PLACE LABEL HERE
MAGNESIUM SULFATE ORDERS
FOR TOCOLYTIC THERAPY
The following orders will be implemented. Orders with a “” are choices and are NOT ordered unless checked.
Initial all hadwritten order modifications and the bottom of each page when indicated.
Allergies: ________________________________________________________________________________
Diabetic:  Yes  No
1.
Diagnosis & Status: Admit as Inpatient to L&D ___________________________________(reason for admission)
2.
In addition to these orders, follow:  Generic Antepartum Orders (form # 15603)
 Other: ________________________________________________
ASSESSMENTS:
3. Obtain baseline maternal/fetal assessments prior to initiation of therapy. This includes maternal vital signs,
breath sounds, deep tendon reflexes (DTRs), oxygen saturation, level of consciousness, fetal heart rate
(FHR), and uterine activity.
4. Maternal/fetal assessments per routine, or more often if clinical condition warrants:
Antepartum
Blood pressure & heart
Every 5 minutes during loading dose,
rate
then every 15 minutes for the first hour,
then every 30 minutes for the second hour,
then hourly.
Respiratory rate
Every 15 minutes for the first hour,
then every 30 minutes for the second hour,
then hourly.
FHR & uterine activity
Continuously
Document with each set of maternal vital signs.
DTRs
Every hour
Intake & output
Every hour
Level of consciousness
Every hour
Breath sounds
Every 2 hours
SaO2 (pulse oximetry)
Every hour
IV site assessment
Every 2 hours
Fundus/lochia
N/A
5.
 Transfer to High Risk Pregnancy Unit when the following criteria have been met for 6-12 hrs:
 Maintenance dose has not been increased
 Uterine activity has been below threshold with no cervical change
 Maternal vital signs and FHR are stable with maternal respiratory rate at or above 16
 Urine output is above 30 ml/hr or 120 ml/4 hrs
 DTRs are at least 1+
 Serum magnesium level is below 8 mg/dl (if ordered)
Order writer’s initials _________
*3-18086*
FORM 3-18086 REV. 07/2012
WHITE: Medical Record
CANARY: Pharmacy
Page 1 of 2
PLACE LABEL HERE
MAGNESIUM SULFATE ORDERS
FOR TOCOLYTIC THERAPY
The following orders will be implemented. Orders with a “” are choices and are NOT ordered unless checked.
Initial all hadwritten order modifications and the bottom of each page when indicated.
6.
Notify physician immediately if patient has:
 Uterine contractions: _______ or more per hr
 Significant changes in BP from baseline values
 Double (or blurring) of vision
 Tachycardia or bradycardia
 Respiratory rate below 14 or above 24
 Oxygen saturation below 95%
 Adventitious lung sounds
 Changes in level of consciousness or neurological status
 Absence of DTRs
 Urine output less than 30 ml/hr for 2 consecutive hrs (or less than 120 ml in fours if no Foley)
 Category III FHR patterns (anticipate minimal variability and loss of accelerations)
 Vaginal bleeding
7. If respirations < 12, discontinue magnesium sulfate, notify Physician, and give supplemental O2 to keep
O2 sat > 95%.
8. Foley catheter to bedside bag OR  do not insert Foley; may use bedpan
9. Activity: Strict bedrest OR  Bedside commode (for BM) with assistance  Bedrest with bathroom
privileges with assistance
10. Hygiene: Bed bath OR  Shower with assistance
IVF/SCHEDULED MEDICATIONS:
11. LR as primary fluids. Maintain total IV intake at 125 ml/hr, or ______________________________
12. Loading dose:  Magnesium Sulfate 4 gram IV loading dose over 20 min x 1 dose
 Magnesium Sulfate 6 gram IV loading dose over 20 min x 1 dose
13. Maintenance: at completion of magnesium sulfate loading dose, run maintenance infusion at ________
gms/hr IV
PRN MEDICATIONS:
14. Respiratory Arrest: Calcium gluconate 10%, 1 gm (10 ml) IV push over 3-5 minutes prn and assess VS q
5 min until respiratory rate is ≥ 12, SaO2 is >95%; then every 15 min x one hr, then resume per above
ADDITIONAL ORDERS:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________
Date
___________________
Time
FORM 3-18086 REV. 07/2012
_________________________________
Physician Signature
WHITE: Medical Record
CANARY: Pharmacy
___________
PID Number
Page 2 of 2