PLACE LABEL HERE

Perinatal Loss Vaginal Delivery

Admission Orders

The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.

Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

Diagnosis: Intrauterine Pregnancy at _____ week’sgestation  IUFD  Inevitable abortion

Other Diagnoses: ______

1.Status: Admit as inpatient to L&D

2.Follow Perinatal Loss /Anticipated Perinatal Loss Pathway

3.Consults: Social Work Services Chaplaincy  Perinatology  Anesthesia

 With: ______Concerning: ______ Routine  Urgent

Have Physician call back to: ______(phone number)

4.Labs:Type and Crossmatch for zero units- if antibody screen positive, order Crossmatch for 2 units PRBCs

CBC with diff

Hemoglobin A1C

UA, if not already done

 DIC profile  Fibrin split products  Preeclampsia Panel TORCH profile HSV-DNA-PCR

Kleihauer-Betke

Parvovirus B-19 IgG and IgM antibody

 Antiphospholipid antibody panel (includes anti-beta2-glycoprotein and anti-cardiolipin)

 Lupus type anticoagulant

 TSH

 Other: ______

If prenatal lab report not available: Rubella, Hepatitis B surface antigen, RPR, HIV

Post-delivery Testing:

Cord blood workup on all O positive and Rh negative patients, if able to be obtained

Karyotype  Microarray

 Cultures of placenta:  Maternal side  Fetal side

 Anaerobic culture (used to test for Listeria) of ______

 Additional Cultures: ______

 Autopsy: Special requests: ______

______

 Other: ______

5.Diet:clear liquids OR  Other: ______

6. Activity:Bedrest with BRP per routine for induction agent OR  Complete BR OR  ______

7. Cervical exam: prn OR  q 2 hrs and prn in active labor OR  ______

8.K-pad prn musculoskeletal discomfort

9. Insert Foley catheter after epidural placement

SCHEDULED MEDICATIONS:

10.IV Access Pain: Lidocaine 0.5 % 0.1 ml intradermally prior to IV start prn per patient request

11.IVF: LR at 125 ml/hr (if high dose oxytocin used, clamp off) OR  INT only OR  ______at _____ ml/hr

12.Oxytocin 20 units in NS 1,000 ml or 10 units IM (if no IV) after delivery of placenta, infuse wide open, decrease rate to 125 ml/hr once bleeding has decreased and fundus is firm

13. Induction of labor using the following medication (choose one as needed):

 Cervidil (dinoprostone) 10 mg suppository per vagina q 12 hrs

 Cytotec (misoprostol):

Less than18 weeks gestational age: 400 mcg per vagina q 8 hrs prn up to 4 doses

18-28 weeks gestational age: 200 mcg per vagina q 6 hrs prn up to 4 doses

Greater than 28 weeks gestational age: 25 mcg per vagina q 4 hrs prn up to 4 doses

Copy to pharmacyOrder writer’s initials ______

*3-16607* FORM 3-16607 REV. 03/2018 Page 1 of 2

PLACE LABEL HERE

Perinatal Loss Vaginal Delivery

Admission Orders

The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.

Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

 High dose Pitocin (oxytocin) protocol (only for less than 28 weeks gestational age)

Oxytocin 100 units in NS 1,000 ml, begin infusion at 30 ml/hr for 30 minutes,

then increase rate to 60 ml/hr for 30 minutes,

then increase rate to 90 ml/hr for 30 minutes,

then increase rate to 120 ml/hr for 30 minutes.

If patient not having 2-5 regular uterine contractions every 10 minutes, discard oxytocin solution,

then obtain new bag of NS 500 ml, add oxytocin 100 units, restart infusion at 60 ml/hr for 30 min,

then increase rate to 90 ml/hr for thirty minutes,

then increase rate to 120 ml/hr.

Maintain oxytocin at this rate until fetus is delivered or for 4 hrs.

If undelivered after 4 hrs, notify Physician/CNM.

 Pitocin (oxytocin)15 units in NS 250 ml. Piggyback through an infusion pump to the mainline IV

Start Pitocin (oxytocin) infusion at 2 milliunits/min IV.

Increase Pitocin (oxytocin) by 2 milliunits/min q 30 min until patient has 2-5 regular contractions q 10 min

If 20 milliunits/minute is reached, perform SVE and notify physician/CNM

14. Antibiotics: ______

______

PRN MEDICATIONS (See policy 520-06 for range orders and pain intensity guidelines.)

15.Pain: May have epidural when cervix dilated 4 or more cm

or cervix dilated ______cm or  at patient’s request

 If no epidural, may begin IV pain medication at  ______cm or  now

 Nubain (nalbuphine) 10 mg IV q 2 hrs prn

or Fentanyl 50 -100 micrograms (mcg) IV q 1 hr prn

or Stadol (butorphanol) 1-2 mg IV q 1 hr prn

16. Nausea/Vomiting: Zofran (ondansetron) 4 mg IV q 6 hrs prn

ADDITIONAL ORDERS:

______

______

______

______

______

______

DateTimePhysician SignaturePID Number

Copy to pharmacy

FORM 3-16607 REV. 03/2018 Page 1 of 2