1. Drugs Used in Obstetrics
Chapter 40
Drugs Used in Obstetrics
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2. Chapter 40
Lesson 40.1
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3. Objectives
Describe nursing assessments and nursing interventions needed for the pregnant patient during the first, second, and third trimesters of pregnancy
Identify appropriate nursing assessments, nursing interventions, and treatment options used for the following obstetric complications: infection, hyperemesis gravidarum, miscarriage, abortion, preterm labor, premature rupture of membranes, gestational diabetes, and pregnancy-induced hypertension
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4. Objectives (cont’d)
State the methods and time parameters of each approach to the termination of a pregnancy
Summarize the care needs of the pregnant woman during labor and delivery and the immediate postpartum period including the patient education needed before discharge to promote safe self-care and care of the newborn
State the purpose of administering glucocorticoids to certain women in preterm labor
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5. Nursing Assessments in Obstetrics
Prenatal visit
Nutritional history
Elimination pattern
Psychosocial cultural history
Medication history
Physical examination
Assessment during the first, second, and third trimesters
Encourage patients to voice concerns about the physiologic changes of pregnancy.
Be aware of cultural and family influences.
Assess if the woman is accepting of the pregnancy.
During subsequent assessments, look for signs of potential complications and preterm labor.
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6. Obstetric Complications
Infections
Hyperemesis gravidarum
Miscarriage, placental separation, abortion
Preterm labor
Premature rupture of membranes
Gestational diabetes mellitus (GDM)
Pregnancy-induced hypertension (PIH)
Amniocentesis may determine fetal lung maturity and detect fetal disorders
Most common infection is urinary tract infection.
PIH includes pre-eclampsia and eclampsia.
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7. Termination of Pregnancy
Abortion methods
Before 12 weeks gestation – suction curettage or dilation and evacuation
Between 12 and 20 weeks gestation – giving hypertonic saline solutions (20%) intra-amniotically, or prostaglandins intra-amniotically, IM or vaginal suppository
After 20 weeks gestation – prostaglandin suppository +/- oxytocin
Encourage talking about the feelings associated with the termination of a pregnancy; feelings of grief, sadness, or anger are common.
Be alert to depression that may develop over the next few weeks.
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8. Normal Labor and Delivery Care
Status of labor, membranes, fetal heart rate
Provide pain relief and comfort measures
Postpartum care of the newborn
Airway
Clamp the umbilical cord
Health status
Temperature maintenance
Eye prophylaxis
Other procedures
Apgar scoring assesses the newborn’s health status at 1 minute and 5 minutes after delivery.
Always carry out interventions between contractions so the patient can use any prepared childbirth techniques.
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9. Patient Education and Health Promotion
Postpartum care
Assess fundal height and lochia
Promote rest postpartum; sleep patterns will be disturbed
Promote adequate fluid intake
Teach
Breastfeeding techniques, as appropriate
Activity and exercise
Nutritional needs
Infant care needs
Follow-up appointments
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10. Chapter 40
Lesson 40.2
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11. Objectives
State the actions, primary uses, nursing assessments, and monitoring parameters for uterine stimulants, uterine relaxants, clomiphene citrate, magnesium sulfate, and Rho(D) immune globulin
Compare the effects of uterine stimulants and uterine relaxants on a pregnant woman’s uterus
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12. Objectives (cont’d)
Describe specific nursing concerns and appropriate nursing actions when uterine stimulants are administered for induction of labor, augmentation of labor, and postpartum atony and hemorrhage
Describe specific assessments needed before and during the use of terbutaline or magnesium sulfate
Identify emergency supplies that should be available during magnesium sulfate therapy
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13. Objectives (cont’d)
Cite the effects of adrenergic agents on beta-1 and beta-2 receptors, and then identify the relationship of these actions to the serious adverse effects when adrenergic agents are used to inhibit preterm labor
Identify the action, specific dosage, administration precautions, and proper timing of the administration of Rho(D) immune globulin and rubella vaccine
Summarize the immediate nursing care needs of the newborn following delivery
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14. Drug Class: Uterine Stimulants
Actions
Stimulate the uterus to induce labor
Uses
Induce or augment labor
Control postpartum atony and hemorrhage
Control postsurgical hemorrhage (as in cesarean birth)
Induce therapeutic abortion
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15. Drug Class: Uterine Stimulants
Drugs: dinoprostone (Prostin E2, Prepidil, Cervidil)
Action
Cause uterine and GI smooth muscle stimulation, start and continue cervical ripening at term
Uses
Expel uterine contents after fetal death, benign hydatidiform mole, missed spontaneous miscarriage, second-trimester abortion
Common adverse effects
Nausea, vomiting, diarrhea, fever
Serious adverse effects
Orthostatic hypotension
Available as vaginal suppository or gel applied to the cervix.
Occasionally used in conjunction with oxytocin.
Antiemetics and antidiarrheals are ordered PRN.
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16. Drug Class: Uterine Stimulants
Drug: misoprostol (Cytotec)
Action
Cause uterine contractions in pregnancy
Uses
Cervical ripening agent, induce labor, treat serious postpartum hemorrhage
Common adverse effects
Nausea, vomiting, diarrhea, fever
Serious adverse effects
Orthostatic hypotension
Synthetic prostaglandin that can also be used to prevent NSAID-induced ulcer disease.
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17. Drug Class: Uterine Stimulants (cont’d)
Drugs: ergonovine (Ergotrate Maleate), methylergonovine (Methergine)
Actions
Directly stimulate uterine contractions
Uses
Control bleeding and maintain firmness in postpartum patients
Common adverse effects
Nausea, vomiting, abdominal cramping
Serious adverse effects
Hypertension
Not used for the induction of labor because of the effect of prolonged contractions and intense uterine activity that is dangerous to the fetus.
Use with caution in patients with eclampsia or pre-existing hypertension.
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18. Drug Class: Uterine Stimulants (cont’d)
Drug: oxytocin (Pitocin)
Action
Stimulate uterine smooth muscle, blood vessels, mammary glands
Uses
Initiate active labor during third trimester; used postpartum to control uterine atony, hemorrhage
Common adverse effects
Uterine contractions, nausea, vomiting
Serious adverse effects
Fetal distress, hypotension, hypertension, water intoxication, dehydration, postpartum hemorrhage
Drug of choice for inducing labor at term.
Always administered IV. Careful monitoring is required because overdosage may cause hyperstimulation of the uterus, possible abruptio placentae, cervical lacerations, impaired uterine blood flow, or rupture and fetal trauma.
Water intoxication may develop when given with electrolyte solutions.
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19. Drug Class: Uterine Relaxants
Drug: magnesium sulfate
Action
Produce anticonvulsant effects and smooth muscle relaxation, inhibit uterine muscle contractions
Uses
Inhibit preterm labor, control seizure activity associated with preeclampsia and eclampsia
Serious adverse effects
Absence of deep tendon reflexes, confusion, reduced urine output
Calcium gluconate used as an antidote for magnesium toxicity
Known as tocolytic agents.
Labor is delayed for 2 to 7 days in order for steroids to be administered for fetal lung maturation.
Watch for signs of toxicity, such as reports of feeling hot all over and being perpetually thirsty.
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20. Drug Class: Uterine Relaxants (cont’d)
Drug: terbutaline sulfate (Brethine)
Actions
Produce relaxation of uterine, bronchial, and vascular smooth muscles; increase heart rate
Uses
Stop premature labor when no underlying pathology indicates pregnancy be discontinued
Serious adverse effects
Tachycardia, palpitations, hypertension, hypotension, tremors, nervousness, anxiety, restlessness, headache, dizziness, nausea, vomiting, hyperglycemia, electrolyte imbalance
Beta-adrenergic receptor stimulant.
Terbutaline is not approved by the FDA for use in premature labor, but can be used in emergency situations determined by the physician.
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21. Other Agents Drug: clomiphene citrate (Clomid) Actions Uses
Stimulate ovaries to release ova for potential fertilization
Uses
Induce ovulation in women with reduced estrogen levels
Common adverse effects
Nausea, vomiting, diarrhea, constipation, hot flashes, abdominal cramps
Serious adverse effects
Severe abdominal cramps, visual disturbances, dizziness
Patients must have a complete physical examination to rule out other pathologic causes for lack of ovulation before initiating clomiphene therapy.
Treatment raises the possibility of multiple fetuses.
Intercourse timing is important to the therapy’s success.
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22. Other Agents (cont’d) Drug: Rho(D) immune globulin Actions Uses
Suppress stimulation of active immunity by Rh-positive foreign blood cells; prevent Rh hemolytic disease of newborns in subsequent pregnancies
Uses
Prevent Rh immunization of Rh-negative patient exposed to Rh-positive blood
Common adverse effects
Localized tenderness, fever, arthralgias, generalized aches, pains
Brand names: RhoGAM, HyperRHO, WinRho, Rhophylac, MICRhoGAM.
Also used to treat idiopathic thrombocytopenia purpura (ITP), diminished platelet count related to spontaneous destruction of platelets.
Administered IM or IV, depending on which type of immune globulin used.
Serious adverse effects: urticaria, tachycardia, hypotension.
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23. Other Agents (cont’d)
Drug: erythromycin ophthalmic ointment (Ilotycin)
Actions and uses
Macrolide antibiotic used prophylactically to prevent ophthalmia neonatorum; effective against C. trachomatis
Common adverse effects
Mild conjunctivitis
A new tube of the medication should be started for each infant.
Wash hands before administration to prevent bacterial contamination.
DO NOT irrigate eyes after administration.
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24. Other Agents Drug: phytonadione Actions Uses Serious adverse effects
Fat-soluble vitamin K for the production of blood clotting factors
Uses
Administered prophylactically to protect against hemorrhagic disease of the newborn
Serious adverse effects
Bruising, hemorrhage
Newborns are often deficient in vitamin K and clotting factors (referred to as vitamin K bleeding deficiency).
There is no assessment required premedication.
NEVER administer IV; ordered to be given IM.
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