Vaccination Obstetrics Standing Orders

PLACE LABEL HERE VACCINATION (Obstetrics) STANDING ORDERS Nurse initiated standing order based on medical staff approved policy (listed below). Orders with a “” are indicator choices and are NOT implemented unless checked.

Seasonal Influenza Vaccination Indicated for all patients who meet any criteria below during Influenza season (Oct-Mar or as recommended by CDC): Pregnancy, planning pregnancy, or within 6 weeks of delivery NOT indicated if: q History of life-threatening allergic reaction to eggs q History of Guillain-Barré syndrome within 6 weeks following a previous dose of influenza vaccine q Already vaccinated during current influenza season q Patient declines q History of serious reaction to any of the components of the vaccines or following previous vaccination

Measles/Mumps/Rubella (MMR) Vaccination Indicated for all patients with Rubella non-immune or equivocal lab results NOT indicated if: q Rubella immune q History of a life-threatening allergic reaction to the antibiotic neomycin q Patient declines q History of serious reaction to any of the components of the vaccines or following previous vaccination

Tetanus/Diptheria/Acellular Pertussis (Tdap) Indicated for all patients without documented vaccination during current pregnancy. NOT indicated if: q Already vaccinated during current pregnancy

q History of epilepsy

q History of Guillain-Barré syndrome

q Patient declines q History of serious reaction to any of the components of the vaccines or following previous vaccination

Vaccination Order  None, patient does not meet criteria  Influenza vaccine 0.5 ml IM x 1 dose prior to discharge (policy 7002-10)  MMR II (Mumps/Measles/Rubella) vaccine 0.5 ml SQ x 1 dose prior to discharge AFTER delivery (policy 7002-11)  Tdap vaccine (tetanus, diphtheria, acellular pertussis) 0.5 ml IM x 1 dose prior to discharge (policy 7002-01)

______Date Time Nurse Signature Physician Signature PID Number

Per hospital policy, this patient has been screened for vaccinations. If a vaccination is indicated based on nursing assessment, the patient will receive the vaccination(s) as indicated unless you indicate otherwise.  Vaccination(s) not indicated because ______

______Date Time Physician Signature PID Number

Copy to pharmacy

*1-26423* FORM 1-26423 REV. 07/2015 Page 1 of 1