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*** UNCHECKED BOXES AND LINED THRU ORDERS ARE NOT APPLICABLE |
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| ALLERGIES: | |
| ADMITTING DIAGNOSIS: | Fetal
Demise Intrauterine Pregnancy |
| ADMIT TO: | [ ] Antepartum [ ] Labor and Delivery |
| ACTIVITY: | Bedrest
with bathroom privileges [ ]Other:__________________________________________________________________ |
| MONITORING: | Vital signs per
routine Tocodynamometer |
| LABS: |
Maternal Blood: |
| RADIOLOGY: | [ ] OB
Ultrasound [ ] MRI whole infant body after delivery [ ] AP plain radiograph of the whole infant body |
| IV THERAPY: | [ ]
Saline lock [ ] D5LR TRA 125 cc/hr [ ] Other_____________________ |
| MEDICATIONS: |
Rhogam if Rh negative
Informed Consent to include possible uterine rupture if undergoing induction. [ ] Pitocin per protocol. If < 28 weeks [ ] Misoprostol 400 mcg intravaginally q 4 hours X 48 hours. Hold misoprostol if patient develops active labor. [ ] Prostin E2 suppository 20 )mg q 4 hours . Hold Prostin if patient develops active labor 20 units pitocin to be added per liter IVF X 1 L,then heplock. [ ] Pitocin 30 units in 1 L TRA 150 cc/hour If the > 28 weeks [ ] Misoprostol 25 micrograms intravaginally q 4 hours for a maximum of 6 doses. Hold misoprostol if patient develops active labor . [ ] After passage of fetus start IV infusion of 30 units pitocin in 1 L D5 LR TRA 125cc/h [ ] Demerol 75-125 mg IM with Vistaril 50 mg q 3 hours PRN pain [ ] Morphine sulfate 8 mg IVP q 3 hours PRN pain [ ] Compazine 10 mg IM q 6 hours [ ] Lomotil 2 tabs PO q 6 hours [ ] Tylenol 650 mg PO/PR q 4 hours PRN fever > 100.4 o [ ] MOM 30 cc PO Q 12 hr prn constipation. [ ] Maalox 30 cc PO Q 4 hr prn indigestion. [ ] Benadryl 50 mg PO @ bedtime prn insomnia. Other_________________________________________ |
| DIET: | [
] NPO [ ] Clear liquid diet [ ]Regular diet [ ] Other: ______________________________________________________________ |
| CALL PHYSICIAN FOR COMPLAINTS OF: | |
| Respiratory rate less than 12
or greater than 25 per minute Temperature >100.4 °F Chest pain 02 Sat less than 90% on room air Decreased loss of consciousness Respiratory distress |
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| OTHER |
Grief Management protocol
[ ] If complete abortion has not occurred within 1 hour of expulsion of the fetus, the patient will be taken to the Operating Room for curettage. [ ] Delivery pack at bedside with pathology container. [ ] Placenta to pathology. [ ] Consent for tissue samples [ ] Fascia lata to pathology [ ] Consent for autopsy. [ ] Consent for photographs |
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Date:____________ Time:_____________ Physician Signature:_________________________
[ ] RBO Date:____________ Time:_____________ Noted: _______________________________________ |
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| PATIENT I.D. LABEL |
FETAL DEMISE PHYSICIAN ORDERS |
1. Froen JF, Arnestad M, Frey K, Vege A, Saugstad OD, Stray-Pedersen B. Risk factors for sudden intrauterine unexplained death: epidemiologic characteristics of singleton cases in Oslo, Norway, 1986-1995. Am J Obstet Gynecol 2001 Mar;184:694-702 2. ACOG: Diagnosis and management of fetal death. ACOG Technical Bulletin Number 176-January 1993. Int J Gynaecol Obstet 1993; 42: 291-9 3. ACOG: Induction of labor. ACOG Practice Bulletin Number 10-November 1999. 4. Jain JK, Mishell DR. A comparison of intravaginal misoprostol with prostaglandin E2 for termination of second trimester pregnancy. N Engl J Med 1994;331:290-3. 5. Bugalho A, Bique C, Machungo F, Bergstrom S. Vaginal misoprostol as an alternative to oxytocin for induction of labor in women with late fetal death. Acta Obstet Gynecol Scand 1995 ; 74: 194-8. 6. Dickinson JD, Evans SF. The optimization of intravaginal misoprostol schedules in second trimester pregnancy termination. Am J Obstet Gynecol 2002; 186 : 470-4. 7. le Roux PA, Pahal GS, Hoffman L, Nooh R, El-Refaey H, Rodeck CH. Second trimester termination of pregnancy for fetal anomaly or death: comparing mifepristone/misoprostol to gemeprost. Eur J Obstet Gynecol Reprod Biol. 2001 ;95:52-4. PMID: 11267720 8. Chapman SJ, Crispens M, Owen J, Savage K.Complications of midtrimester pregnancy termination: the effect of prior cesarean delivery. Am J Obstet Gynecol. 1996;175:889-92.PMID: 8885742 9. Levrant SG, Wingate M. Midtrimester uterine rupture. A case report. J Reprod Med. 1996;41:186-90. PMID: 8778419 10. PROSTIN E2 ® Vaginal Suppository package insert, 2002 11. Oron T, Sheiner E, Shoham-Vardi I, Mazor M, Katz M, Hallak M. Risk factors for antepartum fetal death. J Reprod Med. 2001 Sep;46(9):825-30. PMID: 11584485 12. Nayki U, Taner CE, et al. Uterine rupture during second trimester abortion with misoprostol.Fetal Diagn Ther. 2005 Sep-Oct;20(5):469-71.PMID: 16113576 13. ACOG: ACOG committee opinion. Genetic evaluation of stillbirths and neonatal deaths. Number 178, November 1996. Committee on Genetics. American College of Obstetricians and Gynecologists. Int J Gynaecol Obstet 1997 Mar; 56(3): 287-9