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 _____ weeks gestation
 IUFD
 Inevitable abortion
Other Diagnoses: _________________________________________________________________________
1.
2.
3.
4.
Status: Admit as inpatient to L&D
Follow Perinatal Loss /Anticipated Perinatal Loss Pathway
Consults: Social Work Services Chaplaincy
 Perinatology  Anesthesia
 With: __________________ Concerning: __________________  Routine  Urgent
Have Physician call back to: ____________________________ (phone number)
Labs:
Type and Crossmatch for zero units- if antibody screen positive, order Crossmatch for 2 units PRBCs
CBC
UA, if not already done
 DIC profile  Fibrin split products  Preeclampsia Panel TORCH profile Kleinhauer-Betke
 Antiphospholipid antibody panel (includes anti-beta2-glycoprotein and anticardiolipin)
 Lupus type anticoagulant
 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  DNA 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 than 18 weeks gestational age:
 18-28 weeks gestational age:
 Greater than 28 weeks gestational age:
Send copy to pharmacy
*3-16607*
400 mcg per vagina q 8 hrs prn up to 4 doses
200 mcg per vagina q 6 hrs prn up to 4 doses
25 mcg per vagina q 4 hrs prn up to 4 doses
Order writer’s initials _________
FORM 3-16607 REV. 09/2013
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:
__________________________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
______________
___________________
_________________________________
___________
Date
Time
Physician Signature
PID Number
Send copy to pharmacy
FORM 3-16607 REV. 09/2013
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