#50 Tips for Triage: MFTI, Coregulation, and Navigating Triage - Triage Part 1

In our exciting 50th podcast episode, Justine and Sarah dive into the crucial first steps of triage - the initial assessment. They discuss the key questions to ask, red flags to watch out for, the importance of teamwork, and how to prioritize patient needs. Whether you're a seasoned triage nurse or starting to dip your toes into this complicated process, this episode will provide valuable insights and practical tips to enhance your practice. Thanks for listening and subscribing!

Helpful Links:
- Learn more about the MFTI (Maternal Fetal Triage Index)
- Learn about the Bundle Birth Nurses Mentorship Program
- Visit the Bundle Birth Nurses Website for more helpful classes and tools

Transcript

Copy Transcript Copied

Justine:
Hi, I am Justine.

Sarah Lavonne:
And I'm Sarah Lavonne.

Justine:
And we are so glad you're here.

Sarah Lavonne:
We believe that your life has the potential to make a deep, meaningful impact on the world around you. You as a nurse have the ability to add value to every single person and patient you touch.

Justine:
We want to inspire you with resources, education, and stories to support you to live your absolute best life, both in and outside of work.

Sarah Lavonne:
But don't expect perfection over here. We're just here to have some conversations about anything birth, work, and life, trying to add some happy to your hour as we all grow together.

Justine:
By nurses, for nurses, this is happy Hour with bundle birth nurses. We polled you the other day on Instagram about episodes you'd like to hear on the podcast. Overwhelmingly, triage was the number one subject, which is so funny because I hate triage. Sarah loves triage.

Sarah Lavonne:
I love triage. I miss triage so much. If I could go back tomorrow, I'd be like, "Throw me into triage."

Justine:
Which is so interesting because I know that I'm in a new role right now and so I want to go back to staff. I don't want to be full-time, but if I go back to staff, when you get a certain years of experience, you're thrown into triage or charge. You don't get the fun labors that I want to do anymore. Being an experienced L&D nurse can be frustrating if you don't like triage. But as we were reviewing what we were going to talk about on this call, I was like, I do triage in a sense. I like it.

Sarah Lavonne:
I was going to say, what don't you like about triage?

Justine:
I think I get lonely. If I could triage with people, I would like it. But our triage is set up where you're all alone in the back. No one's there. It's just you and you have your three patients and you just rotate them in and out and get more. Anyone that works with me is listening like, "Yeah, you do get lonely." You get some company if there's a C-section, the PACU is connected to triage, but yeah, it's just lonely. That's probably why.

Sarah Lavonne:
See my triage has always been two people.

Justine:
Yeah. That's awesome.

Sarah Lavonne:
And it really did depend on whether or not you kind of liked the other person. You'd be like, "Oh, it's you and me in triage? It's going to be a great night." But being able to tag team for me at the last hospital was at, we only had four triage rooms really. We'd have overflow occasionally, but the two of us would tag team those four rooms. I don't know how you can take on three when an initial assessment is one-on-one technically.

Justine:
Challenging for sure.

Sarah Lavonne:
Anyway. We digress.

Justine:
Yeah, so Sarah and I just wanted to chit chat. We have no guests, which is rare I know in this season. I hope you've enjoyed all our guests, but we're just going to talk a little bit about triage in a few part series. I think we can for sure say there's going to be three, there could possibly be four. Let's talk triage.

Sarah Lavonne:
Today we're talking through the initial assessment and rule out labor if we can get to it.

Justine:
We're going to start with MFTI. If you have heard of this, the maternal fetal triage index created by AWHONN. I would imagine many of you have this in place, either officially you've taken the course or unofficially you've printed off the thing and you're following it. But the idea is we're actually triaging like an ER does. A lot of units, even if you don't have a MFTI, if you have two patients walk in at the same time, you are going to look at them and know most of the time which one you're going to see first. You're going to see the person that's actively bleeding through her pants versus someone that came in for rule out labor having contractions every five minutes.
It is an official way and it makes it so nice and pretty and color coordinated to say like, "Hey, you're non-urgent. You're stat priority number one." What is it? It goes from level one to level five. Level one being they are stat, some signs of that is they are hemorrhaging, they're seizing. You can see severe respiratory distress or baby's coming out. You see a cord or feel a cord. Any of those situations would make that patient a stat priority one.

Sarah Lavonne:
And the question that goes with it is, does the woman or fetus have a stat priority vital sign? Does the woman or fetus require immediate life-saving intervention? Or, is the birth imminent? So those are the first questions we're asking. You're calling it MFTI, and we talked about this before and I was like, "MFTI? What the heck is that?" I'm like, "Oh my God, I'm so behind." Then once I saw it, I was like, "Oh, I used this. I remember when this came out." Also, the more you do it, the more you're likely triaging and triaging is just organizing in your brain who's the highest priority, and then deciding whether the patient stays or goes home. For those of you that maybe aren't nurses or haven't triaged before, that's what it's for. I like the questions that it asks because it really simplifies are they going to deliver? Do they need lifesaving intervention or do they have a priority stat vital sign?

Justine:
They even go further and they tell you that. Their heart rates under 40 or over 130, their SBO2 is under 93%, or their systolic blood pressure is greater than 160 or diastolic greater than 110. They have it all written down for you to know what those vital signs are. Then it goes into all, the answer is no. Then you're going to say, do they have priority two vital signs, which they go into the heart rate's over 120 or under 50. They delve in a little more on those. Are they in severe pain without complain of contractions? They're not having contractions, but their stomach is rock hard and they're in tons of pain, et cetera. Is this a high risk situation, which they'll give you examples of. Some of the ones they say are like high risk medical conditions, difficulty breathing, altered mental status, et cetera.
If you say no to any of those, then you go down to yellow. Does the woman or fetus have priority three vital signs? Again, they show you the vital signs, or do they require prompt attention? The prompt attention they label here as signs of active labor in their greater than 34 weeks? Because if they were less than 34 weeks, that would be that urgent priority two category for our pre-preterm babies in there.
What I like about this though, and what's hard I think is that the non-urgent attention is greater than 37 weeks early labor signs or complaint of SROM. Why I say that's hard is because I have a lot of patients in the waiting room that don't feel like a priority because they are 38 weeks complaining of SROM. They're not priority and we will see them. One of the tips that I do and I wanted to give to charge nurses or team leads is especially at shift change, I feel like is when it gets really messy when they are giving you report and they're like, "Oh yeah, there's like five patients in the waiting room too. You're like, "Okay." So you're looking at the clipboards and you're like, I just need to see all these patients. I'll literally take all the clipboards, go into the waiting room and talk to each one of them, and I'll sit down next to the chair and be like, "What's going on? Tell me more." I'm MFTI'ing them myself basically, but I can get a hands-on look at them, see if any of their previous complaints have changed.
Then a lot of times I have had to pull out the algorithm and show them where they fall and our process because it can be super frustrating as a patient when you're like, "Well, they just walked in and they got seen right away. I've been here for two hours and I'm in labor. I'm leaking fluid and I'm having contractions." That's just a little tip on there, but the MFTI process, triage process, I love how they lay it out. It makes it so much more manageable and it's so easy to read. We will link this tool in the show notes because it's great and it's a class that your unit should definitely take.

Sarah Lavonne:
Well, and I think this is sort of something that if you're a new nurse or even if you're not a new nurse, these kind of resources are amazing summaries for us to review and just learn to memorize. It would be the expectation that we can identify that severe respiratory distress is more urgent than even signs of active labor at 34 weeks. But it's hard when there's so much new information, when there's so many things going on and you're like, "I don't know how to prioritize." This literally lays it out for prioritizing how to assess our patients. Or even you have two patients, which one's the urgent one? They're both calling out, which one are you going to walk to first? There's so much prioritization that takes place for us as nurses, and that skill to me is one of the most important skills that we can develop. This would be an easy tool for us to know and memorize.
I'm also thinking about, I have a new product idea. My business brain is going crazy. I'm like, I think there should be a badge buddy with these vital signs in different categories. Then on the back is our lab values of what's normal and what's abnormal. I would want that. Right?

Justine:
Yeah, it's a good one. The lab values are hard and people listening to this will know because it's based on the institution and they change. But a broad-

Sarah Lavonne:
Yeah, a broad, and then what happens if it's high? What happens if it's low? You can look at your recommendations, and it'll tell you if it's abnormal. If it's low, if it's high, what does that mean?

Justine:
Yeah, well, you just gave that example of knowing who to see first. I think it's really interesting if you look on this list of priority three, which would be over priority four. If you have a patient that comes in and their blood pressure is 145 over 92, they would be more priority than a patient that is SROM leaking 38 weeks in the waiting room. And I say that because I think a lot of times we get patients from the office like, "Oh, they had some high pressures." But then we hear 140s and we're like, "Whatever." And we're used to like, oh no, severe is 160, so we don't even care until then. I think that's interesting.

Sarah Lavonne:
Well, and this leads us into broader conversation about triaging and the skills that are necessary to be a killer triage nurse. And I know for me that was part of the game that I felt like it was. First of all, I learned very quickly that the longevity of same same, this is the same, blah, blah, blah over and over again. Whereas with triage, there's sort of the thrill and adventure of not knowing what's going to come in the door and having to like...it's a game to me. That sounds bad, but also it's like. I get to figure out what's going on here. I get to piece it together. I get to learn to ask the right questions. I get to lay my hands, I get to see my eyes and go..."Hhhmmm. Uh oh!" Or, "Hmmm great!". And that sort of process of...we don't know what's going to happen. I get to lay eyes, and I get to move them one direction or another, to me is really exciting and really thrilling and sort of the core of what we're meant to do as nurses. If you've listened to the Suzanne episode from Critical Concepts in Obstetrics, we talked all about the importance of assessment, so for you as a triage nurse, if you know you're being moved that direction, you better have your assessment skills on point!
For anyone who missed out on Cancun, listen up because I have some very exciting news. For literally one time only, we are offering a two-day physiologic coping workshop as a live online event on February 29th and March 1st, 2024. The class lasts nine hours total and we'll split it into two days for you to make it super digestible, and it includes everything that we taught in Cancun. So that's a $900 value for just $299 prior to January 15th.
This is a crazy deal. We also offer amazing group discounts for groups of 10 or more, so reach out and save even more by getting in with your friends and coworkers. Besides earning you a whopping 9.4 CEs, you'll also learn everything you need to know about how to promote physiologic coping and physiologic birth, and positively interact with the diverse demographic of birthing people. That's epiduralized and non-epiduralized patients through non-pharmacological coping interventions that help contribute to a vaginal birth. You'll also know exactly how that's possible. And don't worry if you can't attend some or all of the live sessions because we're going to record it for you to view for up to two weeks following the event.
This can't miss event took me two years of reading more than 300 resources. I traveled the world. I trained with some of the leading minds in physiology and childbirth and other random specialties, and I even became an intermediate MFR practitioner so that I could create and whittle all of that down to one, single, easy-to-understand class that's applicable to your practice tomorrow. All of those who purchase tickets to the event will be entered for incredible prize giveaways that I will draw about each week leading up to the class, as well as a chance at an absolutely unprecedented grand prize that will seriously blow your minds.
You will not want to miss it, and I will draw the winner at the class. This is the biggest prize we have ever given away, and you don't want to miss your chance by missing the class. You literally have nothing to lose. We would love to have you. Register now to get in on this amazing one-time opportunity using the link in the show notes below or on the bundlebirthnurses.com website.
 That's why they say you need to have experience because a lot of this triaging that happens in our brains going through the MFTI, which I've never called it that, but I will now that going through the MFTI in our heads that it does come natural. It's like if I see you bleeding, dripping down the hallway, I'm going to go, "Oops." And press alert button, whatever your button is on your unit and get some help and get an IV started, get some vital signs and get them moving versus even this baby's coming out. That's where I think we have to remember, I think a lot of times we think of triage and it's like our biggest concern is the precipitous birth when we are working in a world where things can go wrong and they do all the time, and it is our responsibility to be able to recognize what's normal, what's abnormal.

Justine:
And don't let that scare you because you can recognize that and you can become really good at that and it's just going to strengthen all of your other skills. Once you start triaging and then you get assigned to labor the next shift, every time you're going to be like, "Man, I'm just really good at this assessment stuff." You're going to grow these skills. Please just take a big deep breath. If you're one of those nurses that are like, "I'm going to triage soon and I'm freaking out." We're going to help you figure it out, it's going to be okay.
Okay. They have been MFTI'd. I like that you've never heard of the word. I think it's cute, and it is time to get them back into triage. We wanted to actually start there because there's so much you can do or your team can do to help regulate their nervous system. Sarah's going to go a little bit on that before we even start their official triage. I think about it, even just starting to give them power and control over their experience on do you want to walk or do you want a wheelchair? Do you want to wear the gown? Do you want to keep your underwear on? Do you want to take your bra off? What's more comfortable for you? Reassuring them. Because it can get frustrating when you see the same thing over and over again in triage, but reassuring them that coming to be seen is never a bad thing.
They know their body, they know their baby. It's better to be safe. You're listening to your body. I'm really proud of you for making these decisions. This wasn't an easy decision to make. Just congratulating them on their decisions already and their parenthood journey to make sure the baby's good and make sure they're good. Walking them from the waiting room to triage is such a great opportunity to start building that rapport.

Sarah Lavonne:
Well, and you're the first face. If they're already annoyed because they've been waiting in the waiting room for 45 minutes, an hour, four hours, whatever it is, actually saying and acknowledging their wait time and validating their experience. "I am so sorry you have been waiting in here so long. It is not intentional. We have been trying our best to get you in. There's just been some other urgent matters that are more emergent that we have to prioritize. I'm only one person. But I'm so excited that you're here now and we want to get you settled. We want to get you to a room and get you comfortable and make sure that all of your concerns are cared for and hopefully ..." Fill in the blank, whatever the reason is, and get this figured out about your blood pressure or get this baby out safely or assess for the fetal movement. Where's fetal movement on this thing, by the way? Decreased fetal movement. How urgent is that?
It's actually a level two, priority two. That honestly, I'm like, I'm not shocked. That's where I was looking. But also I think it's really good to say out loud that a decreased fetal movement, I think we're like, "Oh, okay, they can't feel their baby move." Most of the time they walk in, they're like, "Oh, I feel it. I just was stressed or whatever." But occasionally that really is the reason why we do kick counts and they're paying attention to the movements is for this exact reason because it can be an urgent priority to triage case.

Justine:
Our waiting room is constantly four or five, six hour long waits. With the decreased fetal movements though, a lot of us will just go to the waiting room, grab them real fast, bring them into an empty room, and doppler for them so they can have a peace of mind, especially if they're going to be waiting for a long time because that's just awful for their nervous system to be sitting in that waiting room like, "I don't feel my baby move and it's been three, four, or five hours."

Sarah Lavonne:
Right. Well, and liability wise, they've been sitting there for six hours and no one got them on the monitor and who knows what happened when they arrive versus what happened when we're told that there was no longer a heartbeat. That's not a scenario I want, that's for sure. That is someone you want to see. As you're walking them back, you can validate, "Let's get this baby on the monitor and see what's going on. I'm not going to make any assumptions." "I'm sure it's fine." We're not going to say that. We're going to say, "We're here to take care of you. We're going to do our absolute best. Let's get you there. Let's get you settled. Let's get this baby on the monitor so that we can see what's going on." And even that, no one's telling them something false, but it is reassuring. All of a sudden what happens? They go, "Oh, thank God."

Justine:
Right. You want to be a big deep breath to them. They're going to just be so reassured like, "Okay, everything's fine. I've got the nurse that I needed to make sure I'm okay."

Sarah Lavonne:
Well, and I almost go back to that pause at the door idea that if you're in triage, there is the opportunity to pause before every patient because when you're running around, oh my god, I remember that me and a partner saw 42 triage patients in one shift.

Justine:
That's so many.

Sarah Lavonne:
It was the revolving door. They got 10 minutes of our time. There was a lot of emergencies where we'd be like, "All right, we need a nurse. All right, we need a nurse." But it was like the craziest night of our entire lives. I didn't breathe. I didn't know what I was doing. I didn't pee. We did have some help coming in there, but it was the two of us assigned to triage that night. Okay?
Easily what happens is the patient absorbs our energy. We co-regulate. All of a sudden I'm like, "Hi, what's your name? Why are you here? Oh, okay, let me get you on the monitor and blah, blah, blah." And now you're on this robot train, whereas you may still have to move that quickly, but to say, "Hold on, what's your name? Hi, I am Sarah. I'm going to be your nurse for tonight. I know it looks like there's a lot going on. I'm going to be popping between rooms, but I definitely want to get you settled here so that you can just rest and ..." Fill in the blank, whatever the complaint is. Get your contractions going, get you to a room, rule you out, get you home, whatever.
Those little things, we have to remember the impact of our words, of our energies, of even our stress level. We don't want them to feel like they're a nuisance when this is the memory that will last them forever. If we go into the physiology, physiologic coping, physiologic birth that it does affect their hormones and can set them up for their hormones working well, which is the catalyst for a birth or their hormones not working well.

Justine:
Which could be the catalyst for a dystocia. You said co-regulate. I was wondering if you can dive into that a little bit more if maybe people have been hearing that word. I feel like it keeps going around and they're like, what does co-regulate mean? If you want to talk a little bit about that and how we can help our patients co-regulate.

Sarah Lavonne:
We can ride on the wave of other people's nervous systems, we do this thing. Parenting is the perfect example that you have a toddler and they're freaking out and the parent can either escalate the toddler and start yelling and being heightened in emotion and the toddler's not going to calm in that case. More often than not, they're going to look to the parent or another example would be if I see a spider walk across and I go, "Ah." And I freak out, what's the kid going to do? They're going to go, "Ah, I'm freaking out." I'm learning that based on riding onto my attached person or the person around me. It doesn't even necessarily that you have to be attached to them.

Justine:
So true. I hold so many bugs now and I'm screaming inside, but I'm like, "It's totally fine. This bug's totally fine."

Sarah Lavonne:
That's hilarious. Why do you do it? Because you're trying to teach your son that he's safe, that this is fun, that this is educational, that you can do this. Right? He is looking to you to say, "Am I safe? Am I okay? Am I going to be all right? Should I be freaking out? Should I be calm about this scenario?" That parenting again is the perfect example, but if we turn it clinical, they're walking into a new place where this is our home, this is where we are comfortable. Most of us, I say most of us, but we might also be like pooping our pants every shift and really nervous, but we fake it till we make it. Right? If we walk in and you see me and I am (makes panicked noise) and I'm like, "I don't know." And my hands are shaking, what's the patient going to do?
They're going to go, "Oh my God. First of all, I don't trust this person. Second of all, if I'm going to try to co-regulate with them, maybe there's something going on that they're seeing that's not okay that's causing them to be nervous and all of a sudden now I'm nervous." If you are flying around and saying, "Ah." And being chaotic, they're going to think something's wrong because they're co-regulating with you. Now the opposite is also true, so we can use that as a hack to their nervous system that if we're calm and if I'm freaking out inside, but somehow I pull it together and I say it's going to be all right, and I give the perception that we're good, even though I'm freaking out inside, they're going to look to me and go, "Okay, it must be all right." Because we're looking to our surroundings to know whether we should be looking out for danger or not.

Justine:
I think about my sister who's in nursing school and my clinical instructors and I am a clinical instructor. My students, they all look calm and I think about when we were in nursing school, we look calm, we're losing our shit inside. You need to channel back when you were at clinicals for the first time, I was like, you look calm, you're talking calm.

Sarah Lavonne:
Until you get there. You will get there.

Justine:
You will get to a point where you are calm.

Sarah Lavonne:
Yeah. My sister does this really well with her son where he's freaking out and I'm like, "Hannah, you are a sight." Because she'll be like, "Okay, which do you want? Do you want to try a sandwich?" "No." And she's like, "All right, do you want some juice? Do you want to try an apple?" It's so calm. What happens is eventually it deescalates the scenario. As much as we're not dealing with children, especially in a labored state or in a heightened state of our nervous system, which is likely what's happening when they walk into a hospital, that we can shift their nervous system into a more state of calm.

Justine:
Awesome. What are your thoughts and feelings partners in triage and how they could help the nervous system?

Sarah Lavonne:
I know we got to ask our questions, so kick them out for a second and whatever, but any separation in a vulnerable state I don't think is helpful. I think it's only potentially harmful. It's isolating. Everything done that's hard done alone is always harder. If they have a support system, we talked about this with the patient case that I shared, that they let the partner and me go into the operating room during anesthesia. That separation, the number of times I hear about, "My partner wasn't allowed in when I got my spinal." It's traumatic. It's potentially traumatic for patients. Think about what happened during Covid when we were all separated and people were having to do it on their own. We do it because we're resilient and we're strong, but are they really in the way? No, they're not. Tell them where to go. Oh, he's in the way, but, "Could you sit in the chair just so that I can move around freely because we're concerned about this bleeding?" Most of the time partners are like, "I'm so sorry, I'm in the way. I'm so sorry." I'm like, "You're fine, you're fine."

Justine:
Right. They're way more concerned about it than we are.

Sarah Lavonne:
But think about how much safer that patient feels just by having a safe person there with it. Think about going to a party. If I am going to a birthday party where I literally know no one and I have to go completely by myself, I'm freaking out a little and I'm super social, I have woo as a strength, I know I'll be fine and I will suck it up, but I'm freaking out inside for sure. Versus if I'm like, "Justine, why don't we go to this party?" Or, "My partner, why don't you come to this party?" All of a sudden there's this safety net where I can fully be myself. I feel calmer. I feel like, "Okay, I can handle it." I feel like it's the same idea. It might be more convenient for us, but we have to be doing what's best for our patients within the realm of safety. Obviously if they're coding, somebody pull them to the side, but we're not assuming every patient is coding.

Justine:
Well and on the same side in coding-

Sarah Lavonne:
...and the partner is in the way.

Justine:
But they suggest to have family members in there now. That's the new thing too.

Sarah Lavonne:
Well then we literally have no excuse.

Justine:
Yeah, we have no excuse.

Sarah Lavonne:
Literally none.

Justine:
Also, especially at nighttime, at nighttime triage nurse, the partners don't get to go to the OB visits as much, and so this can be the first time that they hear their baby's heartbeat and get to actually be involved in the care of the baby. That could be something to think about too. I think it's just literally going back to such a cheesy phrase of do to others what you'd like to be done to yourselves. What do you want? What would you want? Just do that.

Sarah Lavonne:
Yeah.

Justine:
Unless you're like, "I would not want my partner there." Well then, okay, well, you're the exception, but we don't think enough about just how would you want to be treated. Yeah. Anyways, okay, so those are some tips on how to start your relationship with the patients in triage. Sarah, what do you want to know initially when you're triaging a patient?

Sarah Lavonne:
I want to know why they're there and I'm looking at that. Mind you, I'm always using my eyes going head to toe. How's their color? How's their affect? How's their emotional state? Do they have a partner with them? Is there any physical signs of bleeding, of fluid? Are they waddling? Are they moaning? Are they leaning over? Are they grabbing a certain place? What's their body language saying? That alone can give a "hmmm hmmm", and we're trusting our gut here of like something's off, but I want to know why they're there. "I have some vaginal bleeding." "How much?" And based on that chief complaint, I'm going to push into the chief complaint first before going into how many pregnancies, and I want to know what their gestational age is very early because it's different if they're 39 weeks versus 31 weeks and you kind of have an idea based on looking at their belly, but who knows, maybe it's twins at 31 weeks, one or two.
"How many babies?" "One baby." "Great." Now I've completely eliminated, because what we're doing is I sort of pictured my brain, my systematic brain, of imagine the wealth of all of the possibilities of how labor could go, of how the body could fail, of how complications could happen, vital signs, the uterus, all of the pathophysiologies of the entire world. What I'm doing is I'm process of eliminating down to a very clear this is what's going on here. If I'm asking what's going on, I'm going to rule out preeclampsia until I take a vital sign, which I'm going to do pretty early on, but I'm going to say they're not here because they had high blood pressures in the office. They're here because they had some leaking of fluid.
Any complications with pregnancy, they're going to say, "Well, no, it was pretty normal." Or "Yeah, I have gestational diabetes." Or, "Yeah, I was treated or I have GBS." A lot of times they think that's a complication. You'll start to get some clinical picture of what's going on and when's your due date, how many weeks. You can go into, what number of pregnancy is this? Because especially in a rule out SROM if this is pregnancy number six versus one. I'm going to want to know that because what I'm doing is weeding down how urgent is this case? I'm going through MFTI in my head without going through MFTI on a piece of paper and saying, "How quickly do I need to move? Do I need to alert and get help here or is this something I can handle by myself?" What's going on with you gives me an idea.
Then again, like I said, so I'll go through again because externally processing this, when's your due date? Any complications in the pregnancy? And then clearly obviously asking say a vaginal bleeding, when did it start? How much? Did you soak a pad? Do you have any pictures? Do you feel the baby moving? All of those things, because what happens is once they give you a chief complaint, then you can start to go, what could that complaint mean? In the case of vaginal bleeding, I'm going to say, first of all, is the baby moving because I'm concerned that there is a demise potentially. Do you have any previous history of any pregnancies and were they vaginal births or a C-section? All of a sudden she's a C-section. I'm going, "Oh uh." Uterine rupture now becomes even more of a risk, which by the way, uterine rupture can happen with or without a C-section, but much more higher chance if you've had a C-section in the past.
We're weeding it down to a place where I go, "What's the clinical picture?" Until, and all of that honestly can sort of happen on initial room. You're trying not to ask those medical questions in the hallway, but especially if it looks like there's an urgent case that I'm leaning over, there's blood, I'm like, when did it start? I'm going to ask that in the hallway because everyone around me is aware that there's blood on the floor, so I need to know this started five seconds ago or this has been going on for two days or this is normal for my pregnancy. Do you have any complications with the pregnancy? I have a previa. Oh shoot, we have a bleeding previa. Hold on. I know for a fact that's probably a level one. Right? Is it? I don't know, but in my head it would be a level one or two.
Either way, I need to alert the team. I need to get moving. I need to first of all get the baby on the monitor. I'm going to need to get a set of vital signs and I'm likely going to be calling to get an IV quickly versus a rule out SROM, they can go without an IV the whole labor if everything's normal. It's that weeding down from the plethora of options. How do I get it to a place where I can kind of piece together and get a clinical picture and be able to report this is what's happened.
Now, whether or not have you had any nipple discharge or do you plan to breastfeed or do you want skin to skin? To me, all of those kind of questions happen later. I get the clinical picture, I treat the patient, I lay hands, I do my assessment, I do my vital signs, I listen to the lungs. I determine whether or not I need to ask for help and get more people in the room. If not, then I go, "Okay, let me breathe. I have the clinical picture. I'm not concerned, or I am concerned. And then later we can ask all of those other questions.

Justine:
I want to say too, once you get that clinical picture, you still might not know what's going on and that's okay because you're not making a diagnosis and you're not putting orders in. You are just going to relay that information, all of that great information you just got to the physician or midwife, which is great.

Sarah Lavonne:
Yeah, and I think that's, to me, what I think would've been helpful with my anxiety to really understand, and I think once I got that, it was like, oh, no big deal. I have eyes, I have hands. I have a really smart brain that can piece it all together and I don't have to make sense of it. I can make my own hypotheses because I like that. That's the game to me of like, "Ooh, can I figure out what's going on here?" And whether or not I'm right or not, who cares? But either way, it's do I need help and when do I need help because you're not going to do it forever. At what point do I need to bring the physician in? MFTI being a really helpful example of how you can do that when you haven't sort of figured that out in your brain.
For me, it's like this goes into, I'm not at the bedside right now, but I had a client that texted me and she's like, "Yeah, I'm bleeding." And I was like, "How much?" She's like, "A lot.' And then sent me a picture. I was like, "You're in the car?" And thinking you either call an ambulance or you're getting in the car and they're like, "We're already in the car. We're on our way to the hospital." I said, "Great, you're moving there. Don't run lights. Don't kill yourself on the way, but I'll meet you at the hospital." She lost two liters throughout the course of her labor. She did deliver vaginally. It was all very confusing and no one could figure out what was going on. They thought she was abrupting. We didn't really abrupt but so much vaginal bleeding to the point where I'm grabbing it to weigh it myself in the room because I'd pull out chunks. I'm like, no one could figure it out.
Sometimes you might not. It wasn't my role to figure it out, but it was my role to recognize that's not a like, "Okay, let's labor at home for a little bit. I'll be there in a second. Then I can look at it and you live 45 minutes away from me." Hell no, I am not playing that game. Not with blood literally pouring down her legs. That's how bad it was. I was like, "Okay." Then actually once they got in the car, she was like, "We will be there in 10 minutes, but I just need to know what do I need to expect when I get there?" I said, "Expect they're going to see you quickly and either you could be going for an emergency C-section," so I was ready for that, "or there's nothing going on and anything in between." She goes, "Is my baby alive?" And I said, "I hope so." But I'm not going to promise her that.
It would be within the realm of as she's waiting for an analysis from a provider, I'm not diagnosing anything. I'm giving her education regarding the spectrum of what could happen. And she was like, "Okay." And she handles it really well, and luckily actually nothing happened and baby's fine. She's fine. I think she might've gotten some units in postpartum, but just very strange. But that's where, for us, you also can't leave them hanging if there's something happening and I am concerned we need to say that if we are concerned. If you're not concerned, say "I'm not concerned. Everything looks really normal to me. I'm still going to bring the doctor in, but from my assessment, I see that everything happening right here appears normal, so take a deep breath, we're going to get you there. We're going to figure it out, but right now I don't see any signs of alarm."

Justine:
Yeah, that's great. Sarah mentioned a lot of the questions that we would say on our first assessment, and I don't know, maybe we'll write some of those down, but it's really going to be based on what your hospital charting system is. Just looking at that, especially on downtime or if you know you're going to be triaging soon or you're a new triage nurse when you're in a lull, look through those questions so you can get them down. You can do a lot of that when you're hooking them up to the monitor and starting all the machines. It doesn't have to be so rigid, and you can get a picture really soon and just take a big deep breath really soon. Or like Sarah said, grab your team.

Sarah Lavonne:
I love this as an initial conversation related to triage, especially if you're anticipating going into triage. Mind you, again, this all goes back to us being experts at the bedside, really taking charge of our own education, of our own learning, of our own expertise, and asking those questions at the bedside using any extra time that you have to talk through the things that you feel uncomfortable about. If you have a moment when you're talking with an experienced nurse, when you're going through triage, what does that mean to you and what are you most concerned of and what are some of the rules? I know for me, I learned very early from one of the experienced nurses, you never check a bleeding patient that has vaginal bleeding before 37 weeks or a previa, obviously. Any vaginal bleeding before 37 weeks, never put your fingers inside. I was like, "Okay."
I remember that in my early days. We have a lot that we can learn from each other. The other thing is that we have a lot that you can be learning here, and so I'm going to recommend our mentorship program. If you're a new nurse, if you're experienced, if you're feeling like you need a juje of the practice and kind of like, "I hear you that I need to level up my care, I hear you, but I don't want to do the research. I don't want to read all the books and the articles. I want to go through it with a cohort of other like-minded nurses." That's what our mentorship is for. You have two years to access 14 classes, multiple on demand courses that really go through all different topics in OB, they do have CEs, so you get, what is it, like 64 CEs or something like that.
It may even be reimbursable if you have reimbursable CEs in your hospital. So look into that. You also get a massive workbook. I think it's like 160, 180 pages that goes along with it, and then you can join any of our mentorship calls. If you're a previous mentee and maybe you're like, oh, shoot, I didn't really take advantage of the calls, if you're still within that two year framework of time when you purchased it, you can jump on to any of our calls and we've sort of shifted that rule and we want to make that really public that you're like, oh, I went to the intro call and then I couldn't make it to some of the others, but I really missed it, that you can just email us at bundlebirthnurses@gmail.com and we will get you into a cohort.
If you're like, "I really just want to go to a breastfeeding call. I missed that." No problem. We got you. Trauma-informed care, high risk nursing, oh baby for all of the neonatal stuff of the transition to life, EFM, all of it's there all to help support your practice, and so that's really a great next step for you as we learn to critically think and we learn to know the entire world and plethora of options that are out there, we have to have that knowledge in our brains and make sure we're not missing it in order to be able to triage correctly.
Everything is linked in the show notes down below bundle birth nurses.com, and we hope to see you on future calls, and we hope to get to know you personally and help support your practice in an even more meaningful way.

Justine:
Thanks for spending your time with us during this episode of Happy Hour with Bundle Birth Nurses. If you like what you heard, it helps us both if you subscribe, rate, leave a raving review and share this episode with a friend. If you want more from us, head to bundlebirthnurses.com or follow us on Instagram.

Sarah Lavonne:
Now it's your turn to go and get yo ass in triage and work it all out and get some practice and ask for help and start to piece it all together and play the game of trying to figure it out and prioritizing the needs of your patient to keep them safe. We'll see you next time.