KASTURBA COLLEGE OF NURSING

INSERVICE EDUCATION ON
PHARMACOTHERPEUTICS IN
OBSTETRICS
PRESENTED BY
MS JYOTI DAS
MS RINJU JOY
BSc NURSING 4TH YEAR

INTRODUCTION
Most women are exposed to drug of one type or
another during pregnancy . They may be given as
part of the management of the pregnancy itself or
that of coincidental medical problem. The use of
any drugs in pregnancy or breast feeding women, it
is important to consider the effects of drug not only
on the women itself, but also on the fetus or
neonate. Many drugs have undesirable effects of
the fetus and should therefore be avoided during
pregnancy.

DEFINITION OF DRUG

Drug is a substance or product is used for intended

to be used to modify or explore physiological system
or pathological status for the benefit of the
recipient.
_ WHO

DRUGS USED DURING PREGNANCY,

LABOR AND PUERPERIUM
Oxytocics

or uterine stimulants
Tocolytic agents
Antihypertensive drugs
Diuretics
Anti convulsants
Analgesics

OXYTOCICS

OXYCTOCICS IN OBSTETRICS
Oxytocics are the drugs that have the power
to excite contractions of the uterine muscle.
Important & extensively used drugs are: Oxytocin
Ergot

derivatives
prostaglandins

OXYTOCIN
MODE OF ACTION :-

Acts directly on myofibrils

producing uterine contraction and stimulates milk
ejection by the breast.

PREPARATIONS:- Synthetic oxytocin available for

parental use include
Syntocinon 5 unit/ml in ampules of 1 ml
Pitocin 10 units/ml in ampules of 0.5 ml

Syntometrine :A combination of syntocinon 5 units and

ergometrin 0.5 mg
Oxytocin nasal solution 40 units/ml

INDICATIONS OF OXYTOCIN
pregnancy

To induce abortion(inevitable, missed).

To expedite expulsion of hydatidiform mole.
For oxytocin challenge test.
To stop bleeding following evacuation.
To induce labor.
labour
To augment labour.
In uterine inertia.
To prevent and treat post partum haemorrhage.
Postpartum
To initiate milk let down in breast engorgement.

OXYTOCIN

Contraindications of oxytocin:
Pregnancy:
Grand multipara.
Contracted pelvis.
History of caesarean or hysterotomy.
Malpresentation.
Labour:
All the contraindications in pregnancy.
Obstructed labour.
Inco-ordinate uterine action.
Foetal distress.
Any time:
Hypovolemic state.
Cardiac disease.

DOSAGE & ROUTE OF

ADMINISTRATION

Methods of administration:
Controlled intravenous infusion
For induction in labour.
Use in labour.
Intramuscular
5-10

units after the birth of the baby

as an alternative to ergometrine.

ADVERSE EFFECTS

Uterine hyperstimulation
Uterine rupture
Water intoxication
Hypotension
Fetal distress
Fetal hypoxia
Fetal death.

NURSES RESPONSIBILITIES

Assess
Intake

output ratio.
Uterine contractions and FHR.
Blood pressure, pulse and respiration.

Administer
By

IV infusion. Monitor drop rate.

Make crash cart available.

Evaluate
Length

and duration of contractions.

Notify physician of contractions lasting over 1 minute or absence of
contractions.

Teach
To

report increased blood loss, abdominal cramps or increased

temperature.

ERGOT
DERIVATIVES

ERGOT DERIVATIVES
Mode

of action:
Ergometrine acts directly on the myometrium. It
stimulates uterine contractions and decreases
bleeding.
Preparations:
a. Ergometrine 0.25mg or 0.5mg ampoules and
0.5 to 1mg tablet.
b. Methargine (methyle-ergometrine) 0.2mg
ampoules and 0.5 to 1mg tablet.
c.

Syntometrine ergometrine 0.5mg+ syntocinon

5.0 unit ampoules.

INDICATION OF ERGOT
DERIVATIVES
Indications:

Therapeutic:

To stop the atonic uterine bleeding

following delivery, abortion or expulsion of
hydatidiform mole.
Prophylactic:
Against excessive haemorrhage following
delivery.

ERGOT DERIVATIVES
CONTRAINDICATIONS:
Prophylactic:
Suspected pleural pregnancy.
Organic cardiac diseases.
Severe pre-eclampsia and eclampsia
Rh- negative mother.
Therapeutic:
Heart disease or severe hypertensive disorders

ERGOT DERIVATIVES
Hazards:
Common side effects are nausea and
vomiting.
Precipitate rise of blood pressure, myocardial
infarction, stroke and bronchospasm because
of vasoconstrictive effect.
Prolonged use may result in gangrene
formation of the toes.
Prolonged use in puerperium may interfere
with lactation.

ERGOT DERIVATIVES
Cautions:
Ergometrine should not be used during
pregnancy, first stage of labour, second
stage of labour, second stage prior to
crowning of the head and in breech delivery
prior to crowning

ERGOT DERIVATIVES
Nurses responsibilities:
Assess
Blood pressure, pulse and respiration.
Watch for signs of haemorrhage.
Administer
Orally or IM in deep muscle mass.
Have emergency cart readily available.
Evaluate
Therapeutic effect: decreased blood loss.
Teach
To report increased blood loss, abdominal cramps,
headache, sweating, nausea, vomiting or dyspnoea.

PROSTAGLANDINS

PROSTAGLANDINS

prostaglandins are synthesized from one of

essential fatty acid , acachidonic acid ,
which is widely distributed throughout the
body. In the females ,these are identified in
the menstrual fluid , endometrium, decidua
and amniotic membrane.

PROSTAGLANDINS
Mechanism of action
Ripening of cervix :- natural and
synthetic PGs can ripen the cervix at
any stage in pregnancy by inducing
collagen breakdown and tissue
hydration .

PROSTAGLANDINS
INDICATION

Induction of abortion.
Termination of molar pregnancy.
Induction of labour.
Cervical ripening prior to the induction of
abortion or labour.
Augmentation /Acceleration of labour.
Management of atonic PPH.
Medical management of tubal ectopic
pregnancy.

PROSTAGLANDINS
Contraindications:
Hypersensitivity .
Uterine fibrosis.
Cervical stenosis .
Pelvic surgery.
Pelvic inflammatory disease.
Respiratory disease.

PROSTAGLANDINS
ADVERSE EFFECT :o Headache .
o Dizziness .
o Hypotension .
o Leg cramp.
o Joint swelling .
o Blurred vision .

PROSTAGLANDINS
DOSAGE AND ROUTE OF ADMINISTRATION : Tablet :0.5 mg prostin E2
Vaginal suppository :20mg PGE2 or 50 mg
PGF2alpha
Vaginal pessary 3mg PGF2 .
Injectable ampoules or vials of prostin E2 :
1mg/ml , prostin F2 5mg/ml.
Misoprostol (PGE1) 50 mg given 4 hourly by
oral , vaginal or rectal routes for induction of
labour .

PROSTAGLANDINS

Nurses responsibility :Assess

Respiratory rate , rhythm and depth.

Vaginal discharge , itching or irritation indicative of infection .

Administer

antiemetic or antidiarrheal preparation prior to giving this drug .

after warming the suppository by running warm water over
package .

Evaluate

Length and duration of contraction .

Fever and chills.

Teach client

To remain supine for 10 to 15 minute after vaginal insertion .

TOCOLYTIC
AGENTS

TOCOLYTIC AGENTS

These drugs can inhibit uterine contraction s

and used to prolong the pregnancy . In
women who develop premature uterine
contractions , in addition to putting them to
absolute bed rest and sedating , tocolytic
drugs are administered in an attempt to
inhibit uterine contraction .
The commonly used drugs are :
Isoxsuprine (duvadilan )
Ritodrine hydro chloride (yotopar)
Magnesium sulphate

ISOXSUPRINE
Mode of Action :
Acts directly on vascular smooth muscle ,
cause cardiac stimulation and uterine
relaxation .
DOSE & ROUTE:
Initial:iv drip 100mg in 5% Dextrose . Rate 0.2
ug per minute . To continue atleast 2 hours
after the contractions ceases .
Maintenance :
IM 10 mg 6 hourly for 24 hours
Tablet 10 mg 6-8 hourly.

SIDE EFFECTS

Hypotension.
Tachycardia
Nausea and vomiting pulmonary edema
Cardiac arrhythmias
Adult respiratory distress syndrome
Hyperglycemia
Hypokalemia

CONTRAINDICATION
Hypersensitivity and post partum hemorrhage

NURSES RESPONSIBILITY

Assess

Blood pressure , pulse during treatment.

Take B.P lying and standing orthostatic hypotension is common .

Intensity and length of uterine contraction .

Fetal heart rate.

Administer

With meals to reduce GI upset .

Evaluate
Therapeutic response :

reduce uterine contraction .

Absence of preterm labor .

Increase pulse volume .

Teach

To avoid hazardous activities until stabilized on medicine . Dizziness may

occur .

To make position change slowly or fainting may occur .

To notify physician if rash , palpitation or sever flushing develop .

ANTIHYPERTENSIVE
DRUG

ANTIHYPERTENSIVE DRUG

Antihypertensive drugs are used in

hypertensive disorders of pregnancy .
Antihypertensive drugs are used when the B.P is
160/110 mmHg to protect the mother from
eclampsia , cerebral hemorrhage , cardiac failure
and placental abruption .
The commonly used drugs are :
o Adrenergic inhibitor : methyldopa .
Adrenergic blocking agent : labetalol ,propanolol .
o Vasodilator :hydralazine , diazoxide sodium .
o Calcium channel blocker :nifedipine

METHYLDOPA

Mode of Action : stimulate central alpha adrenergic

receptors or acts as false transmitter ,resulting in
reduction of arterial pressure .

Dosage and Route

-Orally :250 mg BD to 1gm TID .
-IV infusion :250 to 500mg .

METHYLDOPA
Side effects:
Nausea , vomiting , diarrhoea constipation .
bradicardia, orthostatic hypotension, angina, weight gain.
Drowsiness, dizziness, headache, depression.
Leukopenia, thrombocytopenia.
contraindications
Active hepatic disease
Congestive cardiac failure
Blood dyscrasias
Psychiatric disorder

NURSES RESPONSIBILITY

Assess

Blood values : neutrophils , platelets .

Renal studies : protein , BUN, creatinine .

Liver function test.

Blood pressure before beginning treatment and periodically .

Evaluate

Decrease in blood pressure .

Allergic reaction: rash , pruritis, urticaria.

Symptoms of congestive heart failure .

Renal symptoms : polyuria ,oliguria , frequency.

Teach

To avoid hazardous activities

Administer 1 hour before meal

Not to discontinue drug abruptly or withdrawal symptoms may occur .

Not to skip or stop drug unless directed by physician .

Not to over the counter medication .

Notify physician of untoward signs and symptoms.

DIURETICS
Diuretics are used in the following
conditions during pregnancy.
Pregnancy induced hypertension with
massive edema.
Eclampsia with pulmonary edema.
Severe anemia in pregnancy with heart
failure.
Prior to blood transfusions in severe
anemia.
As an adjunct to certain antihypertensive
drugs, such as hydralazine or dioxide

FUROSEMIDE
Mechanism of action
Acts on loop of the Henle by increasing excretion
of sodium and chloride.
Dose
40 mg tab, daily following breakfast for 5 days a
week.
In acute conditions, parenterally doses40-120 mg
daily.
Contraindications:
Hypersensitivity
Hypovolemia

FUROSEMIDE
Maternal
Weakness
Fatigue
muscle cramps
hypokalemia
hyponatremia
hypokalemia
hypochloremic
alkalosis
postural hypotension

fetal
fetal compromise
due to decreased
placental
perfusion.
Thrombocytopenia
Hyponatremia

NURSES RESPONSIBILITY
Assess

Weight, input & output daily to determine fluid loss .

Respiration : rate ,and rhythm

Blood pressure : lying and standing

Electrolyte :Na , Cl ,K,BUN , blood sugar , CBC ,serum creatinine ,blood Ph,
ABGs.

Glucose in urine, if patient is diabetic.

Administer

In AM to avoid interference with sleep

Potassium replacement ,if serum potassium is less than 3.0 .

With food , if nausea occur ,absorption may be decreased slightly .

Evaluate

Improvement in edema of feet ,leg ,and sacral area

Signs of metabolic acidosis : drowsiness and restlessness.

Signs of hypocalemia, postural hypotension malaise, fatuige, tachycardia &

leg cramps.

Rashes and temperature elevation.

CONTI..
Teach
To increase fluid intake 2-3 lit. per day
unless contraindicated.
To rise slowly from lying and sitting position.
To report adverse effect like muscle cramps,
nausea, weakness or dizziness.
To take with food or milk.

ANTICONVULSANTS

ANTICONVULSANTS
Convulsion in pregnancy is largely due
to eclampsia. Other causes are epilepsy,
meningitis, cerebral malaria and cerebral
tumors.
The commonly used anticonvulsant is
magnesium sulphate. Diazepam, phenytoin
and phenobarbitone are also used.

ANTICONVULSANTS
1. MAGNESIUM SULPHATE:
Mode of action:
It decreases the acetylcholine release from
the nerve endings.
Dose:
IM loading dose: 4 gm IV [20% solution] over
3-5 min. to follow 10 gm deep IM, 5gm in each
buttocks. Maintenance dose : 5gm deep IM on
alternate buttocks every 4 hrs.
IV- loading dose: 4-6 gm IV over 15-20 min.
maintenance dose: 1-2 gm/hr. IV infusion.

MAGNESIUM SULPHATE
Side effects:
Maternal : severe CNS depression (respiratory
depression and circulatory collapse)
Evidence of muscle paresis (diminished knee
jerk)
Foetal: tachycardia and hypoglycaemia
Antidote:
Injection of calcium gluconate 10% 10 ml IV.

NURSES RESPONSIBILITY

o
o
o

o
o

Assess
Vital signs q 15min after iv dose. Do not exceed 150mg/min
Monitor magnesium level
Urine output should be remain 30ml/hr or more if less
notify physician.
Uterine contraction when used as tocolytic agent.
Reflexes- knee jerk, patellar reflex.

Administer
o Only after calcium gluconate is available for treating
magnesium toxicity.
o Using infusion pump or monitor carefully; IV at less than
150mg/min; circulatory collapse may occur.

evaluate:
o mental status, sensorium, memory
o Resp status :respiratory depression ,rate &
rhythm .hold drug if respirations are less than
12/min.
o Hypermagnesemia: depressed patellar reflex,
flushing,confusion,flaccid paralysis ,dyspnea.
o Resp rate,rhythm & reflex of newborn if drug
given within 24 hrs prior to delivery.
o Reflex :knee jerk& patellar reflex, decrease with
magnesium toxicity.
Teach:
o On all aspects of the drug :action ,side effects &
symptoms of hypermagnesemia
o To remain n bed during infusion.

ANALGESIC & ANESTHESIA

ANALGESICS & ANESTHESIA

Relief pain during labor & delivery ;is an

essential part in good obstetric care.
Pain during labor results from a combination
of uterine contractions & cervical dilatation.
The common drugs used were pethidine
,fentanyl & promethazine.

ANALGESIA AND ANAESTHESIA

PETHIDINE
Mechanism of action:
Inhibits ascending pain pathways in CNS , increase
pain threshold and alters pain perception.
Indications:
Moderate to severe pain in labour, postoperative
pain, abruption placentae, pulmonary edema.
Dose:
Injectable preparations contains 50mg/ml can be
administered SC, IM,IV. Its dose is 50-100 mg IM
combined with promethazine.

PETHIDINE
Contraindications:
Pethidine should not be used IV within 2 hrs.
and IM within 3 hrs. of expected time of
delivery of the baby, for fear of birth
asphyxia. It should not be used in cases of
preterm labour and when respiratory reserve
of the mother is reduce.

Side effects:
Maternal
Drowsiness
Dizziness
Confusion
Headache
Sedation
Nausea
Vomiting
Euphoria
Fetal
Respiratory depression
Asphyxia

NURSES RESPONSIBILITY
Assess:
o may cause light urinary retention
Administer :
with antiemetic to prevent nausea & vomiting
When pain is beginning to return determine dose interval by
patient response.
Evaluate:
Therapeutic response: decrease in pain
CNS changes: dizziness, drowsiness, euphoria
Allergic reaction: rash, urticaria
Respiratory depression, notify physician if respiration are
<12/minute.
Teach :
To report symptoms of CNS changes, allergic reaction.

MATERNAL MEDICATIONS WITH

ESTABLISHED TERATOGENIC
PROPERTIES AND THEIR EFFECTS

drug

Teratogenic effect

Cytotoxic drug

multiple fetal malformations and abortion.

-Diethyl stillbestrol

vaginal stenosis, cervical hoods, uterine hypoplasia of

the female offspring.

-androgenic steroids

masculinization of the female offspring.

-lithium

cardiovascular anomalies, neonatal goitre, hypotonia

and cyanosis.

benefits of treatment outweigh the risks to the foetus.

Polytherapy should be avoided.

-anticonvulsants
Phenytoin
Valproate

-aspirin

Increase risk of neural tube defects, neonatal bleeding.

-paracetamol

amount too small to be harmful.

high doses in the last few weeks cause premature

closure of ductus arteriosus. Persistent pulmonary
hypertension and kernicterus in new-born.

drug

Tertogenic effect

antimalarial

chloroquine, quinine- no evidence of fetal toxicity in

therapeutic doses; benefits outweighs the risk.
high doses[ >10 mg prednisolone daily] may produce fetal and
neonatal adrenal suppression.

-corticosteroids

Auditory or vestibular damage.

-aminoglycosides

Gray baby syndrome [peripheral vascular collapse].

-chloramphenicol

Dental discolouration [yellowish] and deformity.

-tetracycline

-long acting
sulphonamides

Inhibition of bony growth- should be avoided.

-nitrofurantoin

Haemolysis in new-born with G6 PD deficiency, if used at term

Neonatal haemolysis, jaundice and kernicterus.

drugs

Teratogenic effect

-metronidazole

o Noevidenceoffetalorneonataltoxicity,
highdosesregimensshouldnotbeused.

-ACEinhibitors
-vitaminK[largedose]
-allliveviralvaccines
-narcotics
-anaestheticagents
-anticoagulants
[warfarin]
-antidepressants
[imipramine]
-benzodiazepines

o IUGR,fetalandneonatalrenalfailure.
o Hyperbilirubinemiaandkernicterus.

o Potentiallydangeroustothefoetus.

o Depression of CNS-apnoea, bradycardia

andhypothermia.
o Convulsion, bradycardia, acidosis,
hypoxia,andhypertonia.
o Fetalbleedingandanomalies.

o cardiovascularabnormalities.

o Growthrestriction,CNSdysfunction.

MATERNAL DRUG INTAKE AND BREASTFEEDING

Transfer of drugs through breast milk depends

on following factors:
Chemical properties
Molecular weight
Degree of protein binding
Ionic dissociation
Lipid solubility
Tissue ph.
Drug concentration.
Exposure time.

DRUGS IDENTIFIED AS HAVING EFFECT

ON LACTATION AND THE NEONATE

Bromide: Rash. Drowsiness, and poor feeding.

Iodides: Neonatal hypothyroidism
Chloramphenicol: Bone marrow toxicity
Oral pill: Suppression of lactation.
Bromocriptine: Suppression of lactation.
Ergot: Suppression of lactation.
Metronidazole: Anorexia, blood dyscrasias, irritability, weakness,
neurotoxic disorders.
Anticoagulants: Haemorrhagic tendency.
Isoniazid: Anti-DNA activity and hepatotoxicity.
Anti-thyroid drugs and radioactive iodine: Hypothyroidism and goitre,
agranulocytosis.
Diazepam, opiates, phenobarbitone: Sedation effect with poor
sucking reflex.

ROLES & RESPONSIBILITY OF

NURSE-MIDWIVES

Know and comply with the state laws and regulations

regarding prescribing of medications.
Avoid refilling narcotics and pain medications by
telephone and outside of regular office hours.
Maintain drug in a safe area with limited access.
Store drug at manufacturers recommended temperature.
Store drug in a separate location away from food or other
material or supplies.
Avoid storing similar looking drugs near one another.
Avoid keeping drug with similar sounding names of the
formulary but if such similarities do occur, provide
adequate additional warnings on packing.

ANY DOUBTS ?

CONT..

Regularly check drug expiry date and properly

discard/destroy expired drug prescribing medication.
Know the appropriate indication, dosage range,
routes of administration, contraindications, side
effects and warning related to the drug prescribed or
administered.
Consults the physicians and pharmacists when
appropriate to confirm appropriate drug selection
prescription and ordering, and to check for potential
drug interaction or contraindication with patients
existing drug therapy.

QUESTIONS
1) Among this which drug comes under oxytocics.
a )Methyl-ergometrine b )magnesium sulfate
c)Isoxsuprine d )Pethidine.
2) Out of this drugs which drug is used as tocolytic agent and
anticonvulsant.
a)duvadilan
b) methyldopa
c)magnesium sulfate d) misoprostol
3) Which drug is contraindicated to mother with Rh negative blood group.
a)Oxytocin
b) frusemide
c) Methergine d)isoxsuprine

4) The action of Duvadilan drug is __________

a)Analgesic
b) to induce abortion
c) Anticonvulsant d) to inhibit uterine contraction
5) Which drug cause Hyperbilirubinimia and kernicterus in fetus.
a)Aspirin b) aminoglycosides
c)Vitamin D d)vitamin K
6) Which drug is used to relief the pain in labor.
a)Fentanyl b)magnesium sulphate
c)Methyldopa d)Lasix
7)Antidote of magnesium sulphate is__________
a)Calcium carbonate b) calcium gluconate
c)Calcium disodium versenate d)campral

8) Why diuretics used in pregnancy.

a)PIH b)eclampsia with pulmonary edema
c)Severe anemia in pregnancy with heart failure
d)All of above
9)Which drug is used for the ripening of the cervix.
a)Syntometrine b)ergot derivatives
c)Methyldopa d) prostaglandins
10)Which drug acts directly on the myofibrils producing
uterine contraction & stimulates milk ejection by the
breast.
a)Prostaglandins b) pethidine
c)Oxytocin d)syntometrin

THANK YOU