UW Obstetrics & Gynecology Clerkship: Obstetric Orders

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Pregnancy Patient Written Orders

Routine Antepartum Admit	Severe Preeclampsia
Premature Labor	Diabetes: Initial Management
PROM	Vaginal Delivery: Postpartum
Placenta Previa	C-Section: Postpartum
Mild Preeclampsia	Discharge

Routine Antepartum Admit Orders

Admit: Give Ward Number
Dx: Give diagnosis
Condition: Fair, serious, critical
VS q: Hours/minutes
Diet: NPO, clear liquid, full liquid, soft, or regular
Activity: Bed rest, ambulate with assistance, ad lib, etc.
Allergies
Medications:
- Ferrous sulfate 300 mg po tid with meals
- Multivits 1 po q AM
- Seconal 100 mg po qhs prn sleep
- Colace 100 mg po bid prn constipation
IV orders: If needed
Nursing orders if needed:

Laboratory:
- CBC, UA, urine, C&S, M6
- Rubella titer, VDRL
- Blood type, if not already done earlier in pregnancy
Tests, if indicated:
- US, urine estriols, fetogram, amniocentesis,
- NST, OCT, CC, urine for 24-hour protein

Premature Labor Orders

As for routine admit with the following:

VS q 4-6 hr
Diet: If still actively contracting—NPO; If stabilized—regular diet
Activity: Bedrest (with BRP if stable)
Medications: Used to increase surfactant and decrease risk of respiratory immaturity and severe intraventricular hemorrhage
- Betamethasone: 12 mg IM q 24 hr x 2 doses, or
- Dexamethasone: 6 mg IM q 12 hr x 4 doses
Laboratory: CBC and group B Streptococcus culture
Make sure you order a UA and urine C&S as UTI may be the cause of the premature labor.
Tests: US - amniocentesis for maturity indices (MI) if the patient possibly more than 36 weeks.

PROM Orders

As for Routine Admit with the following:

VS q 4 hr: Especially the temperature
Activity—Bedrest (with BRP if stable)
Nursing orders: Check for contractions q 4 hr
Laboratory: Initially get WBC count q 6-12 hr then daily WBC counts
Tests: Endocervical Gram stain and C&S or amniotic fluid for Gram stain and C&S. Routine study cultures: Check with nurses.
Medications:
- Ampicillin: 2 g IV q 6 hrs x 48 hrs, then Amoxicillin 500 mg q 6 hrs x 5 doses
- Erthromycin: 250 mg IV q 6 hrs x 48 hrs, then Erthromycin 250 mg PO q 6 hrs x 5 days

Placenta Previa Orders

As for Antepartum Admit with following specifics:

VS q 6 hr
Diet: Regular
Activity: Absolute bedrest or bedrest with BRP if stable
Nursing orders: Report all vaginal bleeding to HO, weigh all pads, check for contractions q 6 hr; Maintain IV access and change q 3 days
Laboratory: 2 units whole blood to be in house at all times; initial coagulation screen with followup fibrinogen and platelets.
Tests: Hct, US to confirm diagnosis, NST
No pelvic examinations

Mild Preeclampsia Orders

As for Routine Admit with the following:

VS q 4 hr
Activity: Bedrest (depending on her condition she may have BRP)
Nursing orders: I&Os q 4 hr, daily weights, VSs with reflexes, dipstix q 4 hr for protein
Laboratory: Initial coagulation screen, CBC, platelet count, uric acid, UA, urine C&S; ANA if not an essential primagravida; LFTs, if indicated
Tests: 24 hr urine for CC/TP/E3; NST, depending upon her course; test to further evaluate fetal maturity may be needed—US, amniocentesis

Severe Preeclampsia Orders

As for the Routine Admit with following:

VS q 1 hr
Activity: bedrest
Medications to consider:
- MgSO4 2-4 gm bolus, then 1-2 gm/hr drip if clonus present. Goal is 3.5-7.5 blood level. If there is a question about effectiveness or side effects, then draw magnesium level. Apresoline 5 mg IV bolus (may repeat in 20 min), then 5-8 mg/hr IV drip for a diastolic > 110. Aldomet 250-500 mg IV q 6 hr (consider this if the patient is allergic to Apresoline). If the patient stabilizes, consider: Apresoline 25-75 mg po q 6 hr, Aldomet 250-500 mg po q 6 hr
Nursing orders: Hourly I&Os, BP, urine dipstix for protein, and reflexes
Laboratory: See Preeclampsia mild
Tests: NST; Depending upon her condition, further tests for fetal maturity may be done or she may go to delivery immediately after stabilization.

Diabetes Orders: Initial Management

As for the Routine Admit with following:

VS q shift when awake
Diet: ADA with approx. 35 kcal/kg from pregnant weight. The diet will be arrived at between patient and dietician, consisting of anything the patient will follow to meet above requirements.
Medications: Insulin, as indicated by blood sugars.
Laboratory:

Tests: US to establish dates, 24 hr urine for CC/TP.
Other: Ophthalmology consult for baseline retinal exam; diabetic teaching with dextrostix—blood sugar and dextrostix are correlated for 48 hr; if they agree, then dextrostix alone are sufficient. If dextrostix ever reads > 250, draw a blood sugar.

Vaginal Delivery Postpartum Orders

Some orders may already be stamped on chart:

C-Section Postpartum Orders

VS q 15 min x 1 hr, then q 1 hr x 4 hr, then q 4-6 hr
Diet: clears after surgery and advance as tolerated
Activity: Up with assistance as soon as possible.
Medications:
- IM/IV meds for pain (Demerol, Vistaril or MS, as needed)
- Rhogam and Rubella vaccine, if indicated
- Methadone: 10 mg PO x 1 18 hrs after surgery and then 5 mg PO q 6 hrs x 2
- Oxycodone: 5–10 mg PO q 4 hrs PRN
IV: As for antepartum, may also use lactated Ringer's; keep IV running until taking po fluids and afebrile for 24 hr
Nursing orders: I&O, dressing changes, Foley catheter—discontinue in AM unless on MgSO4
Laboratory: Hct in AM of day following delivery; Urine C&S when Foley discontinued; Endometrial C&S—check results if done at time of C/S
Other: Incentive spirometer q 2 hr while awake

DIscharge Orders

Make sure face sheet has Pap, VDRL, Rh, Rubella, and HCT recorded
Discharge to: Home, hospital, private physician
Medications:
- Ferrous sulfate, multivits, antibiotics/pain meds, if needed; antihypertensives for preeclamptic; BCPs starting within first week postpartum if not breast feeding and BP (diastolic) < 90
RTC: 6 wks if NSVD, 2 wks if C-section—to check wound (tell her to return earlier if she has fever or inflammation of incision), and 1-2 weeks for a preeclamptic.

rev 5/3/07, D Pigott, MD