post partum hemorrhage medications

[LnDPPRN]

Something has been bugging me.

I've been working in Post Partum. I have orders for all kinds of PRN meds for pain, heart burn, itching, constipation, etc. One thing that I rarely see ordered PRN is utero-tonic medications such as pitocin, cytotec, methergine, or hemabate. Yes, I know not all hemorrhages are the result of a boggy uterus, but it would be nice to have these PRN if that's what my assessment tells me. Of course, if I had to give any utero-tonic, I would tell the OB immediately. And hopefully whatever utero-tonic is ordered PRN is not contraindicated. (In other words, the doctor customized the orders to the individual patient, which I find rarely happens, but I digress.)

The lack of PRN orders has been bugging me because I have worked at other facilities and, even though they didn't have PRN utero-tonics either, there was either a resident, OB hospitalist, or on call obstetrician you could grab for an order if you couldn't get a hold of the patient's doctor in a timely manner. The facility I currently work for has no OB hospitalist. Obstetricians come and go all day, but no one has to physically be there at all times. In fact, I've heard L/D call overhead more than once "Any OB to L/D STAT" they've been THAT desperate sometimes.

Therefore, I have this concern that if my patient hemorrhaged (despite all my other interventions such as emptying the bladder, fundal massage, etc.) and the doctor doesn't call me back very quickly (which they generally do, but it can be 10-15 minutes sometimes), she may lose an unnecessary amount of blood while waiting for a medication order.

I read the policy on postpartum hemorrhages. It says I can "increase IV oxytocin rate and infuse 500ml bolus" before calling the doctor, but it is already discontinued by the time she gets to me so that doesn't help me at all. Me bolusing pitocin would be in addition to what was administered previously, which, to me, is technically another dose and another order. As for the other utero-tonics, it says "If uterus remains atonic to oxytocin infusion, give another utero-tonic medication per physician order." In other words, I have no standing orders to back me up.

So then, I asked the manager my concern about not getting a utero-tonic order quickly enough. (As I can't prescribe, right?) She advised me to grab ANY OB doctor. If I can't get an OB, what about anesthesia? She didn't think the anesthesiologist would give me an order as it is not his/her specialty (he/she has to be physically be there at all times so I thought he/she would be a possibility). She said that if all else failed, I could call the ED doctor. (Oh yeah, he or she will drop what they're doing and help me with a patient he/she doesn't know, and by the time I summon him/her, I've already wasted time trying to get an OB. And I doubt he/she will give me a telephone order without laying eyes on her first, wasting more time. A Rapid Response Code won't get the ED doctor to my floor, but a Code Blue will. I suppose I could STAT page the ED doctor overhead if all else failed, but again, what a waste of time).

She also said that a L/D nurse can be summoned to start pitocin IV without first obtaining an order, because a L/D RN has a "wider scope of practice" (according to who?). I asked my manager if that was written in any policy, because I couldn't find it. (I should be able to access ANY policy, right? Surely she doesn't have some secret book of super policies that us staff nurses can't readily obtain.) She said she would find the policy where it says that for me. When I followed up a week later, she said she was too busy to find it, but assured me a L/D RN could start pitocin for me in a pinch. Based on her tone, I don't think the manager is invested in helping me research this to the end if I ask her again.

I'm not satisfied with where this stands right now. Any advice?

[klone, MSN, RN]

No, L&D nurses do not have a greater scope of practice. I have never seen PPH meds as a PRN standing order. If a woman starts to hemorrhage, there is a physician there to assess and order whatever is needed.

[cayenne06, MSN, CNM]

We have PO methergine as a standing order at the hospital I work at as an RN. As a midwife, I've written orders for prn methergine (I want to abbreviate that to meth so badly lol!) for a pt with a PPH and/or a persistently boggy uterus. Of course I expect to be called if it is given (and I call the doc if I give it as an RN), but yeah I agree that it's nice to have a uterotonic on hand when needed.

I'm not a big fan of pitocin for managing a persistently boggy uterus after PP recovery. Sustained contraction is what's needed, and methergine is my go-to (unless contraindicated of course). As an RN, I'd have no problem asking the provider for a prn uterotonic for an at risk patient, and also an order to maintain the saline lock. That is how I would address this issue in your situation, if the unit is not able/willing to provide it as a standing order.

[queenanneslace, ADN, MSN, APRN, CNM]

The facility where I work has PRN anti-hemorrhagic medications in the standard postpartum orders (Oxytocin, Methergine, Cytotec, Hemabate). For the all the reasons you've explained. If a woman is hemorrhaging in postpartum (yes, it happens), the nurse needs to be able to try to stop the hemorrhage instead of trying to get orders from the doctor. The orders include - "administer med, then notify physician."

This is an issue for your facility though, and the risk management team. For some reason, the people who make up standard orders, don't think it's important to have anti-hemorrhagic medications readily available for the postpartum nurses. It sounds like the patients could lose a lot of blood before you could get an order. But there might be some other reason for this.

[vandermom]

We have 2 PPH "kits" available. One in med fridge and one in tackle box with all admin supplies. Often the Doc is gone 30min after the delivery (small rural hospital). We start treatment with fluids and Pitocin while Doc is being called.

[kidsmom002]

We have a postpartum hemorrhage kit in our med rooms. The doctors have the option to choose to include methergine, cytotec, and hemabate in our routine postpartum orders. Most often they will choose the methergine and cytotec. Occasionally some docs will add the hemabate. While we always call the OB for a hemorrhage they can't always be reached immediately. We often need to administer our prn meds while someone is making the call to the MD. Our postpartum unit is on a separate floor than L&D so we do not have easy access to any OB and if we didn't have regular prn access to those drugs we'd be in big trouble when our patients hemorrhage.