Sample Obstetrics Orders By:Mitra Ahmad Soltani :med-ed-online 2008 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.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.


Recommended laboratory tests in the initial prenatal care visit :med-ed-online 2008 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


Impression: normal labor :med-ed-online 2008 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


Impression: NVD+Epi :med-ed-online 2008 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


7 contraindications for lactation :med-ed-online 2008 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)


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


IMP:Mastitis (out patient) :med-ed-online 2008 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


Postoperative infection :med-ed-online 2008 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


Imp:chorioamnionitis :med-ed-online 2008 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


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


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


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


Low output cardiogenic shock-4 :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


Glasgow Coma Scale :med-ed-online 2008 Glasgow Coma Scale


Slide 16:med-ed-online 2008


IMP: R/O abruption :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


Slide 18:med-ed-online 2008


Slide 19:med-ed-online 2008


Slide 20:med-ed-online 2008


PE :med-ed-online 2008 PE


Slide 22:med-ed-online 2008


ABG reading :ABG reading med-ed-online 2008


Slide 24:med-ed-online 2008


Slide 25:med-ed-online 2008


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


Slide 27:med-ed-online 2008


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 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)


IMP:PLP before 37 weeks, hospitalized :med-ed-online 2008 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


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


Contraindication for beta mimetics :med-ed-online 2008 Contraindication for beta mimetics Maternal cardiac disease Diabetes Thyrotoxicosis HTN


Contraindication for MgSO4 :med-ed-online 2008 Contraindication for MgSO4 Hypocalcemia Myasthenia gravis Renal failure


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


Dosage of Ritodrine or Terbutaline for tocolysis :med-ed-online 2008 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


Endocarditis Prophylaxis :med-ed-online 2008 Endocarditis Prophylaxis


Slide 36:med-ed-online 2008


IMP: Hyperemesis Gravidarum :med-ed-online 2008 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


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


Suspecting Chronic Hepatitis :med-ed-online 2008 Suspecting Chronic Hepatitis HBe Ag, Ab HBS Ag ,Ab Anti HCV


IMP: Pyelonephritis :med-ed-online 2008 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


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


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


IMP: Diabetes :med-ed-online 2008 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


Slide 44:med-ed-online 2008 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


IMP: mild preeclampsia :med-ed-online 2008 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


IMP: Severe preeclampsia :med-ed-online 2008 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,


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


The night before elective C/S :med-ed-online 2008 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


8 hours after C/S :med-ed-online 2008 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


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


36-48 hours after C/S :med-ed-online 2008 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)


Diabetic C/S :med-ed-online 2008 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 :Asthma management med-ed-online 2008


Slide 54:med-ed-online 2008


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: :med-ed-online 2008 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


Prolonged spotting in a 14 year old anemic girl :med-ed-online 2008 Prolonged spotting in a 14 year old anemic girl Low dose OCP 21 days for 3-6 cycles


DUB in a 16 year old girl with stable vital signs: :med-ed-online 2008 DUB in a 16 year old girl with stable vital signs: Monophasic OCP q6h for 7 days + Iron supplements


Recurrent abortion tests :med-ed-online 2008 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 :Abortion without fever: Doxy 100 mg bidortetracycline 250 mg qid for 5-7 days med-ed-online 2008


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 :med-ed-online 2008 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


Indication of MTX for EP :med-ed-online 2008 Indication of MTX for EP Hemodynamic stability No intra uterine pregnancy Max sac diameter not equal or more than 4 cm


EP :EP Adenexal mass MTX adenexal mass=> 3.5 cm -> laparascopy uncertain US + beta HCG increase less than 50% -> D&C unstable conditions->laparatomy med-ed-online 2008