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Systemic medications for Pain relief during labor

1. Sedative hypnotics• Generally given for false labor or latent

labor, or with ruptured membranes but no true labor.

• Promotes rest and relaxation and help to reduce fear and anxiety but do not provide pain relief.

• Have ataractic effect (they potentiate the analgesic action of a low-dose narcotic) in addition to decreasing anxiety and apprehension


2. Narcotic agonists• Morphine sulfate may be used for pain

control in active labor in active labor and in prolonged latent labor for “obstetric rest” with a therapeutic goal for the woman to rest or sleep and then wake in active labor.

3. Mixed Narcotic agonist-antagonists• Agonist at one site and an antagonist at

another.


3. Mixed Narcotic agonist-antagonists• Have a ceiling effect in which additional

doses have no effect and do not increase the degree of respiratory depression.

• The agonist should be given first. If agonist-antagonist has been administered first, administration of meperidine provides markedly diminished or no additional pain relief.


GENERIC (BRAND)

ROUTE AND DOSAGE

USES AND CONSIDERATIONS

Sedative Hypnotics Secobarbital (Seconal)

IM: 50-100mgPO: 100-200mg

•Used to decrease anxiety during latent phase of labor•Onset: 10-30 min; peak 20-30 min; duration 4-8 hrs•No effect on uterine tone or contractility; rapidly crosses placenta


GENERIC (BRAND)


Sedative Hypnotics Secobarbital (Seconal)

•Can cause decreased variability in FHR•Administered only if delivery is not expected for 24-48h•Excreted in breast milk•May increase CNS depression with alcohol, narcotics, antihistamines, tranquilizers, and MAOIs•Pregnancy category D


GENERIC (BRAND)

ROUTE AND DOSAGE


Sedative Hypnotics Pentobarbital (Nembutal)

Pregnancy category C

PO: 20-30mg •Short acting barbiturate•SE/AR: paradoxically increased pain and excitability, lethargy, subdued mood, decreased sensory perception, hypotension, decreased FHR variability and neonatal respiratory depression, sleepiness , hypotonia,


GENERIC (BRAND)


Sedative Hypnotics Pentobarbital (Nembutal)


•SE/AR: delayed breastfeeding with poor sucking response for up to 4 days


GENERIC (BRAND)

ROUTE AND DOSAGE


AtaracticsPromethazine HCl (Phenergan)

IM/IV: 12.5-25 mg q4 -6h or IM: 25-50mg with 25-75mg meperidine or IV: 15-25 mg with 25-75mg meperidine; repeat if needed; max 100mg in 24 hrs

•A phenothiazine antihistamine; used as adjunct to narcotic analgesic during 1st stage of labor; antiemetic properties.•Do not give SC•Used alone to promote rest and sleep.•CI during lactation•At term, rapidly crosses placenta


GENERIC (BRAND)


AtaracticsPromethazine HCl (Phenergan)


•Transient hypotonia, lethargy and electroencephalographic changes for 3d in NB•May cause maternal tachycardia, may impair NB platelet aggregation.•If given with miperidine, give slowly at beginning of contraction over several minutes to decrease amount of drug perfused immediately to the fetus via placenta. AR: dizzines, dry mouth, excessive sedation, weakness, blurred vision, and restlessness


GENERIC (BRAND)

ROUTE AND DOSAGE


AtaracticsPamoate (Vistaril, Atarax)

IM: 25-50 mg q4 -6h; repeat if neededIV, SC, and Intraarterial not recommended (causes thrombus and digital gangrene)

•Antianxiety agent; antihistamin; antiemetic; sedative hypnotic.•Used alone early in labor or later to potentiate action of narcotic agonists.•Use Z-track method for IM to reduce pain.•Can cause decreased variability in FHR


GENERIC (BRAND)


AtaracticsPamoate (Vistaril, Atarax)


•Extravasation can result in sterile abscesses and marked tissue induaration.•Use with caution in clients with chronic obstructive pulmonary disease and asthma.•AR: hypotension, drowsiness, dizziness, ataxia; may cause CNS depression with alcohol, analgesics, barbiturates, narcotics; may decrease effects of epinephrine.


GENERIC (BRAND)

ROUTE AND DOSAGE


Narcotic AgonistsFentanyl citrate (Sublimaze)

0.5 to 1 mcg/kg IV titrated in 25 mcg increments over several minutes

•Opioid agonist; 100 times more potent than morphine sulfate. Analgesic activity of 100 mcg is equivalent to 10 mg morphine or 75 mg meperidine. Binds with opiate receptors in the CNS, altering perception and emotional response to pain through an unknown mechanism.


GENERIC (BRAND)



•Only trained in administration of IV anesthetics and management of adverse effects should administer IV fentanyl.•Often used IV with droperidol to produce neuroleptanalgesia.•Have rescucitation equipment and opiate antagonist (naloxone) readily available.•AR: sedation, somnolence, clouded sensorium, euphoria, dizziness, headache, confusion, asthenia, nervousness, hallucination, anxiety,


GENERIC (BRAND)



•AR: depression, seizures, hypotension, hypertension, arrhythmias, chest pain, nausea, vomiting, constipation, abdominal pain, dry mouth, anorexia, diarrhea, dyspepsia, urine retention, respiratory depression, hypoventilation, dyspnea, apnea•Pregnancy category C


GENERIC (BRAND)

ROUTE AND DOSAGE


Narcotic AgonistsMorphine sulfate Opioid analgesicCSS II

SC/IM: 10-15 mg

•Administer drug slowly, rotate injection sites to avoid irritation of local tissue. •Crosses placenta and found in breast milk.•Watch for respiratory depression in neonates of mothers who received this in labor.


GENERIC (BRAND)


Narcotic AgonistsMorphine sulfate Opioid analgesicCSS II

•May see withdrawal symptoms in neonates if mother was a regular opioid user during pregnancy.•Be alert to risk of overdose in clients with circulatory impairment.•Use with extreme caution in clients with asthma, respiratory depression, anoxia, seizures, shock, and acute alcoholism.•Pregnancy category C


GENERIC (BRAND)

ROUTE AND DOSAGE


Mixed Narcotic Agonists-AntagonistsButorphanol tartrate

Pregnancy category B

IM: 2 mg q3- 4h IV: 1mg q3-4h

•Potent nonnarcotic analgesic (2mg dose approximately equivalent to 10-15mg morphine); has mixed narcotic agonist-antagonist mechanism of action with central analgesic actions; binds to CNS opiate receptors and inhibits ascending pain pathways.


GENERIC (BRAND)



•Used for relief of moderate to severe pain; for preoperative medication; as supplement to anesthesia.•Do not give SC•Have naloxone available for antidote•Additive effects with CNS depressants•May see withdrawal symptoms in narcotic-dependent clients; may cause drowsiness and respiratory depression, sedation, euphoria, hallucinations, headache, palpitations.

Systemic medications for Pain relief during laborGENERIC (BRAND)



•Do not give if RR is <12bpm•Use with caution in clients delivering preterm infant because fetus may exhibit decreased beat-to-beat variability on FHR monitor.•NB may have moderate CNS depression, hypotonia at birth, and mild behavioral dpression.

Systemic medications for Pain relief during laborGENERIC (BRAND)

ROUTE AND DOSAGE


Mixed Narcotic Agonists-AntagonistsNalbuphine(Nubain)

Pregnancy category B

SC/IM/IV: 10-20 mg q3- 4h PRN; Max: 160 mg/d

•Limited respiratory depression.• Less analgesic effect than morphine.•About 10-15% of laboring women experience hallucinations with nalbuphine.•Toxicity can be reversed with naloxone.

Drugs that enhance Uterine Muscle Contractility

INDICATIONS FOR LABOR INDUCTION

CONTRAINDICATIONS TO LABOR INDUCTION

PIHChronic HypertensionMembrane rupture >24 hrsChorioamnionitisPostdates (>42wks AOG)Intrauterine growth retardationPositive contraction stress test (CST)Maternal DM (classes B-F)RH IsoimmunizationIntrauterine fetal death

Cephalopelvic disproportionNonfavorable fetal presentationDocumented fetal intolerance of uterine contractionsPrematurityPlacenta previa and/ or susceptible abruptio placentaSevere PIHGrand multiparityMultifetal gestationHistory of uterine traumaPrevious major surgery in the area of cervix or uterusExcessive amniotic fluid causing overdistended uterus


GENERIC (BRAND) ROUTE AND DOSAGE


Dinoprostone cervical gel, 0.5 mg (Prepidil Gel)

Endocervical: supplied in 3 g prefilled syringe applicators; 3 doses (1dose q6h) 6h after last dose IV oxytocin administered; max: 1.5mg/24 h (7.5 ml or 3 syringes

•Prostaglandin•Used to ripen unfavorable cervix at or near term in pregnant women needing labor induction.•Must be administered in a hospital with intensive care and acute surgical facilities.•Clients should have a reactive nonstress test before 1st dose.


GENERIC (BRAND)



•Monitor uterine activity and FHR•Drug must not be placed above level of cervical os•Client is to remain recumbent 1h following each dose.•Used with caution in clients with renal or hepatic dysfunction, asthma, glaucoma, or increased intraocular pressure.•Not recommended for clients whom oxytocic drugs are contraindicated or with prolonged uterine contractions, placenta previa or active genital herpes


GENERIC (BRAND)



•AR: Uterine hyperstimulation, nausea, vomiting, diarrhea, back pain, fetal distress

•Pregnancy category C




Dinoprostone (Cervidil Vaginal Inserts)

Intravaginal: 10mg over 12 h; remove 12 h after insertion or at onset of active labor

•Administer only in setting with emergency equipment and trained personnel•Use suppository at rm temperature•Provider should wear gloves to decrease risk of absorption as inserted high into the vagina.•Client should remain in lying position 10 min after administration.


GENERIC (BRAND)


Dinoprostone (Cervidil Vaginal Inserts)

•Have medication available for frequent GI side effects of abdominal cramping, diarrhea, nausea, and vomiting•Provide emotional support


GENERIC (BRAND)

ROUTE AND DOSAGE


Oxytocin (Pitocin, Syntocinon)

Pregnancy category X

For induction of laborIV: 10 units (1amp) diluted in 1L LR in 10 mU/ml; connect to primary IV line

•MOA: Action of myofibrils to stimulate letdown of milk and promote uterine contraction.•To induce or augment labor contractions; to treat uterine atony; milk letdown (nasal spray)


GENERIC (BRAND)

ROUTE AND DOSAGE




PostdeliveryIV:10-20 units added to 1L electrolyte or dextrose solutionIM: 10 units after delivery of placenta

•CI: Proven cephalopelvic dysproportion, fetal intolerance of labor, hypersensitivity, anticipated nonvaginal delivery, pregnancy (intranasal spray)•SE: Maternal effects with undiluted IV use only: Hypotension, hypertension, nausea, vomiting,


GENERIC (BRAND)

ROUTE AND DOSAGE




Nasal spray: 1 spray into 1 or both nostrils 2-3 min. before nursing or pumping; not for use during pregnancy

•SE: constipation, decreased uterine blood flow, rash, anorexia•AR: Seizures, water intoxication with large doses•Life threatening:Client: Intracranial hemorrhage, cardiac dysrhythmias, asphyxiaFetus: jaundice, hypoxia

Drugs that enhance Uterine Uterine Motility




Ergonovine maleate (Ergotrate)

Refer above

PO: 0.2-0.4 mg (1-2 tabs) q6- 12h over 48 hIM: 0.2 mg q2-4h; max: 5 doses IV: 0.2 mg over 1 min while BP is monitored ( for acute emergency)

•Refer above

•Oxytocic, ergot alkaloid•MOA: Directly stimulate vascular smooth muscle to vasoconstrict peripheral and cerebral vessels•I: Prevent and treat postpartum or postabortion hemorrhage caused by uterine atony


GENERIC (BRAND) USES AND CONSIDERATIONS

Ergonovine maleate (Ergotrate)


•CI: Coronary artery disease, , hypertension, PIH, before delivery of placenta•Use with caution in clients with sepsis or hepatic or renal impairment.•AR: diaphoresis, palpitations, transient chest pain, thrombophlebitis, seizures, CVA, dizziness, headache, nausea, vomiting, tinnitus, dyspnea




Methylergonovine maleate (Methergine)

PO: 0.2-0.4 mg q6- 12h max: 1wkIM: 0.2 mg after delivery of anterior shoulder, after delivery of placenta, or postpartum; repeat q2-4h, oral may follow parenteral

•I: Prevent and treat subinvolution, postpartum or postabortion hemorrhage•CI: maternal sepsis, labor induction, threatened spontaneous abortion, do not use with vasodepressors, other ergot alkaloids, or vasoconstrictors.




Methylergonovine maleate (Methergine)


IV: Same as for IM; but slowly over 1 min with careful monitoring of BP

•AR: transient hypertension, diaphoresis, palpitations, dizziness, headache, nausea, vomiting, tinnitus, transient chest pain, dyspnea

Drugs used during the Postpartum period

5 Primary purposes:1. To prevent uterine atony and postpartum

hemorrhage.2. To relieve pain from uterine contractions,

perineal wounds, and hemorrhoids.3. To enhance or suppress lactation.4. To promote bowel function.5. To enhance immunity.

Drugs used for pain relief for Perineal Wounds



Benzocaine (Americaine, Dermoplast OTC)

Spray liberally tid or qid 6-12 inches from perineum after perineal cleansing

• Local anesthetic inhibits impulses from sensory nerves as a result of alteration of cell membrane permeability to ions. •CI: Secondary bacterial infection of tissue and known hypersensitivity

Drugs used for pain relief for Perineal Wounds



Witch Hazel pads (Tucks)

Apply premoistened pads tid or qid to wound site

• Precipitates protein, causing tissue to contract. May be chilled/refrigerated in original container for additional comfort. If liquid, pour over ice and dip absorbent pads into solution; change when diluted.•SE: local irritation (discontinue)

Drugs used for pain relief for Hemorrhoids



Hydrocortisone acetate 10mg (Anusol HC, Anusol Ointment)


1 suppository bid for 3-6 days

• Relieves pain and itching from irritated anorectal tissue. Acts as an antiinflammatory agent. • Wear gloves. • Contraindicated with hypersensitivity. If second infection in tissue, discontinue. If anorectal symptoms do not improve in 7 d or if bleeding, protrusion, or seepage occurs, inform health care provider.




Hydrocortisone acetate 1% and promazine HCL 1% topical aerosol (Proctofoam-HC)

1 applicator transferred to a 2x2 inch pad and placed against rectum inside peripad bid or tid and after BM

• Same actiona and considerations as above. • Shake foam aerosol before use.• SE: burning, itching, irritation, dryness, infrequent folliculitis reactions.




Dibucaine ointment USP 1% (Nupercaine)


Apply as above tid or qid using no more than 1 tube in 24 h

• Action same as benzocaine• Do not use if rectal bleeding is present• Don’t use near eyes or over denuded surfaces or blistered areas. • Don’t use if known hypersensitivity to amide-type anesthetics• SE: burning, tenderness, irritation, inflammation, contact dermatitis, urticaria, cutaneous lesions, edema

Drugs used for promotion of Bowel function



Docusate sodium (Colace) 50 mg or 100 mg capsuleDocusate calcium (Surfak) 240 mg capsule

50-200 mg PO daily usually hs 50-400 mg PO daily in 1-4 divided doses

• Reduces surface tension of the oil-water interface of the stool, resulting in enhanced incorporation of water and fat, allowing for stool softening.• Do not use concomitantly with mineral oil. • CI: Intestinal obstruction, acute abdominal pain, nausea, or vomiting present.




Docusate sodium (Colace) 50 mg or 100 mg capsuleDocusate calcium (Surfak) 240 mg capsule


50-200 mg PO daily usually hs 50-400 mg PO daily in 1-4 divided doses

• Do not use > 1 wk; prolonged use may cause bowel dependence or electrolyte imbalance. • Compatible with breastfeeding• SE: bitter taste, throat irritation, rash




• Casanthranol with docusate sodium (Peri-Colace); docusate sodium 100mg; casanthranol 30mg

• Docusate potassium (Dialose Plus)

1-2 caps PO usually hs

1 cap PO daily/ bid

• Mild stimulant laxative.• Should be taken with full glass of water• Do not use if abdominal

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