed cord (the umbilical cord wrapped around the baby’s neck) requires immediate intervention.

• Birth is imminent

This is evident when parts of the baby are visible externally, or when the mom needs to be instructed to avoid pushing until there is an irresistible urge (called bearing-down efforts).

Urgent/Priority 2

This is assigned when any of these four situations is present:

• The mother or unborn baby has abnormal vital signs.

For the mom, this includes a heart rate of less than 50 or greater than 120; temperature of 101 degrees or greater; respiratory rate higher than 26 or lower than 12; oxygen saturation of less than 95%; systolic blood pressure (top number) greater than 140, or diastolic blood pressure (bottom number) of 90 or higher with symptoms, or less than 80/40 repeated.

For the baby, a heart rate of greater than 160 beats per minute for over one minute, or decelerations (drops in the fetal heart rate).

• Severe pain unrelated to contractions.

This is considered a score of seven or higher on a 0–10 pain scale.

• High-risk situations.

Examples include: Less than 34 weeks gestation (pregnancy) with complaints of spontaneous rupture of membranes (bag of water broke); leaking or spotting; active vaginal bleeding; complaints of decreased fetal movement; recent trauma; less than 34 weeks gestation with uterine contractions; unstable, high-risk medical conditions; difficulty breathing; and suicidal or homicidal thoughts.

Mothers at 34+ weeks gestation or spontaneous ruptured membranes/leaking and any of the following also meet the criteria for Urgent/Priority 2: multiple gestation (e.g., twins, triplets); placental previa; HIV+; planned, medically-indicated C-Section; or breech or other malposition.

• Transfer of care needed to a higher acuity hospital.

Prompt/Priority 3

This is assigned when either of these situations is present:

• The mother has abnormal vital signs.

This includes a temperature of greater than 100.4 degrees; systolic blood pressure (top number) greater than 140, or diastolic blood pressure (bottom number) of 90 or higher with no symptoms.

• Prompt attention is necessary.

Factors include clinical signs and symptoms such as signs of active labor at 34+ weeks gestation; mom complains of early labor signs and/or spontaneous ruptured membranes are leaking at 34–36 6/7 weeks gestation; 34+ weeks gestation with regular contractions and HSV lesion; 34+ weeks gestation with planned, elective, repeat C-Section planned and regular; 34+ weeks with multiple gestation (e.g., twins, triplets) pregnancy and regular contractions; or woman isn’t coping with labor.

Non-Urgent/Priority 4

This is assigned when the woman has a non-urgent complaint.

This category includes moms at 37+ weeks gestation with early labor signs and/or complaint of spontaneous ruptured membranes or leaking. It also includes non-urgent symptoms including things such as pregnancy discomforts, vaginal discharge, constipation, ligament pain, nausea, and anxiety.

Scheduling/Requesting Priority 5

This category is assigned when the woman requests a service or has a scheduled procedure, with no complaint.

While the main idea behind the Maternal Fetal Triage Index is to prioritize nursing attention in the labor and delivery unit, this tool also highlights areas that should trigger advocacy by competent labor and delivery nurses.

In my view as a former hospital administrator, nursing advocacy is one of the most unique and important rules of professional nurses. By using tools such as the Maternal Fetal Triage Index, labor and delivery nurses are guided through the critical thinking process of assessing patients as individuals. This should lead to advocacy for prioritizing care of high-risk patients over routine patients.

This type of nursing advocacy can involve speaking to the charge nurse or supervisor about reassigning C-Section delivery rooms from scheduled C-Section deliveries to high-risk deliveries.

If you or your child has been seriously injured because of poor labor and delivery care in Texas, then contact a top-rated experienced Texas medical malpractice lawyer for a free consultation about your potential case.

Robert Painter is an award-winning medical malpractice attorney at Painter Law Firm PLLC, in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits all over Texas. Contact him by calling 281-580-8800 or emailing him right now.


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