A 35-year-old female presented to triage stating she was three months pregnant and was experiencing lower back and abdominal pain. She had begun experiencing bright red vaginal bleeding 10 minutes prior to arrival. The patient had limited command of the English language, and it is unknown if a medical translator was used during the triage. No other subjective information was obtained. Vital signs at triage were: Temperature: 97.8F (36.5C), B/P: 116/65, HR: 74, RR: 20, Pulse oximeter: 100%. Objective assessment was limited to a notation that the patient had blood on her feet and legs. Using a five-level acuity, scale she was assigned a level 3 (urgent) triage acuity and placed in the waiting room with blood running down her legs.

Case Progression

Approximately one hour and eight minutes after arrival, the patient was placed in a treatment bed. Environmental services were requested to respond to the waiting room because a patient "had bled out." At some point after placement in a treatment bed, the patient had a pelvic ultrasound which revealed an 11-week viable fetus. It is unknown if she required blood replacement or what any further vital signs or assessments revealed. However, she did require admission to the hospital and subsequently sustained loss of her fetus.

What Went Wrong?

A better question would be, "What didn't?" The pregnant patient in this scenario presented with uncontrolled bright-red vaginal bleeding and yet was sent to the waiting room where she continued to hemorrhage. Perhaps the decision was made that the bleeding was not significant because the patient had "normal" vital signs. This, however, would indicate that the worst-case scenario was not considered in this patient. Had it been, it would have lead to the recognition that the bleeding had begun only 10 minutes prior to arrival and, with continued bleeding, deterioration of the patient's status was predictable. It is imperative to recognize that normal vital signs do not rule out significant bleeding, particularly when the onset has been recent, as it was in this case. According to ENA's Emergency Nursing Core Curriculum: 6th edition, hemorrhage in pregnancy requires immediate treatment (2007). Furthermore, there is no documentation that any reassessment was done on this patient while she was in the waiting room. The overall triage documentation was also an issue in this case. Minimally, the patient should have been asked the date of her last menstrual cycle, her gravida/para status, whether she had begun prenatal care, had she experienced any difficulty with this or any other pregnancy, her EDC (estimated date of confinement), current medications, and any past medical or surgical history. Her pain was not thoroughly assessed and the objective assessment did not provide a picture of how stable or unstable this patient was - Was she pale or diaphoretic? Was she ambulatory upon arrival?

Triaging Women of Childbearing Age with Abdominal Complaints

This case provides an opportunity to engage in a larger discussion: the triage of women of childbearing age who present to the emergency department with lower abdominal or back pain and/or vaginal bleeding. Approximately 500,000 women each year seek care in emergency departments because of vaginal bleeding in early pregnancy, and the evidence indicates that number is increasing (Wittels & et al, 2008). When we also consider the number of women who present with unknown pregnancy status and abdominal or back pain without vaginal bleeding, this number increases substantially. Because these are common presentations, there is a risk for triage nurses to become complacent, resulting in the potential for these patients to be under-acuitized. We must maintain a high index of suspicion when assessing these patients and assign a triage acuity based on the criteria of the triage acuity scale in use. We must not allow our triage decision to be swayed by how common this or any other presentation may be.

Emergency Nurses Association (2007). Emergency Nursing Core Curriculum. Saunders: St Louis.
Wittels, K. A., Pelletier, A. J., Brown, D. F., & Camargo, C. A. (2008). United States Emergency Department Visits for Vaginal Bleeding During Early Pregnancy, 1993-2003. American Journal of Obstetrics & Gynecology, 198. 523.e1-523.e6.