| 1. Allergies: | |
| 2. Admit or OBS to: | [ ] Antepartum [ ] Labor and Delivery |
| 3. Admitting Diagnoses: | Fetal demise |
| 4. Secondary Diagnoses | |
| 5. Condition: | [ ] Stable [ ] Fair [ ] Serious [ ] Critical |
| 6. VS: | [ ] Per routine [ ] Every 4 hours |
| 7. Fetal Monitoring | [ ] Tocodynamometer |
| 8. Activity: | [ ] Bedrest with bathroom privileges |
| 9. Nursing: [ ] | Grief Management protocol |
| 10. Diet: | [ ] NPO [ ] Clear liquids [ ] Regular diet [ ] Other______________________ |
| 11. IV: | [ ] Heplock [ ] D5LR TRA 125 cc/hr [ ] Other_____________________ |
| 12. Labs: | Maternal Blood: |
|
[X]Random glucose, CBC with platelet count, PT, PTT,
fibrinogen, antibody screen,
VDRL, Kleihauer-Betke, urine toxicology screen. [ ] Thyroid function testing [ ] CMV titer (IgM and IgG) [ ] Parvovirus antibody [ ] Lupus anticoagulant and anticardiolipin antibody [ ] Factor V Leiden mutation [ ] Antithrombin III [ ] Protein C and Protein S [ ] Serum creatinine [ ] Liver function tests [ ] Viral cultures [ ] Bacterial cultures (Alert the lab that Campylobacter and Listeria are in the differential) [ ] Other _____________________ |
|
| Fetal Blood | |
|
[ ] Cytogenetics (1-10 ml in green top tube)
[ ] Bacterial culture at least 1 ml [ ] Serology (PCR if available) for STORCH (syphilis, toxoplasma, other (e.g. parvovirus), rubella, CMV, HSV) [ ] CBC |
|
| 13. Meds: | [X]Rhogam if Rh negative |
| 15. Other: |
[ ] If complete abortion has not occurred within 1 hour of
expulsion of the fetus, the patient will be taken to the OR 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 [ ] MRI fetus [ ] AP plain radiograph of the whole infant's body |