Delivery Room Drug Study 603i4t

DRUG STUDY

1. Generic Name: Methylergonovine maleate Brand Name: Methergine Classification: Oxytocic Therapeutic Actions: • A partial agonist or antagonist at alpha receptors; as a result, it increases the strength, duration, and frequency of uterine contractions. Indications: • Routine management after delivery of the placenta. • Treatment of postpartum atony and hemorrhage; subinvolution of the uterus. • Uterine stimulation during the second stage of labor following the delivery of the anterior shoulder, under strict medical supervision. Contraindications • Contraindicated with allergy to methylergonovine, hypertension, toxemia, lactation, pregnancy. Adverse Effects: CNS: Dizziness, headache, tinnitus, diaphoresis CV: Transient hypertension, palpitations, chest pains, dyspnea GI: Nausea and vomiting Nursing Considerations: • Assess history of allergy to the drug. • ister by IM injection or orally unless emergency requires IV use. Complications are more frequent with IV use. • Monitor postpartum women for BP changes and amount and character of vaginal bleeding. • Avoid prolonged use of the drug. • Teach client to report difficulty breathing, headache, numb or cold extremities, severe abdominal cramping. 2. Generic Name: Dinoprostone (prostaglandin E2) Brand Name: Cervidil Classification: Prostaglandin; abortifacient Therapeutic Actions: • Stimulates the myometrium of the pregnant uterus to contract; similar to the contractions of the uterus during labor, thus evacuating the contents of the uterus. Indications: • Termination of pregnancy 12-20 wks from the first day of the LMP. • Evacuation of the uterus in the management of missed abortion or intrauterine fetal death up to 28 wk gestational stage • Initiation of cervical ripening before induction of labor Contraindications: • Contraindicated with allergy to prostaglandins; acute PID; active cardiac hepatic; pulmonary, renal disease; women in whom prolonged uterine contractions are inappropriate. Adverse Effects: CNS: Headache, paresthesias, anxiety, weakness, syncope, dizziness CV: Hypotension, arrthymias, chest pain Fetal: Abnormal heart rates GI: vomiting, diarrhea, nausea Respiratory: Coughing, dyspnea Nursing Considerations: • Monitor uterine tone and vaginal discharge throughout the procedure and several days after the procedure. • Ensure adequate hydration throughout the procedure.

• Be prepared to patient through labor. Give oxytocin infusion 612 hr after dinoprostone. • Teach client to report severe pain, difficulty breathing, palpitations, eye pain, rash.

3. Generic Name: Oxytocin Brand Name: Pitocin Classification: Oxytocic; hormone Therapeutic Actions: • Synthetic form of an endogenous hormone produced in the hypothalamus and stored in the posterior pituitary; stimulates the uterus, especially the gravid uterus just before parturition, and causes myoepithelium of the lacteal glands to contract, which results in milk ejection in lactating women. Indications: • Antepartum: to initiate or improve uterine contractions to achieve early vaginal delivery; stimulation or reinforcement of labor in selected cases of uterine inertia; management of inevitable or incomplete abortion; 2nd trimester abortion • Postpartum: to produce uterine contractions during the third stage of labor to control postpartum bleeding or hemorrhage • Lactation defieciency Contraindications: • Significant cephalopelvic disproportion, unfavorable fetal positions or presentations, obstetric emergencies that favor surgical intervention, prolonged use in severe toxemia, uterine inertia, hypertonic uterine patterns, induction or augmentation of labor when vaginal delivery is contraindicated, previous cesarian section. Adverse Effects: CV: cardiac arrhythmias, PVCs, hypertension, subarachnoid hemorrhage Fetal effects: fetal bradycardia, neonatal jaundice, low Apgar scores GI: nauseas, vomiting GU: postpartum hemorrhage, uterine rupture, pelvic hematoma, uterine hypertonicity, spasm Nursing Considerations: • Ensure fetal position and size and absence of complications that are contraindicated with oxytocin therapy • Ensure continuous observation for induction of labor; fetal monitoring is preferred. • Regulate rate of oxytocin delivery; monitor rate and strength of contractions • Monitor BP during istration

4. Generic Name: Lidocaine hydrochloride Brand Name: Dilocaine Classification: Local anesthetic Therapeutic Actions: • Blocks the generation and conduction of action potentials in sensory nerves by reducing sodium permeability, reducing height and rate of rise of the action potential, increasing excitation threshold, and slowing conduction velocity Indications: • Infiltration anesthesia, peripheral and sympathetic nerve blocks, central nerve blocks, spinal and caudal anesthesia Contraindications: • Contraindicated with allergy to lidocaine or amide-type local anesthetics, CHF cardiogenic shock, 2nd or 3rd degree AV blocks Adverse Effects:

CNS: headache, backache, septic meningitis, persistent sensory CV: hypotension Dermatologic: urticaria, pruritus, erythema, edema GU: urinary retention, urinary or fecal incontinence Nursing Considerations: • Check drug concentrations carefully • Establish safety precautions if CNS changes occur • Teach client to report difficulty speaking, thick tongue, numbness, tingling, difficulty breathing, pain or numbness at site, swelling or pain at site 5. Generic Name: Terbutaline Sulfate Brand Name: Brethine Classification: Tocolytic Therapeutic Actions: - In low doses, acts relatively selectively at beta 2-adrenergic receptors to cause bronchodilation and relax the pregnant uterus; at higher doses, beta 1 selectivity is lost and the drug acts at beta 2 receptors to cause typical sympathomimetic cardiac effects Indications: - Tocolytic to prevent preterm labor Contraindications: - Contraindicated with hypersensitivity to terbutaline, tachyarrythmias, tachycardia, hypertension, lactation. Adverse Effects: CNS: restlessness, apprehension, anxiety, fear, CNS stimulation, hyperkinesias, insomnia, tremors CV: cardiac arrhythmias, palpitations, angina pain, changes in BP and ECG GI: Nausea, vomiting, heartburn, unusual or bad taste Respiratory: Respiratory difficulties, pulmonary edema, coughing, bronchospasm Nursing Considerations: - Use minimal doses for minimal periods of time; drug tolerance can occur - Maintain a beta-adrenergic blocker on standby in case cardiac arrhythmias occur - Teach client to report chest pain, dizziness, insomnia, weakness, tremor 6. Generic Name: Carboprost tromethamine Brand Name: Hemabate Classification: Prostaglandin; Abortifacient Therapeutic Actions: • Stimulates the myometrium of the pregnant uterus to contract; similar to the contractions of the uterus during labor, thus evacuating the contents of the uterus. Indications: - Termination of pregnancy 13-20 wk from the first day of the LMP - Evacuation of the uterus in instance of missed abortion or intrauterine fetal death in the 2nd trimester - Postpartum hemorrhage due to uterine atony unresponsive to conventional methods Contraindications: - Contraindicated with allergy to prostaglandin preparations, acute PID; active cardiac,hepatic, pulmonary, renal disease Adverse Effects: CNS: headache, paersthesias, flushing, anxiety, weakness, syncope, dizziness CV: hypotension, arrhythmias, chest pain GI: vomiting, diarrhes, nausea Nursing Considerations: - Assess allergy to the drug - Monitor uterine tone and vaginal discharge during procedure and several days after to assess drug effects and recovery - Ensure adequate hydration

7. Generic Name: Nalbuphine hydrochloride Brand Name: Nubain Classification: Narcotic agonisy-antagonist analgesic Therapeutic Actions: - Nalbuphine acts as an agonist at specific opioid receptors in the Cns to produce analgesia, sedation but also acts to cause hallucinations and is an antagonist at mu receptors Indications: - Relief of moderate to severe pain - For obstetric analgesia during labor and delivery Contraindications: - Contraindicated with hypersensitivity to nalbuphine, sulfites; lactation Adverse Effects: CNS: sedation, clamminess, sweating, headache, nervousness, restlessness, depression, crying, confusion, faintness, hostility, unusual dreams, hallucinations, euphoria, blurred vision CV: hypotension, hypertension, bradycardia, tachycardia Dermatologic: itching, burning, urticaria GI: N/V, cramps, dyspepsia, bitter taste, dry mouth GU: Urinary urgency Respiratory: Respiratory depression, dyspnea, asthma Nursing Considerations: - Assess hypersensitivity to the drug - Provide narcotic antagonist, facilitates for assisted or controlled respiration on standby in case of respiratory depression - Reassure patient about addiction liability; most patients who receive opiates for medical reasons do not develop dependence syndrome - Inform clients about these side effects: dizziness, sedation, drowsiness, impaired visual acuity, nausea, loss of appetite

8. Generic Name: Magnesium sulfate Brand Name: Epsom salt Classification: electrolyte; anticonvulsant; laxarive Therapeutic Actions: - Cofactor of many enzyme systems involved in neuromuscular transmission and muscular excitability Indications: - Preeclampsia/eclampsia - Inhibition of premature labor Contraindications: - Contraindicated with allergy to magnesium product; heart block, myocardial damage, abdominal pain, N/V, acute surgical abdomen, fecal impaction, hepatitis. DO NOT GIVE 2 HR PRECEEDING DELIVERY BECAUSE OF RISK OF MAGNESIUM TOXICITY IN THE NEONATE. Adverse Effects: CNS: weakness, dizziness, fainting, sweating CV: palpitations GI: excessive bowel activity, perianal irritation Metabolic: Magnesium intoxication, hypocalcemia with tetany Nursing Considerations: - Assess history of allergy to the drug and other contraindications - Reserve IV use in eclampsia for immediate life- threatening situations - Monitor magnesium levels during parenteral therapy - Monitor knee-jerk reflex before repeated parenteral istration, if happens, do not ister because respiratory failure may occur

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Do not give orally with abdominal pain, N/V Monitor urine output

9. Generic Name: Butorphanol tartrate Brand Name: stadol Classification: Narcotic agonist- antagonist analgesic Therapeutic Actions: - Acts as an agonist at opioid receptors in the CNS to produce analgesia, sedation, but also acts to produce hallucinations; has low abuse potential Indications: - Relief of moderate to severe pain - To supplement balances anesthesia and to relieve prepartum pain Contraindications: - Contraindicated with hypersensitivity to butorphanol, physical dependence on a narcotic analgesic, pregnancy lactation Adverse Effects: CNS: sedation, clamminess, sweating, headache, vertigo, dizziness, lethargy, confusion, unusual dreams, agitation, euphoria, hallucinations CV: Palpitations, increase or decrease in blood pressure Dermatologic: Ras, hives, pruritus, flushing, warmth, sensitivity to cold EENT: diplopia, blurred vision GI: N/V Respiratory: slow, shallow respiration Nursing Considerations: - Assess history of allergy to butorphanol , depression DM, lactation, and dependence - Monitor diet for presence of caffeine- containing foods that may contribute to overdose - Inform patients that these side effects may occur: diuresis, restlessness, insomnia, muscular tremors, light- headedness, nausea, abdominal pain - Remind patient to report abnormal heart rate, dizziness, palpitations

10. Generic Name:

Misoprostol Brand Name: Cytotec Classification: Prostaglandin Therapeutic Actions: - A synthetic prostaglandin E1 analog; inhibits gastric acid secretion and increases bicarbonate and mucus production, protecting the lining of the stomach Indications: - With mifepristone as an abortifacient - Cervical ripening and labor induction Contraindications: - History of allergy to prostaglandins; pregnancy; lactation Adverse Effects: GI: nausea, diarrhea, abdominal pain, flatulence, vomiting, dyspepsia, constipation GU: Miscarriage, excessive bleeding, spotting, cramping, menstrual disorders Nursing Considerations: - Assess history of allergy to the drug - Report severe diarrhea, spotting, or menstrual pain, severe menstrual bleeding

Generic Name: Midazolam hydrochloride Brand Name: Versed Classification: Benzodiazepine (short-acting); CNS depressant Therapeutic actions:

Exact mechanisms of action not understood; acts mainly at the limbic system and reticular formation; potentiates the effects of GABA, an inhibitory neurotransmitter; anxiolytic and amnesia effects occur at doses below those needed to cause sedation, ataxia; has little effect on cortical function. Indications - IV or IM: Sedation, anxiolysis, and amnesia prior to diagnostic, therapeutic, or endoscopic procedures or surgery - Induction of general anesthesia - Continuous sedation of intubated and mechanically ventilated patients as a component of anesthesia or during treatment in the critical care setting - Unlabeled uses: Treatment of epileptic seizure or refractory status epilepticus -

Contraindications and cautions - Contraindicated with hypersensitivity to benzodiazepines; psychoses, acute narrow-angle glaucoma, shock, coma, acute alcoholic intoxication; pregnancy (cleft lip or palate, inguinal hernia, cardiac defects, microcephaly, pyloric stenosis have been reported when used in first trimester; neonatal withdrawal syndrome reported in infants); neonates. - Use cautiously in elderly or debilitated patients; with impaired liver or kidney function, lactation. Adverse effects CNS: Transient, mild drowsiness (initially); sedation, depression, lethargy, apathy, fatigue, light-headedness, disorientation, restlessness, confusion, crying, delirium, headache, slurred speech, dysarthria, stupor, rigidity, tremor, dystonia, vertigo, euphoria, nervousness, difficulty in concentration, vivid dreams, psychomotor retardation, extrapyramidal symptoms; mild paradoxical excitatory reactions (during first 2 wk of treatment), visual and auditory disturbances, diplopia, nystagmus, depressed hearing, nasal congestion CV: Bradycardia, tachycardia, CV collapse, hypertension, hypotension, palpitations, edema Dermatologic: Urticaria, pruritus, skin rash, dermatitis GI: Constipation, diarrhea, dry mouth, salivation, nausea, anorexia, vomiting, difficulty in swallowing, gastric disorders, elevations of blood enzymes: LDH, alkaline phosphatase, AST, ALT, hepatic dysfunction, jaundice GU: Incontinence, urinary retention, changes in libido, menstrual irregularities Hematologic: Decreased Hct, blood dyscrasias Other: Phlebitis and thrombosis at IV injection sites, hiccups, fever, diaphoresis, paresthesias, muscular disturbances, gynecomastia; pain, burning, and redness after IM injection Dependence: Drug dependence with withdrawal syndrome when drug is discontinued (more common with abrupt discontinuation of higher dosage used for longer than 4 mo) Nursing considerations -

History: Hypersensitivity to benzodiazepines; psychoses, acute narrow-angle glaucoma, shock, coma, acute alcoholic intoxication with depression of vital signs; elderly or debilitated patients; impaired liver or kidney function; pregnancy, lactation

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Physical: Weight; skin color, lesions; orientation, affect, reflexes, sensory nerve function, ophthalmologic examination; P, BP; respiratory rate, adventitious sounds; bowel sounds, normal output, liver evaluation; normal output; LFTs, renal function tests, CBC Do not ister intra-arterially, which may produce arteriospasm or gangrene. Do not use small veins (dorsum of hand or wrist) for IV injection. ister IM injections deep into muscle. Arrange to reduce dose of midazolam if patient is also being given opioid analgesics; reduce dosage by at least 50% and monitor patient closely. Monitor level of consciousness before, during, and for at least 2–6 hr after istration of midazolam. Carefully monitor P, BP, and respirations carefully during istration. Keep resuscitative facilities readily available; have flumazenil available as antidote if overdose should occur. Keep patients in bed for 3 hr; do not permit ambulatory patients to operate a vehicle following an injection. Establish safety precautions if CNS changes occur (use side rails, accompany ambulating patient). Client may experience these side effects: Drowsiness, dizziness (these may become less pronounced after a few days; avoid driving a car or engaging in other dangerous activities if these occur); GI upset; dreams, difficulty concentrating, fatigue, nervousness, crying (it may help to know that these are effects of the drug; consult your health care provider if these become bothersome). Report severe dizziness, weakness, drowsiness that persists, rash or skin lesions, visual or hearing disturbances, difficulty voiding.

Generic Name: Fresofol Brand Name: Propofol Classification: sedative hypnotic; anesthetic agent Therapeutic Actions: - Propofol is a short-acting hypnotic. Its mechanism of action has not been well-defined. Indications: - induction of general anesthesia in adults and in pediatric patients greater than 3 years of age - maintenance of anesthesia utilizing balanced techniques with other appropriate agents such as opioids and inhalation anesthetics in adults and pediatric patients greater than 2 months of age - produce sedation or amnesia as a supplement to local or regional anesthetics Contraindications: - Contraindicated in pediatric patients for monitored anesthesia care (MAC) sedation or for sedation in intensive care; epileptics; use cautiously in lactation Adverse Effects: CV: Arterial hypotension; decreased systemic vascular resistance, myocardial blood flow, and oxygen consumption, palpitations, tachycardia Respiratory: apnea, hyperventilation, bradypnea, dyspnea, wheezing, swelling of throat

CNS: increased I, lethargy, drowsiness, euphoria, hallucinations, blurred vision, anxiety, tension, seizure, lightheadedness, fainting DERM: skin rash, flushing, urticaria Nursing Considerations: - Assess history of allergy to the components of the drug. - Use safety precautions after istration. - Advise patient that mental alertness, coordination, and physical dexterity may be impaired for some time after istration. - For IV, do not mix with other therapeutic agents prior to istration. Avoid mixing blood or plasma in same IV catheter. - Minimize pain associated with istration by infusing into larger veins. - Should be istered only by personnel who are trained in istration of general anesthesia and familiar with drug. - Shake well before use. Do not use if there is evidence of separation of phases of emulsion.

Generic Name: Hyoscine-N-butylbromide Brand Name: Buscopan Classification: Antispasmodic; Anticholinergic Therapeutic Actions: - acts by interfering with the transmission of nerve impulses by acetylcholine in the parasympathetic nervous system. Indications: - Buscopan Tablets are indicated for the relief of spasm of the genitourinary tract or gastro- intestinal tract and for the symptomatic relief of Irritable Bowel Syndrome Contraindications: - Buscopan Tablets should not be istered to patients with myasthenia gravis, megacolon and narrow angle glaucoma. In addition, they should not be given to patients with a known hypersensitivity to hyoscine-N-butylbromide or any other component of the product. Adverse Effects: CNS: dizziness, anaphylactic reactions, anaphylactic shock, increased I, disorientation, restlessness, irritability, dizziness, drowsiness, headache, confusion, hallucination, delirium, impaired memory CV: hypotension, tachycardia, palpitations, flushing GI: Dry mouth, constipation, nausea, epigastric distress DERM: flushing, dyshidrosis GU: Urinary retention, urinary hesitancy Resp: dyspnea, bronchial plugging, depressed respiration EENT: mydriasis, dilated pupils, blurred vision, photopobia, increased intraocular pressure, difficulty of swallowing. Nursing Considerations: - Drug compatibility should be monitored closely in patients requiring adjunctive therapy - Avoid driving & operating machinery after parenteral istration. - Avoid strict heat

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Raise side rails as a precaution because some patients become temporarily excited or disoriented and some develop amnesia or become drowsy. Reorient patient, as needed, Tolerance may develop when therapy is prolonged Atropine-like toxicity may cause dose related adverse reactions. Individual tolerance varies greatly Overdose may cause curare-like effects, such as respiratory paralysis. Keep emergency equipment available.