INSTRUCTIONS:
1. Before placing in chart, imprint patient’s
plate as indicated below
2. After doctor writes a medication order
scan duplicate copy to Pharmacy
Page 1 of_2___
Imprint Patient’s name Plate or Print Information Above
ORDERED
PHYSICIAN’S ORDERS: Preterm Labor
DATE
TIME
Admit:
LDRP … Triage
Diagnosis:
Preterm Labor
Allergies:
None
Vital Signs:
EFM:
IV Primary:
Yes
List:
•
•
Bp,pulse,respirations every 2 hours
Temp every 4 hours if membranes intact, every 2 hours if
membranes ruptured
• Vital signs and DTRs hourly while on magnesium sulfate
Continuous per protocol
Infuse _________________ at ______ ml/hr via infusion pump
(Type of solution)
Other
Intake and Output every 8 hr, hourly if on magnesium sulfate infusion
Foley catheter
Output:
Diet:
Activity:
Lab
Studies:
Radiology
Studies:
NPO with sips/ice chips
Clear liquids
Regular
Bathroom privileges
Strict bedrest
Fetal Fibronectin if > 22 weeks< 34 weeks (STAT___)
UA (STAT__)
Urine C & S
CBC with diff (STAT___)
VDRL
Type and Rh
GC/Chlamydia culture
Group B Strep culture
Serum magnesium level every ____ hours while magnesium sulfate
infusing (STAT___)
Other:
Ultrasound (STAT___ at bedside____) for
Cervical length
Gestational age
Amniotic Fluid Index
Biophysical Profile
Anatomy/Fetal Survey
Other:_____________, _______________, _______________
Other:
(orders continued next page)
Last Update: 04/24/06
Sent To Pharmacy
Date: _________ Time:________ Initials: ________
NOTED BY/
TIME DATE AND
SIGNATURE
INSTRUCTIONS:
1. Before placing in chart, imprint patient’s
plate as indicated below
2. After doctor writes a medication order
scan duplicate copy to Pharmacy
Page 2 of_2___
ORDERED
DATE
Imprint Patient’s name Plate or Print Information Above
PHYSICIAN’S ORDERS: Preterm Labor Pg 2 of 2
TIME
Medications
Magnesium sulfate: See Magnesium Sulfate preprinted order sheet
Terbutaline (Brethine) 0.25 mg subcutaneously now. May repeat 0.25
mg in 30 minutes if uterine contractions do not decrease to 2 or less in
10 minutes.
(Hold dose and notify care provider if maternal pulse> 120bpm)
Indomethacin (Indocin): 50 mg loading dose orally now. May repeat
50 mg orally in one hour if uterine contractions do not decrease to
2 or less in 10 minutes.
Then give:
25 mg orally every 6 hours for 48 hours
50 mg orally every 6 hours for 48 hours
Nifedipine (Procardia):
Note:
• Not to be administered with magnesium sulfate.
• Not to be administered within 4 hours of discontinuing
magnesium sulfate.
• Not to be administered sublingually.
10 mg loading dose orally now. Repeat 10 mg orally in 20
minutes if contractions do not decrease to 2 or less in 10
minutes. Then give 10 mg orally every 6 hours.
20 mg loading dose orally now. Repeat 20 mg orally in 20
minutes if contractions do not decrease to 2 or less in 10
minutes. Then, give 20 mg orally every 6 hours.
(Hold dose if maternal pulse> 120bpm and notify care provider)
Betamethasone (Celestone)12 mg IM now, then 12 mg IM 24 hours
from time first dose administered.
Dexamethasone (Decadron) 6 mg IM now, then 6 mg IM every 12
hours thereafter for 3 more doses.
Other:
Other
HOLD VAGINAL EXAMS UNTIL PRESCRIBED BY PHYSICIAN/CNM
Other:
Physician Signature:
Last Update: 04/24/06
Sent To Pharmacy
Date:
Time:
Date: _________ Time:________ Initials: ________
NOTED BY/
TIME DATE AND
SIGNATURE