Sample Obstetrics Orders
By:
Mitra Ahmad Soltani
References:
1-Williams Obstetrics / 22nd Edition/ MC. Graw Hill/ 2005
2-Novak’s Gynecology/ 13 th Edition/ Williams and Wilkins/ 2002
3-TE Linde’s (Operative Gynecology) 9 th Edition / Williams and
Wilkins / 2003
4-Iranian Council for Graduate Medical. Education. Promotion and
board Exam questions.(2000-2007)
5- www.cdc.gov/asthma/speakit/slides/managing_asthma.ppt
6- An extract from Tan T& Yeo G. IUGR. Current Opinion in Obstetrics
and Gynecology 2005, 17: 135-142
7-Panda S . IUGR. Department of Obstetrics & Gynecology Medical
College of India 2002
8-med-ed-online.org/rcurricula/med_decision_making.
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Recommended laboratory tests
in the initial prenatal care visit
1.
2.
3.
4.
5.
6.
7.
8.
9.
Hct, Hb
U/A,U/C
BG,Rh
Pap smear
Antibody screen
Rubella status
Syphilis screen
Hbs Ag
Offer HIV testing
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Impression: normal labor
• General: condition/position/diet
• Lab: CBC, BG, Rh, U/A, reserve of 2 units of PC
• IV : 1000cc Ringer at KVO
for long labors 1/3,2/3 60-120mL/h
• PO:• OTHER: Control of vital sign q4hrs, control of
FHR q30 min in 1st stage of labor q15 min in the 2nd
stage, amniotomy if fetal head is fix
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Impression: NVD+Epi
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General: condition/position/diet
Lab: F/U CBC
IV : 1000cc Ringer +20 units of oxytocin
PO:
cap cephalexin 500 mg qid
Tab ferrus sulfate daily,
cap mefenamic acid TDS
• OTHER: Control of vital sign q15 min for the1st hr
then q1hr for 4 hrs then as routine
• Inform if BP is abnormal/bleeding is excessive/ no
voiding after 4 hrs
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7 contraindications for lactation
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Alcohol and Drug abusers
Galactosemia of the newborn
HIV
Active, untreated TB
Ongoing breast cancer treatment
Cytomegalovirus
Hepatitis B virus (not contraindicated if hepatitis
B immune globulin is given to infants of
seropositive mothers)
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10 drugs contraindicated in
lactation
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Bromocriptine
Cocaine
Cyclophosphamide
Cyclosporine
Doxorubicin
Lithium
Methotrexate
Phencyclidine
• phenindione
• Radioactive iodine and other radiolabled elements
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IMP:Mastitis (out patient)
• Lab:, Milk culture , CBC diff
• PO: dicloxacillin 500 mg qid 7-10 days
• Or erythromycin to penicillin sensitive
women
• Or vancomycin to MRS
• OTHER: Control of vital sign q 4 hrs,
pumping breasts until nursing can be
resumed
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Postoperative infection
• General: condition/position/diet
• Lab: CBC diff, MP, WW, B/C X2, U/A ,
U/C,CXR,BUN/Cr
• IV : 1000cc Ringer at KVO
AMP clindamycin 900 mg iv TDS +gentamicin im
80mg stat then 60 mg TDS
add amp ampicillin 2gr iv qid and pelvic exam and
imaging study if fever persists 72 hours,
OTHER: Control of vital sign hourly
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Imp:chorioamnionitis
• General: condition/position/diet=NPO
• Lab: CBC diff, MP, WW, B/C X2, U/A ,
U/C,CXR,BUN/Cr
• IV : 1000cc Ringer +10 units of oxytocin start at
2 drops /min, add 4 drops every 15 min if FHR
and contractions are normal
Amp ampicillin 2gr iv qid +gentamicin im 80mg stat then
60 mg TDS
AMP clindamycin 900 mg iv TDS for allergic women to
penicillin(continue antibiotics after delivery until the
mother is a febrile
OTHER: Control of vital sign hourly
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Sepsis syndrome
• General: condition/position/diet
• Lab: CBC diff, hct, MP, WW, B/C X2, U/A , U/C ,
CXR, BUN/Cr
• IV :
AMP clindamycin 900 mg iv TDS +gentamicin im 80mg stat
then 60 mg TDS
add amp ampicillin 2gr iv qid and pelvic exam and imaging
study if fever persists 72 hours
Amp dopamine 5 mcg/kg/min or dubotamine iv drip
OTHER: Control of vital sign hourly ,oxygen
therapy, correct acidosis, excise infected tissue,
fix foley ,
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Low output cardiogenic shock-1
SBP<70 mmHg +sign/symptoms of shock:
Noreinephrine IV 0.5 to 30 mcg/min
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Low output cardiogenic shock-2
SBP=100-70+sign/symptoms of shock:
DOPAMINE: 5-15 mcg/kg/min IV
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Low output cardiogenic shock-3
SBP=100-70 no sign/symptoms of shock:
Dobutamine: 2-20 mcg/kg/min IV
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Low output cardiogenic shock-4
SBP>100
NTG=10-20 mcg/min IV
Consider SNP: 0.1-5 mcg/kg/min IV
ACEinh. if SBP is not<30 mmHg below
baseline.
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Glasgow Coma Scale
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Eye
3
To Voice
Opening 4
Spontaneous
2
To Pain
1
Nil
Verbal
4
Response 5 Confused
Orientated
3
Words
2
Groans
Motor
5
Response 6 Localizes
Pain
Obeys
Commands
4
3
Withdraws Flex
from Pain
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1
Nil
2
Ext
1
Nil
IMP: R/O abruption
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Condition/position/diet:NPO
Lab: CBD-BG-Rh-U/A-U/C-PT-PTT-Fib-FDP-D-DimerPrep 4 units of crossmatched packed red blood cells
Continuous high-flow supplemental oxygen
One or 2 large-bore IV lines with normal saline (NS) or
lactated Ringer (LR) solution+10 units of oxytocin in 1 lit
of ringer start at 2 drops/min add 2 drops every 15 min if
fetal heart rate and uterine contractions are favorable.
• perform amniotomy
• Closely observe the patient. Monitor vital signs and urine
output, fetal heart rate and uterine height measurement.
• Prepare OR for emergent C/S
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Class 1
Class 2
Class 3
Class 4
Blood Loss
Volume (mls) in
adult
750mls
800 - 1500mls
1500 - 2000mls
>2000mls
Blood Loss
% Circ. blood
volume
<15%
15 - 30%
30 - 40%
>40%
Systolic Blood
Pressure
No change
Normal
Reduced
Very low
Diastolic Blood
Pressure
No change
Raised
Reduced
Very low /
Unrecordable
Pulse (beats /min)
Slight tachycardia
100 - 120
120 (thready)
>120 (very thready)
Capillary Refill
Normal
Slow (>2s)
Slow (>2s)
Undetectable
Respiratory Rate
Normal
Normal
Raised (>20/min)
Raised (>20/min)
Urine Flow
(mls/hr)
>30
20 - 30
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10 - 20
0 - 10
Estimated
blood loss
Suitable fluid regimes
1000 mls
3000 mls crystalloid
o
r
1000 mls colloid
1500 mls
1500 mls crystalloid & 1000mls
colloid
o
r
4500 mls crystalloid
2000 mls
1000 mls crystalloid, 1000mls colloid
& 2 units blood
o
r
3000 mls crystalloid & 2
units blood
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Infection
Suggested oral adult
dose
Price
Acute cystitis
Trimethoprim 200 mg
bd or Augmentin 625
mg tid or
Nitrofurantoin 50 mg
qid
Nalidixic acid 500 mg
qid
TRIMETHOPRIM
100MG TAB= 66 Rls.
CO-AMOXICLAV 625
(500/125) TAB = 2,970
Rls.
NITROFURANTOIN
100MG TAB
= 57 Rls.
Acute
pyelonephritis
(pre- hospital
admission)
Ciprofloxacin 750 mg
bd
CIPROFLOXACINEXIR® 250MG TAB =
350 Rls.
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PE
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Is PaCO2 increased?
Is PAO2-PaO2
increased?
Yes=hypoventilation
Is PAo2-PaO2
increased?
Hypoventilation
alone
Decreased
inspired PO2
Yes=hypoventilation
+another mechanism
If yes then find out
if low PO2 is correctable with
O2?
Yes=V/Q mismatch
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Shunt
ABG reading
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Check if the blood is from an artery (CO2=15+HCO3)
Calculate Anion Gap
(AG=Na – (Cl +HCO3)
Calculate if the response is compensatory or not
If there’s no significant AG (more than10-12), then it
must be either RTA or GI loss. In GI loss this formula
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applies => Urinary
Cl>Urinary Na +K
PE, DVT
• IV heparin 5000 unit q4h
• Check of PTT Q6h
• Discharge with warfarin 5 mg /day for 4-6
months
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PTT (sec)
Heparin Dosing Instructions
Recheck PTT
Repeat Bolus
Dose
Hold Infusion
Change Rate of
Infusion
units
minutes
ml/h (units/h)
50 - 59
0
0
+2 cc/h
(+80 u/h)
6h
60 - 85
0
0
no change
next am
86 - 110
0
0
-2 cc/h
(- 80 u/h)
next am
< 50
5000
0
+4 cc/h
(+160 u/h)
6h
>110
0
60 2008
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-4 cc/h
(- 160 u/h)
6h
IMP:PLP before 37 weeks out patient:
(contractions 4 in 20 min or 8 in 60 min +progressive change in cervix
cervical dilation of more than one
cervical effacement of more than 80 % or greater)
if:
Check of contractions:+
U/A, U/C: Fern:Then: Hydrate and sedate
Stop of contractions: discharge
With:isoxsuprine 10 mg TDS for
10 days
Contractions persist: hospitalize
Next slide
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IMP:PLP before 37 weeks,
hospitalized
• General: condition/position/diet
• Lab: CBC, BG, Rh, U/A, U/C, fern, reserve of 2 units of PC
• IV :
1-1000cc Ringer free
2-MgSO4 (4 gr) in 200cc DW5% in 20 min then 20 gr in 1000cc
infused in 100cc/hrs (check of I/O, RR,DTR, prep CPR set- I/O
with measure)
3-Amp pethidine 25 mg iv 25 mg im
4-Amp ampicillin 2 gr IV qid
5-Amp erythromicin 400 mg QID
6- Amp betamethasone 12 mg im, repeat after 24 hrs for GA below
34 wks
• OTHER: Control of vital sign q4hrs, Inform if LP, leakage, VB, ab VS
or FHR
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Contraindication to tocolysis
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Acute fetal distress
Chorioamnionitis
Eclampsia or sever preeclampsia
Fetal demise
Fetal maturity
Maternal hemodynamic instability
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Contraindication for beta
mimetics
Maternal
• cardiac disease
• Diabetes
• Thyrotoxicosis
• HTN
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Contraindication for MgSO4
• Hypocalcemia
• Myasthenia gravis
• Renal failure
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Contraindication for
indomethacin
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Asthma
CAD
Gastrointestinal bleeding
Oligohydramnios
Renal failure
Suspected fetal cardiac or renal anomaly
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Dosage of Ritodrine or Terbutaline
for tocolysis
• 50-100 mcg/min increase by 50 mcg/min
every 10 min
• max dose:350mcg/min
If labor is arrested continue the infusion for
at least 12 hrs
• SC:
250 mcg q3-4 hrs
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Endocarditis Prophylaxis
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GI or GU surgery
High Risk patient
Standard
Ampicillin
+Gentamycin 30
min before the
procedure and have
to be repeat
Ampicillin after 6
hours
Moderate Risk
Allergy
Standard
Gentamycine +
Vancomycine
Amoxycillin
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Allergy
Vancomycine
Should be infused
One hour before to
30 minutes after the
procedure
IMP: Hyperemesis Gravidarum
• General: condition/position/diet
• Lab: CBC, BG,Rh, U/A, U/C, k, Na, BUN/Cr,
TFT
• reserve of 2 units of PC
• IV : 3000cc(DW10%+ DW5%+1/3,2/3)divided in
24 hrs
• AMP Promethazine 25 mg iv qid
• Amp plazil 10 mg qid
• Tab navidoxin daily
• OTHER: Control of vital sign q4hrs, daily weight,
check of I/O with measure sono OB
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Suspecting Acute Hepatitis
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HBS Ag, Ab
Anti HBC (IgM)
ANTI HAV (IgM)
Anti HCV
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Suspecting Chronic Hepatitis
• HBe Ag, Ab
• HBS Ag ,Ab
• Anti HCV
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IMP: Pyelonephritis
• General: condition/position/diet
• Lab: CBC diff, BG, Rh, U/A,U/C, k, Na, BUN/Cr, WW,
MP,B/CX2
(Repeat of U/C after initiation of antibiotics if positive then
kidney sono)
• reserve of 2 units of PC
• IV : 1000cc DW5% free
• AMP keflin 2 gr stat then 1 gr q6h
• Amp gentamicin 80 mg im stat then 60 mg tds
• OTHER: Control of vital sign q4hrs, control of FHR,FAD
chart , check of I/O with measure, sono OB
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GFR=(140-age)/72x PCr x 85% for females
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Blood sugar
• For pregnancy
Ab>105 FBS
Ab>120 2hr PP
POSTPARTUM
Ab>140 FBS
Ab>200 2hr PP
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IMP: Diabetes
• General: condition/position/diet =diabetic
• Lab: CBC diff ,BG, Rh, U/A,U/C, BUN/Cr,
BS(FBS, 10AM,4 PM,8PM), (PT, PTT, Fib)
(reserve of 2 units of PC
• IV :Ringer at heparin lock
• Insulin morning (10 units NPH +4 Reg)
• Insulin afternoon(4 NPH+4 Reg)
• OTHER: Control of vital sign q4hrs, control of
FHR, FAD chart , NST, sono OB,
ophthalmologic consultation
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• For each increase in BS more than 200
add 2 units to regular to each 50 mg of BS
• Insulin is used before breakfast and
evening meal
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IMP: mild preeclampsia
• General: condition/position/diet =low salt,high prot
• Lab: CBC ,BG, Rh, U/A,24hr urine (prot,cr,vol), BUN/Cr,
PT,PTT,Fib, ALT,AST,Al P, Bil (T, D)
• reserve of 2 units of PC
• IV :Ringer at heparin lock
• OTHER: Control of vital sign q4hrs, control of FHR, FAD
chart , NST, sono OB, daily weight inform if
BP>160/110, blurred vision, head ache, epigastric pain,
seizure
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IMP: Severe preeclampsia
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General: condition/position/diet =NPO
Lab: CBC ,BG, Rh, BUN/Cr, PT, PTT,Fib ,ALT,AST,Al P, Bil (T, D)
prep 2 units of PC
IV :Ringer 1000cc +10 u of oxytocin
if BP>160/110,blurred vision, head ache, epigastric pain, seizure
then amp hydralazine 5 mg iv prn
MgSO4 (4 gr) in 200cc DW5% in 20 min then 10 gr(1/2)
im in each buttock then 5 gr im q4h
If platelet is below 100000 then 20 gr in 1000cc infused
in 100cc/hrs (check of I/O,RR,DTR, prep CPR set with 2
gr 20% MgSO4 ready) +Amp Dexa 6 mg im bid for 4
doses
OTHER: Control of vital sign q15 min , control of FHR, fix
foley,
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Emergency C/S
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Prep 2 units of pc
Amp keflin 2 gr iv
Prepare for C/S
Transfer to OR
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The night before elective C/S
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CBC, BG, Rh, (FBS,BUN/CR, CXR, ECG)
Prep 2 units of pc
NPO from 12 am
Iv Ringer KVO
Check of FHR and contractions
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8 hours after C/S
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fair, RBR, surgical diet,
IV 2 lit Ringer
Continue keflin
Supp bisacodyl 2 stat then tab bisacodyl
bid
• Foley DC,
• I/O DC
• F/U CBC
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24 hours after C/S
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Condition good ,RBR, reg diet,
IV as heparin lock
Continue keflin
tab bisacodyl bid
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36-48 hours after C/S
• Remove dressing
• Discharge with
Cap cephalexin 500 mg qid
Cap mefenamic acid 500 mg tds
Cap hematinic (according to Hb)
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Diabetic C/S
NPO from 12 am
Prep 2 units of PC
1000 cc Ringer IV fluid q8 hrs the night before surgery
Amp keflin 2 gr iv stat half an hour before surgery
• Before operation: 10 units of regular +1000 cc DW5%
150cc/hr
• Check of BS q6h after operation
Inform in cases of ROM or bleeding or pain
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Asthma management
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Heavy vaginal bleeding in a 14 year old girl with Hb
value of 7 gr/dl and normal coagulation tests and
platelets and pelvic sonography:
Conjugate estrogen 25-40 mg IV q6h or Conjugated
estrogen 2.5 mg q6h PO until bleeding is
controlled followed by medroxy progesterone
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Prolonged spotting in a 14 year old anemic
girl
Low dose OCP 21 days for 3-6 cycles
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DUB in a 16 year old girl with stable vital
signs:
Monophasic OCP q6h for 7 days
+ Iron supplements
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Recurrent abortion tests
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Karyotype
HSG
Luteal phase biopsy of endometrium
TSH and prolactin level
ACL ab
LAC
CBC
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Abortion without fever:
Doxy 100 mg bid
or
tetracycline 250 mg qid
for 5-7 days
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Beta HCG below 2000+
no visible intrauterine sac+
mass in tube below 3.5 cm
______________________
control of beta HCG q 48 h
A-If a dead IP is confirmed (beta HCG increase less than
50% or below 1000mIu/mL- P below 5 ng/mL + visible
intrauterine sac) then curettage
B-If EP is confirmed (beta HCG more than 2000 and mass
>3.5 cm) then laparascopy
C-If a dead IP and EP is confirmed (beta HCG more than
2000 and mass < 3.5 cm) then MTX
FETUS SHOULD BE VISIBLE ON DAY 45 OF GESTATION
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Indication of MTX for EP
• Hemodynamic stability
• No intra uterine pregnancy
• Max sac diameter not equal or more than
4 cm
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EP
• Adenexal mass< 3.5 cm-> MTX
• adenexal mass=> 3.5 cm -> laparascopy
• uncertain US + beta HCG increase less
than 50% -> D&C
• unstable conditions->laparatomy
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