REPRODUCTION

Hormonal Contraception

  • Drug Names / Classes: Combined synthetic estrogen (ethinyl estradiol) and progestin (norethindrone, norgestrel, levonorgestrel / LNG), or single-ingredient progestin-only (Opill / norgestrel).

  • Therapeutic Indication: Pregnancy prevention and treatment of moderate acne. Action: Inhibits ovulation (estrogen prevents formation of a dominant follicle; progestin suppresses the luteinizing hormone surge so ovulation does not occur).

  • Contraindications or Precautions: Pregnancy, thrombophlebitis, deep vein thrombosis (DVT), pulmonary embolism (PE), cerebrovascular accident (CVA), coronary artery disease (CAD), liver disease, undiagnosed vaginal bleeding, breast or endometrial cancer, and smoking > 15 cigarettes/day if over 35 years old.

  • Cautions: Hypertension (HTN), postpartum < 3 weeks, lactation < 6 weeks, hyperlipidemia, diabetes mellitus > 20 years, hypercoagulable disorders, and age > 35 years. Black Box Warning: Cigarette smoking increases the risk of serious cardiovascular events. Estrogen increases the risk of both arterial and venous thrombosis.

  • Nursing Considerations:

    • Assess for contraindications and drug interactions (interactions include St. John's wort, black cohosh, carbamazepine, phenytoin, amoxicillin, doxycycline, metronidazole).

    • Assess vital signs (specifically blood pressure).

    • Assess last menstrual period (LMP) and administer a pregnancy test to rule out pregnancy.

    • Assess baseline weight and smoking status.

    • Monitor for adverse effects.

  • Side Effects and Adverse Effects:

    • Side/Adverse Effects: Nausea/vomiting (n/v), breast tenderness, breakthrough vaginal bleeding, oligomenorrhea or amenorrhea, increased appetite, weight gain, acne, and decreased bone density (Depo injection only).

    • Serious Complications (ACHES Mnemonic):

      • Abdominal pain

      • Chest pain (including shortness of breath)

      • Headache (sudden and severe)

      • Eye problems (blurry vision, flashing lights, loss of vision)

      • Severe leg pain / Swelling of legs or feet

  • Route of Administration: Oral (PO; 21- or 28-day packages), transvaginal (ring), transdermal (patch), intramuscular injection (Depo-progestin only), or subcutaneous implant (progestin only).

  • Nursing Education:

    • Administration Timing: Take at the same time daily; start on the first Sunday after period starts or on the first day of menstrual period.

    • Missed Dose Protocol:

      • Combined Pills: If 1 pill missed, take as soon as remembered; if 2 pills missed, take 2 tablets daily for 2 days + use backup contraception for remainder of cycle; if 3 pills missed, discontinue pack, allow withdrawal bleeding, and restart new pack 7 days later + backup for 7 days.

      • Progestin-Only Pills: If 1 or more pills missed, take immediately and use backup contraception for 48 hours.

    • Lifestyle & Supplements: Take Calcium and Vitamin D if receiving progestin injections to protect bone density. Recommends STI barrier protection and smoking cessation.

    • Follow-up & Warnings: Follow up in 3 months. Notify provider before planned surgery or prolonged immobilization due to clotting risk. Seek emergency care (call 911/ER) immediately if ACHES symptoms occur.

Hormone Replacement Therapy (HRT)

  • Drug Names / Classes: Combination estrogen/progestin or estrogen alone.

  • Therapeutic Indication: Treatment of vasomotor symptoms (hot flashes) and vaginal dryness associated with menopause.

  • Contraindications or Precautions: Undiagnosed vaginal bleeding, severe liver disease, active or past venous thrombosis / cardiovascular event, history of breast cancer, and dementia.

  • Cautions: FDA Warning: Hormone therapy should only be used for menopausal symptoms at the lowest effective dose for the shortest duration (< 5 years). Increased risk of thromboembolic events.

  • Nursing Considerations:

    • Assess for history or risk of thromboembolic disease.

    • Monitor symptom response and evaluate for contraindications.

    • Confirm need for contraception if menopause (1 full year without menses) has not yet been reached.

  • Side Effects and Adverse Effects: Hot flashes, tachycardia, sleep disruption (associated with LH surges during therapy adjustments), mood fluctuations, headache, and increased risk of thromboembolic events.

  • Route of Administration: Oral (PO), transdermal patch, vaginal ring, or topical vaginal cream/tablets.

  • Nursing Education:

    • Educate patient on exact route-specific usage.

    • Emphasize smoking cessation (no smoking while on therapy).

    • Clarify that contraception is still required to prevent pregnancy until full menopause is reached.

    • Reinforce using the lowest dose for the shortest duration possible (< 5 years).

Pre-term Labor Drugs: Tocolytics (Uterine Relaxants)

General Overview: Used off-label to arrest premature labor (20–37 weeks gestation) to allow time for antenatal corticosteroids (betamethasone or dexamethasone) to mature fetal lungs. General Contraindications to Arrest Labor: Gestation < 20 weeks, bulging premature rupture of membranes (PROM), confirmed fetal death or anomalies incompatible with life, maternal hemorrhage, or chorioamnionitis.

1. Indomethacin

  • Drug Class: Nonsteroidal Anti-inflammatory Drug (NSAID); uterine relaxant.

  • Therapeutic Indication: Inhibits prostaglandin synthesis to relax uterine smooth muscle and delay preterm labor.

  • Contraindications or Precautions: Do not give after 32 weeks gestation due to risk of premature closure of the fetal patent ductus arteriosus (PDA). Do not administer for longer than 48 hours.

  • Cautions: Use with caution in patients with asthma or aspirin allergy.

  • Nursing Considerations: Confirm gestational age is under 32 weeks before administration; strictly limit therapy duration to ≤ 48 hours.

  • Side Effects and Adverse Effects: Dizziness, GI upset, headaches, nausea, vomiting, and gastritis. Fetal risk includes premature closure of the patent ductus arteriosus (PDA).

  • Route of Administration: Oral (PO) or Rectal (PR).

  • Nursing Education: Reassure patient that medication is a short-term measure (≤ 48 hours) intended to buy time for fetal lung development.

2. Nifedipine

  • Drug Class: Calcium Channel Blocker; uterine relaxant.

  • Therapeutic Indication: Relaxes uterine smooth muscle to arrest preterm contractions.

  • Contraindications or Precautions: Severe maternal hypotension or cardiogenic shock.

  • Cautions: Requires ongoing monitoring of maternal blood pressure and heart rate.

  • Nursing Considerations: Monitor blood pressure (BP), heart rate (HR), and uterine contraction frequency/intensity. Note: Has no direct fetal side effects.

  • Side Effects and Adverse Effects: Dizziness, hypotension, and bradycardia.

  • Route of Administration: Oral (PO) or Sublingual (SL).

  • Nursing Education: Advise patient to change positions slowly to prevent orthostatic dizziness; report severe lightheadedness or slow pulse immediately.

3. Magnesium Sulfate

  • Drug Class: Calcium antagonist and CNS depressant; uterine relaxant (not preferred tocolytic).

  • Therapeutic Indication: Relaxes uterine smooth muscle via calcium displacement to delay preterm labor; also used to prevent and treat seizures in preeclampsia/gestational hypertension.

  • Contraindications or Precautions: Contraindicated in myasthenia gravis, neuromuscular disease, impaired renal function, or recent myocardial infarction (MI).

  • Cautions: Use with caution! May be used up to 48 hours if delivery is anticipated within 7 days.

  • Nursing Considerations:

    • Dosing: Loading dose of 4–6 g IV over 20–30 minutes, followed by a continuous infusion of 1–2 g/hr.

    • Monitoring: Monitor serum magnesium levels (therapeutic range: 4–7 mEq/L). Assess deep tendon reflexes (DTRs; absent or decreased DTRs indicate magnesium toxicity risk). Monitor respiratory rate, BP, neuro status, and urinary output (I&O; watch for decreased output).

    • Fetal Monitoring: Monitor FHR for decreased variability, neonatal respiratory depression, and slight hypotonia with diminished reflexes.

    • Toxicity Signs: Flushing, increased warmth, perspiration, thirst, sedation, heavy eyelids, slurred speech, hypotension, loss of DTRs, and respiratory depression.

    • Antidote: Keep Calcium Gluconate IVP readily available at the bedside.

  • Side Effects and Adverse Effects:

    • Side Effects: Warm flushing feeling, nausea/vomiting.

    • Adverse Effects: Hypotension, CNS depression, respiratory depression (toxicity), and neonatal depression.

  • Route of Administration: Continuous IV infusion.

  • Nursing Education: Explain that the medication prevents seizures or delays labor; prepare patient for a warm, flushed feeling during infusion; instruct to report extreme sleepiness, muscle weakness, or difficulty breathing immediately.

4. Terbutaline

  • Drug Class: Beta-2 Adrenergic Agonist; uterine relaxant.

  • Therapeutic Indication: Stimulates Beta-2 receptors on uterine smooth muscle, decreasing the frequency and intensity of contractions as the muscle relaxes. Note: Usage in the US is reduced due to maternal and fetal cardiovascular risks.

  • Contraindications or Precautions: Black Box Warning: Do not use for more than 48–72 hours.

  • Cautions: Intended for short-term emergency use only (< 48–72 hours).

  • Nursing Considerations: Continuous monitoring of maternal HR, fetal heart rate (FHR), and uterine contractions. Monitor for maternal arrhythmias, tachycardia, hyperglycemia, hypokalemia, pulmonary edema (PE), and myocardial infarction (MI). Note: Crosses the placenta.

  • Side Effects and Adverse Effects:

    • Maternal: Tachycardia, cardiac arrhythmias, cardiac ischemia, hyperglycemia, hypokalemia, MI, and pulmonary edema.

    • Fetal/Neonatal: Fetal tachycardia (increased FHR) and neonatal hypoglycemia.

  • Route of Administration: Subcutaneous (SUBQ; usually given as a 1-time dose).

  • Nursing Education: Explain that the dose is a temporary short-term injection to halt strong contractions; instruct patient to report chest pain, racing heartbeat, or shortness of breath right away.

Preeclampsia: Methyldopa

  • Drug Class: Alpha-2 Adrenergic Agonist (1st line antihypertensive for preeclampsia).

  • Therapeutic Indication: Decreases blood pressure in preeclampsia and gestational hypertension.

  • Contraindications or Precautions: Active hepatic disease / severe liver impairment.

  • Cautions: Causes significant sedation, particularly when initiating therapy or increasing doses.

  • Nursing Considerations: Implement safety precautions due to sedation (fall risk); closely monitor blood pressure.

  • Side Effects and Adverse Effects: Sedation (at start and dosage adjustments), peripheral edema, anxiety, depression, and nightmares.

  • Route of Administration: Oral (PO).

  • Nursing Education: Warn patient regarding drowsiness; advise against driving or operating machinery when starting or changing doses; instruct to report mood shifts, severe depression, or worsening swelling.

Uterotropics (Drugs to Stimulate Uterine Contractions)

1. Dinoprostone (Cervadil) & Misoprostol (Cytotec)

  • Drug Class: Synthetic Prostaglandins.

  • Therapeutic Indication: Cervical ripening to prepare the cervix for labor induction.

  • Contraindications or Precautions: Oxytocin must NOT be started until 6–12 hours after prostaglandin gel removal or 30–60 minutes after insert removal. Patient must remain NPO except for ice chips.

  • Cautions: Risk of insert displacement; requires strict recumbent positioning.

  • Nursing Considerations:

    • Apply using sterile technique vaginally or cervically.

    • Educate patient to stay in a recumbent position for 15–30 minutes after gel or 2 hours after vaginal insert placement.

    • Monitor uterine contractions, fetal heart rate (for signs of distress), and cervical dilation/effacement.

  • Side Effects and Adverse Effects: Uterine hyperstimulation and fetal heart rate distress.

  • Route of Administration: Vaginal or cervical (preparations include gel, insert, or tablet).

  • Nursing Education: Explain the cervical softening procedure; instruct patient to lie flat/recumbent for the required duration (up to 2 hours); instruct to report severe cramping or vaginal bleeding.

2. Oxytocin

  • Drug Class: Uterotropic / Endogenous Hormone (High Alert Medication).

  • Therapeutic Indication: Induce labor, augment contractions, treat postpartum hemorrhage, and treat a boggy uterus after delivery. Action: Directly stimulates uterine smooth muscle.

  • Contraindications or Precautions: Do not initiate until 6–12 hours after prostaglandin gel or 30–60 minutes after prostaglandin insert removal.

  • Cautions: High Alert Med requiring dedicated continuous infusion and constant assessment; keep a tocolytic and oxygen readily available.

  • Nursing Considerations:

    • Administer IV continuous infusion, titrated based on contraction frequency/strength and fetal response.

    • Priority Assessments: Fetal heart rate, contraction pattern/strength, maternal heart rate, IV site patency (monitor for infiltration/complications), and monitor for seizures.

  • Side Effects and Adverse Effects:

    • Side Effect: Uterine hyperstimulation.

    • Adverse Effects: Cardiac dysrhythmias, maternal seizures, and brain hemorrhage.

  • Route of Administration: Intravenous (IV) continuous infusion piggyback.

  • Nursing Education: Reassure patient that IV flow is precisely controlled to assist contractions; explain that continuous fetal and contraction monitors are necessary for safety.

Treat Postpartum Hemorrhage: Methylergonovine (Methergine)

  • Drug Class: Ergot Alkaloid (derived from fungi).

  • Therapeutic Indication: Direct smooth muscle cell receptor stimulation causing firm uterine contractions to control bleeding after delivery / treat postpartum hemorrhage and a boggy uterus.

  • Contraindications or Precautions: CONTRAINDICATED DURING LABOR (causes sustained, tetanic uterine contractions leading to fetal hypoxia or uterine rupture). Contraindicated in hypertension / severe preeclampsia.

  • Cautions: Check maternal blood pressure before administration; notify provider immediately if BP is elevated.

  • Nursing Considerations:

    • Assess BP prior to giving dose; monitor BP, uterine firmness, uterine contractions, and vaginal bleeding.

    • Notify provider immediately for severe HTN (e.g., BP 185/98).

    • Administration Protocol: 0.2 mg IM stat; select a 3 mL syringe with a 22-gauge, 1-inch needle for IM injection into the deltoid muscle in an average-weight patient.

  • Side Effects and Adverse Effects:

    • Adverse Effects: Hypertension (HTN), chest pain, and seizures.

    • Expected/Normal Post-Admin Findings (do not require provider notification): Mild/moderate cramping pain (e.g., 3/10), clear blood-tinged urine output (150 mL), and increased uterine firmness.

  • Route of Administration: Intramuscular (IM stat in deltoid/gluteal) or Oral (PO); rarely given IV.

  • Nursing Education: Explain that the injection stops postpartum bleeding by helping the uterus contract firmly; instruct patient to expect uterine cramping; advise patient to report chest pain, severe headache, or numbness/tingling in extremities immediately.

Additional Supportive Medications Noted in Sources

  • Betamethasone / Dexamethasone: Corticosteroids administered IM during preterm labor management to stimulate fetal surfactant production and increase fetal lung maturity.

  • Calcium Gluconate: Specific antidote for Magnesium Sulfate toxicity; administered IV Push (IVP).

  • Nalbuphine: Opioid analgesic indicated for severe labor pain PRN (e.g., 10 mg IV q 3 hours PRN).

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