Subject: Intravenous Therapy Protocol

POLICY: Intravenous therapy is used in midwifery practice as an effective means of electrolyte replacement in laboring and postpartum women. IV fluid replacement can reverse the effects of blood volume loss, maternal exhaustion, and maternal dehydration.  An IV may also be a means by which to administer medications, such as antibiotic therapy or pain relieving medication as per the clinical director. 

GUIDELINES: IV therapy will be considered for the following indications:

1.   Prolonged labor, long prodromal labor

2.   Vomiting and/or diarrhea in labor

3. Maternal exhaustion in labor or the immediate postpartum

4. Blood volume loss in the immediate postpartum, PPH

5. Transfer to the hospital become necessary and IV access is necessary

6. Administration of antibiotics for prophylaxis intrapartum or postpartum

PROCEDURE: 1.  Assess client’s clinical situation: need for IV, vital signs, inform client of risks/benefits of procedure, document in the client’s chart

2. Assess type and amount of fluid to be used     

·         Lactated Ringer’s(LR) will generally be used; Normal Saline (NS) may be used to administer antibiotic treatment in a 100 cc size.

·         LR fluids will be given in 1000cc bag. In some cases, fluids given should be commiserate with fluid volume lost. (1cc of fluid=1 gm)

3. Prepare IV Equipment

·         Maintain aseptic technique.

·         Close clamp and connect tubing to the IV bag

·         Fill drip chamber half full, by gently squeezing the chamber and allowing fluid to fill, hang fluid bag using IV pole, adjusting height appropriately.

·         Open the clamp and flush the tubing with fluid, removing air, and visualizing fluid flowing out the end.

·         Prepare catheter extension set (saline lock) as needed by flushing 1-2 cc NS through tube and locking.

·         Administer medication to IV bag if indicated, mixing well by gently inverting bag, and label bag.

·         Prepare IV catheter (18g or 20g), tegaderm and appropriate transparent surgical tape that will be used to secure the IV in place.  Have at hand before placing the IV.

4. Select appropriate venipuncture site for IV administration.

·         Cleanse IV site, maintaining aseptic technique and universal precautions. Place an under pad under the arm.

·         Apply tourniquet and prepare woman for catheter insertion.

·         Advance catheter at a 45-degree angle into the vein, as in normal venipuncture.

·         Decrease the angle and advance the catheter into the vein, maintaining stabilization on the venipuncture site.

·         Check for a flashback of blood into the catheter chamberto insure proper placement into the vein.

·         Withdraw the needle slightly, separating the needle from catheter.  Then, while withdrawing the needle completely, advance the plastic catheter into the vein.  You should not feel any resistance.

·         Quickly apply gentle pressure superior to the injection site on the vein, release the tourniquet, as to reduce flow of blood from the vein.

·         Attach either IV tubing or the prepared catheter extension set (saline lock) to the catheter.

·         Open the clamp on the IV tubing to assure flow and to be sure of a patent IV system. Open the locking clamp on the saline lock, if using. Adjust the flow as needed; in most cases begin with bolus rate.

·         Properly cover IV site with bioclusive adhesive (tegaderm) and secure tubing with tape neatly.

·         Make sure mother is comfortable, taking VS after administration of the IV and documenting the procedure in the client’s chart: reason for IV administration, volume and type of fluid, gauge of catheter used, flow rate, time started and ended, how the procedure was tolerated.

5.  Flow rate:

·         Initial bolus of at least 250cc of fluid by allowing fluid to flow with clamp fully open.  Adjust flow by closing the clamp slightly after bolus and good response noted.

·         After initial bolus decrease the flow rate to 125cc/hr (2-3 drops in 5 seconds) by closing the clamp.

6. Monitoring of client with IV:

·         Take maternal vital signs: BP, pulse, respiratory rate, level of consciousness (LOC) after IV administration, and in intervals of every 30 minutes and after IV has been discontinued.

·         Assess mother’s bleeding, uterine position, ability to void, resolution of problem (if postpartum).

·         Assess patency of IV, flow, puncture site.

     7.  Discontinuing the IV:

·         Close the clamp.

·         Remove tape and tegaderm on puncture site, while holding the catheter in place.

·         Apply slight pressure to IV site with gauze and gently remove the catheter in a swift, smooth motion.

·         Cover the site with a band-aid and document.

Possible Complications and Problems with IV Administration:

·         Over hydration (headache, pounding pulse, changes in heart rhythm, confusion, weakness)

·         Pyrogenic shock ( high fever, general malaise, nausea, vomiting)

·         Local Infiltration (edema, pain, redness at the IV site, swelling at IV site)

·         Air Embolism (sudden vascular collapse, cyanosis, shock symptoms, loss of consciousness)

·         Catheter Emboli (piece of catheter enters circulatory system)

·         Arterial puncture (puncture into artery instead of vein, blood moving up catheter, need to start a new IV site)

·         Nerve damage (tingling, pain)

·         Phlebitis (inflammation of the vein, redness and swelling of the vein, feels warm to the touch)

·         Infection ( site reddened, inflamed, streaks up the arm)