Unique Plan Description: OB Misoprostol for Stillbirth
Plan Selection Display: OB Misoprostol for Stillbirth
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2011-11-26 14:37:47
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2021-12-21 10:23:41
Available at all facilities: Yes

OB Misoprostol for Stillbirth
Admit/Discharge/Transfer
	Admit to Inpatient Status
		T;N, Anticipated LOS 2 midnight or more
Vital Signs
	Vital Signs
		T;N, Q1H, 2, Dose(s)/Time(s)
			Comment: at time of Misoprostol
		T;N+120, Q4H
Activity
	Ambulate
		T;N+120
			Comment: patient may ambulate 2 hours after initial Misoprostol administration with continuous monitoring
	Bedrest
		T;N, Prone, 2, hr
			Comment: for 2 hours after Misoprostol administration.
Diet
	Regular Diet
		T;N+120
			Comment: as tolerated after Misoprostol Administration and/or no active labor.
	NPO
		T;N, After Midnight, NPO Except for: NPO Except For Ice
IV Solutions
	Lactated Ringers Injection
		1,000 mL, IV, L&D Rate
Medications
		Before 28 weeks of gestation with no uterine scar(NOTE)*
	Cytotec
		200 mcg, Tab, VAGINAL, Q6H
			Comment: oxytocin should not be administered for at least 4 hrs after last dose of Misoprostol
		200 mcg, Tab, VAGINAL, Q4H
			Comment: oxytocin should not be administered for at least 4 hrs after last dose of Misoprostol
		400 mcg, Tab, VAGINAL, Q6H
			Comment: oxytocin should not be administered for at least 4 hrs after last dose of Misoprostol
		400 mcg, Tab, VAGINAL, Q4H
			Comment: oxytocin should not be administered for at least 4 hrs after last dose of Misoprostol
		600 mcg, Tab, VAGINAL, Q6H
			Comment: oxytocin should not be administered for at least 4 hrs after last dose of Misoprostol
		600 mcg, Tab, VAGINAL, Q4H
			Comment: oxytocin should not be administered for at least 4 hrs after last dose of Misoprostol
		800 mcg, Tab, VAGINAL, Q6H
			Comment: oxytocin should not be administered for at least 4 hrs after last dose of Misoprostol
		800 mcg, Tab, VAGINAL, Q4H
			Comment: oxytocin should not be administered for at least 4 hrs after last dose of Misoprostol
		24-28 weeks of gestation with low transverse uterine scar(NOTE)*
		200 mcg, Tab, VAGINAL, Q6H
			Comment: oxytocin should not be administered for at least 4 hrs after last dose of Misoprostol
		After 28 weeks of gestation(NOTE)*
		50 mcg, Tab, VAGINAL, Q4H
			Comment: oxytocin should not be administered for at least 4 hrs after last dose of Misoprostol
		25 mcg, Tab, VAGINAL, Q4H
			Comment: oxytocin should not be administered for at least 4 hrs after last dose of Misoprostol
		100 mcg, Tab, By Mouth, Q4H
			Comment: oxytocin should not be administered for at least 4 hrs after last dose of Misoprostol
		50 mcg, Tab, By Mouth, Q4H
			Comment: oxytocin should not be administered for at least 4 hrs after last dose of Misoprostol
	butorphanol
		1 mg, Injection, IV Push, Q1H, PRN, pain-moderate, 2 Dose(s)/Time(s)
	fentaNYL
		50 mcg, Injection, IV Push, Q1H, PRN, pain-moderate, T;N, 1 Dose(s)/Time(s)
		100 mcg, Injection, IV Push, Q1H, PRN, pain-moderate, T;N, 1 Dose(s)/Time(s)
	Ambien
		5 mg, Tab, BY MOUTH, QHS, PRN, insomnia
Patient Care
	Resuscitation Status
		T;N, Full Code
		T;N, No Code
	Shower
		T;N, QHS, 1, Dose(s)/Time(s)
			Comment: with chlorhexidine gluconate
	External Toco Monitoring
		T;N
			Comment: CONTINUOUSLY, for greater than 20 weeks gestation after Misoprostol administration when uterine cont
	Assess for contraction duration, frequency, intensity
		T;N
			Comment: CONTINUOUSLY for < 20 wks gestation after Misoprotol administration when uterine contractions present.
	Notify MD
		T;N
			Comment: anesthesia to insert epidural, PRN
	Vaginal Exam
		T;N
			Comment: prior to administration of Misoprostol; HCP may administer Misoprostol if there are no more than 5 contractions in 30 minutes
Consults/Follow-up
	Consult Social Work
		T;N, Evaluation
			Comment: Stillborn
	Consult Chaplain
		T;N

Nausea Protocol EKM
Medications
	ondansetron
		4 mg, Injection, IV PUSH, Q24H, PRN for nausea and/or vomiting
			Comment: Administer for nausea if not previously administered by anesthesia, PACU, or ED and unable to take oral meds.
		4 mg, Injection, IV PUSH, Q6H, PRN for nausea and/or vomiting
			Comment: Administer for nausea if not previously administered by anesthesia, PACU, or ED and unable to take oral meds.
		4 mg, Tablet-Disintegrating, By Mouth, Q6H, PRN for nausea and/or vomiting
			Comment: Administer for nausea if not previously administered by anesthesia, PACU, or ED
		Select either promethazine or prochlorperazine orders:(NOTE)*
	prochlorperazine
		10 mg, Injection, IV PUSH, Q6H, PRN, nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures
		25 mg, Suppository, RECTALLY, BID, PRN, nausea
			Comment: Give if ondansetron ineffective and if no history of seizures, give if IV access not available
	Phenergan (JE)
		25 mg, Tab, By Mouth, BID, PRN, nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures
		25 mg, Suppository, RECTALLY, BID, PRN, nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures, give if IV access not available
	Phenergan (MH/WH)
		25 mg, Tab, By Mouth, BID, PRN, nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures; give if unable to take oral meds.
		25 mg, Suppository, RECTALLY, BID, PRN, nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures; give if unable to take oral meds.
		6.25 mg, Injection, IM-Intramuscular, Q6H, PRN for nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures; give if unable to take oral meds
	Phenergan (FH)
		25 mg, Tab, By Mouth, BID, PRN for nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures; give if unable to take oral meds.
		25 mg, Suppository, RECTALLY, BID, PRN for nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures; give if unable to take oral meds.
		12 mg, INT, IVPB, Q6H, PRN for nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures; give if unable to take oral meds.
	Benadryl
		12.5 mg, Injection, IV PUSH, Q6H, PRN, nausea and/or vomiting
			Comment: Give if ondansetron and phenothiazine ineffective
	Ativan
		1 mg, Tab, BY MOUTH, Q8H, PRN, nausea and/or vomiting
			Comment: Give if ondansetron, phenothiazine, or other anti-nausea medications ineffective
		1 mg, Injection, IV PUSH, Q8H, PRN, nausea and/or vomiting
			Comment: Give if ondansetron, phenothiazine, or other anti-nausea medications ineffective
	Reglan
		10 mg, Injection, IV PUSH, Q6H, PRN, nausea and/or vomiting
			Comment: Give if ondansetron, phenothiazine, or other anti-nausea medications ineffective; avoid in patients > 65yo
		10 mg, Injection, IM-Intramuscular, Q6H, PRN, nausea and/or vomiting
			Comment: Give if ondansetron, phenothiazine, or other anti-nausea medications ineffective; avoid in patients > 65yo

OB Oxytocin Protocol EKM
IV Solutions
	Pitocin 30 units/lactated ringers 500 mL Premix IV
		30 units, EVERY BAG, 1 milliunits/min
		500 mL, IV, Routine, T;N
			Comment: (MJE/MWH) Start at 1milliunit/min and may increase by 1milliunit/min at a minimum interval of every 15 minutes
		30 units, EVERY BAG, 1 milliunits/min
		500 mL, IV, Routine, T;N
			Comment: (FH) Start at 1milliunit/min and may increase by 1milliunit/min at a minimum interval of every 30 minutes
Patient Care
	Oxytocin Protocol
		T;N
			Comment: 1. Titrate oxytocin according to maternal and fetal response, labor progress, and the "Oxytocin in Use" checklist. Components of the “Oxytocin In Use” Checklist include the following: 	• Fetal Assessment parameters		o At least one acceleration of 15 bpm x 15 seconds in 30 minutes or minimal to moderate variability for 10 of the previous 30 minutes.		o No more than one late deceleration occurred.		o No more than two variable decelerations exceeding 60 seconds in duration and decreasing greater than 60 bpm from the baseline within the previous 30 minutes. 		o Absence of prolonged decelerations(s).	• Uterine Contraction Assessment parameters		o No more than 5 uterine contractions in 10 minutes for any 30 minute interval.		o No more than one contraction lasting greater than 120 seconds duration.		o Uterus palpates soft between contractions. 		o If IUPC is in place, MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg.2.  If adequate progress of labor cannot be determined by external monitors, notify healthcare provider for specific order for internal pressure catheter. 3.  If dilation is 5-6cm with adequate labor progress, oxytocin may be decreased in increments of 1 milliunit/minute. 4.  If the oxytocin infusion has been discontinued for less than 30 minutes and when fetal and uterine assessment parameters have been met, per the “Oxytocin In Use” Checklist components, oxytocin may be restarted at not more than one-half of the rate at which it was discontinued and then increased by 1 milliunit/minute at a minimum of every 15 minutes. 5.  If the oxytocin infusion has been discontinued for more than 30 minutes, and when fetal & uterine assessment parameters have been met, per the “Oxytocin In Use” Checklist components, oxytocin may be restarted at 1 milliunit/minute and then increased by 1 milliunit/minute at a minimum of every 15 minutes. 6.  Once oxytocin is at 20 milliunits/minute and contraction pattern fails to result in cervical effacement and dilation, a nurse should call the healthcare provider for specific orders for oxytocin.7.  When there is a Category II tracing, the following interventions may be considered: decrease or discontinue oxytocin, reposition patient, administer oxygen, assess hydration status, and consider IV bolus and notify the healthcare provider.  If no resolution and uterine tachysystole is present or the need to reduce uterine contraction activity is present, the RN will consider Terbutaline administration per order in the Oxytocin Power Plan. 8.  When there is a Category III tracing, the following interventions are recommended:  discontinue oxytocin, reposition patient, administer oxygen, consider IV bolus, and notify the healthcare provider for prompt evaluation / delivery.  If no resolution and if uterine tachysystole is present, the RN will consider Terbutaline administration per order in the Oxytocin Power Plan.

*Report Legend:
DEF - This order sentence is the default for the selected order
GOAL - This component is a goal
IND - This component is an indicator
INT - This component is an intervention
IVS - This component is an IV Set
NOTE - This component is a note
Rx - This component is a prescription
SUB - This component is a sub phase