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Sample Obstetrics Orders By:

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.pptwww.cdc.gov/asthma/speakit/slides/managing_asthma.ppt 6- An extract from Tan T& Yeo G. IUGR. Current Opinion in Obstetrics An extract from Tan T& Yeo G. IUGR. Current Opinion in Obstetrics and Gynecology 2005, 17: 135-142and Gynecology 2005, 17: 135-1427-Panda S . IUGR. Department of Obstetrics & Gynecology Medical 7-Panda S . IUGR. Department of Obstetrics & Gynecology Medical College of India 2002College of India 20028-med-ed-online.org/rcurricula/med_decision_making.8-med-ed-online.org/rcurricula/med_decision_making.

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Recommended laboratory tests in the initial prenatal care visit

1. Hct, Hb2. U/A,U/C3. BG,Rh4. Pap smear5. Antibody screen6. Rubella status7. Syphilis screen8. Hbs Ag9. 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

• General: condition/position/diet• Lab: F/U CBC• IV : 1000cc Ringer +20 units of oxytocin • PO:

cap cephalexin 500 mg qidTab 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

• 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

• 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 KVOAMP 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 ,

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>100NTG=10-20 mcg/min IV Consider SNP: 0.1-5 mcg/kg/min IVACEinh. if SBP is not<30 mmHg below baseline.

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Glasgow Coma Scale

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Eye Opening 4 Spontaneous

3 To Voice

2 To Pain

1 Nil

Verbal Response 5 Orientated

4 Confused

3 Words

2 Groans

1 Nil

Motor Response 6 Obeys Commands

5 Localizes Pain

4 Withdraws from Pain

3 Flex

2 Ext

1 Nil

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

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  Class 1 Class 2 Class 3 Class 4

Blood LossVolume (mls) in

adult750mls 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 ReducedVery low /

Unrecordable

Pulse (beats /min)Slight tachy-

cardia100 - 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 10 - 20 0 - 10

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Estimated blood loss

Suitable fluid regimes

1000 mls 3000 mls crystalloidor

1000 mls colloid

1500 mls1500 mls crystalloid & 1000mls

colloidor

4500 mls crystalloid

2000 mls1000 mls crystalloid, 1000mls colloid

& 2 units bloodor

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

CIPROFLOXACIN-EXIR® 250MG TAB = 350 Rls.

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PE

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Is PaCO2 increased?

Yes=hypoventilationIs PAO2-PaO2

increased?

Is PAo2-PaO2 increased?

Hypoventilation alone

Yes=hypoventilation +another mechanism

Decreased inspired PO2

If yes then find outif low PO2 is correctable with

O2?

Yes=V/Q mismatch 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

applies => Urinary Cl>Urinary Na +K

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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

DoseHold Infusion

Change Rate of Infusion

units minutes ml/h (units/h)

50 - 59 0 0+2 cc/h

(+80 u/h)6 h

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 60-4 cc/h

(- 160 u/h)6h

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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)

if:Check of contractions:+

U/A, U/C: -Fern:-

Then: Hydrate and sedate

Stop of contractions: dischargeWith:isoxsuprine 10 mg TDS for 10 days

Contractions persist: hospitalizeNext 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 im4-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

• 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

• 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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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

• 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• 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

• 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

• 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

• 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

• 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

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

• Karyotype

• HSG

• Luteal phase biopsy of endometrium• TSH and prolactin level

• ACL ab

• LAC

• CBC

Abortion without fever:

Doxy 100 mg bidortetracycline 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 hA-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 laparascopyC-If a dead IP and EP is confirmed (beta HCG more than 2000 and mass < 3.5 cm) then MTXFETUS 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

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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