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Sample Obstetrics Orders By: Mitra Ahmad Soltani

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

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Sample Obstetrics Orders By: Mitra Ahmad Soltani

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  1. Sample Obstetrics OrdersBy:Mitra Ahmad Soltani References: 1-Williams Obstetrics / 22nd Edition/ MC. Graw Hill/ 20052-Novak’s Gynecology/ 13 th Edition/ Williams and Wilkins/ 20023-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. med-ed-online 2008

  2. Recommended laboratory tests in the initial prenatal care visit • Hct, Hb • U/A,U/C • BG,Rh • Pap smear • Antibody screen • Rubella status • Syphilis screen • Hbs Ag • Offer HIV testing med-ed-online 2008

  3. 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 med-ed-online 2008

  4. Impression: NVD+Epi • 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 med-ed-online 2008

  5. 7 contraindications for lactation • 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) med-ed-online 2008

  6. 10 drugs contraindicated in lactation • Bromocriptine • Cocaine • Cyclophosphamide • Cyclosporine • Doxorubicin • Lithium • Methotrexate • Phencyclidine • phenindione • Radioactive iodine and other radiolabled elements med-ed-online 2008

  7. 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 med-ed-online 2008

  8. 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 med-ed-online 2008

  9. 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 +gentamicinim 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 med-ed-online 2008

  10. 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 , med-ed-online 2008

  11. Low output cardiogenic shock-1 SBP<70 mmHg +sign/symptoms of shock: Noreinephrine IV 0.5 to 30 mcg/min med-ed-online 2008

  12. Low output cardiogenic shock-2 SBP=100-70+sign/symptoms of shock: DOPAMINE: 5-15 mcg/kg/min IV med-ed-online 2008

  13. Low output cardiogenic shock-3 SBP=100-70 no sign/symptoms of shock: Dobutamine: 2-20 mcg/kg/min IV med-ed-online 2008

  14. 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. med-ed-online 2008

  15. Glasgow Coma Scale med-ed-online 2008

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  17. IMP: R/O abruption • Condition/position/diet:NPO • Lab: CBD-BG-Rh-U/A-U/C-PT-PTT-Fib-FDP-D-Dimer- • Prep 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 med-ed-online 2008

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  21. PE med-ed-online 2008

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  23. ABG reading med-ed-online 2008

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  26. PE, DVT • IV heparin 5000 unit q4h • Check of PTT Q6h • Discharge with warfarin 5 mg /day for 4-6 months med-ed-online 2008

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  28. IMP:PLP before 37 weeks out patient:(contractions 4 in 20 min or 8 in 60 min +progressive change in cervixcervical dilation of more than onecervical effacement of more than 80 % or greater) med-ed-online 2008

  29. 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 med-ed-online 2008

  30. Contraindication to tocolysis • Acute fetal distress • Chorioamnionitis • Eclampsia or sever preeclampsia • Fetal demise • Fetal maturity • Maternal hemodynamic instability med-ed-online 2008

  31. Contraindication for beta mimetics Maternal • cardiac disease • Diabetes • Thyrotoxicosis • HTN med-ed-online 2008

  32. Contraindication for MgSO4 • Hypocalcemia • Myasthenia gravis • Renal failure med-ed-online 2008

  33. Contraindication for indomethacin • Asthma • CAD • Gastrointestinal bleeding • Oligohydramnios • Renal failure • Suspected fetal cardiac or renal anomaly med-ed-online 2008

  34. 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 med-ed-online 2008

  35. Endocarditis Prophylaxis med-ed-online 2008

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  37. 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 med-ed-online 2008

  38. Suspecting Acute Hepatitis • HBS Ag, Ab • Anti HBC (IgM) • ANTI HAV (IgM) • Anti HCV med-ed-online 2008

  39. Suspecting Chronic Hepatitis • HBe Ag, Ab • HBS Ag ,Ab • Anti HCV med-ed-online 2008

  40. 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 med-ed-online 2008

  41. GFR=(140-age)/72x PCr x 85% for females med-ed-online 2008

  42. Blood sugar • For pregnancy Ab>105 FBS Ab>120 2hr PP POSTPARTUM Ab>140 FBS Ab>200 2hr PP med-ed-online 2008

  43. 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 med-ed-online 2008

  44. 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 med-ed-online 2008

  45. 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 med-ed-online 2008

  46. IMP: Severe preeclampsia • 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, med-ed-online 2008

  47. Emergency C/S • Prep 2 units of pc • Amp keflin 2 gr iv • Prepare for C/S • Transfer to OR med-ed-online 2008

  48. The night before elective C/S • 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 med-ed-online 2008

  49. 8 hours after C/S • 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 med-ed-online 2008

  50. 24 hours after C/S • Condition good ,RBR, reg diet, • IV as heparin lock • Continue keflin • tab bisacodyl bid med-ed-online 2008

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