Module 1: Pregnancy/Preterm Labor/Labor, Delivery, & Postpartum

1. steroid hormones

2. GI motility

3. pH

4. GFR

5. drug dilution

6. concentrations

Changes in Drug Action During Pregnancy

-Effect of circulating (1) (progestin, estrogen) on liver’s metabolism of drugs

-Reduced (2) and increased gastric (3)

GERD is common

-Increased (4) and increased renal perfusion

-Expanded maternal circulating blood volume causing (5)

-Alteration in drug clearance in later pregnancy causing decrease in drug (6)

pregnancy, labor, certain disease states

What are three factors that alter drug half lives?

teratogens

substances that cause developmental abnormalities

prevent maternal iron deficiency anemia - not to supply the fetus

What is the goal of iron supplementation during pregnancy?

Adverse Reactions of Iron

N/V, constipation, black tarry stools, diarrhea, epigastric pain, urine discoloration

-inform patient of adverse rxns (not tolerated well by most individuals)

-should be separated 2 hr before or after meals

-green tea can affect absorption rates

What are three nursing implications for iron?

before pregnancy

When should you start folic acid supplements?

reduce birth defects, notably neural tube defects

What's the goal for folic acid supplements r/t pregnancy?

Adverse Reactions of Folic Acid

bronchospasm, flushing, rash, pruritus, erythema, malaise, dark yellow urine

Cues Associated w/Preterm Labor

-Headache

-Sinus congestion

-Eye strain

-Backaches

-Joint pain

-Round ligament pain

N/V, heartburn (pyrosis), constipation, pain

Name four discomforts associated w/pregnancy.

hyperemesis gravidarum

excessive vomiting during pregnancy

Elevation

Crackers

Adequate hydration

Avoid greasy, gas-forming foods, citrus juices, reclining immediately after eating

Name four non-pharmacologic measures for treating discomfort during pregnancy.

pyridoxine hydrochloride (B6), doxylamine succine (antihistamine + B6)

What are two medications that help treat N/V r/t pregnancy?

antacids, chewable calcium carbonate, histamine2 receptor antagonists, proton pump inhibitors

What are four medications that help treat heartburn r/t pregnancy?

acetaminophen; ASA and NSAIDs aren't recommended

300 mg

What's the recommended analgesic during pregnancy and its max dosage/day?

SSRIs, tricyclic antidepressants

What are two antidepressants that are commonly used during pregnancy?

1. birthweight

2. preterm

3. attentiveness

4. irritability

Antidepressant Drugs During Pregnancy

Associated w/adverse birth outcomes

-Low (1), born small for gestational age

-(2) delivery

-decreased (3)

-increased neonatal (4)

1. substance abuse

2. aspirin

3. iron

Clinical Judgment: Antepartum Drugs

Concept: Reproduction

Recognize Cues:

-Identify pts at risk for (1)

-Review history of (2) use

Analyze cues and prioritize hypothesis:

-Anxiety, need for pt teaching

Generate Outcomes

-Pt will discuss drugs and herbal supplements w/HCP before use

Take action

-Advise pt ot use decaffeinated products or dilute caffeinated products

-Instruct patient about nonpharmacologic and pharmacologic measures to relieve discomforts

-Instruct patient about nausea, constipation, and bowel habit changes if they’re taking (3)

-Encourage patient to speak w/their HCP before taking any drugs

smooth

What type of muscle is the uterus?

39-40 weeks

What is full-term pregnancy?

preterm labor (PTL)

cervical changes and uterine contractions occurring at 20 to 37 weeks of pregnancy

12% of pregnancies

How prevalent is PTL?

Goals of PTL Care

-Interrupt or inhibit uterine contractions to create additional time for fetal maturation in utero

-Delayed delivery so antenatal corticosteroids can be delivered to facilitate fetal lung maturity

-Allow safe transport of the patient to an appropriate facility if required

1. 20 weeks

2. rupture

3. fetal death

4. hemorrhage

Contraindications of Tocolytic Therapy

-Pregnancy of less than (1) gestation

-Bulging or premature (2) of the membranes

-Confirmed (3) or anomalies incompatible w/life

-Maternal (4) and evidence of severe fetal compromise

-Chorioamnionitis

chorioamnionitis

infection of the amniotic fluid and tissue that surrounds a fetus during pregnancy

tocolytic therapy

-Drug therapy used to decrease uterine contractions

-Not FDA approved and are used “off label”

beta-2-sympathomimetic (terbutaline) and magnesium sulfate (calcium antagonist)

What are two drugs used in tocolytic therapy?

delay delivery by 48 hr to maximize effect of the glucocorticoids

What's the goal of corticosteroid therapy in PTL?

stimulates beta 2-receptors on uterine smooth muscle (relaxes them), which decreases the frequency and intensity of uterine contractions

What's the action of terbutaline?

only for short term prolongation of pregnancy

What's the black box warning of terbutaline?

tachycardia, ketoacidosis, pulmonary edema, anaphylactic shock

What are four adverse reactions of terbutaline?

SUBQ injection

How is terbutaline administered?

relaxes smooth muscle of the uterus through calcium displacement

What's the action of magnesium sulfate?

calcium gluconate

What's the antidote of magnesium sulfate?

1. maturation 2. surfactant 3. respiratory distress syndrome 4. intraventricular

Action of Corticosteroid Therapy

-Accelerates lung (1) and lung (2) development in the fetus in utero

Infants don’t produce much surfactant, which is what keeps alveoli open

-Decreases incidence and severity of (3)

-Increases survival of preterm infants

-Decreases incidence of (4) bleeds

betamethasone, dexamethosone

What are two drugs used during corticosteroid therapy?

1. 24 hr 2. shake 3. heat/light 4. large muscle

Clinical Judgment: Betamethasone

Concept: Reproduction

Recognize Cues:

-assess for history of hypersensitivity

-assess VS and FHR

Analyze Cues

-Anxiety, need for pt teaching

Generate Solutions

-The pt will not deliver within (1) of receiving betamethasone

Take Action

-(2) the suspension well

-avoid exposing drug to excess (3)

-inject drug into (4), not the deltoid

-maintain accurate I&)

gestational hypertension

-Most common serious complication of pregnancy

-SBP > 140 or DBP > 90

-AKA pregnancy-induced HTN

preeclampsia

hypertension, edema, and proteinuria during pregnancy

HELLP syndrome

What's a severe sequel of preeclampsia?

defined by hemolysis, elevated liver enzymes, and low platelet count [thrombocytopenia]

What does the acronym of HELLP stand for?

eclampsia

(preeclampsia + seizures)

New-onset grand mal seizures in a patient w/preeclampsia

reduction of vasospasm and prevention of seizures?

In addition to delivery of an uncompromised fetus and psychological support for the patient and family, two primary treatment goals in preeclampsia are what?

methyldopa

What's the first line therapy for mild preeclampsia?

stimulates alpha-adrenergic receptors (resulting in decreased sympathetic outflow to heart, kidneys, and peripheral vasculature)

What's the action of methyldopa

Adverse Reactions of Methyldopa

-Peripheral edema, anxiety, nightmares, fever

-Drowsiness, headache, dry mouth, mental depression

hydralazine

What drug is used to treat acute onset, severe HTN r/t gestational HTN?

arterial vasodilator

What's the action of hydralazine?

Adverse reactions of Hydralazine

-Headache, dizziness, nasal congestion, angina

-Nausea, vomiting, tachycardia, hypotension, palpitations

magnesium sulfate

What drug is used to treat severe preeclampsia?

calcium antagonist

What type of drug is magnesium sulfate?

Adverse Reactions of Magnesium Sulfate

-Lethargy, flushing, warmth, perspiration, thirst, sedation

-Heavy eyelids, slurred speech, hypotension, decreased DTR, decreased muscle tone

1. BP

2. preeclampsia

3. emergency drugs

4. left lateral recumbent

5. toxicity

Clinical Judgment: Gestational HTN

Concept: perfusion

Recognize cues:

-VS from early pregnancy, (1) readings during prenatal visits

-Pt history predisposing pt to (2)

Analyze cues and prioritize hypothesis:

-Decreased tissue perfusion

Generate Solutions

BP within acceptable ranges

Take action

-Airway, suction, resuscitation equipment, and (3) available

-Maintain pt in a (4) position in low-stimulation environment

-S/S of magnesium (5)

Nonpharmacologic Pain Management r/t pregnancy

Ambulation

Effleurage and counterpressure

Touch and massage

Changing positions and rocking

Engaging support persons

Breathing and relaxation techniques

Transcutaneous electrical nerve stimulation

Application of heat and cold

Aromatherapy

Hydrotherapy (warm water baths)

Alternative and complementary drugs

visceral pain during labor

First 2 stages of labor from uterine contractions and pressure of stretching cervix

somatic pain during labor

-Pressure of presenting part and stretching of the perineum and vagina

-Pain of transition phase and 2nd stage of labor

sedative hypnotics

-Drugs that can act in the body either as sedatives or as hypnotics

-Adverse effects: opioid based risks, crosses placenta to baby

-e.g. Pentobarbital, hydroxyzine.

opioid agonists

-Adverse effects: opioid based risks, crosses placenta to baby

-E.g. fentanyl, morphine

mixed opioid agonist-antagonists

Adverse effects - opioid based risk

E.g. butorphanol

Drugs cross placenta; may temporarily affect HR of fetus

What's the black box warning of systemic pain management drugs used during pregnancy?

(sedative-hypnotics, opioid agonists, and mixed opioid agonst/antagonists)

Goals of Regional Anasthesia

-Achieves pain relief during labor and delivery w/o loss of consciousness

-Temporarily blocks painful impulse conduction while maintaining consciousness

Lidocaine for episiotomy, which can cause burning at site of injection

What's an example of local anesthesia?

subarachnoid, T10-S5; lumbar

Regional anesthesia includes spinal, in the ____ space ____, or epidural, in the _____.

general anesthesia

May be necessary for emergency deliveries and/or when spinal and epidural is C/I

uterotropics

Used in term/near term pregnancy w/an indication for labor induction of labor augmentation

dinoprostone, oxytocin, and ergot alkaloids

What are three uterotropic drugs?

dinoprostone (Cervidil)

-Cervical ripening agent

-Creates cervical effacement and softening for cervical dilation

oxytocin

-Labor induction

-Stimulate uterine contraction by increasing intracellular calcium

-Synthesized in hypothalamus and secreted from posterior pituitary gland

Direct smooth-muscle-cell receptor stimulation

What's the action of ergot alkaloids?

Can cause tetanic contractions resulting in fetal hypoxia and possible ruptured uterus

Why aren't ergot alkaloids used during labor?

1. hemorrhage

2. involution

Uses of Ergot Alkaloids

USED AFTER DELIVERY

-Control postpartum (1) (bleeding)

-Promote uterine (2)

preexisting/gestational HTN, peripheral vascular diseases

What are two contraindications for ergot alkaloids?

Side effects of ergot alkaloids

-Uterine cramping, nausea, vomiting, sweating

-Dizziness, tinnitus, sudden severe headache

-Itching, HTN, chest pain, dyspnea

-Ergot toxicity

hypertensive patients

In which population should you proceed with caution for ergot alkaloids?

1. dilation

2. hydration status

3. positioning

4. FHR

5. distension

Clinical Judgment: Regional Anesthetics

Concept: pain

Recognize cues:

-Check sensitivity to local anesthetic agents

-Assess cervical (1)

Generate solutions

Verbalization of pain relief

Take action

-Assess (2) before anesthesia is given

(IV bolus of 500-1000 mL)

-Proper (3) (left side)

-Monitor maternal VS and (4)

-Assess uterine contractions

-Assess for bladder (5)

1. peri-bottle

2. benzocaine spray

3. 6-12

4. prolonged use

Clinical Judgment for Pain Relief for Perineal Wounds

Concept: pain

Recognize cues

-Pain rating

-Presence of infection at perineal site

Generate solutions

-Free of S/S of infection

Take Action

-Teach pt use of (1)

-Don’t use (2) when perineal infection is present

-Shake spray can and administer benzocaine (3) inches from perineum w/pt lying on her side, top leg up and forward

-Advise pt that drug is not for (4)

maternal rubella

-German Measles (virus)

-Devastating to a fetus

-Depends on gestational age

-First trimester risks are worst

-Goals in care: immunize and prevent rubella in pt of child bearing age

congenital rubella syndrom

-transmission of rubella virus to fetus via the placenta

-cataracts, glaucoma, deafness, heart defects, mental retardation

1. Rh sensitization

2. second

3. after delivery

Rh₀ (D) Immune Globulin

-Rh-negative mother + Rh-positive fetus → mother is at risk for (1) (development of protective antibodies against incompatible Rh-positive blood)

-in (2) pregnancy, there's a more rapid IgG immune response and an increased potential for fetal hemolysis in an Rh-positive fetus

-Rh₀ (D) immune globulin is routinely administered (3) to women w/maternal/fetal blood mixing

1. hypersensitivity reactions

2. 72 hr

3. epinephrine

Clinical Judgment: Clients Receiving Rh₀ (D) Immune Globulin

Concept: Perfusion

Recognize Cues

-Determine blood type and Rh status of prenatal patient

-Follow agency policy for Rh blood testing for patients and infants at delivery

Analyze cues

(1)

Generate solutions

Pt will receive Rh0(d) immune globulin as indicated within (2) after delivery or abortion

Take action

-Document Rh workup and eligibility of pt to receive drug

-Check lot numbers on vials and lab administration

-Administer Rh0(d) immune globulin according to gestational weeks, exposure and route, provider orders, and agency protocol

-Have (3) available to treat anaphylaxis

Use of NSAIDs for Pain Relief During Uterine Contractions

-Mild to moderate pain

-Cause GI irritation - take w/full glass of water

-Ongoing assessment for GI bleeding

Dark, tarry stools

Blood in urine

Coffee-ground emesis

What are three S/S of GI bleeding?

Avoidance of drugs while pregnant if symptoms of GI bleeding occur; Avoidance of concurrent use of alcohol, aspirin, an corticosteroids

What are two patient teachings for NSAIDs used during pregnancy?

Use of Opioids for Pain Relief During Uterine Contractions

-Decreased alertness

-Observe the pt as she cares for her newborn to ensure safety

-Assess bowel function and respirations

Topical and local agents used for perineal wounds and hemorrhoids

Witch hazel

Benzocaine

Dibucaine ointment

Hydrocortisone, pramoxine, and pramoxine hydrochloride

ducosate sodium

stool softener; promotes bowel function to relieve postpartum constipation

1. bisacodyl

2. color

3. simethicone

Clinical Judgment: Postpartum Discomfort (specifically Laxatives)

Recognize cues

Assess perineal area for wounds, hemorrhoids, and episiotomy

Generate solutions

-Pt will have bowel movement by 2-4 days postpartum

-Pt will resume bowel pattern within 4-6 weeks

Take action

-Full glass of water

-Don’t crush tablets of (1)

-No straining required

-Senna may change (2) of output

-Administer (3) after meals and at bedtime

Purpose of Drugs Used During Postpartum

-Prevent uterine atony (flabby uterus) and postpartum hemorrhage

-Relieve pain from uterine contractions, perineal wounds, and hemorrhoids

-Enhance or suppress lactation

-Manage engorgement, sore, or cracked nipples

-Promote bowel function

-Enhance immunity