Labor, Delivery, and Neonatal Drugs: Understanding the Female Reproductive Cycle

1. Female Reproductive Cycle II Labor, Delivery and Preterm Neonatal Drugs Dena Evans, EdD(c), MPH, BSN, RN, CNE Assistant Professor Department of Nursing The University of North Carolina at Pembroke

2. Pain Control

3. Stages • Four • First (3 sub-phases) • Effacement and dilation • Latent 0-4 cm • Active 4-7 cm • Transition 8-10 cm • Second • Pelvic • Complete dilation and delivery • Third • Placental separation and delivery • Fourth • Stabilization and bonding

4. Pain Stage 1 • Stronger, longer, more frequent contractions • Pain increases due to: • Cervical dilation • Effacement • Hypoxia of contracting myometrium • Perineal pressure

5. Pain Perception Physiologic Psychologic Social Culture Past experience with pain Anticipation Fear Anxiety

6. Nonpharmacological Measures Ambulation Supportive positioning Touch/massage Hygiene and comfort measures Involving support persons Breathing and relaxation TENS Hypnosis Accupuncture Hydrotherapy Herbal supplements ---CAUTION

7. Analgesia/Sedation Sedative-tranquilizers Narcotic Agnonists Opioids with mixed narcotic agonist/antagonist effects

8. ParenteralOpioids • Given at onset of contractions to ↓ fetal exposure • meperidine (Demerol) • fentanyl (Sublimaze) • morphine sulfate • nalbupine (Nubain) • butorphanol (Stadol)

9. Anesthesia • Local • Perineal Infiltration-before delivery or late 2nd stage • No effect on FHR or client’s vital signs • Regional-No loss of conciousness • Paracervical-1st stage-not widely used • Pudendal-2nd stage • Caudal-After labor well-established-not widely used • Spinal-Immediately before delivery or late 2nd stage

10. Pudendal Block RISKS: Hematoma, infection, trauma to sciatic nerve, rectal puncture.

11. Agents Chloroprocaine Tetracaine Lidocaine Bupivacaine Ropivacaine

12. Adverse Reactions-SPINAL Hypotension, nerve injury, respiratory impairment (if given too high), headache. Remember the spinal headache. Should lie flat after procedure.

13. Nursing Considerations Nursing: Make sure your client is well-hydrated. Placed in side-lying position for administration. Monitor BP every 1-2 minutes for the first 10 minutes after administration. Assess analgesia.

14. Indication Cesarean Forceps delivery Postpartum for traumatic lacerations Removal of retained placenta

15. Area Blocked Umbilicus to toes (vaginal) Xyphoid process to toes (C-section)

16. Adverse Reactions - Epidural Hypotension, nerve injury, headache (dura puncture), hematoma, impaired respirations (if given too high).

17. Nursing Considerations Clients should be well-hydrated Assess dizziness, tinnitus, metallic taste or toxic response (indicates vein injection). Assess BP Mother on L side if hypotension occurs Assess level of analgesia After delivery-motor strength prior to ambulation Assess for presence of bilateral analgesia

18. Area Blocked T12-S5 (entire pelvis)

19. Nursing Process Regional Anesthetics pg. 841 Know

20. A note about positions Aortocaval compression Wedge Left lateral position Inferior vena cava and aortic compression Hypotension

21. Drugs that Enhance Uterine Contractility

22. Oxytocin/Pitocin Titrated based on uterine and fetal response Need to establish adequate contraction pattern which promoted labor progress Contractions every 2-3 minutes lasting 50-60 seconds/moderate intensity Prevents uterine atony after delivery

23. Uterine Hyperstimulation Avoid Increased pain Compromised FHT patterns Must use infusion pump Half life is 1-9 minutes Onset: 3-5 minutes unless IV then immediate Duration: 2-3 hours

24. Nursing Process Assess: consent, confirm gestation, collect baseline data, contraindications? Diagnoses: Deficient knowledge Planning Interventions: Have agents and O2 available; Monitor I&O; Monitor VS, Monitor FHR; Monitor infusion, positioning Evaluation: Effective labor progress, report changes in vital signs, FHR.

25. Ergot Alkaloids Not used during labor Given after delivery to prevent or control postpartum hemorrhage and promote uterine involution (return to pre pregnancy size). Ergonovine maleate (Ergotrate Maleate) and methylergonovine maleate (Methergine).

26. Administration PO. IV not recommended unless emergency IV: Assess hypertension Client already has HTN or PVD-should not receive

27. Ergot Alkaloids Side Effects/Adverse Reactions Uterine cramping N/V Hypertension (IV administration) Chest pain, Dyspnea Sudden and severe headache

28. Ergot Toxicity Ergotism Pain in arms, legs, lower back Numbness, cold hands and feet Blood hypercoagulation Hallucinations

29. Nursing Process pg. 851 Know Important: Notify MD if systolic BP increases by 25mm/Hg or diastolic 20mm/Hg over baseline. Teaching client that this may inhibit lactation.

30. Surfactant Therapy Prevents the development of respiratory distress syndrome Surfactant-keeps alveoli open during expiration Also given in clients already diagnosed with RDS to prevent severity.

31. Products beractant Survanta calfactant Infasurg proactant alfa Curosurf **All products require intubation for administration and specific positioning to ensure proper disbursement Those adventitious breath sounds may be present after administration—unless respiratory distress—No suction x 2 hours

32. Adverse Reactions Reflux up ET tube

33. When to slow or stop administration • Infant • Dusky colored • Agitated • Bradycardic • O2 sats increases of more than 95% • Improved chest expansion • CO2 levels less than 30 mm/Hg

34. Nursing Process pg. 852 Know