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During Labor & Delivery Types of ... epidural, general Anesthetics ... Trade name Promethazine HCl Regional Analgesia Local Infiltration Epidural Block Epidural Block ... – PowerPoint PPT presentation

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Title: Pharmacology

  • During Labor Delivery

Types of Pharmacological Pain Management
  • Analgesics
  • Systemic drugs that reduce pain without loss of
  • - Nurses give
  • Anesthetics
  • Drugs that cause a loss of sensation, especially
    to pain
  • local anesthetics may be given by Dr. or Midwife
    _at_ time of birth
  • other anesthetics given by Anesthesiologist or
    CRNA-spinal, epidural, general

  • Regional
  • block sensation from a localized area without
    causing loss of consciousness
  • - Local, epidural, spinal
  • General
  • systemic drugs that cause loss of consciousness
    sensation to pain

Factors affecting pregnant womans response to
analgesia anesthesia
  • Pregnant woman _at_ higher risk for hypoxia caused
    by pressure of the enlarging uterus on the
  • Sluggish GI tract of the pregnant woman can
    result in increased risk for vomiting
  • Aortocaval compression (Vena Cava Syndrome)
    increases risk of hypotension shock
  • The effect on the fetus must be considered

Advantages of Pharmacological Pain Management
  • Helps the woman be a more active participant in
    the birth
  • Helps her relax work with the contractions
  • Appropriate pain relief during labor can promote
    a positive outcome for both the mother the

Limitations of Pharmacological Pain Management
  • Both the mother the fetus are medicated
  • Drug effects may be prolonged in the infant after
  • May directly or indirectly affect the fetus d/t
    effects in the mother (hypotension)
  • May slow labor progress if used in early labor
  • A method that requires an infusion of a large
    amount of IVF may overload the mothers
  • If the mother takes other medications, may
    interact adversely with the pain medications

Narcotic Analgesics
Meperidine Generic name Demerol Trade name
  • Actions synthetic morphine-like compound
    produces comparable effects provides relief of
    moderate to severe pain by binding to opiate
    receptors in CNS, altering perception of
    response to painful stimuli produces generalized
    CNS depression
  • Dose 25-75 mg IVP or IVPB q 3-4 hr prn

  • Adverse reactions
  • Respiratory depression
  • Hypotension
  • HR increase or decrease
  • Palpitations
  • Sedation
  • Dizziness
  • Urinary retention
  • Pruritis
  • Constipation
  • Nursing Implications
  • Monitor VS closely esp. Respirations
  • Encourage CDB
  • Assess pt. need for prn
  • medication
  • Give as ordered (IM or IV) in smallest effective
  • Assess and reassess pain level

Effect on Mother Effect on Labor Progress Effect on Fetus or Newborn
Effective analgesic feeling of well-being Pain level decreased Relaxation possibly aiding progress during cervical dilation Slow contractions if given early in labor Should be given 3hrs. before delivery to avoid resp. depression in newborn decreases FHR Variability
Nalbuphine Hcl Generic name Nubain Trade name
  • Actions binds with opiate receptors in CNS
    alters perception of emotional response to
    pain treatment of moderate to severe pain
  • 5-10 mg IVP q 3-4 hr prn

Nalbuphine Hcl
  • Adverse reactions
  • BP variations
  • Decreased HR
  • Respiratory depression
  • Sedation
  • Headache
  • Vertigo Syncope
  • Restlessness Crying
  • Confusion
  • Nursing Implications
  • Monitor circulatory respiratory status hold
    med notify Dr. if Resp
  • shallow or lt12/min
  • Monitor bowel bladder function stool
    softeners may be ordered
  • Assess and reassess pain

Nalbuphine Hcl
Effect on Mother Effect on Labor Progress Effect on Fetus or Newborn
Effective analgesic Decreased resp. rate May slow progress d/t mild maternal sedation May be some respiratory depression Dec. variability
Morphine Sulfate Generic name Duramorph or
Roxanol Trade names
  • Actions Binds to opiate receptors in the CNS
    alters perceptions of response to painful
    stimuli produces generalized CNS depression
    relieves severe pain

Morphine Sulfate
  • Adverse Reactions
  • Respiratory depression
  • CNS depression
  • Lightheaded dizzy
  • Sedation
  • Anorexia, N, V
  • Constipation
  • Pruritis
  • Nursing Implications
  • Monitor VS, esp. Resp
  • Monitor level of sedation
  • Assess pain

Morphine Sulfate
Effect on Mother Effect on Labor Progress Effect on Fetus or Newborn
Effective analgesic ?Respirations Pruritis Possible slowly of labor Minimal effect
Butorphanol Generic name Stadol Trade name
  • Action Centrally-acting analgesic provide
    relief of moderate to severe labor pain by
    binding to opiate receptors in CNS alters
    perception of response to painful stimuli
    produces CNS depression
  • Adverse reactions drowsiness, sedation, resp.
    depression, vertigo, dizziness, decreased HR, BP
    variations, flushing
  • Nursing Implications monitor for resp.
    depression dont give if lt15, monitor VS,
    safety precautions d/t sedation dizziness,
  • 1-2 mg IVP q 1-2 hr

Effect on Mother Effect on Labor Progress Effect on Fetus or Newborn
Withdrawal SS if woman is opiate-dependent Possible slowing if given early Respiratory depression
Fentanyl Generic name Sublimaze Trade name
(Duragesic as transdermal)
  • Actions Binds with opiate receptors in CNS,
    alters perception of emotional response to pain
  • Adverse Reactions Resp. depression, BP
    variations, seizures, sedation, vertigo,
    confusion, headache, anxiety, N V
  • Nursing Implications Monitor respiratory
    circulatory status, monitor O2 saturation,
    monitor urinary function
  • Used in Epidurals spinals

Effect on Mother Effect on Labor Progress Effect on Fetus or Newborn
Hypotension Respiratory depression Slowing of labor if given early Possible resp. depression
Narcotic Antagonist
  • Drugs that displace the previously administered
    narcotic or opioid analgesics from their receptors

Naloxone HCl Generic name Narcan Trade name
  • Actions displace previously administered
    narcotic or opioid analgesics from receptors use
    in known or suspected narcotic-induced
    respiratory depression in neonates
  • Can not give to infants of cocaine addictive

Naloxone HCl
  • Adverse Reactions
  • Tremors
  • Seizures
  • BP variations
  • N V
  • Nursing Implications
  • Monitor resp. rate depth rate ? in 1-2 min.
  • Be prepared to administer O2, ventilation,
    other resuscitative measures
  • May repeat Q 2-3 min.
  • Administer IV into umbilical vein

Adjunctive Drugs
  • Drugs that potentiate or enhance the
    pain-relieving effects of analgesics reduce

Hydroxyzine Pamoate Generic name Vistaril
Trade name
  • Actions Acts as a CNS depressant, reduces
    anxiety, potentiates effects of narcotics
    resulting in a lower dose of narcotic needed for
    pain relief

Hydroxyzine Pamoate
  • Adverse Reactions
  • drowsiness
  • dry mouth
  • discomfort _at_ injection site if given IM
  • Nursing Implications
  • Monitor patient for sedation
  • IM inject deeply into a large muscle, aspirate
    carefully to prevent inadvertent IV administration

Promethazine HCl Generic name Phenergan Trade
  • Actions Reduces anxiety potentiates effects of
    narcotic drugs, resulting in lower dose of
    narcotic needed for pain relief antinausea
    antiemetic effects

Promethazine HCl
  • Adverse Reactions
  • Sedation
  • BP variations
  • Urinary retention
  • Seizure
  • Blurred vision
  • Nursing Implications
  • May be mixed in same syringe with Demerol
  • IM inject deeply into large muscle

Regional Analgesia
  • Anesthesia

Local Infiltration
  • Given just before birth when head visible
  • Used for episotomy or laceration repair
  • Injection of local anesthetic (caine drug)
  • Area anesthetized perineal area
  • Adverse Reactions none if no allergy to med
  • Maternal effects may slow labor
  • Fetal effects may temporarily ? FHR
  • Nursing Interventions monitor FHR, maternal VS,

Epidural Block
  • Area Anesthetized pelvic region
  • Puncture made with needle into epidural space
    then catheter inserted
  • Woman in sitting or side-lying position back
    straight and curved around uterus and outward
    toward doctor (mad cat)
  • Test dose given first. Continued infusion thru
    catheter and pump
  • Adverse Reactions maternal hypotension (can
    cause fetal compromise), urinary retention
  • Maternal Effects Hypotension, may not be able
    to push during delivery, may slow labor if
    started early
  • Fetal effects - ?FHR with decelerations from low

Epidural Block
  • Nursing Interventions Monitor FHR maternal VS
    closely, use excellent aseptic technique for
    insertion, palpate bladder for distention Q2hrs.
  • Dural Puncture dural membrane punctured
    accidentally w/epidural needle or catheter a
    relatively large amount of spinal fluid can leak
    from the punctured area result in a headache

Epidural Block
  • Contraindications
  • abnormal blood clotting low platelet count
  • infection in the area of injection or
  • hypovolemia
  • history of chronic back problems

Spinal Block
  • Also called Subarachnoid Block
  • Area Anesthetized nipple line to toes quick
  • One-shot block no catheter used
  • Local anesthetic agent used, smaller amount
  • Pt. should be positioned so that back is curved
    around uterus in a C-shape
  • Adverse Effects hypotension, urinary retention,
    post-spinal headache, pruritis
  • Maternal Effects hypotension, post-spinal H/A
  • No effect on fetus

Spinal Block
  • Nursing Interventions IVF O2, if develops a
    post-spinal H/A lie flat for several hrs., BR,
    analgesics, ? fluids, caffienated beverages
  • If spinal headache not relieved may do a Blood
    patch blood drawn from pts vein injected
    (10-15ml.) into epidural space in area of
    subarachnoid puncture blood clots forms a seal
    to stop spinal fluid leakage clot later breaks
    down is reabsorbed

Epidural Spinal Anesthesia
General Anesthesia
  • Circumstances in which it may be used
  • Emergency C-section
  • C-section in woman who refuses or has
    contraindications to epidural or spinal
  • Adverse effects in mother regurgitation with
    aspiration, may lead to aspiration pneumonia, NPO
    8 hours before procedure

General Anesthesia
  • Adverse effects in neonate Respiratory
    depression may require aggressive resuscitation
  • To ? risk of respiratory depression
  • -keep time from induction of anesthesia to
    clamping of cord as short as possible
  • -keep anesthesia as light as possible until
  • cord is clamped

General Anesthetics
  • Nitrous Oxide
  • Inhaled thru mask
  • entire body anesthetized
  • Mother - aspirate if vomits
  • Fetus respiratory depression hypoxia risks
  • Be prepared for V observe for ?uterine
    bleeding d/t uterine relaxation
  • Pentothal (Thiopental Na)
  • given IV
  • entire body anesthetized
  • Mother vomiting with
  • aspiration, resp. dep, arrhythmias
  • Fetus no effect
  • Monitor respiratory status closely

Nursing Responsibilities r/t General anesthesia
  • Assess document oral intake
  • Administer meds to ? gastric acidityBicitra
  • Reassure pt that will be asleep before incision
    is made
  • After receives assess resp. status freq.,
    monitor pulse ox, give O2, monitor urine output,
    assess fundus vaginal bleeding

  • Nursing Responsibilities r/t Pharmacological Pain
  • ? pt re allergies to food, meds (including
    dental anesthetics) latex to ID pain relief
    measures not advisable for her
  • ? re preference for pain relief
  • note factors that may impact choice of pain
    relief measures BP abnormalities,
    contraindications to epidural
  • SAFETY - SR? - d/t drowsy/dizzy, ?d movement
  • reinforce explanations given by anesthesiologist
    many do not remember initial explanations d/t
    severe discomfort

  • Nursing Responsibilities r/t Pharmacological Pain
  • help pt assume hold position for epidural or
  • tell anesthesiologist when pt having a
    contraction epidural/spinal usually inserted
    b/w contractions
  • observe for hypotension BP Q5min. until stable
  • monitor pulse ox
  • monitor for fetal compromise
  • coach re pushing
  • assess for respiratory depression, sedation,
    effects in neonate
  • keep Narcan on hand !!!

  • Nursing Process
  • Assessment pain, coping mechanisms, VS,
    determine if are environmental factors that may
    be controlled
  • Nursing Diagnosis
  • acute pain knowledge deficit
  • risk for injury ineffective coping
  • constipation

  • Nursing Process
  • Planning should be individualized for each
  • Implementation monitor VS esp. respiratory
  • monitor pain management comfort measures ? for
    distended bladder provide explanations re
    relief measures labor progress encourage
    nonpharm. pain management techniques administer
    pain medications monitor for SS impending
    birth monitor movement, strength, sensations
  • Evaluation pain relief, adverse reactions

Drugs Acting on the Uterus
  1. Oxytocics
  2. Uterine Relaxants
  3. Abortifacients

  • Oxytocic Drugs
  • Used to induce uterine contractions similar to
    those of normal labor stimulate the uterus
  • Ergonovine
  • Trade name Ergotrate
  • Uses - uterine atony hemorrhage
  • Adverse reactions NV, ?BP, CP, H/A, dizzy
  • Contraindications known sensitivity, do not
    give before delivery of placenta
  • Precautions pt with HTN, heart vasc.
    disease, renal hepatic disorders, lactation
  • No interactions
  • May be given IV or IM

  • Oxytocic Drugs
  • Methylergonovine
  • Trade name Methergine
  • Uses uterine atony hemorrhage
  • Adverse reactions NV, ?BP, CP, H/A, dizzy
  • Contraindications Do Not Use to Induce Labor,
    known hypersensitivity
  • Precautions HTN, renal or hepatic impairment
  • Interactions vasopressors, heavy cigarette
  • -with both, excessive vasoconstriction may occur
  • May be given IV, IM, or PO

  • Oxytocic Drugs
  • Oxytocin
  • Trade name Pitocin
  • Uses initiate or improve contractions before
    delivery, produce contractions in 3rd stage of
    labor, control postpartum bleeding/hemorrhage
  • Adverse reactions NV, uterine hypertonicity
    rupture, fetal bradycardia, arrhythmias,
    anaphylaxis, H2O intoxication (fluid overload)
  • Contraindications known hypersensitivity,
    cephalopelvic disproportion, unfavorable fetal
    position or presentation, fetal distress when
    delivery not imminent, hypertonic uterus, total
    placenta previa, toxemia (PIH), OB emergencies

  • Oxytocic Drugs
  • Oxytocin(cont.)
  • Precautions use cautiously during 1st 2nd
    stages of labor monitor mother fetus closely
  • Interactions vasopressors (severe HTN may
  • Given by IV route
  • Must monitor VS, FHTs, UCs,
  • Oxytocin is an endogenous hormone produced in
    the body by the posterior pituitary gland
  • also stimulates milk let-down can be given
    intranasally for this use

  • Nursing Process r/t Oxytocics
  • Assessment before admin. - ? maternal VS,
    uterine activity, monitor FHR, health obstetric
  • ongoing VS _at_ ordered intervals 11
    nurse-patient ratio recommended 3-4 firm
    contractions should occur Q10min. followed by
    palpable relaxation of uterus, no more than 5
    contractions in 10 min period
  • Antidote Mag sulfate
  • Nursing Diagnosis
  • Pain Fluid volume excess (meds in IVF)
  • Anxiety Risk for injury (fetal /or maternal)

  • Nursing Process
  • Planning plan to meet goals of obtaining
    optimal response to drug therapy pt
    understanding treatment regimen plan must be
    individualized to your patient
  • Implementation explain purpose expected
    results offer encouragement reassurance
    administer meds as ordered ID report adverse
  • Evaluation therapeutic effect achieved adverse
    reactions managed effectively no evidence of
    fluid volume excess pt knowledgeable r/t drug

  • Uterine Relaxants
  • Used to prolong pregnancy to allow the fetus to
    develop more fully ? chance of fetal survival
    ? uterine activity
  • Terbutaline
  • Trade name Brethine, Brethaire
  • Uses preterm labor only after 20th week
  • Adverse Reactions HTN, palpitations,
    arrhythmias, hypokalemia, pulmonary edema,
    anxiety, H/A, tremors, nervousness, restlessness
  • Contraindications known hypersensitivity,
    severe cardiac problems, HTN, Digitalis toxicity

  • Uterine Relaxants
  • Terbutaline (cont.)
  • Precautions CVA, cardiac disease, seizure
    d.o., hyperthyroidism
  • Interactions Halothane (anesthetic)-?d risk
    of cardiac arrhythmias
  • May be given IV, SQ, or PO
  • Also acts as a Bronchodilator

Magnesium Sulfate
  • Uses Smooth muscle relaxant to stop preterm
    labor and prevent seizures.
  • Adverse reactions gt12 mg/dl can lead to
    respiratory arrest, loss of DTRs,
  • Nursing responsibilities monitor VS (esp resp),
    IO, DTRs, Lung sounds, FHTs, uterine tone,
    administer IVPB via pump
  • Antidote Calcium gluconate

  • Smooth muscle relaxant
  • Antihypertensive

  • Nursing Process r/t Uterine Relaxants
  • Assessment VS, respiratory status, FHR, uterine
    contractions, monitor IV site rate, signs of
    adverse reactions
  • Nursing Diagnosis
  • Anxiety r/t preterm labor Alteration in comfort
    or Pain
  • Risk for impaired gas exchange (pulm. Edema)
  • Risk for ineffective management of therapeutic
    regimen (not taking med as ordered, knowledge
    deficit, or indifference)

  • Nursing Process
  • Planning individualized for ea. pt aimed _at_
    obtaining optimal reponse to therapy reducing
    anxiety pt understanding treatment of preterm
  • Implementation administer meds as ordered
    cardiac monitoring position in left lateral
    position to ? hypotension encourage pt to
    verbalize fears answer pt ?s offer emotional
    support keep Dr. informed of pt response may
    need to adjust dose explain instruct on
    treatment regimen taking med correctly

  • Nursing Process
  • Evaluation anxiety reduced therapeutic drug
    effect achieved pt demonstrates understanding of
    both in hospital treatment dosing regimen to be
    followed _at_ home pt verbalizes understanding of
    when to notify Dr. if problems occur after

  • Abortifacients
  • Drugs used to abort or terminate pregnancy
  • Carboprost
  • Trade name Hemabate
  • Uses termination of pregnancy b/w 13 20
    weeks gestation evacuation of uterus in missed
    abortion or fetal demise
  • Adverse Reactions N,V, D H/A paresthesia
    perforated uterus or cervix
  • Contraindications fetus _at_ viable age known
    hypersensitivity acute PID cardiac, renal, or
    hepatic d.o.

  • Carboprost (cont.)
  • Precautions asthma ?BP DM anemia epilepsy
    scarred uterus women who have had up to 5
    previous term pregnancies
  • Interactions Oxytocics-? effect of oxytocic
  • Given IM
  • Dinoprostone
  • Trade name Prostin E2
  • Uses termination of pregnancy b/t 12 20
    weeks gestation cervical ripening before
    induction of labor
  • Adverse Reactions N,V, D H/A hypotension

  • Dinoprostone (cont.)
  • Contraindications fetus of viable age known
    hypersensitivity previous C-section
    cephalopelvic disproportion gt6 full-term
    pregnancies hyperactive or hypertonic uterus
    placenta previa acute PID ruptured membranes
    unexplained vaginal bleeding emergency requiring
    uterine surgery
  • Precautions asthma ?BP DM anemia epilepsy
    scarred uterus women who have had up to 5 term
  • Interactions Oxytocics-? effect of Oxytocic
  • Given by vaginal suppository

  • Nursing Process r/t Abortifacients
  • Assessment monitor VS per Dr. order or facility
    policy observe for onset of contractions
    record time of onset, length intensity of
    contractions, interval b/w each
  • Nursing Diagnosis
  • alteration in comfort anxiety r/t procedure
  • Planning individualized aimed _at_ obtaining
    expected response to drug therapy ? anxiety
    management of adverse reactions pt understands

  • Cytotec
  • Laminaria

  • Nursing Process
  • Implementation administer drug appropriately
    monitor for adverse reactions notify Dr. save
    all expelled tissue for examination by Dr./Lab
    monitor IO administer antiemetics
    antidiarrheals as ordered provide comfort
    measures report ? temp
  • ? fluid intake
  • Evaluation therapeutic drug effect achieved
    anxiety reduced pt verbalizes understanding of
    procedure post-procedure directions adverse
    reactions managed effectively

  • END