3. OXYTOCIN
It is synthesised in the supra-optic and para
ventricular nuclei of the hypothalamus.
a half life of 3-4 minutes and duration of
action of approximately 20 minutes
Mode of action
receptor and voltage mediated calcium
channels
amniotic and prostaglandin decidual
production
5. INDICATIONS
THERAPEUTIC:
Pregnancy:
Early:
• to accelerate abortion.
• To stop bleeding following evacuation of the
uterus.
• Used as an adjunct of abortion along with
other abortifacient agents.
Late:
• To induce labour.
• To facilitate cervical ripening for effective
induction.
• Augmentation of labour.
• Uterine intertia.
6. INDICATIONS
Labour:
In active management of third stage of labour.
Following expulsion of placenta.
Pueperium:
To minimize the blood loss and to control the PPH.
DIAGNOSTIC:
Contraction stress test
Principles:
The test is based on the determination of
respitratory function of the feto placental unit
during induced contractions
7. CST
Candidates for CST:
Intra uterine growth restriction.
Postmaturity.
Hypretensive disorders of pregnancy.
Diabetes
Contraindications:
Compromised fetus.
Previous history of caesarean section.
Complications likely to produce preterm labour.
APH.
8. INTERPRETATION :CST
Positive: persistent late deceleration of FHR following
50 % or more uterine contrations.
Negative: no late deceleration or significant variable
deceleration.
Suspicious: inconsistent but definite decelerations do
not persist with more uterine contractions.
Unsatisfactory: poor quality of recording or adequate
uterine contraction is not achieved.
Hyperstimultaion:
Deceleration of FHR with uterine contraction lasting >
90 seconds or occurring more frequently than every 2
minutes.
9. OXYTOCIN STIMULATION TEST
Procedure
Inference
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.
Fetal distress.
Any time:
Hypovolemic state.
Cardiac disease.
10. OXYTOCIN STIMULATION TEST
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
11. ADVERSE EFFECTS
MATERNAL
Uterine hyperstimulation
Uterine rupture
Water intoxication
Hypotension
Anti-diuresis
FETAL
Fetal distress, fetal hypoxia and fetal death
12. NURSE’S 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 contrcations.
Teach
To report increased blood loss, abdominal cramps or
increased temperature.
13. ERGOT DERIVATIVES
Mode of action:
Ergometrine acts directly on the myometrium
Effectiveness
It is highly effective in hemostasis
Indications:
Therapeutic:
To stop the atonic uterine bleeding following delivery,
abortion or expulsion of hydatidiform mole.
Prophylactic:
Against excessive haemorrhage following delivery.
16. Onset of action
Routes Ergometrine Methergin
IV
IM
Oral
45-60sec
6-7mt
10 mt
5.min
7 min
10 min
17. 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.
18. 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
19. ERGOT DERIVATIVES
Nurse’s 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.
21. PROSTAGLANDINS
Use in obstetrics
Induction of abortion.
Termination of molar pregnancy.
Induction of labour.
Cervical ripening prior to the induction of abortion or
labour.
Acceleration of labour.
Management of atonic PPH.
Medical management of tubal ectopic pregnancy.
23. PROSTAGLANDINS
Advantages:
It has got a powerful oxytocic effect,
irrespective of period of pregnancy. As such
it can be used independently specially in the
induction of abortion with success.
In later months it can be used for
acceleration of labour.
It has got no anti diuretic effect.
24. PROSTAGLANDINS
Drawbacks:
It is costly.
Unpleasant side effects on systemic use are
nausea, vomiting, diarrhoea, pyrexia or
bronchospasm.
When used as abortifacient, extensive lacerations
may occur.
Tachysystole.
25. ANTI-HYPERTENSIVE THERAPY
1. Symp
athom
imetic
s
1. adrenergic
Receptor
blocking
agent
1. vasodilat
ors
1. calcium
channe
l
blocke
rs
1. ACEI
Inhibit
ors
Methyldo
pa
Reserpin
e
Labetalol
Propanalol
Hydralazine
Prazocin
Sodium
nitroprusside
Nifedipine
nicardia
Captopril
lisinopril
26. METHYLDOPA
Mechanism of action
-Drugs of first choice
-Central and peripheral anti-adrenergic action
-Effective and safe for both mother and fetus.
Contraindications
-hepatic disorders
-psychic patients
-CCF
Dose
-orally 250mg bid may be increased to 1 gm tid
depending upon the response.
-IV infusion 250-500mg
28. LABETALOL
Mechanism of action
Combined alpha and beta adrenergic blocking agents.
Contraindication
hepatic disorders.
Dose
orally: 100mg tid. May be increased upto 800 mg daily.
-IV infusion [hypertensive crisis] 1-2 mg/mt until desired
effect
Side effects
Experience is less compared to methyl dopa. efficacy
and safety with short term use. Appear equal to methyl
dopa.
29. PROPRANOLOL
Mechanism of action
Beta adrenergic receptor blocker
Contraindication
bronchial asthma.
renal insufficiency.
diabetes.
Cardiac failure
The drug is better avoided for long term therapy
during pregnancy.
Dose
orally: 80-120 mg in divided doses
30. PROPRANOLOL
Side effects
maternal:
severe hypotension
sodium retension
Bradycardia
Bronchospasm
CCF
hypoglycaemia.
fetal:
bradycardia and impaired fetal responses to hypoxia,
IUGR when began in I and II trimester.
-neonatal: hypoglycaemia
31. PRAZOCIN
Mechanism of action
-selective post synaptic blocker. Decrease plasma
renin activity.
-reduces cardiac preload and after load.
Contraindication
Low first dose, to avid hypotension and syncope.
Dose
Orally 1 mg bd may be increased upto 20 mg/day
Side effects
-hypotension
-nasal congestion
-fluid retension
32. HYDRALAZINE
Mechanism of action
Arteriolar vasodilator.
Contraindication
Because of the variable sodium retention, diuretics should
be used.
Dose
orally: 100mg/day in 4 divided doses.
-IV : 5mg bolus followed by 25g in 200 ml NS at a rate of
2.5 mg/hr to be doubled every 30 mts.
Side effects
-maternal: hypotension,tachycardia, arrhythmia,
palpitation, lupus like syndrome.
-fetal: reasonably safe.
-neonatal: thrombocytopenia
33. NIFEDIPINE
Mode of action:
Direct arteriolar vasodilation.
Dose:
Orally 5-10 mg TID.
Contraindications:
Simultaneous use of magnesium sulphate could
be hazardous due to synergic effect.
Side effects:
Flushing
Hypotension
Head ache
Tachycardia
Inhibition of labour.
34. SODIUM NITROPRUSSIDE
Mechanism of action:
Direct vasodilator.
Dose:
Orally 6.25 bid.
Side effects:
Maternal
Nausea
Vomiting
Fetal
Oligohydramnios
IUGR
Fetal and neonatal renal failure.
35. NITROGLYCERINE
Mechanism of action
Release mainly venous but also arteriolar smooth
muscles.
Dose:
Given as IV infusion 5µg/min. to be increased at
every 3-5 min. upto 100µg/min.
Side effects:
Tachycardia
Headache
Methaemoglobinaemia
36. 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 as adjunct to certain antihypertensive
drugs, such as hydralazine or dioxide
37. FUROSEMIDE
Mechanism of action
Acts o 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, parentrally 40-120 mg
daily.
Contraindications:
Hypersensitivity
39. HYDROCLOROTHIAZIDE
Mechanism of action:
Acts on distal tubule by increasing excretion of
water, sodium, chloride and potassium. It is used in
edema and hypertension.
Dose:
PO 25-100 mg/day.
Side effects:
Polyuria, glycosuria, frequency.
Nausea, vomiting, anorexia.
Rash, urticarial, fever.
Increased creatinine, decreased electrolytes.
41. BETAMIMETICS
Commonly used drugs:
Terbutaline
Ritodrine
Isoxurpine
Mechanism of action:
Activation of the intracellular enzymes [adenylate
cyclase, cAMP, protein kinase] reduces intracellular
free calcium [Ca++] and inhibits the activation of
MLCK
42. BETAMIMETICS
Dose:
Ritodrine is given by IV infusion, 50µg/min. and
increased by 50µg every 10 min. until contractions
cease. Maximum dose of 350µg/ min. may be given.
Infusion is continued for about 12 hours after
contraction cease.
Terbutaline has longer half life and has fewer side
effects. Subcutaneous injection of 0.25 mg every 3-4
hours is given.
Isoxurpine is given as IV drip 100 mg in 5D. Rate 0.2
µg/minute. To continue for at least 2 hours after
contraction ceases. Maintenance is by IM 10mg six
hourly for 24 hours, tab 10 mg 6-8 hourly.
44. BETAMIMETICS
Side effects
Hyperglycemia
ARDS
Hyperinsulinemia
Lactic academia
Hypokalemia
Even death
Neonatal:
Hypoglycaemia
Intraventricular haemorrhage
45. INDOMETHACIN
Mechanism of action:
Reduces synthesis of PGs thereby reduces intracellular
free Ca++, activation of MLCK and uterine contractions.
Dose:
Loading dose , 50 mg P.O. or .P.R. followed by 25mg
every 6 hrs for 48 hours.
Side effects:
Maternal
Heart burn
G.I. bleeding
Asthma
Thrombocytopenia
Renal injury.
46. CALCIUM CHANNEL BLOCKERS
Nifedipine
Nicardipine
Mechanism of action:
Nifedipine blocks the entry of calcium inside the cell.
Compared to β- mimetics, effects are less. It is
equally effective to MgSO4.
Dose:
Oral 10-20 mg every 6-8 hours.
48. MAGNESIUM SULPHATE
Mechanism of action:
inhibition to calcium ion
Contraindications:
Myasthenia gravis
Impaired renal function
Dose:
Loading dose: 4-6 gm I.V. over 20-30 min. followed
by an infusion of 1-2 gm/hr to continue tocolysis for
12 hours after contarctions have stopped.
50. OXYTOCIN ANTAGONISTS:
Atosiban
Mechanism of action:
It blocks myometrial oxytocin receptors.
Dose:
I.V.infusion 300µg/min. initial bolus may be needed.
Side effects:
Nausea
Vomiting
Chest pain
51. 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.
52. MAGNESIUM SULPHATE
Side effects:
MgSO4 is relatively safe and is the drug of choice.
Muscular paresis[ diminished knee jerks],
respiratory failure. Renal function to be monitored.
Antidote:
Injection of calcium gluconate 10% 10 ml IV.
53. DIAZEPAM
mode of action:
central muscle relaxant and anticonvulsant.
Dose:
20-40 mg IV
Side effects:
Maternal:
Hypotension
Fetal
Respiratory depression
Hypotonia
Thermoregulatory problem
54. PHENYTOIN
Mode of action:
Centrally acting anticonvulsant
Dose:
10 mg/ kg IV at the rate not more than 50 mg/ min
followed 2 hrs later by 5 mg/kg. In epilepsy 300-
400 mg daily orally in divided doses.
Side effects:
Maternal
Hypotension
Cardiac arrhythmias
Phlebitis at injection site.
Fetal
Fetal hydantoin syndrome
55. ANTICOAGULANTS:HEPARIN
Mechanism of action:
It inhibits action of thrombin
Dose:
5000-10000 I.U. to be administered parenterally [SC or IV].
Low molecular weight heparin is 2500 IU
Side effects:
Maternal:
Haemorrhage
Urticarial
Thrombocytopenia
Osteopenia.
Fetal
It does not cross the placenta
56. WARFARIN
Mechanism of action:
Interferes with synthesis of vit K dependent factors.
Dose:
10 mg orally
Side effects:
Maternal
Haemorrhage
Fetal
Contradi’s syndrome [skeletal and facial anomalies]
Optic atropy
Microcephaly
Chondrodisplasia punctate.
57. ANALGESIA AND ANAESTHESIA IN
OBSTETRICS
1. SEDATIVES AND ANALGESICS
OPIOID ANALGESICS:
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.
58. PETHIDINE
Contraindications:
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 reduced
60. FENTANYL
Mechanism of action:
Inhbits ascending pathways in CNS, increases pain
threshold and alters pain perception.
Indications:
Moderate to severe pain in labour, post operative
apin an dadjunct to general anaesthetic.
Dose:
0.05 to 0.1 mg IM q1-2 hrs prn. Available in
injectable form, 0.05 mg/ml.
62. PENTACOZIN
dose of 30-40 mg
Naloxone is an efficient and reliable antagonist.
Adverse effects
Neonate respiratory depression secondary tothe
medication crossing the placenta and affecting
the fetus.
Unsteady ambulation of the client.
Inhibition of the mother’s ability to cope with the
pain of labor.
63. TRANQUILIZERS
DIAZEPAM:Usual dose is 5-10 mg.
MIDAZOLAM:Dose of 0.05 mg/kg is given
intravenously
COMBINATION OF NARCOTICS AND
TRANQUILIZERS
BUTORPHANOL and NALBUPHINE
64. INHALATIONAL METHODS
Nitrous oxide and air
Premixed nitrous oxide and oxygen
Trichloroethylene
Methoxyflurane, isoflurane, enflurane
65. EPIDURAL AND SPINAL REGIONAL
ANALGESIA
Adverse effects
nausea and vomiting.
Inhibition of bowel and bladder elimination
sensations.
Bradycardia or tachycardia.
Hypotension.
Respiratory depression.
Allergic reaction and pruritus.
66. PUDENDAL BLOCK
It consists of a local anesthetic such as
lidocaine(Xylocaine) or bupivacaine (Marcaine)
being administered transvaginally into the space in
front of the pudendal nerve.
67. EPIDURAL ANAESTHESIA
Epidural block consists of a local anesthetic
bupivacaine (Marcaine) along with an
analgesic morphine (Duramorph) or fentanyl
(Sublimaze) injected into the epidural space at the
level of the fourth of fifth vertebrae.
Adverse effects
Maternal hypotension.
Fetal bradycardia.
Inability to feel the urge to void.
Loss of the bearing down reflex.
68. SPINAL BLOCK
Spinal block consists of a local anaesthetic injected
into the subarachnoid space into the spinal fluid at
the third, fourth, or fifth lumbar interspace, alone or
in combination with an analgesic such as fentanyl .
Adverse effects
Maternal hypotension.
Fetal bradycardia.
Loss of the bearing down reflex.
69. PARACERVICAL BLOCK
It consists of lidocaine (Xylocaine) being injected
into the cervical mucosa early in labor during the
first stage to block the pain of uterine contractions.
Adverse effects include fetal bradycardia. Improper
technique can result in serious toxicity.
70. GENERAL ANAESTHESIA
100% oxygen is administered by tight mask fit for
more than 3 minutes. Induction of anaesthesia is
done with the injection of thiopentone sodium 200-
250 mg as a 2.5 % solution IV.,followed by
refrigerated suxamethonium 100 mg. the patient is
intubated with cuffed ET tube. Anaesthesia is
maintained with 50% NO2 , 50% oxygen and a trace
of halothane. Relaxation is maintained with non-
depolarizing muscle relaxant [ vecuronium 4 mg or
atracurium 25 mg].
71. FETAL HAZARDS ON MATERNAL
MEDICATION DURING PREGNANCY
Mechanism of teratogenicity
Folic acid deficiency.
Epoxides or arena oxides
Environmental and genes
abnormalities.
Maternal disease and drugs
Homebox genes
72. Maternal-fetal drug transfer and the hazards:
before D 31:
Teratogen produces an all or none effect.
D31-d71:
It is the critical period for organ formation.
After D 71:
The development of other organs continues.
73. PLACENTAL TRANSFER OF DRUGS
The factors responsible for transfer are:
Molecular weight [molecular wght more than 1000
Da do not cross the placenta].
Concentration of free drug.
Lipid solubility.
Utero-placental blood flow.
Placental solubility.
74. GUIDELINES
If the benefit outweighs the potential risks, only then
can the particular drugs be used with prior
counselling.
Only, well tested and reputed drugs are to be
prescribed and that too using the minimum
therapeutic dosage for the shortest possible
duration.
75. CATEGORY DESCRIPTION EXAMPLE
A Adequate studies in pregnant woman have failed to show a risk to the fetus in
the first trimester of pregnancy; there is no evidence of risk in last trimester.
Thyroid hormone
B Animal studies have shown an adverse effect on the fetus. But, there are no
adequate studies on humans. Pregnancy risk is unknown.
Insulin
C Animal studies have shown an adverse effect on the fetus, but there are no
adequate studies on humans, or there are no adequate studies in animals or
humans. Pregnancy risk is unknown.
Docusate-sodium
D There is evidence of risk to the human fetus, but potential benefits of use in
pregnant woman may be acceptable despite potential risks.
Lithium acetate
X Studies in animals or humans show fetal abnormalities, or adverse reaction
reports indicate evidence of fetal risk. The risks involved clearly outweigh
potential benefits
isotretinoin
76. drug Teratogenic effect
Cytotoxic drugs
-Diethyl stilbestrol
-androgenic steroids
-lithium
-anticonvulsants
Phenytoin
Valproate
-aspirin
-paracetamol
multiple fetal malformations and abortion.
vaginal adenosis, cervical hoods, uterine hypoplasia of
the female offspring.
masculinization of the female offspring.
cardiovascular anomalies, neonatal goitre, hypotonia and
cyanosis.
benefits of treatment outweigh the risks to the fetus.
Polytherapy should be avoided.
Increase risk of neural tube defects, neonatal bleeding.
high doses in the last few weeks cause premature
closure of ductus arteriosus. Persistent pulmonary
hypertension and kernicterus in newborn.
amount too small to be harmful.
77. drug Tertogenic effect
antimalarials
-corticosteroids
-aminoglycosides
-chloramphenicol
-tetracycline
-quinolones
-long acting
sulphonamides
-nitrofurantoin
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.
Auditory or vestibular damage.
Gray baby syndrome [peripheral vascular collapse].
Dental discolouration [yellowish] and deformity.
Inhibition of bony growth- should be avoided.
Arthropathy in animal studies
Neonatal hemolysis, jaundice and kernicterus.
Hemolysis in newborn with G6 PD deficiency, if used at term
78. drugs Teratogenic effect
-metronidazole
-ACE inhibitors
-vitamin K[large dose]
-all live viral vaccines
-narcotics
-anaesthetic agents
-anticogulants
[warfarin]
-antidepressants
[imipramine]
-benzodiazapines
o No evidence of fetal or neonatal toxicity,
high doses regimens should not be used.
o IUGR, fetal and neonatal renal failure.
o Hyperbilirubinemia and kernicterus.
o Potentially dangerous to the fetus.
o Depression of CNS-apnoea, bradycardia
and hypothermia.
o Convulsion, bradycardia, acidosis,
hypoxia, and hypertonia.
o Fetal bleeding and anomalies.
o cardiovascular abnormalities.
o Growth restriction, CNS dysfunction.
79. 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.
80. DRUGS IDENTIFIED AS HAVING EFFECT ON
LACTATION AND THE NEONATE
Bromide: Rash. Drowsiness, and poor feeding.
Iodides: Neonatal hypothyroidism
Chloramohenicol: 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.