Patient Name

Date of Birth Admission/Visit Date Site

Medical Record Number Financial NumberPOSTPARTUM

VAGINAL DELIVERY ORDERS 1 of 4 Patient ID Area

ORDERS

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KH00165 Rev. 01/09/12

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Initials

9 BREAST FEEDING 9 BOTTLE FEEDING

TRANSFER TO MOTHER/BABY UNIT (MBU) WHEN RECOVERY CRITERIA MET

()Check,circleand/orfillinallorderstobeimplementedasappropriate.

1.NEONATALRESUSCITATION 9 Requested Advanced Skills Neonatal Resuscitation at Delivery

2.EPIDURALCATHETER 9 RN may remove epidural catheter

3.VITALSIGNSANDASSESSMENT 9 Monitor vital signs every 15 minutes x 2 hours or as needed until transfer. Transfer if stable. Obtain vital signs

and complete assessment upon admission to MBU and every 4 hours x 24 hours, then every 8 hours while awake and as needed until discharge.

9 Other:

4. DIET 9 Regular as tolerated

9 Other:

5. ACTIVITY 9 Bathroom with assistance until motor/neuro stability, then activity as tolerated. 9 May Shower

9 Other:

6. URINARYBLADDERCATHETERIZATION 9 Catheterize as needed x 1 during recovery period

9 Catheterize as needed postpartum if unable to void by 8 hours post delivery/post removal of indwelling urinary catheter

7. LABS 9 Complete Blood Count (CBC) first postpartum day

9 Other:

8. TREATMENTSASNEEDED 9 Ice to perineum as needed first 24 hours 9 Warm water sitz bath after 24 hours every 4 hours as needed

9 Other:

9. MEDICATIONS A.EXISTINGMEDICATIONS: RefertoPowerchartmedicationHistory

9 Actual 9 Estimated Weight kg 9 Actual

9 Estimated Height cm ALLERGIES: REFER TO ALLERGY PROFILE/ POWERCHART

Patient Name

Date of Birth Admission/Visit Date Site

Medical Record Number Financial NumberPOSTPARTUM

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KH00165 Rev. 01/09/12

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copy being scanned

Initials

()Check,circleand/orfillinallorderstobeimplementedasappropriate.

B.IMMEDIATEPOSTPARTUMMEDICATIONSONLABOR&DELIVERY

PainMedication 9 Ibuprofen 600 mg by mouth with food or milk as needed x 1 dose (moderate) 9 Ibuprofen 800 mg by mouth with food or milk as needed x 1 dose (severe)

Other Pain Medication dose route interval

NauseaMedication 9 Metoclopramide (Reglan) 10 mg intravenous every 6 hours as needed 9 Metoclopramide (Reglan) 10 mg by mouth every 6 hours as needed 9 Ondansetron (Zofran) 4 mg intravenous every 6 hours as needed

RhImmuneGlobulin(RhIg)Prophylaxis 9 Fetal Screen if Rh negative 9 Administer one vial RhIg intramuscular if indicated per protocol

RubellaVaccine 9 Rubella Non-immune: Administer Rubella vaccine 0.5 mL subcutaneous prior to discharge

Intravenous/UterineBleedingProphylaxis 9 Methylergonovine (Methergine) 0.2 mg intramuscular every 6 hours as needed x dose(s) Hold if blood pressure is greater than mmHg 9 Methylergonovine (Methergine) 0.2 mg by mouth every 6 hours as needed x dose(s) Hold if blood pressure is greater than mmHg 9 Oxytocin 20 units/1,000 mL Lactated Ringers x liters. Infuse mL at mL/hour 9 Discontinue intravenous or convert to intermittent infusion device prior to transfer if lochia is within normal limits and no further orders for intravenous medications.

SleepMedication dose route interval

InfectionMedication dose route interval

OtherMedication dose route interval indication

a.

b.

c.

d.

e.

Patient Name

Date of Birth Admission/Visit Date Site

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KH00165 Rev. 01/09/12

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copy being scanned

()Check,circleand/orfillinallorderstobeimplementedasappropriate. C.MEDICATIONSFORSELFADMINISTRATION(SAMS) 9Patientreceivesallmedicationsbelow:

• Docusate Sodium with Senna (Pericolace/Senokot-S) 2 capsules/tablets by mouth every evening as needed for constipation

• Benzocaine (Americaine) spray to perineum every 6 hours as needed for pain• Witch hazel pads on episiotomy or hemorrhoids every 6 hours as needed for pain• Hydrocortisone 1% ointment topically 3 to 4 times daily as needed for pain• Ibuprofen 400 mg by mouth with food or milk every 6 hours as needed for mild pain• Ibuprofen 600 mg by mouth with food or milk every 6 hours as needed for moderate pain• Ibuprofen 800 mg by mouth with food or milk every 6 hours as needed for severe pain* Ibuprofen dosage should not exceed 3200 mg in a 24 hour period* Replace Ibuprofen with Acetaminophen 325 mg 3 tabs (975 mg) orally every 4 hours as needed for pain in

NSAID/Aspirin sensitive patients (not to exceed 4 doses in 24 hours)

D.DEEPVEINTHROMBOSIS(DVT)PROPHYLAXIS(RiskAssessmentonBack) REQUIRED to () check all that apply: 9 Heparin 5000 units subcutaneous every 8 hours 9 Pneumatic Compression Device (PCD) for KneeHigh/CalfPump 9 Other Orders: 9 DVT Prophylaxis not indicated/contraindicated (Reason):

E.IMMUNIZATIONS

Offer Tdap vaccine (tetanus diphtheria pertussis) 0.5 mL intramuscular x 1 for prophylaxis (contraindicated in patients who have previously received the Tdap vaccine)

Per New York State Department of Health (NYS DOH) Mandatory Immunization Program and Kaleida Policy CL.6, administer vaccine(s) if patient meets criteria.

• PneumococcalVaccine0.5mLintramuscularx1forprophylaxis If contraindicated please () check one of the NYS DOH acceptable contraindications below: 9 Allergy to pneumococcal vaccine 9 Previously immunized Date:

• InfluenzaVaccine0.5mLintramuscularx1forprophylaxis(September1-April1) If contraindicated please () check one of the NYS DOH acceptable contraindications below: 9 Allergy to influenza vaccine 9 Vaccinated this flu season Date:

10.ADDITIONALORDERS

NURS

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9 TORB From: Date: Time: Signature: ORDERS NOTED BY RN Date: Time: Signature:

PROV

IDER

Date: Time:

Print Name/Stamp:

Signature: TORB = Telephone Orders Read Back

Patient Name

Date of Birth Admission/Visit Date Site

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KH00165 Rev. 01/09/12

DEEP VEIN THROMBOSIS (DVT) PROPHYLAXIS RISK ASSESSMENTRISK FACTORS

AGE points IMMOBILITY points SURGERY pointsgreater than 60 years 2 Coma 2 Hip/Pelvic/Long Bone Fracture 541 - 60 years 1 Patient confined to bed greater than 72 hours 2 Multiple Trauma 5

Laparoscopic/Pelvic Surgery 2Recent uninterrupted travel greater than 4 hours 1 Major Surgery greater than 45 minute duration 2

PRE-EXISTING/CURRENT MEDICAL CONDITIONSpoints points

Ischemic Stroke/Paralysis 5 Current Heart Failure/ Myocardial Infarction 1Previous DVT or Pulmonary Embolism (PE) 3 Obesity (greater than 20% Ideal Body Weight [IBW]) 1Hypercoagulation State* 3 Pregnancy/Postpartum less than 1 month 1Cancer 2 Severe Dehydration 1

Central Venous Catheter greater than 1 week (excludes Renal Access) 2 Nephrotic syndrome 1Varicose Veins/Vein Surgery/Phlebitis 1

Infection (severe/sepsis) 1 Inflammatory Bowel Disease 1Chronic Obstructive Pulmonary Disease (COPD)/Respiratory Distress/Steroid or Oxygen Dependent 1 Chemotherapy 1

Estrogen Use (oral contraceptives, hormone replacement therapy [HRT]) 1 Family Medical History unexplained DVT 1* Examples of Hypercoagulation State: • Protein C or S deficiency • Antithrombin III deficiency • Lupus Anticoagulant • Homocysteinemia

LOW RISK (Score of 1 or less) MODERATE TO HIGH RISK* (Score of 2 - 4) HIGHEST RISK/MULTI MODAL* (Score of 5 or higher)No prophylaxis Ambulate Heparin 5000 units subcutaneous every 8 hours -OR- PCD Heparin 5000 units subcutaneous every 8 hours -AND- PCD

* Recommendations apply to general medical and surgical patients. Please see below for additional recommendations for specific patient populations.ALTERNATIVE RECOMMENDATIONS FOR SPECIFIC PATIENT POPULATIONS

Neurosurgery Orthopaedic Surgery Trauma/Spinal Cord Injury

Coronary Artery Bypass Surgery

Bariatric Surgery

High Risk Bleeding

History of Heparin-induced Thrombocytopenia

Heparin 5000 units subcutaneous every 8

hours-AND-

Pneumatic CompressionDevice (PCD)

See form KH00202 “Total Knee/Hip

Arthroplasty Post-Operative Orders”

Enoxaparin 30 mg subcutaneous every 12

hours -AND-

Pneumatic CompressionDevice (PCD)

Enoxaparin 40 mg subcutaneous daily (Enoxaparin 30 mg

subcutaneous daily if Creatinine Clearance [CrCl]

less than 30 mL/minute)

Enoxaparin 40 mg

subcutaneous every 12 hours

(any population with moderate to high venous thromboembolism [VTE]

risk) Pneumatic

Compression Device (PCD)

Fondaparinux 2.5 mg subcutaneous daily

(Contraindicated if Creatinine Clearance [CrCl]

less than 30 mL/minute)

Consider platelet monitoring for prolonged anticoagulationReferences:Modified From: Motyke, GD, Zebal, LP and Caprini, et al. A Guide to Venous Thromboembolism Risk Factor Assessment. Journal of Thrombosis and Thrombolysis, 2000.Geerts W, Bergqvist D, Pineo G et al. Prevention of Venous Thromboembolism. Chest 2008; 133: 381S-453S

IMMUNIZATIONNEW YORK STATE DEPARTMENT OF HEALTH LAW SECTION 2805-8, CHAPTER 443: • Every in-patient must be assessed for pneumococcal and influenza vaccine need • Appropriate vaccines must be administered • Standing Physician Order for all in-patients, signed by Dr. Margaret Paroski, EVP CMO • Additional physician order is not requiredCRITERIAINDICATIONS for BOTH PNEUMOVAX and INFLUENZA: • Age 65 or greater • Age greater than 18 with chronic illnesses such as diabetes, asthma, emphysema, pneumonia, congestive heart failure, coronary artery disease, chronic renal failure,

immunosuppression • If previous vaccination unknown, and criteria met, revaccinate • NO VACCINATION INDICATED if patient is between 18 and 65 years old, without chronic illnessCONTRAINDICATIONS:

PNEUMOVAX(must be administered year round)

• Received pneumococcal vaccine at age 65 or greater.If date unknown, revaccinate

• Received pneumococcal vaccine at age 65 or less, wait 5 years to revaccinate. If date unknown, revaccinate.

• Previous severe reaction to pneumococcal vaccine (urticaria, laryngeal edema,anaphylaxis)

INFLUENZA(Flu season is September 1 - April 1, as vaccine available from pharmacy)

• Received vaccine earlier THIS flu season. If unknown, revaccinate• History of allergic reaction to eggs or contact lens solution (Thimerosal - preservative in

solution)• Previous severe reaction to influenza vaccine (urticaria, laryngeal edema, anaphylaxis)

CONSENTS:PNEUMOVAX

(must be administered year round)Patient read Vaccine Information Sheet (KH01159)• Patient consented - patient/ health care proxy signed Vaccine Information Sheet. Form

scanned to pharmacy for vaccine dispensing.• Patient refused and reason stated

INFLUENZA(Flu season is September 1 - April 1, as vaccine available from pharmacy)

Patient read Vaccine Information Sheet (KH01160)• Patient consented - patient/ health care proxy signed Vaccine Information Sheet. Form

scanned to pharmacy for vaccine dispensing.• Patient refused and reason stated