Maternity Med Exam (in progress)

Tocolytics

• given to stop labor contractions & cervical changes (stops and slows contraction)

• No FDA approval, all off label

• They do not prevent pre-term brits, just give more time

Maternal C/I to tocolytics

• Preeclampsia with severe features or eclampsia

• Bleeding with hemodynamic instability

Fetal C/I to tocolytics

• Intrauterine fetal demise

• Lethal fetal anomaly

• Nonreassuring fetal status

• Chorioamnionitis

• Preterm Prelabor ROM

Nursing Care for the Woman Receiving Tocolytic Therapy

• explain purpose & S/E

• Position the woman on her side to enhance placental perfusion and reduce pressure on the cervix

• monitor vitals and FHR

• asses for adverse reactions

• asses fluid I&O

• Limit fluid intake to 2500–3000 mL/day, especially if a beta2-adrenergic agonist or magnesium sulfate is being administered

• offer support and other comfort measures

Magnesium Sulfate: Action

• tocolytic

• NS depressant

• relaxes smooth muscles (uterus)

Magnesium Sulfate: Dosage & Route

• IV fluid should contain 40g in 1000ml piggyback

• Loading: 4-6 g over 20-30 Minutes

• Maintenance: 1-4g per hour

• d/c in 24-48 hours at maintenance dose or if adverse effects occur

Magnesium Sulfate: adverse effects in mom

• hot flushes, sweating

• burning @ IV site

• nausea & vomiting

• dry mouth

• drowsiness/ dizzyness/ lethargy

• diplopia (double vision)

• headache

• ileus (GI slowing)

• muscle weakness

• hypocalcemia

• dyspnea

• transient hypotension

Magnesium Sulfate: emergency adverse effects in mom

• RR less than 12

• pulmonary edema

• Absent DTR

• Chest pain

• severe hypertension

• Altered LOC

• extreme muscle weakness

• urine output less that 25-30ml/hr or less than 100ml/hr

• serum levels 10 MEql (9mg/dl) or greater

Magnesium Sulfate: adverse effects in baby

• decreased FHR and variability

• decreased fetal movement

Magnesium Sulfate: Nursing considerations

• asses baseline before giving med, and before & after each dose

• usually IV but may be IM

• therapeutic rane 4-7.5 mEq (5-8mg)

• calcium gluconate: antidote

• Total IV intake limited to 125ml/hr

• C/I: myasthenia gravis, hypocalcemia, renal failure

Terbutaline (Brehtine) Class & action

• tocolytic - inhibits uterine activity & causes bronchodilation

• Beta-2 adrenergic agonist (beta-mimetic)

Terbutaline (Brehtine) Dosage & route

• Sub Q .25 mg Q4hr

• No longer than 24 hrs

• d/c if adverse effects occur

Terbutaline (Brehtine) Adverse effects in mom (12)

• most are mild and transient

• tachycardia chest discomfort

• palpitations

• arrythmias

• tremors

• dizzy

• nervous

• headache

• nasal congestion

• nausea&vomiting

• hypokalemia

• hyperglycemia

• hypotension

Terbutaline (Brehtine) Intolerable Adverse effects in mom

• HR above 130 bpm

• BP greater than 90/60

• chest pain

• arrhythmia

• MI

• Pulmonary edema

Terbutaline (Brehtine) Adverse effects in baby

• tachycardia

• decreased FHR variability

Terbutaline (Brehtine) C/I

• known or suspected heart disease

• diabetes of any kind

• preeclampsia or s/s of eclampsia

• hyperthyroidism

• glaucoma

• seizure disorders

Terbutaline (Brehtine) nursing considerations

• asses glucose and potassium levels before giving and periodically

• significant hyperglycemia - above 180 mg/dl (more likely when she is on corticosteroids)

• propranolol (inderal) reverses S/E r/t cardiac function

Terbutaline (Brehtine): Notify OB if

• HR over 130

• arrhythmia or chest pain

• BP over 90/60

• s/s of pulmonary edema (dyspnea, crackles, decreased SpO₂)

• FHR over 180

Inodmethacin (Indocin) class & Action

• tocolytitic - relaxes uterine muscle by inhibiting prostaglandins

• Prostaglandin synthetase inhibitor (NSAID)

Inodmethacin (Indocin) dosage and route

• loading: 50 mg PO

• maintenance: 25-50 mg PO q6-8hrs

• no more than 48hrs

Inodmethacin (Indocin) adverse effects on mom (3 common & 4 serious)

• common: nausea/vomiting, heartburn, dizziness

• less common & more serious : GI bleeding, prolonged bleeding time, thrombocytopenia, asthma in aspirin sensitive pts.

Inodmethacin (Indocin) adverse effects on baby

• constricts ductus arteriosus

• oligohydramnos - reduced fetal urine production

• neonatal pulmonary hypertension

Inodmethacin (Indocin) C/I

• renal/ hepatic disease

• active peptic ulcer disease

• poorly controlled hypotension

• asthma

• coagulation disorders

Inodmethacin (Indocin) nursing considerations

• only used if gestational age is less than 32 weeks

• long acting formulas decrease incidence of adverse effects

• may mask maternal fever

• asses AFV and fetal ductus arteriosus before giving and within 48 hours of d/c

• give with food to lessen GI effects

• monitor for s/s of pp hemorrhage

Nifedipine (adalat, Procardia) class & action

• tocolytic - relaxes smooth muscle by blocking calcium entry

• calcium channel blocker

Nifedipine (adalat, Procardia) dosage and route

• loading: 10-20 mg PO q3-6 hrs until contractions are rare

• maintenance: long acting 30-60 mg q8-12 hrs for 48 hrs with corticosteroids

Nifedipine (adalat, Procardia) adverse effects on mom

• hypotension

• headache

• flushing

• dizziness

• nausea

Nifedipine (adalat, Procardia) adverse effects on baby

• hypotension (questionable ??)

Nifedipine (adalat, Procardia) C/I

• intrauterine infection

• hypertension/ cardiac disease’

• not used with magnesium - skeletal muscle blockade

• not used with terbutaline - HR and BP effects

• No sunblingual routes

Antenetal glucocorticoid therapy (betamethasone or dexamethasone) Action

• stimulates fetal lung maturity

• promotes release of enzymes that undue surfactant

• also mature brain, kindly and gut

• FDA has not approved for this use, its off-label for OB

Antenetal glucocorticoid therapy (betamethasone or dexamethasone) Indication

• preventing/ reducing neonatal respiratory distress syndrome

• accelerates lung maturity @ 24-34 wks gestation

• infants are less likely to experience intraventricular hemorrhage, necrotizing enterocolitis or death.

Antenetal glucocorticoid therapy (betamethasone or dexamethasone) maternal effects

• increases WBC and platelet count (transient 72hrs)

• hyperglycemia

Antenetal glucocorticoid therapy (betamethasone or dexamethasone) fetus effects

• decrease in breathing movement and body movements

• transient - 48-72 hours after last dose

Antenetal glucocorticoid therapy (betamethasone or dexamethasone) Nursing considerations

• deep IM injection in ventral gluteal or vastus laterals

• alway IM, never PO

• injection is painful

• should not effect BP

• asses blood glucose

• diabetics may need increased insulin for several days

Prostoglandin E1 (PGE1): Misoprostol (Cytotec) Action

• ripens/ softens cervix

• begins dilation and effacement

• stimulates contractions

Prostoglandin E1 (PGE1): Misoprostol (Cytotec) indications + C/I

• for ripening the cervix before using Pitocin when bishop score is 4 or less

• to induce labor or abortion

• Not FDA approved for this use; used off label

• C/I: hx of c-section or major uterine surgery

Prostoglandin E1 (PGE1): Misoprostol (Cytotec) vaginal dosage

• initial dose - 25 mcg

• void before insertion

• administer in or near brith unit (pills need to be spilt in pharmacy)

• inset using fingers without lubricant

• Redose if: cervix remains unchanged, uterine activity is minimal, FHR is normal (category 1), and at least 3hrs have passed since last dose

Prostoglandin E1 (PGE1): Misoprostol (Cytotec) oral dosage

• initial dose - 25 mcg

• administer in or near brith unit (pills need to be spilt in pharmacy)

• may increase labor satisfaction, comfort and convenience

• administer in or near brith unit (pills need to be spilt in pharmacy)

Prostoglandin E1 (PGE1): Misoprostol (Cytotec) adverse effects

• dose dependent (higher risk with high, frequent doses)

• uterine tachysystole (more than 5 contractions in 10 minutes) with or without abnormal FHR

Prostaglandin S/E

• tachysystole

• fever

• chills

• vomiting

• diarrhea

Prostoglandin E1 (PGE1): Misoprostol (Cytotec) nursing considerations

• obtained informed consent

• asses: maternal vitals, FHR, cervical ripening, induction of labor, signs of impending labor, bishop score

• asses before and during course of treatment (4hrs after each dose)

• if adverse effects occur, administer 0.25 mg SubQ of terbutaline

• oxytocin cannot be given until at least 4hrs have passed since last dose to induce labor

Prostoglandin E2 (PGE2); dinoprostone (cervadil insert/ prepidil gel) action

• ripens and softens cervix → effacement and dilation

• stimulates contractions

• the onlyl med FDA approved for cervical ripening or labor induction

Prostaglandin E2 (PGE2); dinoprostone (cervadil insert/ prepidil gel) indications and C/I

• used for pre induction cervical ripening (before pitocin when bishop score is 4 or less)

• used for induction of labor or abortion

• C/I - hx of c-section or other major uterine surgery

Prostaglandin E2 (PGE2); dinoprostone cervadil insert Dosage & route

• 10mg gradually released (0.3mg/hr) over 12hr

• insert removed after 12 hrs, or at the onset of active labor, or if tachysystole and abnormal FHR occur

• frozen until just before insertion , no warming needed

• administer in or near brith unit

• mom is in supine position with a lateral tilt, or side lying position for 2hrs after insertion

• pull string and give 0.25 terbutaline SubQ if adverse effects occur

Prostaglandin E2 (PGE2); dinoprostone prepidil gel Dosage & route

• 0.5mg in a 2.5 mL syringe

• bring gel to room temp, but do not force warming (can inactivate drug)

• mom is in supine position with a lateral tilt, or side lying position for 30 min after insertion

• attached to catheter inserted into the cervical canal just below internal cervical os.

• dose may be repeated q6 hrs PRN for cervial ripening

• max dose of 1.5mg (3 doses) in a 24hr period

• administer in or near brith unit

• cant be effectively removed if adverse effects occur

Prostaglandin E2 (PGE2); dinoprostone (cervadil insert/ prepidil gel) adverse effects

• headache

• nausea/ vomiting, diarrhea

• fever

• hypotension

• uterine tachystole w/ or w/o abnormal FHR

• fetal massage of meconium

Prostaglandin E2 (PGE2); dinoprostone (cervadil insert/ prepidil gel) nursing considerations

• informed consent

• asses: maternal vitals, FHR, cervical ripening, induction of labor, signs of impending labor, bishop score

• continuously monitor FHR and uterine activity while the insert is in after 15min after it has been removed

• she can ambulate after initial period of bed rest is done and if continuous EFM telemetry is available

• Gel: cant be effectively removed if adverse effects occur

• delay Pitocin for 6-12 hrs after last dose of gel, and 30-60 min after removing insert

oxytocin (pitocin) action

• hormone produced in the posterior pituitary gland

• stimulates uterine contractions

• aids in milk ejection

• pitocin = synthetic form of oxytocin

oxytocin (pitocin) indications

• labor induction and augmentation

• controls pp bleeding

oxytocin (pitocin) dosage (Concentrations)

• standard concentrations:

• 10 units in 1000ml

• 20 units in 1000ml

• 30 units in 500ml

• always IV pump

oxytocin (pitocin) route and goal

• always IV pump

• begin at 1-2 milliuntis/min

• increase by 1-2 milliunits/min, no more frequently than 30-60 minutes based on response

• we want to use the lowest does possible to achieve adequate labor

• signs of adequate labor include: progressive effacement, dilation of 0.5-1cm/hr after active labor has been achieved

oxytocin (pitocin) adverse effects on mom

• uterine tachysystole

• placental abruption

• uterine rupture

oxytocin (pitocin) adverse effects on fetus

• fetal compromise

• progressive decline in oxygen status

• neonatal acidemia

oxytocin (pitocin) nursing considerations

• high alert med - causes harm if used incorrectly

• teach mom and partner: why we use it, possible reactions (more intense contractions, longer peak, more regular and more often)

• continue to tell her about her progress

• women vary greatly in response to oxytocin

• uterine response only takes 3-5 min after administered

oxytocin (pitocin) assessments

• record uterine activity and FHR using EFM

• evaluate at least every 15 minutes in 1st stage of labor and during passive fetal descent int he 2nd stage

• 5 minutes in the pushing (active) 2nd stage of labor

• contractions should not occur any more frequently than 2 min

• dose can be d/c or decreased by ROM and in active phase of 1st stage of labor

• perform vaginal exams as indicated

oxytocin (pitocin) documentation should include ?

• any time the oxytocin infusion has begun and each time it is increased, decreased or d/c

• assessment data

• interventions for tachystole and abnormal FHR

• notification of OB and their response

s/s of uterine tachystole with pitocin

• more than 5 contractions in 10 min (averaged over 30 min)

• contractions that are 2 min or longer

• insufficient resting tone between contractions

• or intramnitoic pressure greater than 25mmHG between contractions measured via IUPC

Interventions for tachystole with normal FHR

• reposition to sidelying

• IV fluid bolus (at least 500ml of LR)

• decrease oxytocin by at least half if uterine activity has not returned to normal in 10-15 minutes

• if another 10-15 minutes goes by d/c oxytocin until contractions are lees than 5 in 10 minutes

Interventions for tachystole with abnormal FHR

• d/c oxytocin immediately

• reposition to sidelying

• IV fluid bolus (at least 500ml of LR)

• consider giving O₂ at 10L/min via nonrebreather mask if above interventions fail

• still no response after O_2, give terbutaline 0.25mg Sub Q

• Notify OB of actions taken and maternal/fetal response

resuming oxytocin after tachystole is resolved

• if oxytocin was d/c for less than 20-30min, resume at no more than half the previous rate

• if oxytocin was d/c for more than 30-40min, resume at initial dose