Drugs used in pregnancy, labor and puerperium

DRUGS USED IN PREGNANCY, LABOR &
PEUPERIUM
ANAMIKA RAMAWAT
M.Sc. Nursing Prev.
Batch 2017-8
GCON, Jodhpur

INTRODUCTION
The midwife should have through knowledge of the
indications, actions and side effects of these drugs as well as
the nursing considerations related to each of them in order
to plan and implement effective nursing process.
Drugs used in obstetrics have a huge impact on the
outcome of both mother and baby.

Drugs used during
first trimester can
produce
congenital
malformation and
the period of
greatest risk is
from the third to
eleven weeks of
pregnancy.
During second and
third trimester
drugs can affect
the growth and
functional
development of
the fetus or they
can have toxic
effect on fetus
tissues.

Drugs used
in
Pregnancy
Folic
acid
Iron
Calcium
Anti -
hypertensive
drugs
Diuretics

FOLIC ACID
Preparation
• Injection- 10ml vial (5mg/ml with 1.5% benzyl alcohol)
• Tablet- 0.4mg, 0.8mg, 1mg
Mode of Action - Stimulates normal erythropoiesis and
nucleoprotein synthesis.
Indications
• Megaloblastic or macrocytic anemia during pregnancy to prevent
fetal damage
• Prevent fetal neural tube defect during pregnancy
Contraindications - untreated vitamin B12 deficiency.

Adverse effects
1. Abdominal cramps
2. Diarrhea
3. Rash
4. Irritability
5. nausea or bloating
Dosage and route of administration –
0.4mg or 400mcg OD orally
0.4-0.8mg IM or subcutaneously daily.
Nursing consideration
• Patient with H/O fetal neural tube defect in pregnancy should increase folic
acid intake 1 month before and 3 months after conception.
• Patient with intestinal malabsorption may need parenteral administration.

IRON (FERROUS FUMARATE)
Preparation
• Each 100mg provides 33mg of elemental iron.
• Tablet- 90mg,200mg,300mg,325mg,350mg
Mode of Action - Provides elemental iron, an essential component in the formation of
hemoglobin.
Indications
1. Iron deficiency
2. As a supplement during pregnancy
Contraindications
1. Primary hemolytic anemia
2. Peptic ulcer disease
3. Ulcerative colitis
4. Repeated blood transfusions

Adverse effects
1. Metallic taste
2. Temporary stained teeth
3. Nausea or vomiting
4. GI irritation
5. Black stools
Dosage and routes of administration -30mg OD orally
• Injection- 20mg elemental iron/ml in 5ml and 10ml single dose vial (iron sucrose)
• Dose-15mg/kg body weight or max 1000mg in single Inj IM or diluted with 100ml of NS for
IV.
Nursing considerations
1. Advised patient to avoid taking tablet with milk or along with antacids.
2. Caution patient to crush tablet
3. Caution patient not to substitute one iron salt for another because amount of elemental
may vary.
4. Advised patient to report for constipation or change in stool color

CALCIUM (CALCIUM CITRATE)
Preparation
• Each tablet contains 211mg or 10.6meq of elemental calcium
• Tablet- 250mg, 500mg
Mode of Action - Replaces calcium and maintain calcium level
Indication -supplement
Contraindications
1. Cancer patients with bone metastasis
2. Hypercalcemia
3.Hypophosphatemia
4.Renal calculi

Adverse effects
1. Headache
2. Irritability
3.Hypercalcemia
4.Chalky taste
Dosage and route of administration
• 500mg OD orally.
1.Advise patient to take oral calcium 1 or 1.5 hours after meals if GI upset occurs
2. Monitor calcium level if the patient is having mild renal impairment.
3. Advise patient to report for any kind of abdominal pain, vomiting or nausea occurs.

ANTIHYPERTENSIVE DRUGS
HERE IS THE CHOICE OF DRUGS GIVEN DURING PREGNANCY ARE: -
Alpha and Beta blockers
• Labetalol hydrochloride
Calcium channel blockers
• Nifedipine
Alpha Blockers
• Methyldopa
Vasodilators
• Hydralazine hydrochloride

ANTI-HYPERTENSIVE DRUGS CONTRAINDICATED
IN PREGNANCY. THESE DRUGS SHOULD BE
AVOIDED BECAUSE THEY MAY CAUSE POOR
FETAL RENAL FUNCTION, MALFORMATION OR
CAN CAUSE IUGR.

ACE inhibitors
Minoxidil
Sodium Nitroprusside
Diltiazem
Atenolol
Propranolol

Preparation
Injection-5mg/ml in 2oml vial
Tablets- 100mg,2oomg ,300mg
Mode of Action - Reduced peripheral vascular resistance as a result of alpha and beta
blockade.
Indications
1.Hypertension
2.Hypertensive emergencies
• 50mg or 100mg tablet OD orally 20mg/20ml Inj IV bolus wait for 10min if no response
then gives 40mg slow bolus

Contraindications
1.Hypersensitive to drug or its component.
2.Bronchial asthma
3.Hepatic or heart failure
4.Prolonged hypotension
5.Severe bradycardia
Adverse effects
1. Dizziness
2. Fatigue
4. Headache
5. Vertigo
1. Advised patient to remain in supine position for 3hrs after infusion.
2. Monitor BP frequently
3. In diabetic patient monitor glucose level closely.
4. Advised patient that dizziness can be minimized by rising slowly and avoiding sudden position
change

Preparations
Capsule-10mg,20mg Tablet-20mg,30mg,60mg,90mg
Mode of Action
Thought to inhibit calcium ion reflex across cardiac and smooth muscle cells, decreasing
contractility and oxygen demand and also dilates arteries and arterioles.
Indications
1. Hypertension
2. Classic chronic stable angina pectoris.
Contraindications
1.Heart failure
2. Hypotension
3. Severe GI narrowing

Adverse effects
1. Dizziness
2. Syncope
3. Heart failure
4. Muscle cramps
5. Peripheral edema
Dosage and route of administrations - 5-20mg OD orally.
1. Monitor BP & HR regularly
2. Advise patient to avoid taking this drug with grapefruit juice.
3. Watch for symptoms for heart failure.
4. Advise patient if chest pain worsen immediately report to doctor.

Preparations
Tablet-250mg,500mg
Inj-50mg/ml
Mode of Action
Inhibit the central vasomotor center, decreasing sympathetic outflow to the heart, kidney and
peripheral vasculature.
Indications
1. Hypertension
2. Hypertensive crisis
Contraindications
1. Hepatic disease or liver cirrhosis
2. Lactating mother

Adverse effects
1. Decrease mental acuity
2. Sedation
3. Headache or depression
4. Bradycardia
5. Hepatic necrosis
6. Hepatitis
Dosage and routes of administration - 250mg BD or TDS max 2g daily titrated by BP
1. Monitor BP regularly.
2. Monitor patient coomb’s test result.
3. Report for involuntary movements.
4.Tell patient to check weight daily and notify if he gains 2 or more pounds in a week

Preparation
Inj-20mg/ml in 1ml vial
Tablet-10mg,25g,50mg,100mg
Mode of Action - Direct acting peripheral vasodilator that relaxes arteriolar smooth muscle.
Indications
1. Hypertension
2. Severe essential hypertension
Contraindications
1. Coronary artery disease
2. Rheumatic heart disease
3. Stroke
4. Severe renal impairment

Adverse effects
1. Neutropenia
2. Leukopenia
3.Thrombocytopenia
4. Orthostatic hypotension
• 25mg tablet BD and if necessary may increase to 50mg BD
• 5mg diluted in 10ml of NS slow IV at 15-20minutes interval.
1. Monitor patient BP, pulse rate, body weight frequently.
2. Monitor patient for muscle and joint pain, fever or throat pain.
3. Advised patient to take drug after food to increase absorption

DIURETICS
Diuretics are used in the following conditions during
pregnancy:
1. PIH with massive edema
2. Eclampsia with pulmonary edema
3. Severe anemia in pregnancy with heart failure
4. Prior to blood transfusion in severe anemia
5. As an adjunct to certain antihypertensive drugs.

Preparation
Inj-10mg/ml
Tablets-20mg,40mg,80mg,500mg
Mode of Action - Inhibits sodium and chloride reabsorption at proximal and distal tubules and
loop of Henle.
Indications
1. Acute pulmonary edema
2. Edema
3. Hypertension
Contraindications
1. Anuria
2. Hepatic cirrhosis
3. Allergic to sulfonamides

Adverse effects
1. Maternal: Weakness, fatigue, muscle cramps, hypokalemia
2. Fetal: May occur due to decreased leading to fetal compromise, hyponatremia.
Dosage and routes of administration
40 mg tablet, daily following breakfast.
In acute conditions, the drug is administered parenterally in doses of 40-120 mg daily.
1. Monitor weight, BP and pulse rate routinely for long term use.
2. Monitor patient I/O chart.
3. Watch the signs for hypokalemia such as muscle weakness and cramps.
4. Monitor uric acid if patient is having gout.
5. Advise the patient to take drug in the morning after food.
6. Advised patient to avoid direct sunlight to prevent photosensitivity reactions.

TOCOLYTIC AGENTS
• These drugs can inhibit uterine contractions & used to prolonged the
pregnancy. In women who develop premature uterine contractions, in
addition to putting them to absolute bed rest & sedating.
• Tocolytic drugs are administered in an attempt to inhibit uterine
contraction.
Here are the drugs used are: -
• 1. Isoxsuprine Hydrochloride
• 2. Ritrodrine hydrochloride

ISOXSUPRINE HYDROCHLORIDE
(DUVADILAN)

Preparation
• Tablet -10mg
• Inj-10mg/ml
Mode of Action
• Acts directly on vascular smooth muscle, causes cardiac stimulation & uterine relaxation
and thus causing relaxing the veins and arteries and making them wider to increase the
blood flow to certain parts of the body.
Indication
1. Prevent Preterm labour
2. Inhibit uterine contractions.
Contraindications
1. Hypersensitivity
2. Postpartum

Adverse effects
1. Hypotension
2. Tachycardia
4. Pulmonary edema
5. Cardiac arrhythmias
6. Hyperglycemia or hypokalemia
Dosage & routes of administration
• Initial: IV drip 100 mg in 5% dextrose @Rate0.2ug/minute.
• To continue at least 2 hours after the contractions cease
• Maintenance: IM 10mg 6 hourly for 24 hrs or tab 10mg 6- 8hrly.
1. Assess patient BP, pulse during treatment
2.Take BP lying & standing as orthostatic hypotension is common
3. Monitor for Intensity & length of uterine contractions and FHS.
4. Advise patient to make position changes slowly as fainting may occur.

RITODRINE HYDROCHLORIDE
(YUTOPAR)

Preparation
• Inj-5ml amp-10mg/ml=50mg per amp.
• Tablet-10mg
Mode of Action - Acts directly on vascular smooth muscle, causes cardiac
stimulation & uterine relaxant.
Indications - Prevent preterm labour
Contraindications
1. Hypersensitivity
2. Eclampsia
3. Hypertension
4. Dysrhythmias

Adverse effects
1.Hyperglycemia
2. Headache
3. Restlessness or sweating
4. Chills and drowsiness
6. Altered maternal & fetal heart tone & palpitations.
• Initial: IV drip 100 mg in 5% dextrose @ 0.1 mg/minute gradually increased by 0.05mg/min
• To continue for at least 2 hrs, after contractions cease.
• Maintenance -Tab 10mg 6-8 hourly PO 10 mg given half hour before termination of iv, then 10 mg q2 hr x 24
then 10-20 mg q4th, not to exceed 120 mg/day.
1. Assess Maternal & fetal heart tones during infusion and also Intensity & length of uterine contractions
2. Monitor Fluid intake to prevent fluid overload, discontinue if this occurs.
3. Administer only clear solutions after dilution 150 mg in 500 ml D5W or NS, give at 0.3 mg/ml By Using infusion
pumps/monitor carefully
4. Positioning of patient in left lateral recumbent position to decrease hypotension & increase renal blood flow.
5. Advise patient to remain in bed during infusion.

DRUGS USED IN LABOR
Here are the drugs used in labor are: -
1. Oxytocic's
2. Analgesics
3. Anticonvulsant
4. Anticoagulant

• Oxytocic’s are the drugs that have the power to excite contractions of the uterine muscles.
Among a large number of drugs belonging to this group the ones that are important and
extensively used are: -
1. Oxytocin
2. Ergot derivatives
3. Prostaglandins
• It is an octapeptide synthesized in the hypothalamus and stored in the posterior pituitary.
Preparations Synthetic oxytocin available for parenteral use includes: -
•Syntocinon: 5units/ml in ampoules of 1 ml
•Pitocin:10 units/ml in ampoule of 0.5 ml
•Syntometrine: A combination of Syntocinon on 5 units & ergometrine 0.5mg
•Oxytocin nasal solution 40 unit/ml

• Mode of Action - Acts directly on myofibrils producing uterine contractions &
stimulates milk ejection by the breasts.
Indications
a) Pregnancy
• To induce abortion, labour
• To expedite expulsion of hydatidiform mole
• For oxytocin challenge test
• To stop bleeding following evacuation.
b) Labour
1.To augment labour, in uterine inertia
2. to prevent & treat postpartum hemorrhage
c) Postpartum
1.To initiate milk let-down in breast engorgement.

Contraindications
a) In late pregnancy
• Grand multipara
• Contracted pelvis
• History of LSCS or hysterectomy
• Malpresentation
b) During labour
1. Obstructed labour
2. Incoordinate uterine action
• Anytime - Hypovolemic state, cardiac disease
• Controlled IV infusion (10 units of oxytocin in 1 L of RL/5% Dextrose in water)
• Nasal spray for milk let- down

Adverse effects
1. Hypertonic uterine activity
2. Fetal distress & fetal death
3. Uterine rupture
4. Hypotension
5. Neonatal jaundice
6. Water retention & water intoxication
1. Assess Patient I/O Ratio, Uterine contraction, BP, pulse & respiration.
2. Administer by IV infusion After having crash cart available in the ward.
3. Evaluate patient Length & duration of contractions and Notify physician of
contractions lasting over one minute or absence of contractions.

• Ergot alkaloids are either natural or semi synthetic.
Preparations
• Ergometrine- 0.25mg/ 0.5mg ampoules & 0.5-1mg tablets
• Methergine - 0.2 mg ampoules & 0.5-1mg tablets
• Syntometrine Ergometrine - 0.5 mg+ Syntocinon 5.0 units ampoules.
Mode of Action - Ergometrine acts directly on the myometrium. It stimulates uterine
contractions & decreases bleeding.
Indications Therapeutic
1.To stop the atonic uterine bleeding following delivery, abortion/ expulsion of
hydatidiform mole

Contraindications
1. Suspected plural pregnancy
2. Organic cardiac disease
3. Severe Pre-eclampsia & Eclampsia
Adverse effects
1. Rise of BP due to vasoconstriction action
2. Prolonged use in puerperium may interfere by decrease concentration of prolactin &
gangrene of toes due to vasoconstriction.
• For active management of 3rd stage of labour -0.2mg (1 amp) to be given IM.
• For control of atonic PPH -1amp slowly over 60 seconds, may be repeated after 2hrs.
• For excessive lochia and subinvolution-1 Tablet(0.125mg) TDS for 3 days.

Prophylactic
• As a prophylaxis against excessive hemorrhage, it may be administered after the
delivery of the anterior shoulder with crowing / following delivery of baby.
NOTE
• Ergometrine & Methergine can be used parenterally or orally. As the drug
titanic uterine contractions, it should only be used after delivery of the anterior
shoulder or following delivery of baby.
• It should not be used in induction of labor or abortion.
• Syntometrine should always be administered IM.
1. Assess patient BP, pulse, respiration, signs of hemorrhage
2. Administer Orally/IM deep, have emergency cart readily available
3. Evaluate for decrease blood loss
4. Advised patient to report for increased blood loss, abdominal cramps, headache,
sweating, nausea, vomiting/ dyspnea

• These are synthesized from one of the essential fatty acids, arachidonic acid, which
is widely distributed throughout the body. In the female, these are identified in the
menstrual fluid, endometrium, decidua & amniotic membrane.
Preparations
• Tablet- 0.5mg
• PG E2 – Prostin E2 (Dinoprostone) Gel-0.5mg E2 in 2.5ml gel-comes in pre-loaded
syringe.
• PG F2 alpha- Prostin F2 alpha (Dinoprostodine) Inj- 125 and 250mcg
• PGE1 – Misoprostol Tablet-100mcg,200mcg,600mcg Action Both PGE2 & PGF2
alpha have an oxytocic effect on the pregnant uterus.
• They also sensitize the myometrium to oxytocin. PGF2 alpha acts predominantly on
the myometrium, while PGE2 acts mainly on the cervix.

Indications
1. For induction of abortion during 2nd trimester & expulsion of hydatidiform mole
2. For induction of labor in IUD of fetus
3. In augmentation/ acceleration of labor
4.To stop bleeding from the open uterine sinuses as in refractory cases of atonic PPH
5. Cervical ripening
Contraindications
1. Hypersensitivity
2. Uterine fibroids
3. Cervical stenosis
4. PID
Side effects
1. Headache
2. Dizziness
3. Hypertension
4. leg cramps
5. Joint swelling

• Tablets: containing o.5 mg prostin E2
• Vaginal suppository: containing 20 mg PGE2 or 50 mg PGF2 alpha
• Vaginal pessary: 3mg PGE2 Injectable ampoules/vials of prostinE2
• 1 mg/ml prostin F2 alpha
• 5mg/ml Misoprostol 50mg given 4 hourly by oral, vaginal/ rectal route for
of labour
1. Assess patient RR, rhythm & depth, vaginal discharge, itching/ irritation
2. Administer Antiemetic/ antidiarrheal preparations prior to giving this drug, high in
vagina, after warming the suppository by running warm water over package
3. Evaluate patient for length & duration of contractions, notify physician of
contractions lasting over 1 minute or absence of contractions, fever & chills
4. Advised patient to remain supine for 10-15 minutes after vaginal insertion.

ANTICONVULSANTS-
MAGNESIUM SULPHATE

Preparation
• Inj- 1amp=2ml contains 1gm Mgso4.
• Tablet-64mg
Mode of Action - Decreased acetylcholine in motor nerve terminals, which is
responsible for anticonvulsant properties, thereby reduces neuromuscular
irritability. It also decreases intracranial edema & helps in diuresis. Its
peripheral vasodilatation effect improves the uterine blood supply. Has
depressant action on the uterine muscles & CNS.
Indications
1. It is a valuable drug lowering seizure threshold in women with pregnancy-
induced hypertension.
2. Used in preterm labor to decrease uterine activity.

Contraindications
1. Heart block
2. Impaired renal function
3. Pregnant women actively progressing labor.
Adverse effects
• For control of seizures, 20 ml of 20% solution IV slowly in 3-4 mins, to be followed immediately by
of 50% solution IM & continued 4 hourly till 24 hours postpartum.
• Repeat injections are given only if knee jerks are present, urine output exceeds 100 ml in 4 hours &
respiration are more than 10/ minute.
• The therapeutic level of serum magnesium is 4-7 mEq/L 2. 4gm IV slowly over 10 min, followed by 2
gm/hr and then 1gm/ hr in drip of 5% dextrose for tocolytic effect.
a) Maternal b) Fetal
1. Severe CNS depression
2. Evidence of muscular paresis
1.Tachycardia
2. Hypoglycemia

1. Assess patients Vital signs 15 min after IV dose, do not exceed 150 mg/min
2. Monitor magnesium level If using during labour, time of contractions, determine intensity
3. Urine output should remain 30 ml/hr or more if less notify physician
4. Examine patient Reflexes-knee jerk, patellar reflex.
5. Administer Only after calcium gluconate is available for treating magnesium toxicity
6. Using infusion pump/monitor carefully, IV at less than 150mg/min, circulatory collapse may
occur
7. Provide Seizure precautions: place client in single room with decreased stimuli, padded
rails
8. Positioning of client in left lateral recumbent position to decrease hypotension & increased
renal blood flow
9. Evaluate patient Mental status, sensorium, memory, Respiratory status & Reflexes. 10.
Discontinue infusion if respirations are below 12/min, reflexes severely hypotonic, urine
below 30ml/hr or in the event of mental confusion/ lethargy/ fetal distress.

ANALGESICS
VALETHAMATE BROMIDE (EPIDOSIN)

Preparation Inj-1amp-8mg/ml
Mode of Action - It is both central and peripheral antimuscarinics agent, which is a
competitive inhibitor of acetylcholine at the muscarinic receptor.
Indication
1. Cervical dilatation in the first stage of labor.
2. Symptomatic relief of GI tract and ureteric colic.
Contraindications
1. Paralytic ileus
2. Myasthenia Gravis
3. Hypertension
4. Ulcerative colitis
5. Closed angle glaucoma
6. CVS disorders

Adverse effects
1. Dryness of mouth
2. Thirst
3. Dilatation of pupil
4. Palpitations
5. Giddiness
• Inj-8mg deep IM. It may be repeated after 4 hours if necessary.
1. Advise patient to report for any blurred vision, giddiness, dry mouth immediately.
2. Advise patient to get up from the bed carefully and slowly.

Preparation
Inj-1amp=50mg
Tablet-50mg,100mg,200mg
Mode of Action - Bind to opioid receptor and inhibit reuptake of norepinephrine
and serotonin.
Indications
1. Moderate to moderately severe pain.
2. Safe given during labor as it does not cause depression to fetal respiratory center
and hence safe for baby.
Contraindications
1. Breast feeding mothers
2. Hypersensitivity
3. Hepatic impairment
4. Increased ICP

Adverse effects
1. Dizziness
2. Headache
3. Malaise
4. Hypertonia
Dosage and routes of administration -50 to 100mg IM 6hrly or as required.
1. Monitor patient CV and respiratory status.
2. Monitor patient at risk for seizure.
3. Monitor patient bowel and bladder function.

• Vitamin K (phytonadione at birth, the newborn does not have bacteria in the
colon that necessary for synthesizing fat-soluble vitamin k.
• Therefore, newborns have decreased level of Prothrombin during the first 5
to 8 days of life.
Preparation INJ- 2ml vial=2mg/ml
Mode of Action It promotes the hepatic formation of the clotting factors II,
VII, IX & X.
Indications
1. It is used to treat or prevent certain bleeding problems.
2. It helps liver to produce blood clotting factors
Contraindications
• Hypersensitivity

Adverse effects
1. Pain and edema may occur at injection site.
2. Allergic reaction such as rash and urticarial may occur.
3. Hyperbilirubinemia
Dosage and routes of administration 0.5mg IM within 1 hour of birth.
1. Document the giving of the medication to newborn to prevent an accidental
doubling.
2. Observe for bleeding usually occurs on 2nd and 3rd day.
3. Observe for jaundice
4. Observe for local inflammation.

DRUGS GIVEN DURING
PUERPERIUM
Here are the drugs given during puerperium are: -
1.Iron
2.Folic acid
3.Calcium
4.Acetaminophen(paracetamol)
5.Lactation suppressant (in case of stillbirth, neonatal death, breast abscess or severe
psychiatric illness.

Preparation
• Tablet-80mg,160mg,500mg
• Suppository-80mg,120mg
• Oral solution-16m/ml,80mg/ml
Mode of Action Produce analgesia by inhibiting prostaglandins and other
substances that sensitizes pain receptors.
Indications
1. Mild to moderate pain
2. Fever
Contraindications
1. Liver disease
2. Hypersensitivity

Adverse effects
1. Neutropenia
2. Hemolytic anemia
3. Hypoglycemia
4. Urticaria
Dosage and routes of administration -500mg tablet thrice a day for 5 days
1. Advise the patient to not to exceed the prescribed dose.
2. Advise the patient hat drug is only for short term use and avoid taking
drugs without prescription.
3. Advise patient to take tablet after meal to prevent GI symptoms.

LACTATION SUPPRESSANTS
(BROMOCRIPTINE MESYLATE)

Preparation
• Tablet-0.8mg,2.5mg
Indications
1. Suppression of lactation
2. Pregnancy with prolactinoma
3. Infertility
4.Amenorrhoea
Adverse effects
1. Dizziness or lightheadedness especially when getting up from lying position.
2. Confusion
3. Hallucinations
4. Hypertension
5. Seizures
6. Myocardial infarction

Mode of Action It blocks the release of a prolactin from the pituitary gland.
Dosage and routes of administration 2.5mg tablet orally once in a day.
1. Monitor patient for adverse reactions.
2. Drug may lead to early post-partum conception. after menses resumes,
for pregnancy every 4 weeks or as soon as period is missed.
3. Assess orthostatic vital signs before initiation of the therapy.
4. Instruct the patient to take drug with meal.

Drugs used in pregnancy, labor and puerperium

Drugs used in pregnancy, labor and puerperium

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