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First Trimester Bleeding - Adult/Pediatric - Ambulatory [112]

First Trimester Bleeding - Adult/Pediatric - Ambulatory [112] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Ambulatory Delegation Protocols






Delegation Protocol Number: 112

Delegation Protocol Title:
First Trimester Bleeding - Adult/Pediatric - Ambulatory

Delegation Protocol Applies To:
UW Health OB/Gyn Clinics and Family Medicine Clinics with OB/Gyn services

Target Patient Population:
Pregnant patients within the first trimester (up to 12 weeks) presenting to the clinic either in person for an
appointment or by phone.

Delegation Protocol Champions:
Makeba Williams, MD - Department of Obstetrics/Gynecology
Jacqueline Gerhart, MD – Department of Family Medicine

Delegation Protocol Reviewers:
Jenny Accola, RN, BSN – Clinic Coordinator - UW OB/GYN
Linda Kiefer, RN – Clinical Supervisor – UW Health – Deforest-Windsor Clinic

Responsible Department:
Department of Obstetrics/Gynecology

Purpose Statement:
To delegate authority from the patient’s OB/GYN or Family Medicine provider to Registered Nurses (RNs) to
place orders for the management of bleeding during the first trimester.

Who May Carry Out This Delegation Protocol:
Registered Nurses (RNs) trained in the use of this delegation protocol.

Guidelines for Implementation:
1. This protocol is initiated when a patient presents to the clinic in person or by phone reporting first trimester
bleeding.
2. The RN will determine if an intrauterine pregnancy (IUP) has been confirmed by ultrasound. If not, the nurse
will determine the following:
2.1. Date of positive pregnancy test
2.2. Date of last menstrual period (LMP)
2.3. Normalcy of LPM
2.4. History of abnormal menstrual cycles
2.5. History of previous early pregnancy risk factors (prior ectopic pregnancy, >3 spontaneously early
pregnancy losses, abdominal surgery, pelvis infection)
2.6. Was the patient attempting a pregnancy and if not, what contraception, if any was being used
3. The RN will determine the extent of abnormal bleeding:
3.1. Heavy Bleeding:
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

3.1.1. Heavy bleeding is defined as soaking one or more pads per hour or feeling light-headed, dizzy or
weak.
3.1.2. If heavy bleeding exists, the RN will contact the provider for further direction.
3.2. Intrauterine Pregnancy Confirmed:
3.2.1. The RN will place orders for a STAT quantitative HCG with a repeat beta quantitative HCG in 48
hours and contact provider.
3.2.2. The RN will review the record result of ABO and Rh typing.
• If the patient is Rh negative, the RN will order Rho D immune globulin (RhoGAM) 1500 units =
300 mcg IM x 1.
• If the Rh status is unknown, the RN will place an order for ABO and Rh typing.
3.2.3. The RN will provide the patient with miscarriage instructions and ensure follow-up.
3.3. Intrauterine Pregnancy Not Confirmed by ultrasound:
3.3.1. If no pain, the RN will assess for extent of abnormal bleeding ectopic pregnancy risks, including
prior ectopic pregnancy, prior tubal surgery, prior pelvic infection and a history of endometriosis.
The RN will provide the patient with both ectopic pregnancy and miscarriage instructions.
3.3.2. The RN will place orders for a STAT quantitative beta HCG with a repeat beta HCG in 48 hours and
contact the provider.
4. The RN will assess the patient regarding pain including abdominal, pelvic, shoulder/back pain. If the patient
reports pain, the RN will contact a provider for further direction.

Order Mode:
Lab and Diagnostic Tests: Cosign Required, Protocol/Policy
Medications: Protocol/Policy, Without Cosign

References: N/A

Collateral Documents/Tools:
Department of Obstetrics and Gynecology First Trimester Bleeding Algorithm

Approved By:
UW Health Ambulatory Protocol Committee: March 2015; *November 2016
UW Health Lab Practices Committee: May 2015; *November 2016
UW Health Clinical Knowledge Management Council: June 2015; *November 2016
UWHC Medical Board: July 2015; *November 2016
UW Health Chief Clinical Officer: July 2015; *November 2016

Effective Date: December 2016

Scheduled for Review: December 2018
*expedited approval process
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org