POST-OPERATIVE CESAREAN SECTION ORDERS 2 of 4

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1 9 Actual 9 Estimated DOWNTIME CESAREAN SECTION 1 of 4 Weight kg 9 Actual 9 Estimated Height cm ALLERGIES: REFER TO ALLERGY PROFILE/ POWERCHART 9 BREAST FEEDING 9 BOTTLE FEEDING TRANSFER TO MOTHER/BABY UNIT (MBU) WHEN RECOVERY CRITERIA MET ( ) Check, circle and/or fill in all orders to be implemented as appropriate. 1. NEONATAL RESUSCITATION 9 Requested Advanced Skills Neonatal Resuscitation at Delivery 2. VITAL SIGNS AND ASSESSMENT 9 Monitor vital signs every 15 minutes x 2 hours or as needed until transfer. Transfer if stable. Obtain vital signs and complete assessment upon admission to MBU and every 4 hours x 48 hours (may omit 0400 if patient stable), then every 8 hours while awake and as needed until discharge. 3. DIET 9 Clear liquid and advance as tolerated 9 Ice chips only 9 Nothing by mouth 9 Regular diet 4. ACTIVITY 9 Bathroom with assistance until motor/neuro stability, then activity as tolerated. 9 Postpartum therapeutic exercise instruction. 5. AIRWAY MANAGEMENT 9 Encourage deep breathing and coughing every 1 hour while awake for first 24 hours post operatively 9 Incentive spirometer 6. INTRAVENOUS (IV) HYDRATION 9 Lactated Ringers with 5% Dextrose at ml/hour 9 Lactated Ringers at ml/hour 9 at ml/hour 9 May convert to intermittent infusion device when patient condition warrants 7. INTAKE AND OUTPUT 9 Monitor intake & output every shift. Discontinue when tolerating by mouth, intravenous discontinued, and voiding every shift. 8. URINARY BLADDER CATHETERIZATION 9 Indwelling urinary catheter to gravity drainage. Discontinue if urine clear hours. 9. LABS 9 Complete Blood Count (CBC) first postpartum day Initials Place STAT barcode sticker within this box only on form copy being scanned

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3 DOWNTIME CESAREAN SECTION 2 of 4 ( ) Check, circle and/or fill in all orders to be implemented as appropriate. 10. MEDICATIONS A. MEDICATIONS FOR SELF ADMINISTRATION (SAMS) 9 Patient receives all medications below: Docusate Sodium with Senna (Pericolace/Senokot-S) 2 capsules/tablets by mouth every evening as needed for constipation Ibuprofen 400 mg by mouth with food or milk every 6 hours as needed for mild pain Ibuprofen 600 mg by mouth with food or milk every 6 hours as needed for moderate pain Ibuprofen 800 mg by mouth with food or milk every 6 hours as needed for severe pain * Ibuprofen dosage should not exceed 3200 mg in a 24 hour period * Replace Ibuprofen with Acetaminophen 325 mg 3 tabs (975 mg) by mouth every 4 hours as needed for pain in Non-Steroidal Anti-Inflammatory Drug (NSAID)/Aspirin sensitive patients (not to exceed 4 doses in 24 hours) B. NEW MEDICATIONS Pain Medication 9 Ketorolac (Toradol) 30 mg intravenous every 6 hours for 24 hours 9 Oxycodone/Acetaminophen (Percocet) 5/325 mg by mouth every 4 hours as needed (moderate) 9 Oxycodone/Acetaminophen (Percocet) 10/650 mg by mouth every 4 hours as needed (severe) Other Pain Medication dose route interval a. b. c. Nausea Medication 9 Metoclopramide (Reglan) 10 mg intravenous every 6 hours as needed 9 Metoclopramide (Reglan) 10 mg by mouth every 6 hours as needed 9 Ondansetron (Zofran) 4 mg intravenous every 6 hours as needed 9 Simethicone (Mylicon) 80 mg by mouth after meals and at bed as needed RH Immune Globulin (Rhlg) Prophylaxis 9 Fetal Screen if Rh negative 9 Administer one vial Rhlg intramuscular if indicated per protocol Rubella Vaccine 9 Rubella Non-immune: Administer Rubella vaccine 0.5 ml subcutaneous prior to discharge IV/Uterine Bleeding Prophylaxis 9 Methylergonovine (Methergine) 0.2 mg intramuscular every 6 hours as needed x dose(s) Hold if blood pressure is greater than mmhg 9 Methylergonovine (Methergine) 0.2 mg by mouth every 6 hours as needed x dose(s) Hold if blood pressure is greater than mmhg 9 Oxytocin 20 units/1,000 ml Lactated Ringers x liters. Infuse ml at ml/hour Initials Place STAT barcode sticker within this box only on form copy being scanned

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5 DOWNTIME CESAREAN SECTION 3 of 4 ( ) Check, circle and/or fill in all orders to be implemented as appropriate. Sleep Medication dose route interval Infection Medication dose route interval Other Medication dose route interval indication a. b. c. d. e. C. DEEP VEIN THROMBOSIS (DVT) PROPHYLAXIS (Risk Assessment on Back) REQUIRED to ( ) check all that apply: 9 Heparin 5000 units subcutaneous every 8 hours 9 Pneumatic Compression Device (PCD) for Knee High/Calf Pump 9 Other Orders: 9 DVT Prophylaxis not indicated/contraindicated (Reason): D. IMMUNIZATIONS Offer Tdap vaccine (tetanus diphtheria pertussis) 0.5 ml intramuscular x 1 for prophylaxis (contraindicated in patients who have previously received the Tdap vaccine) Per New York State Department of Health (NYS DOH) Mandatory Immunization Program and Kaleida Policy CL.6, administer vaccine(s) if patient meets criteria. Pneumococcal Vaccine 0.5 ml intramuscular x 1 for prophylaxis If contraindicated please ( ) check one of the NYS DOH acceptable contraindications below: 9 Allergy to pneumococcal vaccine 9 Previously immunized Date: Influenza Vaccine 0.5 ml intramuscular x 1 for prophylaxis (September 1 - April 1) If contraindicated please ( ) check one of the NYS DOH) acceptable contraindications below: 9 Allergy to influenza vaccine 9 Vaccinated this flu season Date: 11. MISCELLANEOUS 9 Abdominal binder 12. ADDITIONAL NURSING 9 TORB From: Date: Time: Signature: NOTED BY RN Date: Time: Signature: PROVIDER Date: Time: Print Name/Stamp: Signature: TORB = Telephone Orders Read Back Place STAT barcode sticker within this box only on form copy being scanned

6 DOWNTIME CESAREAN SECTION 4 of 4 DEEP VEIN THROMBOSIS (DVT) PROPHYLAXIS RISK ASSESSMENT RISK FACTORS AGE points IMMOBILITY points SURGERY points greater than 60 years 2 Coma 2 Hip/Pelvic/Long Bone Fracture years 1 Multiple Trauma 5 Patient confined to bed greater than 72 hours 2 Laparoscopic/Pelvic Surgery 2 Recent uninterrupted travel greater than 4 hours 1 Major Surgery greater than 45 minute duration 2 PRE-EXISTING/CURRENT MEDICAL CONDITIONS points points Ischemic Stroke/Paralysis 5 Current Heart Failure/ Myocardial Infarction 1 Previous DVT or Pulmonary Embolism (PE) 3 Obesity (greater than 20% Ideal Body Weight [IBW]) 1 Hypercoagulation State* 3 Pregnancy/Postpartum less than 1 month 1 Cancer 2 Severe Dehydration 1 Central Venous Catheter greater than 1 week (excludes Renal Access) 2 Nephrotic syndrome 1 Varicose Veins/Vein Surgery/Phlebitis 1 Infection (severe/sepsis) 1 Inflammatory Bowel Disease 1 Chronic Obstructive Pulmonary Disease (COPD)/Respiratory Distress/Steroid or Oxygen Dependent 1 Chemotherapy 1 Estrogen Use (oral contraceptives, hormone replacement therapy [HRT]) 1 Family Medical History unexplained DVT 1 * Examples of Hypercoagulation State: Protein C or S deficiency Antithrombin III deficiency Lupus Anticoagulant Homocysteinemia LOW RISK (Score of 1 or less) MODERATE TO HIGH RISK* (Score of 2-4) HIGHEST RISK/MULTI MODAL* (Score of 4 or higher) No prophylaxis Ambulate Heparin 5000 units subcutaneous every 8 hours -OR- PCD Heparin 5000 units subcutaneous every 8 hours -AND- PCD * Recommendations apply to general medical and surgical patients. Please see below for additional recommendations for specific patient populations. ALTERNATIVE RECOMMENDATIONS FOR SPECIFIC PATIENT POPULATIONS Neurosurgery Orthopaedic Surgery Trauma/Spinal Cord Injury Coronary Artery Bypass Surgery Bariatric Surgery High Risk Bleeding History of Heparin-induced Thrombocytopenia Heparin 5000 units Enoxaparin 30 mg Enoxaparin 40 mg (any population with Fondaparinux subcutaneous every 8 See form KH00202 subcutaneous every 12 moderate to high venous subcutaneous daily Enoxaparin 2.5 mg subcutaneous daily thromboembolism [VTE] hours "Total Knee/Hip hours (Enoxaparin 30 mg 40 mg risk) (Contraindicated if -AND- Arthroplasty -AND- subcutaneous daily if subcutaneous Pneumatic Creatinine Clearance [CrCl] Pneumatic Compression Post-Operative Orders" Pneumatic Compression Creatinine Clearance [CrCl] every 12 hours Compression Device less than Device (PCD) Device (PCD) less than 30 ml/minute) (PCD) 30 ml/minute) Consider platelet monitoring for prolonged anticoagulation References: Modified From: Motyke, GD, Zebal, LP and Caprini, et al. A Guide to Venous Thromboembolism Risk Factor Assessment. Journal of Thrombosis and Thrombolysis, Geerts W, Bergqvist D, Pineo G et al. Prevention of Venous Thromboembolism. Chest 2008; 133: 381S-453S IMMUNIZATION NEW YORK STATE DEPARTMENT OF HEALTH LAW SECTION , CHAPTER 443: Every in-patient must be assessed for pneumococcal and influenza vaccine need Appropriate vaccines must be administered Standing Physician Order for all in-patients, signed by Dr. Margaret Paroski, EVP CMO Additional physician order is not required CRITERIA INDICATIONS for BOTH PNEUMOVAX and INFLUENZA: Age 65 or greater Age greater than 18 with chronic illnesses such as diabetes, asthma, emphysema, pneumonia, congestive heart failure, coronary artery disease, chronic renal failure, immunosuppression If previous vaccination unknown, and criteria met, revaccinate NO VACCINATION INDICATED if patient is between 18 and 65 years old, without chronic illness CONTRAINDICATIONS: PNEUMOVAX INFLUENZA (must be administered year round) (Flu season is September 1 - April 1, as vaccine available from pharmacy) Received pneumococcal vaccine at age 65 or greater. If unknown, revaccinate Received vaccine earlier THIS flu season. If unknown, revaccinate Received pneumococcal vaccine at age 65 or less, wait 5 years to revaccinate. If unknown, revaccinate. Previous severe reaction to pneumococcal vaccine (urticaria, laryngeal edema, anaphylaxis) CONSENTS: PNEUMOVAX (must be administered year round) Patient read Vaccine Information Sheet (KH01159) Patient consented - patient/ health care proxy signed Vaccine Information Sheet. Form scanned to pharmacy for vaccine dispensing. Patient refused and reason stated History of allergic reaction to eggs or contact lens solution (Thimerosal - preservative in solution) Previous severe reaction to influenza vaccine (urticaria, laryngeal edema, anaphylaxis) INFLUENZA (Flu season is September 1 - April 1, as vaccine available from pharmacy) Patient read Vaccine Information Sheet (KH01160) Patient consented - patient/ health care proxy signed Vaccine Information Sheet. Form scanned to pharmacy for vaccine dispensing. Patient refused and reason stated