What are the appropriate postpartum orders for a woman who delivered a preterm infant (<37 weeks) via vaginal or cesarean delivery, with unknown Rh status, after receiving antenatal steroids and magnesium sulfate for fetal lung maturity and neuroprotection?

Postpartum Orders for Preterm Delivery

For a woman who delivered preterm (<37 weeks), administer RhoGAM 300 mcg (1500 IU) IM or IV within 72 hours if Rh status is unknown or if the newborn is Rh(D)-positive, continue magnesium sulfate for 12-24 hours postpartum if it was given for neuroprotection, and ensure standard postpartum monitoring with heightened surveillance for hemorrhage and hypertension. 1, 2, 3

Immediate Postpartum Orders

Rh Immunoglobulin Administration

• Administer RhoGAM 300 mcg (1500 IU) within 72 hours postpartum if the mother is Rh(D)-negative or Rh status is unknown and the newborn is Rh(D)-positive or of unknown Rh status 1
• The dose can be given either intramuscularly or intravenously; if IM route is chosen and reaching the muscle is of concern, use IV administration 1
• Do not administer subcutaneously into fatty tissue 1
• If excessive fetomaternal hemorrhage (>15 mL fetal RBCs) is suspected, increase the dose to 300 mcg plus an additional 20 mcg per mL of Rh(D)-positive fetal RBCs in excess of 15 mL, or give an additional 300 mcg dose if excess bleeding cannot be quantified 1

Magnesium Sulfate Management

• Continue magnesium sulfate infusion for up to 12-24 hours postpartum if it was administered for fetal neuroprotection before delivery at <32 weeks gestation 2, 3
• The standard maintenance dose is 1 g/hour IV, not to exceed a cumulative dose of 50 g or duration beyond 12 hours from the loading dose 3
• Monitor for maternal side effects including respiratory depression, decreased deep tendon reflexes, and oliguria 2
• Discontinue magnesium sulfate once the neuroprotective window has passed (typically 12-24 hours postpartum) 3, 4

Neonatal Care Coordination

• Ensure delayed cord clamping for at least 30 seconds at preterm delivery to reduce need for transfusion, decrease intraventricular hemorrhage risk, and lower risk of necrotizing enterocolitis 5
• Maintain neonatal body temperature between 36.5°C and 37.5°C using warming measures including immediate drying, covering the infant's head, and use of plastic wraps/bags and warming mattresses 5
• Avoid routine suctioning of the airway or gastric aspiration unless secretions appear to be obstructing the airway 5
• Do not routinely supplement with oxygen outside of resuscitation needs 5

Standard Postpartum Monitoring

Vital Signs and Clinical Assessment

• Monitor blood pressure, heart rate, and temperature every 15 minutes for the first hour, then every 30 minutes for the second hour, then hourly for at least 4 hours postpartum 5
• Assess for signs of postpartum hemorrhage with heightened vigilance, as preterm delivery may be associated with placental complications 5
• Monitor uterine fundal height and firmness, lochia amount and character 5

Laboratory Monitoring

• Obtain postpartum hemoglobin/hematocrit if significant blood loss occurred or if the patient received antenatal steroids (which can affect glucose metabolism) 6
• If the patient received antenatal corticosteroids, monitor for hyperglycemia in the immediate postpartum period 6

Medication Management

Antenatal Steroid Effects

• Be aware that maternal hyperglycemia risk persists for 24-48 hours after the last dose of betamethasone 6
• Monitor blood glucose if the patient has diabetes or received steroids within 7 days of delivery 6
• The effects on maternal blood pressure (increased risk of hypertension and preeclampsia) should be monitored closely in the postpartum period 6

Pain Management and Routine Medications

• Provide appropriate analgesia based on mode of delivery (vaginal vs. cesarean) 5
• Resume or initiate routine postpartum medications including prenatal vitamins, iron supplementation if indicated 5
• If the patient was on antihypertensive medications during pregnancy, continue or adjust as clinically indicated 5

Critical Pitfalls to Avoid

• Do not confuse micrograms (mcg) with International Units (IU) when calculating RhoGAM dose; 1 mcg = 5 IU 1
• Do not administer RhoGAM to the newborn infant; it is contraindicated in neonates 1
• Do not continue magnesium sulfate beyond 12-24 hours postpartum as prolonged use (>5-7 days) is not indicated and carries FDA warnings 2
• Do not assume Rh compatibility; when Rh status is unknown, treat as if Rh-incompatible and administer RhoGAM 1
• Do not delay RhoGAM administration beyond 72 hours postpartum, as efficacy decreases significantly after this window 1

Discharge Planning Considerations

Follow-up Timing

• Schedule postpartum follow-up within 1-2 weeks for preterm deliveries, earlier than the standard 6-week visit 5
• Ensure neonatal follow-up is coordinated with pediatrics or neonatology given the preterm birth 5

Patient Education

• Counsel on signs of postpartum complications including excessive bleeding, severe headache, visual changes, chest pain, or shortness of breath 6
• Discuss contraception options, noting that fertility may return quickly even after preterm delivery 5
• Provide information about risk factors for recurrent preterm birth in future pregnancies 5