PLACE LABEL HERE

GWINNETT WOMEN’S PAVILION

ANTEPARTUM PATIENT DISCHARGE

INSTRUCTIONS

Date: ______Time: ______

1. Discharge Outcomes / Initials / 6. Special Instructions:
Afebrile (T<100.4); BP stable per parameters / SIGNS & SYMPTOMS OF PREMATURE LABOR: LABOR IN PATIENTS WHO ARE LESS THAN 37 WEEKS (8 ½ MONTHS)
 More than 4-6 contractions in one hour which may only feel like cramping; back pain and low abdominal pain like a period; vaginal spotting, change or increase in vaginal discharge; pains down inner thighs; nausea, vomiting or diarrhea. Urinary frequency, burning with urination and back pain can be signs of a urinary tract infection. Urinary infections can be the cause of premature labor signs. Dehydration (not drinking enough fluids) can also cause premature labor. Call you doctor if you have more than ______contractions per hour.
 Check your blood sugars as ordered. Call your doctor or clinic if your blood sugar becomes higher than your doctor wants it to be, or stays high despite treatment. Goals: before breakfast = 60-90. 2 hours after meals <120.
KEEP UP WITH HOW WELL YOUR BABY IS DOING
 Fetal kicks counts ______daily. Fetal activity (kicks) is one sign of your baby’s well being. Your baby should move at least 10 times in a 2 hour period. Any type of fetal movement is important. If you notice a decrease or your baby stops moving or changes its movement pattern, call your doctor / clinic. If directed, come to Labor & Delivery, so your baby can be checked.
PREGNANCY INDUCED HYPERTENSION
(HIGH BLOOD PRESSURE DURING PREGNACY)
 Call your doctor / clinic if you have one or any combination of the following: A persistent headache; blurred vision; dizziness, spots before your eyes; excessive swelling of your face, hands, feet or ankles; pain in your lower chest where your ribs meet (epigastric pain).

Without signs/symptoms of labor
Reassuring FHR / good fetal movement
Without vaginal bleeding
Pain controlled to patient’s satisfaction on oral medications
Without leakage or amniotic fluid (except PPROM)
Correctly demonstrates self-care activities
Blood sugars under control (if applicable)
Diabetic education completed or F/U scheduled (if applicable)
Tolerates solid food / follows prescribed diet
Transition plan completed (if applicable)
2. Medications
Prescriptions given  Yes  No
Drug / Route / Frequency / Info
3. Diet
 Regular  Diet as ordered: ______
 If you are diabetic, follow prescribed diet as ordered
 Eat balanced meals that include meats, milk, cheese, eggs, fresh fruits and vegetables, cereals, and bread
 Fluid intake is important. Drink at least (10) 8 ounce glasses of water each day. Tea, soda, and coffee do not count
 Avoid drinks with large amounts of sugar (like juice and soda). Limit caffeine intake
4. Activity / Self Care
 Normal activity  No heavy lifting > 10 pounds
 Limit activity  Bedrest  Bathroom privileges
 Tub bath  Shower  Sponge bath only
 Arrange for family & friends to help with housekeeping and child care
 If preterm labor or ruptured membranes have been diagnosed, no sexual activity or anything placed in the vagina
5. Follow-up / RN Signature: ______
RN Signature: ______
Follow-up physician / clinic appointment:
Date: ______Time: ______
When you go for your appointment, take your current list of medicines and give it to your doctor
 Diabetic education follow-up: ______
 Call your doctor before your scheduled appointment if your symptoms get worse, you notice new symptoms, or you have concerns
 Previous C/Section: come to the hospital immediately if you have vaginal bleeding, abdominal pain that is sharp, hard, and does not go away
 Call your doctor for vaginal bleeding, leaking of fluid from your vagina, or temperature 100.4 on two consecutive readings.
Patient
 I have received & understand my discharge instructions
 My questions have been answered
 Security has returned my valuables
 I did not give security my valuables
 Language line /interpreter used if indicated –
List name or operator ID ______

Patient / Family Signature: ______
Discharge Date and Time: ______

These are guidelines and can be altered at the practitioner’s direction * See Nurses’ Notes

WHITE: Medical Record Copy CANARY: Patient Copy

*1-17990* FORM 1-17990 REV. 12/2005