Medication used
during labor
Outline
o Introduction
o Classifications of medication used during stages of
labour
o Indications for each medication
o Side effects of each medication
o Contraindications for each medication
o Dose and protocol for each medication
o Nursing role for each medication
o Conclusion
o References
Introduction
Labour is a big challenge for most pregnant ladies. It is
defined as the period extended from regular uterine
contractions until two to four hours after delivery of
placenta.
Usually certain medications are used during labor such as
methergin while sometimes other medications are used in
certain cases such as Buscupan.
Purpose of medications given during
different stages of labour
Medications given to women during labour are classified as
the following purposes
No.
Purpose of
medication
name of
medications
Stage of labour in
which the medication is
given
Pregnancy risk factor
1
Laxative
Phosphate rectal
enema
First stage of labour
(early phase)
C
2
Induction of labour
medication
Syntocinon
First stage of labour
(usually early phase)
C
3
Analgesia
medication
Buscupan
First stage of labour
AU: B2
4
Anesthesia
medication
Epidural anesthesia
Spinal anesthesia
First stage (usually early
phase for epidual and
any phase early and
active phase for spinal)
Fentanyl B & Bupivacine
C
5
Bleeding
preventive
medication
Methergine
Third and fourth stage of
labour
Contraindicated during
pregnancy
Phosphate rectal enema
o
o
o
o
o
o
Classification and mechanism of action
Indications
Contraindications
Side effects
Dose and protocol of administration
Nursing role
Classification and mechanism of action
Rectal sodium phosphate is in a class of
medications called saline laxatives.
It works by drawing water into the large intestine
to produce a soft bowel movement.
Indications
Phosphate rectal enema is usually administered to
pregnant women in the early phase of the first stage of
labour (in normal delivery).
It is provided to women in labour for the purpose of
emptying the rectum in order to provide more space for the
fetus to descend and to prevent passing stool in the second
stage of labour while the fetus is coming out from the birth
canal to avoid stool contact with the baby.
Contraindications
Phosphate enema contraindications during labour include:
o Diarrhea
o Planed cesarean section delivery
o Intestinal obstruction diagnosed laboring woman
o Hemorroids
o Hyperphosphatemia
o Hypocalcemia because it causes electrolytes loss from GI
o Dehydration
o Fetal distress because it may stimulate or aggravate uterine
contractions that may worsen fetal heart
Side effects
o
o
o
o
o
o
o
Nausea
Stomach pain
Bloating
Anal discomfort, stinging, or blistering
Chills
Dizziness
Vomiting
Dose and protocol of use
Contents of one 4.5 oz enema as a single dose. And some times
double dose is given.
Phosphate enema is usually given shortly after the laboring woman is
admitted. Let the patient wear gown and lie on left lateral position with
upper knee flexion to make it easier to view the anus. Then ask the
patient to have deep breathing while inserting the tip of the enema after
applying lidocaine gell to prevent anal injury. After that, squeeze the
enema bottle until the whole content is emptied in the rectum. Then,
remove the bottle while still squeezing. Finally inform the patient to hold
it for at least ten minutes before going to bathroom.
Nursing role
o Provide psychological support
o Abdominal assessment for the patient including fetal heart and
bowel sounds
o Obtain history about bowel habits and medical or surgical problems
o Perform education regarding the procedure and advice the woman
to hold the enema for at least ten minutes before going to the
bathroom
o Perform assessment regarding effect of enema after going to the
bathroom
o Obtaining vital signs and fetal heart measurement before and after
the procedure
Syntocinon (oxytocin)
o
o
o
o
o
o
Classification and mechanism of action
Indications
Contraindications
Side effects
Dose and protocol of administration
Nursing role
Classification and mechanism of action
Oxytocin is an Oxytocic. The physiologic effect of oxytocin is by means
of Increased Uterine Smooth Muscle Contraction or Tone. The
chemical classification of oxytocin is Oxytocin.
Recombinant Oxytocin is a synthetic cyclic peptide form of the naturally
occurring posterior pituitary hormone oxytocin.
Indications
o Induction of labour
o Bleeding prevention in the forth stage of labour
by enhancing uterine contractions
Contraindications
o
o
o
o
o
o
o
Cephalopelvic disproportion
Fetal malpresentation or malposition
Planed cesarean delivery
Hypertonic uterine contractions
Fetal distress
Previous two or more cesarean delivery
Known drug sensitivity
Side effects
For the mother
o Nausea
o Vomiting
o Premature ventricular contractions
o Pelvic hematoma
o Hypertonic uterine contractions in case of overdose
For the fetus
o Bradycardia
o Premature ventricular contractions and other arrhythmias
o Permanent CNS or brain damage
o Fetal death
Dose and protocol of use
Nulliparous Women
A senior midwife may commence oxytocin in a nulliparous woman in the first or
second stage of labour at ≥37 weeks’ gestation (with a singleton pregnancy
and
cephalic presentation).
Oxytocin should not be commenced if there is suspicion of non-reassuring fetal
testing.
Continuous electronic fetal monitoring should be performed for a minimum of
20 minutes before starting oxytocin, and should be continued until the baby is
delivered. If there is non-reassuring fetal testing the oxytocin should not be
commenced until the CTG trace has been reviewed by a senior obstetrician
and prescribing oxytocin is the responsibility of the obstetrician.
Dose and protocol of use
Multiparous without a previous scar
Before a multiparous woman in the first or second stage of labour is started on
oxytocin, a clinical assessment must be performed by a senior obstetrician.
Continuous electronic fetal monitoring should be performed for a minimum of
20 minutes before starting oxytocin, and should be continued until the baby is
delivered.
Before a decision is made to commence oxytocin the frequency of uterine
contractions needs to be monitored and recorded in the clinical notes.
Dose and protocol of use
Multiparous woman with a previous caesarean section
Before a multiparous woman with a low transverse uterine scar in labour is
started on oxytocin, a clinical assessment should be performed by a senior
obstetrician. The decision to start oxytocin should be made by a consultant
obstetrician.
Continuous electronic fetal monitoring should be performed for a minimum of
20 minutes before starting oxytocin, and should be continued until the baby is
delivered.
Before a decision is made to commence oxytocin the frequency of contractions
needs to be monitored and documented and recorded in the notes.
The decision to continue treatment with oxytocin should be reviewed made by a
consultant obstetrician if the woman is not delivered within two hours.
Dose and protocol of use
Twin Pregnancy
The decision to accelerate labour in a twin (or multiple) pregnancy should be
made by a senior obstetrician.
A CTG tracing of both babies must be commenced before administering the
oxytocin infusion. If there is any cause for concern the oxytocin should not be
commenced until the CTG trace has been reviewed by a senior obstetrician.
Dose and protocol of use
Procedure for administration of Oxytocin Infusion
(Acceleration and Induction of labour)
A standard dose of 10 iu oxytocin is added to 1 litre of normal saline (NaCl)
0.9%. An oxytocin drug additive label is placed on the infusion bag and signed,
dated and timed by the person adding the drug and by the person who checked
it. The oxytocin should be administered using an infusion pump. Oxytocin in
labour should be constituted by adding 10 IU oxytocin to 1 litre of 0.9% normal
saline starting at an infusion rate of 1-5mU/min (6-30 ml per hour). The infusion
rate may be increased by 1-5mU/min (6-30ml/hour) every 15-30 minutes up to
a maximum of 30mU/min (180 ml/hour).
The oxytocin infusion rate should be titrated against the fetal heart rate,
frequency of uterine contractions and progress in labour. If there is non
reassuring fetal testing present while on oxytocin, the woman should be
reviewed by an obstetrician. Consideration should be given to performing a
fetal blood sample and reducing or stopping oxytocin.
Nursing role
o
o
o
o
o
o
o
o
o
Provide psychological support
Perform uterine contraction assessment
Obtaining obstetrical, medical and surgical history
Measuring vital signs and fetal heart rate
Initiate the medication while the mother under strict observation via
fetal heart and uterine contraction monitoring
Frequent emptying of the urinary bladder
Maintain hydration
Once fetal distress happens, stop oxytocin, lay the patient on left
lateral position, provide oxygen, maintain hydration and inform the
physician
Frequent observation and adjustment to the infusion rate of oxytocin
in accordance with fetal heart and uterine contraction as indicated
by the physician
Buscupan
o
o
o
o
o
o
Classification and mechanism of action
Indications
Contraindications
Side effects
Dose and protocol of administration
Nursing role
Classification and mechanism of action
Hyoscine belongs to the group of medications called
antispasmodics.
Hyoscine is used to relieve smooth muscle spasms
(cramps) in the stomach, intestines, bladder and urethra.
It also has effect in reliving uterine pain.
In labour, it is indicated to provide cervical softening
Indications
Buscupan is indicated during labour for the following
purpose:
o May have analgesic effects during labour pain by
decreasing the intensity of uterine contractions
o It shortens the period of first stage of labour by making
the cervix more soft.
Contraindications
o
o
o
o
o
o
o
o
Allergy to hyoscine
Myasthenia gravis
Megacolon (enlarged colon)
Glaucoma
Narrowing of the gastrointestinal tract
Fast heartbeat
Angina
Heart failure
Side effects
o
o
o
o
o
o
o
o
o
Blurred vision that is temporary
Constipation
Decreased ability to sweat
Diarrhea
Dizziness
Dry mouth
Fast heartbeat
Flushing
Nausea
Dose and protocol of use
One ampoule (20 mg) intravenously is administered slowly
and repeated after half an hour if necessary.
Intravenous injection should be performed 'slowly' (in rare
cases a marked drop in blood pressure and even shock
may be produced by Buscopan).
Nursing role
o
o
o
o
o
o
o
Provide psychological support
Frequent monitoring of vital signs
Maintain hydration
Cervical assessment by PV
Fetal heart monitoring
Uterine contraction assessment
Frequent emptying of urinary bladder
Epidural anesthesia
o Composition of epidural anesthesia & protocol of
administration
o Classification and mechanism of action
o Types of epidural anesthesia
o Indications
o Contraindications
o Side effects
o Nursing role
Composition of epidural anesthesia
Epidural medications fall into a class of drugs called local
anesthetics, such as bupivacaine, chloroprocaine, or
lidocaine.
They are often delivered in combination with opioids or
narcotics such as fentanyl and sufentanil in order to
decrease the required dose of local anesthetic.
The catheter is inserted in the epidural space in the lumber
region
Classification and mechanism of action
Epidural anesthesia is a regional anesthesia that blocks
pain in a particular region of the body.
Epidural medications fall into a class of drugs called local
anesthetics, such as bupivacaine, chloroprocaine, or
lidocaine.
Types of epidural anasthesia and protocol of
administration
o Regular Epidural
o Combined Spinal-Epidural (CSE) or “Walking
Epidural”
Regular epidural anasthesia
After the catheter is in place, a combination of narcotic and
anesthesia is administered either by a pump or by periodic
injections into the epidural space. A narcotic such as
fentanyl or morphine is given to replace some of the higher
doses of anesthetic, like bupivacaine, chloroprocaine, or
lidocaine.
This helps reduce some of the adverse effects of the
anesthesia. Patients have to ask about hospital’s policies
about staying in bed and eating.
Combined Spinal-Epidural (CSE) or
“Walking Epidural”
An initial dose of narcotic, anesthetic or a combination of the two is
injected beneath the outermost membrane covering the spinal cord,
and inward of the epidural space. This is the intrathecal area. The
anesthesiologist will pull the needle back into the epidural space,
thread a catheter through the needle, then withdraw the needle and
leave the catheter in place.
This allows more freedom to move while in the bed and greater ability
to change positions with assistance. With the catheter in place, you can
request an epidural at any time if the initial intrathecal injection is
inadequate. Patients have to ask about hospital’s policy on moving
around, eating and drinking after the epidural has been placed.
With the use of these drugs, muscle strength, balance, and reaction are
reduced. CSE should provide pain relief for 4-8 hours.
Indications
Epidural anasthesia is administered during the
early phase of the early stage of labour by
anesthesiologist in order to provide analgesic
effect while having uterine contraction but no pain
sensation
Contraindications
o
o
o
o
o
o
Active maternal hemorrhage
Maternal septicemia or untreated febrile illness
Infection at or near needle insertion site
Maternal coagulopathy (inherited or acquired)
Scoliosis
Active or latent phase of labour
Side effects
o
o
o
o
o
o
o
Hypotension
Severe headache
Shivering
Ringing of the ears
Backache
Nausea
Difficulty urinating
o Difficulty bearing down
Nursing role
o Provide psychological support
o Frequent monitoring for vital signs
o Continuous monitoring of uterine contraction and fetal heart rate via
monitor
o Frequent emptying of the urinary bladder
o Maintain hydration
o Cervical dilatation assessment
o Comfort assessment
Spinal anasthesia
o
o
o
o
o
o
o
Classification and mechanism of action
Indications
Composition of spinal anesthesia
Contraindications
Side effects
Dose and protocol of administration
Nursing role
Composition of spinal anesthesia
Bupivacaine (Marcaine) is the local anaesthetic.
Most commonly used medications are lidocaine
(lignocaine), tetracaine, procaine, ropivacaine,
levobupivicaine, prilocaine, or cinchocaine may
also be used.
Indications
Spinal anasthesia is administered during the early or active
phase of the stage of labour by anesthesiologist in order to
provide analgesic effect while having uterine contraction
but no pain sensation. It also differs from epidural that is
single one shot of anesthesia and not infusion
Spinal anesthesia can also be used in cesarean delivery
Classification and mechanism of action
It is a local anesthesia. Also called spinal block,
subarachnoid block, intradural block and intrathecal block.
A spinal anaesthetic delivers drug to the subarachnoid
space and into the cerebrospinal fluid, allowing it to act on
the spinal cord directly.
Contraindications
o Local infection or sepsis at the site of injection
o Bleeding disorders, thrombocytopaenia, or systemic
anticoagulation
o Severe aortic stenosis
o Increased intracranial pressure
o Space occupying lesions of the brain
o Anatomical disorders of the spine
o Hypovolaemia
o Allergy
Side effects
o
o
o
o
o
o
o
o
Headache
Backache
Hypotension
Nausea
Shivering
Lower extremities numbness
Difficult urination
Difficult bearing down
Protocol of administration
Most spinals are placed in the lumbar (lower) region of the spine while
the patient either sit upright or lie on side. This position aligns the
vertebrae and flexes the spine. This allows the needle to travel through
the dura and into the spinal space, which contains the cerebrospinal
fluid.
The anesthesiologist is able to feel when the needle has passed
through the various tissues into the spinal space. A local anesthetic
medication is injected into the needle and the needle is removed.
After that the patient should maintain supine position for at least 30
minutes to insure that there is no leakage of CSF and the medication.
In case of need to change position, pressure should be applied over the
injection area
Nursing role
Mainly, the nursing responsibility includes:
o
o
o
o
o
o
o
o
o
o
Provide psychological support
Vital signs monitoring
Fetal heart and uterine contraction monitoring
Maintain warm atmosphere when possible
Maintain pressure on injection site
Maintain hydration
Provide oxygen as indicated by the physician
Comfort assessment
Frequent emptying of urinary bladder
Cervical dilatation assessment
Methergin
o
o
o
o
o
Classification and mechanism of action
Indications
Contraindications
Side effects
Nursing role
Classification and mechanism of action
Methylergonovine belongs to a class of drugs known as
ergot alkaloids.
It works by increasing the rate and strength of contractions
and the stiffness of the uterus muscles. Which in turn
enhances pressure on the bleeding blood vessels and
prevent post partum bleeding
Indications
o
o
o
o
o
Following delivery of the placenta
For routine management of uterine atony
Hemorrhage
Subinvolution of the uterus
For control of uterine hemorrhage in the second stage of
labor following delivery of the anterior shoulder.
Contraindications
o
o
o
o
o
Coronary artery disease
Sepsis
Obliterative vascular disease
Hepatic or renal disease
Hypertension
Side effects
o Hypertension associated with seizure and/or headache
Hypotension
o Abdominal pain
o GI upset
o Rare: cardiovascular effects (eg, vasoconstriction, acute
MI, transient chest pains).
Dose and administration
IM: 0.2mg after delivery of the anterior shoulder, after
delivery of the placenta, or during the puerperium; may be
repeated as required at intervals of 2–4 hours.
IV: 0.2mg given slowly over a period of no less than 60
seconds.
Nursing role
o Provide psychological support
o Frequent monitoring of vital signs
o Frequent assessment of uterine muscle to make sure
that it is firm and well contracted
o Assessment of vaginal blood
o Frequent emptying of urinary bladder
o Comfort assessment
o Maintain hydration
Conclusion
Sometimes labour doesn’t go the way of our expectations.
Different conditions require appropriate medication to be
given to labouring women. Some of them are for pain
relieve while others for bleeding prevention. Sometimes
certain medication is needed to induce labour.
Since nurses spend most of their times bed side the
patients, a very important and great role of nurses help
avoid and manage potential problems during labour such
as fetal distress and vaginal bleeding.
References
o www.webmd.com/baby/guide/pregnancy-pain-relief
o www.drugs.com/condition/labor-augmentation.html
Bohren MA, Vogel JP, Hunter EC, Lutsiv O, Makh SK,
Souza JP, et al. (2015) The Mistreatment of Women during
Childbirth in Health Facilities Globally: A Mixed-Methods
Systematic Review. PLoS Med 12(6): e1001847.
https://doi.org/10.1371/journal.pmed.1001847