PLACE LABEL HERE

Postpartum Readmission

Orders

The following orders will be implemented. Orders with a “” are choices and are NOTimplemented unless checked.

Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

  1. Diagnosis Admit asInpatient ______(reason for admission)

and Place in Observation ______(reason for observation)

Status: Place in Outpatient ______(diagnosis)

To: High Risk Pregnancy Unit  Other: ______

  1. Consults: WOC Nurse consult for wound management  Lactation consult

 With______Concerning:______ Routine  Urgent

  1. Labs:  CBC  U/A  Urine C&S  Preeclampsia Panel  24 hr urine for protein and creatinine clearance

 Glucose monitoring:  FBS q AM  2 hrs postprandial  at Bedtime  at 3 AM

 ______

  1. Diagnostics:  U/S ______ Chest XR  CT ______

 Other: ______

  1.  Vital signs, DTRs, breath sounds, and IO per Magnesium SulfateOrders (form # 20)

 I & O q ______hrs

TPRq _____ hrs; BP q _____hrs

  1.  Foley to bedside bag

 Discontinue Foley at ______

  1. Notify physician for: temperature > 100.4°F x 2, four hrs apart, or 101°F x 1, unstable vital signs, or excessive vaginal bleeding, systolic BP above ______or diastolic BP above ______

 FBS above ______or below ______; 2 hrs postprandial glucose above ______or below ______

 Other: ______

  1. Diet:  Regular  ______calorie consistent carbohydrate  Other: ______
  2. Activity: Ad lib  Up with assistance 1st 4 hrs after magnesium sulfate is discontinued, until stable, then ad lib  Bedrest  Bedside commode Bathroom privileges only  Bathroom/shower privileges

Terrace privileges:  Ad lib  via wheelchair  in reclining position  none

  1. VTE Prophylaxis: Plexi-pulses  with TEDs OR Sequential Compression Device (SCDs)  with TEDs

 Mechanical prophylaxis contraindicated because: ______

  1.  Wound care ______

SCHEDULED MEDICATIONS:

  1. IV Access Pain: Lidocaine 0.5 % 0.1 ml intradermally prior to IV start prn per patient request
  2.  IV fluids: ______at ______ml/hr OR INT
  3. Prenatal vitamin po dailyat 0900 patient may self-administer own prenatal vitamin after pharmacist identifies medication
  4. Antihypertensive: ______
16.Antibiotics: ______
  1. Implement “Insulin Subcutaneous for Obstetrics” orders (form # 21502), send to pharmacy
  2. Implement “Magnesium Sulfate for Pre-Eclampsia” orders (form # 20), send to pharmacy
  3. VTE Prophylaxis: Must select one option:

 Heparin 5,000 units SQ q 12 hrs (if patient has/had epidural, do not begin heparin until epidural has been out for 2 hrs)

Lovenox (enoxaparin) 40 mg SQ q 24 hrs at 1700; if CrCl < 30, give 30 mg SQ q 24 hrs (do not begin enoxaparin until epidural has been out for 12 hrs)

 Chemical prophylaxis contraindicated because: ______

  1. Stool softener: Colace (docusate) 100 mg po bid at 0900 and 2100. Hold for loose stools

Send copy to pharmacy Order writer’s initials ______

*4-19523*FORM 4-19523 REV. 07/2013 Page 1 of 4

PLACE LABEL HERE

Postpartum Readmission

Orders

Reference Page

Recommended Thromboprophylaxis for Pregnancies Complicated by Inherited Thrombophilias*
Clinical Scenario / Antepartum Management / Postpartum Management
Low-risk thrombophilia† without previous VTE / Surveillance without anticoagulation therapy or prophylactic LMWH or UFH / Surveillance without anticoagulation therapy or postpartum anticoagulation therapy if the patient has additional risks factors‡
Low-risk thrombophilia† with a single previous episode of VTE—Not receiving long-term anticoagulation therapy / Prophylactic or intermediate-dose LMWH/UFH or surveillance without anticoagulation therapy / Postpartum anticoagulation therapy or intermediate-dose LMWH/UFH
High-risk thrombophilia§ without previous VTE / Prophylactic LMWH or UFH / Postpartum anticoagulation therapy
High-risk thrombophilia§ with a single previous episode of VTE—Not receiving long-term anticoagulation therapy / Prophylactic, intermediate-dose, or adjusted-dose LMWH/UFH regimen / Postpartum anticoagulation therapy or intermediate or adjusted-dose LMWH/UFH for 6 weeks (therapy level should be at least as high as antepartum treatment)
No thrombophilia with previous single episode of VTE associated with transient risk factor that is no longer present—Excludes pregnancy- or estrogen-related risk factor / Surveillance without anticoagulation therapy / Postpartum anticoagulation therapy||
No thrombophilia with previous single episode episode of VTE associated with transient risk factor that was pregnancy- or estrogen-related / Prophylactic-dose LMWH or UFH|| / Postpartum anticoagulation therapy
No thrombophilia with previous single episode of VTE without an associated risk factor (idiopathic)—Not receiving long-termanticoagulation therapy / Prophylactic-dose LMWH or UFH|| / Postpartum anticoagulation therapy
Thrombophilia or no thrombophilia with two or more episodes of VTE—Not receiving long-term anticoagulation therapy / Prophylactic or therapeutic-dose LMWH
or
Prophylactic or therapeutic-dose UFH / Postpartum anticoagulation therapy
or
Therapeutic-dose LMWH/UFH for 6 weeks
Thrombophilia or no thrombophilia with two or more episodes of VTE—Receiving long-term anticoagulation therapy / Therapeutic-dose LMWH or UFH / Resumption of long-term anticoagulation therapy
Abbreviations: LMWH, low molecular weight heparin; UFH, unfractionated heparin; VTE, venous thromboembolism.
*Postpartum treatment levels should be greater or equal to antepartum treatment. Treatment of acute VTE and management of antiphospholipid syndrome are addressed in other Practice Bulletins.
†Low-risk thrombophilia: factor V Leiden heterozygous; prothrombin G20210A heterozygous; protein C or protein S deficiency.
‡First-degree relative with a history of a thrombotic episode before age 50 years, or other major thrombotic risk factors (eg, obesity, prolonged immobility).
§High-risk thrombophilia: antithrombin deficiency; double heterozygous for prothrombin G20210A mutation and factor V Leiden; factor V Leiden homozygous or prothrombin G20210A mutation homozygous.
||Surveillance without anticoagulation is supported as an alternative approach by some experts.

FORM 4-19523 REV. 07/2013 Reference Page Page 1 of 4

PLACE LABEL HERE

Postpartum Readmission

Orders

The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.

Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

PRN MEDICATIONS(See policy 520-06 for range orders and pain intensity guidelines)

  1. Breast feeding discomfort: Lanolin breast cream topically prn after breastfeeding
  2. Severe pain:  Toradol (ketorolac) 30 mg IV (or IM if no IV access) q 6 hrs prn (if patient weight <50 kg, give 15 mg)
  3. Moderate pain(select one):

Percocet (oxyCODONE/acetaminophen) 5/325 mg 1-2 tabs po or 10/325 mg 1 tab po q 4 hrs prn

OR  Norco (HYDROcodone/acetaminophen) 5/325 mg 1-2 tabs po or 10/325 mg 1 tab po q 4 hrs prn

OR  Other: ______

  1. Mild pain: Ibuprofen 600 mg po q 6 hrs prn. Hold if Toradol (ketorolac) is also ordered; may resume 6 hrs after Toradol (ketorolac) is discontinued.
25.Patient may self-medicate and keep these medications at bedside:
a.Episiotomy pain: Dermoplast (benzocaine) spray topically prn
b.Episiotomy or hemorrhoid discomfort/pain: Witch hazel pads topically with pericare prn
  1. Hemorrhoid discomfort/pain: Dibucaineointmenttopically with pericare prn
  1. Nausea:

Zofran (ondansetron) 4 mg IV or PO q 6 hrs prn

OR  Phenergan (promethazine) 12.5 - 25 mg PO or PR q 4 hrs prn. DC Zofran

OR  Other: ______. DC Zofran

  1. Sleep: Ambien (zolpidem) 5-10 mg po at bedtime prn. If 5 mg given, may repeat x 1 dose after 2 hrs
  2. Indigestion: Maalox XS (aluminum/magnesium/simethicone)30 ml po four times daily prn
  3. Constipation: Dulcolax (bisacodyl) 10 mg rectally prn. May repeat x 1 dose in 1 hr if no results
  4. Pruritis: Benadryl (diphenhydramine) 25-50 mg po q 4 hrs prn

Benadryl (diphenhydramine) 12.5-25 mg IV q 4 hrs prn

  1. Congestion: Saline nose spray q 2 hrs prn

SudafedPE (phenylephrine) 10 mg po q 4 hrs prn

 Mucinex (guaifenesin) 600 mg q 12 hrs prn

  1. Cough: Robitussin DM (guaifenesin/dextromethorphan) 10-20 ml po q 6 hrs prn.

Discontinue if Mucinex (guaifenesin) ordered

ADDITIONAL ORDERS:

______

______

______

______

DateTimePhysician SignaturePID Number

Send copy to pharmacy

FORM 4-19523 REV. 07/2013 Page 1 of 4

PLACE LABEL HERE

Postpartum Readmission

Orders

Reference Page

Recommended Thromboprophylaxis for Pregnancies Complicated by Inherited Thrombophilias*
Clinical Scenario / Antepartum Management / Postpartum Management
Low-risk thrombophilia† without previous VTE / Surveillance without anticoagulation therapy or prophylactic LMWH or UFH / Surveillance without anticoagulation therapy or postpartum anticoagulation therapy if the patient has additional risks factors‡
Low-risk thrombophilia† with a single previous episode of VTE—Not receiving long-term anticoagulation therapy / Prophylactic or intermediate-dose LMWH/UFH or surveillance without anticoagulation therapy / Postpartum anticoagulation therapy or intermediate-dose LMWH/UFH
High-risk thrombophilia§ without previous VTE / Prophylactic LMWH or UFH / Postpartum anticoagulation therapy
High-risk thrombophilia§ with a single previous episode of VTE—Not receiving long-term anticoagulation therapy / Prophylactic, intermediate-dose, or adjusted-dose LMWH/UFH regimen / Postpartum anticoagulation therapy or intermediate or adjusted-dose LMWH/UFH for 6 weeks (therapy level should be at least as high as antepartum treatment)
No thrombophilia with previous single episode of VTE associated with transient risk factor that is no longer present—Excludes pregnancy- or estrogen-related risk factor / Surveillance without anticoagulation therapy / Postpartum anticoagulation therapy||
No thrombophilia with previous single episode episode of VTE associated with transient risk factor that was pregnancy- or estrogen-related / Prophylactic-dose LMWH or UFH|| / Postpartum anticoagulation therapy
No thrombophilia with previous single episode of VTE without an associated risk factor (idiopathic)—Not receiving long-termanticoagulation therapy / Prophylactic-dose LMWH or UFH|| / Postpartum anticoagulation therapy
Thrombophilia or no thrombophilia with two or more episodes of VTE—Not receiving long-term anticoagulation therapy / Prophylactic or therapeutic-dose LMWH
or
Prophylactic or therapeutic-dose UFH / Postpartum anticoagulation therapy
or
Therapeutic-dose LMWH/UFH for 6 weeks
Thrombophilia or no thrombophilia with two or more episodes of VTE—Receiving long-term anticoagulation therapy / Therapeutic-dose LMWH or UFH / Resumption of long-term anticoagulation therapy
Abbreviations: LMWH, low molecular weight heparin; UFH, unfractionated heparin; VTE, venous thromboembolism.
*Postpartum treatment levels should be greater or equal to antepartum treatment. Treatment of acute VTE and management of antiphospholipid syndrome are addressed in other Practice Bulletins.
†Low-risk thrombophilia: factor V Leiden heterozygous; prothrombin G20210A heterozygous; protein C or protein S deficiency.
‡First-degree relative with a history of a thrombotic episode before age 50 years, or other major thrombotic risk factors (eg, obesity, prolonged immobility).
§High-risk thrombophilia: antithrombin deficiency; double heterozygous for prothrombin G20210A mutation and factor V Leiden; factor V Leiden homozygous or prothrombin G20210A mutation homozygous.
||Surveillance without anticoagulation is supported as an alternative approach by some experts.

FORM 4-19523 REV. 07/2013 Reference Page Page 1 of 4