Labor Induction and Preventing Preterm Labor

>, electively, previa, previa, breech, prolapse, myomectomy, herpes

Labor Induction

• Used when risks of continuing pregnancy _ risks of induction

• Can also be used ________

• Non-pharm or medical reasons for labor induction

• Avoid induction in:

  • Vasa ______ or complete placenta ______

  • Abnormal fetal lie, including transverse or ______ presentation

  • Umbilical cord ________

  • Hx of classical or inverted T uterine incision, such as for C-section

  • Hx of significant uterine surgery, such as full thickness _________

  • Active genital ________

contractions, elective, position, vaginal, surgical, antidiuretic, N/V/D, epinephrine, ergotamines, water

Oxytocin

• MoA

  • Stimulates uterine __________

• BBW

  • Not for _________ inductions

• Contraindications

  • Hypersensitivity to agent

  • Unfavorable fetal _______

  • Contraindicated _______ delivery

  • OB emergencies when _______ intervention is preferred

• Warngings/Precautions

  • ___________ effects, CV effects, maternal deaths, uterine effects

• ADRs

  • _/_/_

• Drug Interactions

  • __________ and __________

• Pearls

  • May lead to _____ intoxication with large doses

relaxes, dilation, none, spontaneous, vaginal, embolism, DIC, N/V/D, fever, contractions, oxytocin, 30, 40

Dinoprostone

• MoA

  • ________ cervical smooth muscle and increased ________

• BBW → ____

• Contraindications

  • If _________ labor or ________ delivery is contraindicated

• Warnings/Precautions

  • Amniotic fluid _______ syndrome

  • Disseminated Intravascular Coagulation (___)

  • Hypersensitivity reactions

• ADRs

  • _/_/_

  • _______

  • Uterine _________

• Drug Interactions

  • May enhance ________ or other oxytocic agents

• Pearls

  • Patients at high risk include those > ___ years of age and gestational age of > __ weeks

flushing, weakness, dry, edema, cardiac, lethargy, respiratory, cerebral palsy, gravis, block, renal, pulmonary, neuromuscular, cardiac, toxicity

Magnesium Sulfate (Tocolytic Therapy)

• May cause maternal _______, lethargy, headache, _______, ___ mouth, pulmonary ______, _______ arrest

• May cause neonatal ________, hypotonia, _______ depression

• Recommended by ACOG to reduce ______ ______ risk

• Major Contraindications

  • Myasthenia ________

  • Myocardial compromise or heart ______

  • Significant _______ impairment

  • __________ edema

• Rationale/Notes

  • Magnesium depresses __________ transmission and ________ conduction; impaired renal clearance increases risk of __________

arrhythmias, edema, ischemia, metabolic, hallucinations, hypoglycemia, hyperbilirubinemia, hemorrhage, cardiac, hyperthyroidism, uncontrolled, hypertension, increase, hyperglycemia, cardiac

Terbutaline (Tocolytic Therapy)

• May cause maternal cardiac _________, pulmonary _______, myocardial _______, hypotension, tachycardia, _________ abnormalities, N/V, fever, __________

• May cause neonatal tachycardia, __________, hypocalcemia, ___________, hypotension, intravascular ____________

• Major Contraindications

  • ______ disease

  • Poorly controlled _____________

  • __________ DM

  • Severe _________ or preeclampsia/eclampsia

• Rationale/Notes

  • B-agonist effects ______ HR and myocardial oxygen demand; can worsen tachyarrhythmias and cause ________ or pulmonary edema

• BBW → Prolonged use can cause maternal _______ events and death

flushing, dizziness, hypotension, no, hypotension, failure, magnesium sulfate, vasodilation, decreased

Nifedipine (Tocolytic Therapy)

• May cause maternal _______, headache, ________, nausea, transient _________

• __ fetal or neonatal effects reported

• Contraindications

  • __________ (SBP <90)

  • Heart ________ or preload-dependent cardiac lesions (ex: aortic stenosis)

  • Concurrent ________ __________ (risk of synergistic hypotension)

• Rationale/Notes

  • Causes _________ and _________ afterload, potentially worsening hypotension or cardiac output

heartburn, constriction, hypertension, renal, necrotizing, >, platelet, ulcer, asthma, prostaglandins

Indomethacin (Tocolytic Therapy)

• May cause maternal nausea, _________

• May cause neonatal ________ of ductus arteriosus, pulmonary __________, decreased _______ function, intraventricular hemorrhage, hyperbilirubinemia, _________ enterocolitis

• Contraindications

  • Gestational age _ 32 weeks (risk of premature ductus arteriosus closure)

  • _________ or bleeding disorders

  • Peptic ______ disease

  • Renal or hepatic impairment

  • ________ sensitive to NSAIDs

• Rationale/Notes

  • Inhibits ___________ → affects ductus arteriosus, renal perfusion, and platelet function

ketorolac, sulindac

Which tocolytic therapies have no maternal, fetal, or neonatal effects reported?

Indomethacin, renal, bleeding, asthma, >, NSAIDs, first, ductus

Ketorolac and Sulindac

• Contraindications (same for both)

  • Same as __________

  • _______ impairment

  • GI ulcer or _______

  • Bleeding disorders

  • _______ with NSAID sensitivity

  • Gestational age _ 32 weeks

• Ketorolac → Rationale/Notes

  • Mechanism and risks are comparable to other ______

  • Not commonly ______ line for tocolysis

• Sulindac → Rationale/Notes

  • Less potent fetal ______ effect but same contraindications as indomethacin and ketorolac

relaxes, prolonged, tocolysis, maintenance, bronchospasms, CV, nervousness, potassum, glucose, tremor, diabetic, beta, prolonged, asthma

Terbutaline

• MoA

  • ________ uterine smooth muscle

• BBW → ________ tocolysis

• Contraindications

  • Hypersensitivity to agent

  • Prolonged ________

  • ___________ tocolysis treatment

• Warnings/Precautions

  • ___________, hypersensitivity reactions, __ disease

• ADRs

  • _________/restlessness, decreased serum _________, increased serum ________, ________

• Drug Interactions

  • ________ medications, _____ blockers, enhance QTc ________ agents

• Pearls

  • _______ and bronchospasms can be treated with terbutaline

massage, traction, oxytocin, hypovolemia

Post-Partum Hemorrhage

• Active management strategies

  • Uterine __________

  • Umbilical cord ________

  • _________ administration (IV bolus or IM injection)

• Defined as “a blood loss of greater or equal to 1,000 mL or blood loss accompanied by S/S of __________ w/in 24 hours after the birth process.”

bolus, first, IM, hypertensive, preeclampsia, antiemetics, antidiarrheals, tachycardia

Agents for Post-Partum Hemorrhage

• Oxytocin

  • Do not administer as an IV ______

  • ______ line therapy

  • If IV access is unavailable, may use 10 unit __

• Methylergonovine maleate or ergonovine maleate

  • Avoid in patients with _________ disease, including ________

• Carboprost tromethamine

  • Concurrent use of _________ or __________ recommended to control side effects

• Misoprostol

  • Single dose; can give PO

  • May cause _________

increases, third, blood, none, hypertension, coronary, second, CV, CNS, pain, vasoconstrictors, hypertensive

Methylergonovine

• MoA

  • ________ tone, rate, and amplitude of smooth muscle uterine contractions and shortened _____ stage of labor and reduces blood _____

• BBW → ____

• Contraindications

  • Hypersensitivity agents

  • ________, preeclampsia, pregnancy

• Warnings/Precautions

  • ________ artery disease

  • _______ stage of labor

• ADRs

  • __ effects

  • ____ effects

  • abdominal ____

  • N/D

• Drug Interactions

  • CYP interactions, may enhance other__________ and ___________ agents

• Pearls

  • Ergonovine is not approved in the US

PGF2, experienced, pelvic, GI, hypertension, CV, CNS, oxytocic, oxytocin, ergot

Carboprost Tromethamine

• MoA

  • ____ alpha analog-stimulates uterine contractility

• BBW

  • Use by __________ provider

• Contraindications

  • Hypersensitivity to agent

  • Acute _______ inflammatory disease

  • Active cardiac, pulmonary, renal, or hepatic disease

• Warnings/Precautions

  • Fever, ___ effects, _________

• ADRs

  • N/V/D

  • __ effects

  • ____ effects

• Drug Interactions

  • Other ___________ agents

• Pearls

  • Only use after ________ and uterine massage and potentially ______ derivatives