Patient label here if available
Healthy Beginnings Antenatal Program
Physician’s Orders
Phone 780.735.3046 to speak with Call Nurse
Fax completed orders with referral form, history and prenatal records to 780.342.4883.
Admit to Healthy Beginnings Antenatal Program
Activity Level (see guidelines on reverse)
Level 2 Significantly Reduced Activity
Level 3 Moderately Reduced Activity
Level 4 Normal Activity at Home
Note: Client cannot work in or outside of the home to be eligible for the program
Non-Stress Test
Daily
Every ______ day(s)
Hypertension in Pregnancy
Placenta Previa/Antepartum Hemorrhage
Pre-Term Premature Rupture of Membranes
Weekly CBC, serum creatinine, urate, LD,
AST, ALT, lytes, albumin
Weekly urine total protein/creatinine ratio
Other _______________________________________
CBC on admission to program
Other _______________________________________
Weekly CBC + diff
Other _______________________________________
Pre-Term Labour
Betamethasone 12 mg IM
Two (2) doses - 24 hours apart
Other _______________________________________
Reduced Placental Function
Other _______________________________________
Weekly CBC, AST, ALT, Bile Acids
ICP
Weekly bilirubin
Other ________________________________________
Physician Name
Physician Signature
20643(2016-10)
Date (yyyy-Mon-dd)
Time (hh:mm)
Patient label here if available
Healthy Beginnings Antenatal Program
Physician’s Orders
Activity
Significantly Reduced
Activity
2
Moderately Reduced
Activity
3
Rest
Rest most of day either lying
flat (on side) or
sitting/reclining as tolerated
Rest for 3 hour periods of
either lying flat (on side) or
sitting/reclining three times a
day
Normal for pregnancy (sit
frequently with feet elevated
for short rest periods;
increase rest as required)
Limited walking within
house
Walk for short periods only
(less than 10 minutes)
Walk as tolerated
Preferably no stairs.
Bathroom should be on
same level as bed/sofa
May walk stairs occasionally
Brief shower only or bathe if
condition allows; bathroom
on same level as bed/sofa
May use bathroom and take
showers.
None
Minimal light housework eg
dusting, dishes
Normal housework as
tolerated. Ask for help with
heavy chores: laundry,
vacuuming, grocery shopping
Meals
Very simple meals (e.g. on
feet less than 10 minutes)
Limit standing meal
preparation (e.g. on feet less
than 20 minutes); Eat with
family.
As usual
Child care
May supervise school age
children for short periods if
able to maintain rest needs,
otherwise have alternate
caregiver; No lifting children
Have another caretaker
watch an active toddler
except for short periods
As usual
As per physician
As per physician
You may drive
Don’t exercise. Do
prescribed bedrest activities
to maintain tone.
Limit activity to short walks
(two to three blocks) or stairs
if necessary
Light exercise as tolerated.
(e.g. short walks)
Walking
Stairs
Shower/bath
Housework
Driving
Exercise
20643(2016-10)
Normal Activity
4