OBSTETRIC ADMISSION 1 of 4 Actual Estimated Weight kg Actual Estimated Height cm ALLERGIES: REFER TO ALLERGY PROFILE/ POWERCHART ADMIT TO: Labor and Delivery ( ) Check, circle and/or fill in all orders to be implemented as appropriate. 1. OBTAIN CONSENT FOR: Vaginal delivery and possible episiotomy and/or Cesarean Section (KH00049-010). 2. NEONATAL RESUSCITATION: Request Advanced Skills Neonatal Resuscitator at delivery 3. VITAL SIGNS: Blood pressure, pulse and respirations at regular intervals as patient s condition warrants Temperature every 4 hours until rupture of membranes, then every 2 hours 4. DIET: Clear Liquids Nothing by mouth Ice Chips 5. ACTIVITY: Ambulate as tolerated Bed Rest 6. ELIMINATION: Indwelling catheter to gravity Straight catheter as needed for bladder distention 7. FETAL MONITORING: Per protocol (MAT 103) 8. INTRAVENOUS (IV): No IV Start IV at cm dilation Lactated Ringers at ml/hour titrate per maternal/fetal needs Lactated Ringers and 5% Dextrose at ml/hour titrate per maternal/fetal needs Initials Place STAT barcode sticker within this box only on form copy being scanned
OBSTETRIC ADMISSION 2 of 4 ( ) Check, circle and/or fill in all orders to be implemented as appropriate. 9. LABS: A. ROUTINE ABO Rh Type & Antibody Screen Maternity Hold Complete Blood Count (CBC) CBC with differential Complete Metabolic Panel (CMP) Rapid Plasma Reagin (RPR) B. ORDER ONLY IF INDICATED Hepatitis B Virus Surface Antigen Rubella Virus Antibody Immunoglobulin G (Ab IgG) Types 1 & 2 HIV Counseling and Rapid Test Group B Streptococcus (GBS) culture Cervical Cultures: C. HIGH RISK TOXICOLOGY PANEL WITH CONFIRM Prothrombin Time (PT), Activated Partial Thromboplastin Time (aptt), Fibrinogen ABO Rh Type & Crossmatch units Urinalysis Urine Culture Hepatic Function Panel Uric Acid Lactate dehydrogenase (LD or LDH) Chemistry (list): 10. MEDICATIONS: A. EXISTING MEDICATIONS: COMPLETE MEDICATION RECONCILIATION FORM KH01116 B. NEW MEDICATIONS IV/ Uterine Bleeding Prophylaxis Oxytocin 20 units in 1000 ml/lactate ringers at 250 ml/hour to infuse after delivery of placenta (Millard Fillmore Suburban Hospital) Oxytocin 20 units in 1000 ml/normal saline at 250 ml/hour to infuse after delivery of placenta (John R. Oishei Children's Hospital) Group B Streptococcal Infection (GBS) Prophylaxis: Treat all patients who are: GBS positive Had a previous infant with invasive GBS disease GBS unknown AND have any of the following risk factors: Gestational age less than 37 weeks Rupture of membranes for greater than 18 hours Temperature greater than 38 C Penicillin G, 5 million units intravenous x 1 dose, then 2.5 million units intravenous every 4 hours starting with labor or rupture of membranes until delivery Other GBS Positive Prophylaxis Medication dose route interval Initials Place STAT barcode sticker within this box only on form copy being scanned
OBSTETRIC ADMISSION 3 of 4 ( ) Check, circle and/or fill in all orders to be implemented as appropriate. Pain Medication: Nalbuphine (Nubain) 10 mg intravenous as needed x 1 dose for pain scale 5 or greater, then discontinue after 24 hours Nalbuphine (Nubain) 10 mg subcutaneous as needed x 1 dose for pain scale 5 or greater, then discontinue after 24 hours Epidural consult for pain management/ assessment for pain scale 5 or greater Nausea Medication: Metoclopramide (Reglan) 10 mg intravenous every 6 hours as needed Ondansetron (Zofran) 4 mg intravenous every 6 hours as needed Other Medication dose route interval indication a. b. c. d. e. f. C. DEEP VEIN THROMBOSIS (DVT) PROPHYLAXIS (Risk Assessment on Back) REQUIRED to ( ) check all that apply: Heparin 5000 units subcutaneous every 8 hours Pneumatic Compression Device (PCD) for Knee High Pump Other Orders: DVT Prophylaxis not indicated (Reason): DVT Prophylaxis contraindicated (Reason): 11. ADDITIONAL : NURSING 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
OBSTETRIC ADMISSION 4 of 4 RISK FACTORS DEEP VEIN THROMBOSIS (DVT) PROPHYLAXIS RISK ASSESSMENT AGE points IMMOBILITY points SURGERY points greater than 60 years 2 Coma 2 Hip/Pelvic/Long Bone Fracture 5 41-60 years 1 Patient confi ned to bed greater than 72 hours Recent uninterrupted travel greater than 4 hours 2 1 Multiple Trauma 5 Laparoscopic/Pelvic Surgery 2 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 Nephrotic syndrome 1 2 Access) Varicose Veins/Vein Surgery/Phlebitis 1 Infection (severe/sepsis) 1 Infl ammatory 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 defi ciency Antithrombin III defi ciency Lupus Anticoagulant Homocysteinemia LOW RISK (Score of 1 or less) No prophylaxis Ambulate MODERATE TO HIGH RISK* (Score of 2-4) Heparin 5000 units subcutaneous every 8 hours -OR- Pneumatic Compression Device (PCD) HIGHEST RISK/MULTI MODAL* (Score of 5 or higher) Heparin 5000 units subcutaneous every 8 hours -AND- Pneumatic Compression Device (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 Heparin 5000 units subcutaneous every 8 hours -AND- Pneumatic Compression Device (PCD) Orthopaedic Surgery See form KH00202 Total Knee/Hip Arthroplasty Post-Operative Orders Trauma/ Spinal Cord Injury Enoxaparin 30 mg subcutaneous every 12 hours -AND- Pneumatic Compression Device (PCD) Consider platelet monitoring for prolonged anticoagulation Coronary Artery Bypass Surgery Enoxaparin 40 mg subcutaneous daily (Enoxaparin 30 mg subcutaneous daily if Creatinine Clearance [CrCl] less than 30 ml/minute) Bariatric Surgery Enoxaparin 40 mg subcutaneous every 12 hours High Risk Bleeding (any population History of with moderate Heparin-induced to high venous Thrombocytopenia thromboembolism [VTE] risk) Pneumatic Compression Device (PCD) Fondaparinux 2.5 mg subcutaneous daily (Contraindicated if Creatinine Clearance [CrCl] less than 30 ml/minute) References: Modifi ed From: Motyke, GD, Zebal, LP and Caprini, et al. A Guide to Venous Thromboembolism Risk Factor Assessment. Journal of Thrombosis and Thrombolysis, 2000. Geerts W, Bergqvist D, Pineo G et al. Prevention of Venous Thromboembolism. Chest 2008; 133: 381S-453S