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
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.
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 Recommended laboratory tests
in the initial prenatal care visit
1. Hct, Hb
2. U/A,U/C
3. BG,Rh
4. Pap smear
5. Antibody screen
6. Rubella status
7. Syphilis screen
8. Hbs Ag
9. 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 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
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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 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
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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 ,

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 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>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.

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Glasgow Coma Scale

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Eye 3 2 1
Opening 4 To Voice To Pain Nil
Spontaneous

Verbal 4 3 2 1
Response 5 Confused Words Groans Nil
Orientated

Motor 5 4 3 2 1
Response 6 Localizes Withdraws Flex Ext Nil
Obeys Pain from Pain
Commands
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 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 Loss
Volume (mls) in 750mls 800 - 1500mls 1500 - 2000mls >2000mls
adult

Blood Loss
% Circ. blood <15% 15 - 30% 30 - 40% >40%
volume

Systolic Blood 
No change Normal Reduced Very low
Pressure

Diastolic Blood  Very low /

No change Raised Reduced
Pressure Unrecordable

Slight tachy-
Pulse (beats /min) 100 - 120 120 (thready) >120 (very thready)
cardia

Capillary Refill Normal Slow (>2s) Slow (>2s) Undetectable

Respiratory Rate Normal Normal Raised (>20/min) Raised (>20/min)

Urine Flow med-ed-online 2008

>30 20 - 30 10 - 20 0 - 10
(mls/hr)
Estimated 
Suitable fluid regimes
blood loss

o
1000 mls 3000 mls crystalloid 1000 mls colloid
r

1500 mls crystalloid & 1000mls o

1500 mls 4500 mls crystalloid
colloid r

1000 mls crystalloid, 1000mls colloid o 3000 mls crystalloid & 2

2000 mls
& 2 units blood r units blood
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Infection Suggested oral adult  Price
dose

Acute cystitis Trimethoprim 200 mg TRIMETHOPRIM

bd or Augmentin 625 100MG TAB= 66 Rls.
mg tid or CO-AMOXICLAV 625
Nitrofurantoin 50 mg (500/125) TAB = 2,970
qid Rls.
Nalidixic acid 500 mg NITROFURANTOIN
qid 100MG TAB
= 57 Rls.

Acute Ciprofloxacin 750 mg CIPROFLOXACIN-

pyelonephritis bd EXIR® 250MG TAB =
(pre- hospital 350 Rls.
admission)
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 PE

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 Is PaCO2 increased?

Is PAO2-PaO2
Yes=hypoventilation
increased?

If yes then find out

Is PAo2-PaO2 if low PO2 is correctable with
Decreased
increased? O2?
inspired PO2

Hypoventilation Yes=hypoventilation
Yes=V/Q mismatch Shunt
alone +another mechanism
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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 Change Rate of

Hold Infusion
Dose Infusion

units minutes ml/h (units/h)

+2 cc/h
50 - 59 0 0 6h
(+80 u/h)

60 - 85 0 0 no change next am

-2 cc/h
86 - 110 0 0 next am
(- 80 u/h)

+4 cc/h
< 50 5000 0 6h
(+160 u/h)

-4 cc/h
>110 0 60 2008
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(- 160 u/h)
IMP:PLP before 37 weeks out patient:
(contractions 4 in 20 min or 8 in 60 min +progressive change in cervix
cervical dilation of more than one
cervical effacement of more than 80 % or greater)

if:
Check of contractions:+
U/A, U/C: -
Fern:-
Then: Hydrate and sedate

Stop of contractions: discharge

Contractions persist: hospitalize
With:isoxsuprine 10 mg TDS for
Next slide
10 days
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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 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

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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

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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

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Abortion without fever:

Doxy 100 mg bid

or
tetracycline 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 h
A-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 laparascopy
C-If a dead IP and EP is confirmed (beta HCG more than
2000 and mass < 3.5 cm) then MTX
FETUS 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

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 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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