Maternal Contraindications for Pitocin Admin
-severe preeclampsia/ eclampsia-predisposition to unterine rupture ( mom >35 y/o, multigravida 4 or more, overdistation of utersus, previous major sx of the cervix or uterus)-cephalopelvic disproportion-malpresentation or malpostion of fetus-cord prolapse-more the one previous C-sec-preterm baby-rigid, unripe cervix-total placenta previa-presence of noreassuring fetal status
Pitocin
use to initiating uterine contractions to induce labor and may also be used to enhance ineffective contractionsgive in port closest to the Iv insertion site
Pitocin Goals
to achieve stable contractions every 2-3 mins that last 40-60 secondsthe uterus should relax to full baseline resting tone between each contraction
Risks of pitocin
Hyperstimulation of the uterus with can leas to decrease in placental perfusion and nonreassuring fetal statusmaternal HTN, tachysystolic labor patterns,uterine rupture, rapid labor and birthdecrease in placental fnxwater intoxicationFetal effects include:hypoxia non-reassuring fetal statushyperbilirubinemiatrauma from rapid birthfetal bradycardia
Narcotic Agonist
Parentally or regional blockreduce amt of anesthetic needed when given with neuroaxial anesthesia = ↓ side effects; ↑pain relief
Morphine Sulfate
IM OR IVOnset: IM- 20-30minpeak 30min duration 3-4 hoursIV- onset 3-10 min/ peak 20 min/duration -3 to 5 hoursDilute with 4 to 5 mL sterile H20 and adm slowly (3-5 min)Naloxone (Narcan) antidoteUse caution with SSRI's and hx seizuresObserve withdrawal symptoms in narcotic-dependent clientsDo not give: <12 RRHerbal interaction: St. John Wort - Kava kava
Opiods with Mixed Narcotic agonist-antagonist Effects
Different effects at different sites (agonist at one antagonist at another)Butorphanol tartrate (Stadol)Nalbuphine (Nubain)Dose ceiling effect
Butorphanol tartrate (Stadol)
IV or IMIV onset/peak 4-5 minDuration 3-4hoursHerbal interactions -↑CNS depressionAvoid opiate dependent clientsFor use >37 weeks gestation; no fetal distress; delivery not anticipated < 4 hours
Nalbuphine (Nubain)
IV- onset/peak 2-3 min; duration 3-6 hoursAdminister slowly over at least 2 - 3 minLimited resp depression10- 15% experience hallucinationsAvoid use opiate dependent clientsObserve fetal bradycardiaToxicity reversed with Naloxone
Mixed Narcotic Adverse Effects-MATERNAL
N/V ClaminessSweating- flushedSedationResp depressionVertigoLethargyHeadache
Mixed Narcotic Adverse Effects-FETAL
↓FHR variabilityModerate CNS depressionHypotonia
Patient Education for Pain Management-LABOR
Drugs orderedRoute of administration and reasonPain ScaleExpected effects of drugs on LaborPotential drug effects (Maternal and Neonatal)
Uterine Muscle Contractility Enhancing Drugs
Uterotropic- stimulate smooth muscle of uterusOxytocinErgot alkaloidsSome Prostaglandins
oxytocin-PITOCIN
Uses:Labor inductionLabor augmentationPostpartumhemostasisGiven at individualized rate and titrated based on uterine and fetal responseGoal: Establish adequate contraction pattern that promotes labor progressAvoid: hyperstimulation →↑pain & ↓blood flow to placenta = fetal distressContinuous monitoring is criticalONLY given via volume controlled IV pump as IVPB
OXYTOCIN Induction or Augmentaion of labor
IV: 10 units/1000mL LROrdered milliunits/minConnect closest proximal port to siteBegin with initial dose then ↑ q 20 - 30 min until desired labor pattern achievedMax dose 20-40 milliunits/minuteOnset- within 1 minute- duration 1 hourMetabolized in liver- excreted in urineConcurrent use vasopressors can result in severe HTN
OXYTOCIN-POSTPARTUM
IV or IMIV 10-20units/1000mL LR Rate bolus x 1 L then 150mL/hr x 1 liter IM - 10 units IM x 1 (LAT)Onset 3-5 min Peak 40 min Duration 2-3 hours
OXYTOCIN-adverse effects
Side effectsHTNDysrhythmiasTachysytole (6 or more ctx /20min)Uterine hyperstimulation (ctx last >2min)Adverse reaction:SeizuresWater intoxication s/s : n/v- hypotension-tachycardia- cardiac arrhythmiaLife-threatening:Intracranial hemorrhage- cardiac dysrhythmiaasphyxiauterine ruptureFetal: Jaundice - hypoxia
Methylergonovine maleate (Methergine)
PO- IV emergency onlyDose : PO 0.2-0.4mg po q 6-12 hours x 48 hoursIV 0.2mg over 1 minute (watch for HTN)Adverse Reaction : Same as aboveMonitor b/p carefullyAvoid smoking
Magnesium Sulfate
CNS depressant- relaxes smooth muscles including uterusUsed preterm laborDose: 40 Gm/1000mL D5WIVPB must be on volume control pumpLoading dose: 4-6 Gm / 20 -30 minutesMaintenance dose: 1-4 Gm/hr
Magnesium Sulfate Adverse effects
Hot flushes/ sweatingNausea/ vomitingDrowsiness/ blurred visionHeadacheIleusLethargyMuscle weaknessHypocalcemiaShortness of breathTransient hypotension
Magnesium Sulfate Intolerable Reactions
Pulmonary EdemaRR < 12 per minuteAbsent DTR'sSevere HypotensionAltered LOCExtreme muscle weaknessUrinary Output < 25-30 mL/hrSerum Magnesium level 9mg or greater
Magnesium SulfateNeonatal Effects
Respiratory depressionHypocalcemiaHypotoniaLethargy
Magnesium SulfateNursing Considerations
Monitor magnesium levels (4-8mg/dl)Discontinue infusion if intolerable reaction occursCalcium Gluconate (1Gm of 10% solution) antidote readily availableDo not administer to women with Myasthenia GravisFrequent vital signs with DTR'sStrict I & O
Nalaxone Hydrochloride (Narcan)
Opiod antagonist-reverses opiod induced respiratory depressionIV/IM/SC Dose: 0.4mg-2mg IV every 2-3 minutes up to 10mgCan also administer to newbornAdverse Effects:Maternal hypo or hypertensionTachycardiaHyperventilationNausea/vomitingSweatingNursing Consideration:Do not give to opiod dependent woman or newborn- r/t withdrawal
Postpartum Hemorrhage
Oxytocin (Pitocin)Methylergonovine (Methergine)Methylprostaglandin F2 (Hemabate)Adverse effectsHeadacheNausea/vomitingTachycardiaHTNDiarrheaFeverNursing Considerations:Obtain b/p prior to administrationDo not give asthma/ hypertension / fever