Pregnancy Patient Written Orders

Routine Antepartum Admit

  1. Admit: Give Ward Number
  2. Dx: Give diagnosis
  3. Condition: Fair, serious, critical
  4. VS q: Hours/minutes
  5. Diet: NPO, clear liquid, full liquid, soft, or regular
  6. Activity: Bed rest, ambulate with assistance, ad lib, etc.
  7. Allergies
  8. 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
  9. IV orders: If needed
  10. Nursing orders if needed:
    I&Os, daily weights, 24-hr urine collection, toxemia protocol, etc.
  11. Laboratory:
    CBC, UA, urine, C&S, M6Rubella titer, VDRL
    Blood type, if not already done earlier in pregnancy
  12. 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:

  1. VS q 4-6 hr
  2. Diet: If still actively contracting—NPO; If stabilized—regular diet
  3. Activity: Bedrest (with BRP if stable)
  4. 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
  5. Laboratory: CBC and group B Streptococcus culture
  6. Make sure you order a UA and urine C&S as UTI may be the cause of the premature labor.
  7. Tests: US - amniocentesis for maturity indices (MI) if the patient possibly more than 36 weeks

PROM Orders

As for Routine Admit with the following:

  1. VS q 4 hr: Especially the temperature
  2. Activity—Bedrest (with BRP if stable)
  3. Nursing orders: Check for contractions q 4 hr
  4. Laboratory: Initially get WBC count q 6-12 hr then daily WBC counts
  5. Tests: Endocervical Gram stain and C&S or amniotic fluid for Gram stain and C&S. Routine study cultures: Check with nurses.
  6. 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:

  1. VS q 6 hr
  2. Diet: Regular
  3. Activity: Absolute bedrest or bedrest with BRP if stable
  4. 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
  5. Laboratory: 2 units whole blood to be in house at all times; initial coagulation screen with followup fibrinogen and platelets.
  6. Tests: Hct, US to confirm diagnosis, NST
  7. No pelvic examinations

Mild Preeclampsia Orders

As for Routine Admit with the following:

  1. VS q 4 hr
  2. Activity: Bedrest (depending on her condition she may have BRP)
  3. Nursing orders: I&Os q 4 hr, daily weights, VSs with reflexes, dipstix q 4 hr for protein
  4. Laboratory: Initial coagulation screen, CBC, platelet count, uric acid, UA, urine C&S; ANA if not an essential primagravida; LFTs, if indicated
  5. 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:

  1. VS q 1 hr
  2. Activity: bedrest
  3. 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
  4. Nursing orders: Hourly I&Os, BP, urine dipstix for protein, and reflexes
  5. Laboratory: See Preeclampsia mild
  6. 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:

  1. VS q shift when awake
  2. 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.
  3. Medications: Insulin, as indicated by blood sugars.
  4. Laboratory:
    BUN
    Creatinine
    HgAlc (if over 8.5% then need PDC referral to discuss risk of birth defects)
  5. Monitoring:
    fasting
    2 hr after each meal
    h.s.
  6. Tests: US to establish dates, 24 hr urine for CC/TP.
  7. 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:

  1. VS q 15 min x 1 hr, then q 1 hr x 4, then q 6 hr
  2. Diet: Regular after anesthetic has worn off
  3. Activity: Up as soon as possible
  4. Medications: As antepartum, plus she may have
    Codeine 60 mg po q 3-4 hr
    MS 10 mg IM q 4 hr prn pain x 36 hr
    Rhogam, if indicated
    Rubella vaccine, if indicated
    D 5/RL with 30 U pitocin TTKFF, if needed
  5. Laboratory: HCT 24 hr postpartum
  6. Tests: Placenta to Pathology, if indicated

C-Section Postpartum Orders

  1. VS q 15 min x 1 hr, then q 1 hr x 4 hr, then q 4-6 hr
  2. Diet: clears after surgery and advance as tolerated
  3. Activity: Up with assistance as soon as possible.
  4. 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
  5. IV: As for antepartum, may also use lactated Ringer's; keep IV running until taking po fluids and afebrile for 24 hr
  6. Nursing orders: I&O, dressing changes, Foley catheter—discontinue in AM unless on MgSO4
  7. 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
  8. Other: Incentive spirometer q 2 hr while awake

Discharge Orders

  1. Make sure face sheet has Pap, VDRL, Rh, Rubella, and HCT recorded
  2. Discharge to: Home, hospital, private physician
  3. 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
  4. 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.