GOVERNMENT COLLEGE OF

NURSING, JODHPUR (RAJ.)

DRUG BOOK
ON-

DRUGS USED IN PREGNANCY, LABOR &

PUERPERIUM

SUBMITTED TO - SUBMITTED BY-

Mrs. JYOTI BALA JANGID PRIYANKA GEHLOT
NURSING LECTURER M.Sc. (N) FINAL YEAR
GCON, JODHPUR GCON, JODHPUR
INTRODUCTION

The midwife should have thorough 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

List of drugs used in pregnancy are: -
• Folic acid
• Iron
• Calcium
• Anti -hypertensive drugs
•Diuretics

I) 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
1. Megaloblastic or macrocytic anemia during pregnancy to prevent fetal damage
2. 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
1. Patient with H/O fetal neural tube defect in pregnancy should increase folic acid intake 1 month
before and 3 months after conception.
2. 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 iron 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
5. Nausea or vomiting

Dosage and route of administration

500mg OD orally.

Nursing considerations
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: -

1. Alpha and Beta blockers- Labetalol hydrochloride
2. Calcium channel blockers-Nifedipine
3. Alpha Blockers-Methyldopa
4. Vasodilators-Hydralazine hydrochloride

Anti-hypertensive drugs contraindicated in pregnancy. These drugs should be avoided because they may can
cause poor fetal renal function, malformation or can cause IUGR
1.ACE inhibitors
2. Minoxidil
3. Sodium Nitoprusside
4. Diltiazem
5. Atenolol
6.Propranolol

A) Labetalol Hydrochloride
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

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
3. Nausea or vomiting
4. Headache
5. Vertigo

Dosage and route of administration

50mg or 100mg tablet OD orally 20mg/20ml Inj IV bolus wait for 10min if no response then gives 40mg
slow bolus.

Nursing considerations
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.

B) NIFEDIPINE
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.

Nursing considerations
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.
 C) METHYLDOPA
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  

Nursing considerations
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.
 D) Hydralazine Hydrochloride
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

Dosage and route of administration

 25mg tablet BD and if necessary may increase to 50mg BD
 5mg diluted in 10ml of NS slow IV at 15-20minutes interval.

Nursing considerations
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.

A) FUROSEMIDE (LASIX)

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. 

Nursing considerations
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

A) 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
3. Nausea or vomiting
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.

Nursing considerations
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.
 B) 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
5. Nausea or vomiting
6. Altered maternal & fetal heart tone & palpitations.   

Dosage and routes of administration

 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 hrs, then 10-20 mg q4th, not to exceed 120 mg/day

Nursing considerations  
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.Oxytocics
2. Analgesics
3. Anticonvulsant
4. Anticoagulant

I) OXYTOCICS
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 

A) OXYTOCIN
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
1. To induce abortion, labour
2. To expedite expulsion of hydatidiform mole
3. For oxytocin challenge test
4. 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
1. In late pregnancy
2. Grand multipara
3. Contracted pelvis
4. History of LSCS or hysterectomy
5. Malpresentation  

During labour
1. Obstructed labour
2. Incoordinate uterine action  
Anytime
1. Hypovolemic state, cardiac disease

Adverse effects
1. Hypertonic uterine activity
2. Fetal distress & fetal death
3. Uterine rupture
4. Hypotension
5. Neonatal jaundice
6. Water retention & water intoxication  

Dosage & routes of administration

 Controlled IV infusion (10 units of oxytocin in 1 L of RL/5% Dextrose in water)
 Nasal spray for milk let- down

Nursing considerations
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.

B)ERGOT DERIVATIVES
Ergot alkaloids are either natural or semi synthetic.

Preparations
1. Ergometrine- 0.25mg/ 0.5mg ampoules & 0.5-1mg tablets
2. Methergine - 0.2 mg ampoules & 0.5-1mg tablets
3. SyntometrineErgometrine - 0.5 mg+ Syntocinon 5.0 units ampoules.

NOTE
 Ergometrine&Methergine can be used parenterally or orally. As the drug produces 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.

Mode of ActionErgometrine 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

Prophylactic
As a prophylaxis against excessive hemorrhage, it may be administered after the delivery of the anterior
shoulder with crowing / following delivery of baby.

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.

Dosage and routes of administration

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.

Nursing considerations
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

C) PROSTAGLANDINS
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
1. Tablet- 0.5mg
2. PG E2 – Prostin E2 (Dinoprostone) Gel-0.5mg E2 in 2.5ml gel-comes in pre-loaded syringe.
3. PG F2 alpha- Prostin F2 alpha (Dinoprostodine) Inj- 125 and 250mcg
4. 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
Dosage & routes of administration
 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 induction of labour

Nursing considerations
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
A) 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
a) Maternal 
1. Severe CNS depression
2. Evidence of muscular paresis

b) Fetal 
1.Tachycardia
2. Hypoglycemia

Dosage & routes of administration

1. For control of seizures, 20 ml of 20% solution IV slowly in 3-4 mins, to be followed immediately by
10ml of 50% solution IM & continued 4 hourly till 24 hours postpartum.
2. Repeat injections are given only if knee jerks are present, urine output exceeds 100 ml in 4 hours &
respiration are more than 10/ minute.
3. 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

Nursing considerations
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 side 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 output below 30ml/hr or in the
event of mental confusion/ lethargy/ fetal distress.

II) ANALGESICS
A) Valethamate bromide (epidosin)-Cervical Dilatation
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

Dosage and routes of administration

Inj-8mg deep IM. It may be repeated after 4 hours if necessary.  

Nursing considerations
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.
 B) Tramadol hydrochloride
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
5. Nausea or vomiting

Dosage and routes of administration

50 to 100mg IM 6hrly or as required.  

Nursing considerations
1. Monitor patient CV and respiratory status.
2. Monitor patient at risk for seizure.
3. Monitor patient bowel and bladder function.

III) COAGULANT
a) 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 and 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.  

Nursing considerations
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.

A) Acetaminophen (paracetamol)
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  

Nursing considerations
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 OTC drugs without prescription.
3. Advise patient to take tablet after meal to prevent GI symptoms.

B) Lactation suppressants (Bromocriptinemesylate)

Preparation
Tablet-0.8mg,2.5mg  

Mode of Action It blocks the release of a prolactin from the pituitary gland.

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  

Dosage and routes of administration 2.5mg tablet orally once in a day.  

Nursing considerations
1. Monitor patient for adverse reactions.
2. Drug may lead to early post-partum conception. after menses resumes, test 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.

LABOR AUGMENTATION DRUGS

Type When/How Given Advantages Possible Side

Effects/Disadvantages

 Administered  Increases cervical  Requires fetal

Prostaglandi vaginally prior elasticity and monitoring for one to
n Gel or to induction of softens/ripens two hours after insertion.
insert labor cervix.
(Cervidil)  Risk for sustained
contractions.

 Administered  Assists in cervical  Risk for sustained

Misoprostyl orally or ripening contractions
(Cytotec) vaginally prior
to induction of  May stimulate  Requires fetal
labor. contractions and monitoring
enhance effects of
Pitocin if used

 Used for  Induces (begins)  Requires fetal

C. Oxytocin induction of labor contractions. monitoring.
(Pitocin) labor or
augmentation  Augments  May increase frequency,
during labor. (increases) strength strength and pain of
and frequency of contractions.
 Administered ongoing labor
through contractions.
intravenous
pump.
ANALGESIA AND ANESTHESIA IN OBSTETRICS
THE LABOUR IS REPORTED TO BE ONE OF THE MOST PAINFUL EXPERIENCES IN A WOMAN’S LIFE.

Relief of pain during labor and delivery is an essential part in good obstetric care. Choice of anesthesia
depends upon the patient’s conditions and the associate disorders.
Anesthetic complications may cause maternal death.

ANALGESIA DURING LABOR AND DELIVERY-

 The pain during labor results from a combination of uterine contractions and cervical dilatation.
During cesarean delivery incision is usually made around the T12 dermatome anesthesia is required
from the level of T4 to block the peritoneal discomfort.
 Labor pain is experienced by most women with satisfaction at the end of a successful labor.
Antenatal (mothercraft) classes, sympathetic care and encouraging environment during labor can
reduce the need of analgesia.
 Drugs have an important part to play in the relief of pain in labor but it must not be supposed that
they are of greater importance than proper preparation and training for child birth.
The intensity of labor pain depends on the intensity and duration of uterine contractions, degree of dilatation
of cervix, distension of perineal tissue, parity and the pain threshold of the subject.

Themost distressing time during the whole labor is just prior to full dilatation of the cervix.
 The first phase is controlled by sedatives and analgesics and the second phase is controlled by
inhalation agents.
The idea is to avoid the risk of delivery of a depressed baby.

OPIOID ANALGESICS—

Pethidine:
For a long time pethidine has been used as an analgesic in labor. It has got strong sedative but less analgesic
efficacy.

Pethidine is generally used in the first phase of labor and indicated when the discomfort of labor merges into
regular, frequent and painful contractions.

The initial dose is 100 mg (1.5 mg/kg body wt) IM and repeated as the effect of the first dose begins to
wane, without waiting for the re-establishment of labor pain.

Side effects – to the mother are nausea, vomiting, delayed gastric emptying.

 Ranitidine should be given to inhibit gastric acid production and emetic effect is counteracted
by metoclopramide (10 mg IM).
 Pethidine crosses theplacenta and accumulates in fetal tissues. Pethidine depresses respiration and
suckling of the newborn when administeredbefore delivery.
Fentanyl-
It is a short acting synthetic opioid and is equipotent to pethidine.
It has less neonatal effects and less maternal nausea and vomiting.
It needs frequent dosing.

Phenothiazines-:
Promethazine (phenargan) is commonly used in labor in combination with an opioid.
It does not cause major neonatal depression.
Promethazine is a weak antiemetic drug and causes sedation in the mother.
 1. Inhalational analgesia - N2O in the form of Entonox

Quick onset(1-2min), short duration of effect (2-8min) start inhaling at the onset of a contraction
• Not suitable for prolong use of early labour because hyperventilation can cause hypocapnoea,
dizziness & ultimately fetal hypoxia

 Easy to administer (no needles)

 Nitrous oxide is administered in sub anaesthetic concentrations. (N2O 30-50%)

 Analgesia without loss of consciousness.

 Crosses the placenta but is eliminatedefficiently, no untoward neonatal effects.

 No effects on uterine contractions.

 Most effective for short term (1-2 hrs) pain relief

 Most beneficial in late first stage of labour.

2. Local and regional techniques-

 Local infiltration

 Pudendal block

 Paracervical block

 Paravertebral (lumbar sympathetic block)

 Epidural - lumbar(caudal)

 Spinal

 Combined spinal-epidural (CSE)

COMMONLYUSED LOCAL ANESTHETIC AGENTS IN OBSTETRICS-

1. Lignocaine

Usual dose-7 mg/kg

Onset-Rapid 60-90 min
Uses in obstetrics-
Local or pudendal block and also for epidural or spinal forcesarean delivery

REGIONAL ANESTHESIA
When complete relief of pain is needed throughout labor, epidural analgesia is the safest and simplest
method for procuring it.

Advantages of regional anesthesia-

The patient is awake and can enjoy the birthtime
• Newborn apgar score generally good
• Lowered risk of maternal aspiration
• Postoperative pain control is better.

1. Continuous lumbar epidural block:

A lumbar puncture is made between L2 and L3 with the epidural needle (Tuohyneedle).
 With the patient on her left side, the back of the patient is cleansed with antiseptics before injection.
When the epidural space is ensured, a plastic catheter is passed through the epidural needle for
continuous epidural analgesia.
 A local anesthetic agent is injected into the epidural space. Full dose is given after a test dose when
there is no toxicity.
 Bupivacaine or 1 percent lignocaine are used to maintain analgesia.
 Maternal hydration should be adequate with normal saline or Hartmann’s solution (crystalloid)
infusion prior commencing the blockade.
 The patient’s blood pressure, pulse and the fetal heart rate should be recorded at 15 minutes interval
following the induction of analgesia and hypotension, if occurs, should be treated immediately.

Epidural analgesia is specially beneficial in cases like

• pregnancy induced hypertension
• breech presentation
• Twin pregnancy and preterm labor.

Previous cesarean section is not a contraindication.

Epidural analgesia when used there is no change in duration of first stage of labor. But second stage of
labor appears to be prolonged. This might lead to frequentneed of instrumental delivery like forceps or
ventouse.
CONTRAINDICATIONS OF EPIDURAL ANALGESIA-
• Maternal coagulopathy or anticoagulant therapy
• Supine hypotension
• Hypovolemia
• Neurological diseases
• Spinal deformity or chronic low back pain
• Skin infection at the injection site

COMPLICATIONS OF EPIDURAL ANALGESIA-

• Hypotension due to sympathetic blockade.
• Parturient should be well hydrated with (IL) crystalloid solution before hand.
• Pain at the insertion site.
• Back pain
• Postspinal headache due to leakage of cerebrospinal fluid through the needle hole in the dura
• Injury to nerves, convulsions, pyrexia
• Ineffective analgesia
 2. Paracervical nerve block:
Is useful for pain relief during the first stage of labor.
 Following the usual antiseptic safe guards, a long needle (15 cm or more) is passed into the lateral
fornix, at the three and 9 o’clock positions. 5-10 mL of 1 percent lignocaine with adrenaline are
injected at the site of the cervix and the procedure is repeated on the other side.
 This dose is quite sufficient to relieve pain for about an hour or two, and injections can be given
more than once if necessary.
 Bupivacaine is avoided due to its cardiotoxicity.
 Paracervical block should not be used where placental insufficiency is present.
 In order to avoid complications, a specially constructed guard tube is used.
 A needle is inserted through the tube and is of such a length that it protrudes not more than 7 mm
beyond its tip
 Although paracervical block may be used from 5 cm dilatation of the cervix,
 it is most useful towards the end of the first stage of labor to remove the desire to bear down earlier.
 Paracervical block can only relieve the pain of uterine contraction and the perineal discomfort is
removed by pudendal nerve block.
 Fetal bradycardia is a knowncomplication. This is due to decreased placental perfusion resulting
from uterine artery vasoconstriction or its direct depressant effect on the fetus following
transplacental transfer.
3. Pudendal nerve block:
It is a safe and simple method of analgesiaduring delivery. Pudendal nerve block does not relieve the pain of
labor but affords perineal analgesia and relaxation.

Pudendal nerve block is mostly used for forceps and vaginal breech delivery.
 Simultaneous perineal and vulval infiltration is needed to block the perineal branch of the posterior
cutaneous nerve of the thigh and the labial branches of the ilio-inguinal and genito-femoral nerves
(vide supra).
 This method of analgesia is associated with less danger, both for the mother and for the baby than
general anesthesia.

Technique:
The pudendal nerve may be blocked by either the transvaginal or the transperineal route

A.Transvaginal route:
Transvaginal route is commonly preferred.
 A 20 mL syringe, one 15 cm (6”) 22 gauge spinal needle and about 20 mL of 1% lignocaine
hydrochloride are required.
 The index and middle fingers of one hand are introduced into the vagina, the finger tips are placed on
the tip of the ischial spine of one side.
 The needle is passed along the groove of the fingers and guided to pierce the vaginal wall on the
apex of ischial spine and thereafter to push a little to pierce the sacrospinous ligament just above the
ischial spine tip.
 After aspirating to exclude blood, about 10 Ml of the solution is injected.
 The similar procedure is adopted to block the nerve of the other side by changing the hands
Complications:
• Hematoma formation
• infection

4. Spinal anesthesia:
Spinal anesthesia is obtained by injection of local anesthetic agent into the subarachnoid space.
 It has less procedure time and high success rate.
 Spinal anesthesia can be employed to alleviate the pain of delivery and during the third stage of
labor.
 For normal delivery or for outlet forceps with episiotomy, ventouse delivery, block should extend
from T10 (umbilicus) to S1.
 For cesarean delivery level of sensory block should be up to T4 dermatome.

Hyperbaric bupivacaine (10-12 mg) or lignocaine (50-70 mg) is used.

Spinal anesthesia refers to the technique whereby local anesthetics are administered in the cerebro-spinal
fluid in the sub-arachnoid space to achieve regional anaesthesia in cases where general anaesthesia is not
required or recommended. It results in anesthesia in the umbilical region targeted according to the nerve
supply.

The advantages of spinal anesthesia are:

(a) less fetal hypoxia unless thereis hypotension and
(b) minimal blood loss.
 The technique is not difficult and no inhalation anesthesia is required, but post spinal headache
occurs in 5-10 percent of patients.
 Spinal anesthesia can be obtained by injecting the drug into the subarachnoid space of the third or
fourth lumbar interspace with the patient lying on her side with a slight head uptilt.
 The blood pressure and respiratory rate should be recorded every 3 minutes for the first 10 minutes
and every 5 minutes thereafter.
 Oxygen should be given for respiratory depression and hypotension.
 Sometimes vasopressor drugs may be required if a marked fall in blood pressure occurs. It is used
during vaginal delivery, forceps, ventouse and cesarean delivery.

Indications:
1. Hernia repairs

2. Gynaecological surgeries (manual removal of a retained placenta)

3. Urological repairs

4. Operations in the genital region

5. Operations in perineum

Contra-indications:
1. Inadequate resuscitation measures

2. Hypovolemia
 3. Clotting and Bleeding disorders

4. Sepsis and septicaemia

5. Neurological diseases

6. Unwilling Patient

7. Non suitable Operating Room environment where the team is not accustomed to operating with
patient wide awake.

Risks Involved:
Spinal and epidural anesthesia are generally safe. These possible complications:
 Allergic reaction to the anesthesia used

 Bleeding around the spinal column (hematoma)

 Retention of urine

 Hypotension

 Infection in your spine (meningitis or abscess)

 Nerve damage

 Seizures (As a side affect to anesthetic overdose or reaction)

 Severe headache (PDPH Post Dural Puncture Headache)

Pre-procedure preparation:
 Councelling: The patient must be informed of the type and admisitration of anesthesia along with the
more common sensations associated with the procedure including alteration in sense and weakness
of legs. They must be assured, however, that no pain will be felt once it is administered.

 Pre-loading: Depending on the type of procedures and age and associated co-morbidities of the
patient, 500-1500 of IV fluid may need to be administered before the procedure. The preffered fluids
include crytalloids namely normal ( 0.9%) saline and Hartmans.

 Before start place all the monitors and ensure you have a wide bore functioning I/V line. Record the
baseline vitals. 

Performance of the procedure:

It is most easily performed when there is maximum flexion of the lumbar spine. This can best be achieved
by sitting the patient on the operating table and placing their feet on a stool. If they then rest their forearms
on their thighs, they can maintain a stable and comfortable position. Alternatively, the procedure can be
performed with the patient lying on their side with their hips and knees maximally flexed.
1. Scrub and glove up carefully.

2. Check the equipment on the sterile trolley.

 3. Draw up the local anesthetic to be injected intra-thecally into the 5ml syringe, from the ampoule
opened by your assistant. Read the label. Draw up the exact amount you intend to use, ensuring that
your needle does not touch the outside of the ampoule (which is unsterile).

4. Draw up the local anesthetic to be used for skin infiltration into the 2ml syringe. Read the label
carefully.

5. Clean the patient’s back with the swabs and antiseptic ensuring that your gloves do not touch
unsterile skin. Swab radially outwards from the proposed injection site. Discard the swab and repeat
several times making sure that a sufficiently large area is cleaned. Allow the solution to dry on the
skin.

6. Drape the patients back with a sterile towel to gain more freedom of movements of hands in handling
the back of patient.

7. Locate a suitable inter-spinous space. press fairly hard to feel the spinous processes in an obese
patient.

8. Inject a small volume of local anaesthetic under the skin with a disposable 25-gauge needle at the
proposed puncture site.

9. Insert the introducer if using a 24-25 gauge needle. It should be advanced into the
LigamentumFlavum.

10. If an Epidural is intended care should be exercised in thin patients that an inadvertent dural puncture
does not occur and then we are using a 18 G Epidural needle.

11. Insert the spinal needle (through the introducer, if applicable). Ensure that the stylet is in place so
that the tip of the needle does not become blunt. It is imperative that the needle is inserted and stays
in the midline and that the bevel is directed laterally. It is angled slightly towards the head and
advanced slowly. An increased resistance will be felt as the needle enters the ligamentumflavum,
followed by a loss of resistance as the epidural space is entered. Another loss of resistance may be
felt as the dura is pierced and CSF should flow from the needle when the stylet is removed. If bone is
touched, the needle should be withdrawn a centimetre or so and then re-advanced in a slightly more
cephalad direction again ensuring that it stays in the midline. If a 25 gauge spinal needle is being
used, be prepared to wait 4 to 5 seconds for CSF to appear after the stylet has been withdrawn. If no
CSF appears, replace the stylet and advance the needle a little further and try again.

12. When CSF appears, take care not to alter the position of the spinal needle as the syringe of local
anaesthetic is being attached. The needle is best immobilized by resting the back of the non-
dominant hand firmly against the patient and by using the thumb and index finger to hold the hub of
the needle. Be sure to attach the syringe firmly to the hub of the needle; hyperbaric solutions are
viscous and resistance to injection will be high, especially through fine gauge needles. It is,
therefore, easy to spill some of the local anaesthetic unless care is taken. Aspirate gently to check the
needle tip is still intrathecal and then slowly inject the local anaesthetic. When the injection is
complete, withdraw the spinal needle, introducer and syringe as one and apply a sticking plaster to
the puncture site.

Assessment of the block:

 The patient to lift legs.

 Sensation of pain after pin prick.

  Feel for cold sensations after administration of aerosol spray or cold swab.

Combined spinal – epidural analgesia:

An introducer needle is first placed in the epidural space.
 A small gauge spinal needle is introduced through the epidural needle into the subarachnoid space
(needle through needle technique).
 A single bolus of 1 ml 0.25% bupivacaine with 25 μgfentanil is injected into the subarachnoid space.
The spinal needle is then withdrawn.
 An epidural catheter is thus sited for repeated doses of anesthetic drug.
 The method gives rapid and effective analgesia during labor and cesarean delivery.

5. INFILTRATION ANALGESIA-
1. Perineal infiltration:

For episiotomy—
Perineal infiltration anesthesia is extensively used prior to episiotomy.
A 10 mL syringe, with a fine needle and about 8-10 mL 1% lignocaine hydrochloride (Xylocaine) are
required.
The perineum on the proposed episiotomy site is infiltrated in a fanwise manner starting from the middle of
the fourchette.

Each time prior to infiltration, aspiration to exclude blood is mandatory.

Episiotomy is to be done about 2-5 minutesfollowing infiltration.

For outlet forceps or ventouse—

(Perineal and labial infiltration): The combined perineal and labial infiltration is effective in outlet forceps
operation or ventouse traction.
 A 20 mL syringe, a long fine needle and about 20 mL of 1% lignocaine hydrochloride are required.
 The needle is inserted just posterior to the introitus. About 10 mL of the solution is infiltrated in a
fanwise manner on both sides of the midline (as for episiotomy).
 The needle is then directed anteriorly along each side of the vulva as far as the anterior-third to
block the genital branch of the genito-femoral and ilio-inguinal nerve.
 5 mL is required to block each side
GENERAL ANESTHESIA FOR CESAREAN SECTION-
The following are the important considerations of general anesthesia for cesarean section:
— Cesarean section may have to be done either as an elective or emergency procedure
— A fasting of 6-8 hours is preferable for an elective surgery
— The mother may have a full stomach raising the probability of aspiration
— A large number of drugs pass through the placental barrier and may depress the baby
— Uterine contractility may be diminished by volatile anesthetic agents like ether, halothane
— Lateral tilt of the women during operation. Halothane, isoflurane cause cardiac depression, hepatic
necrosis and hypotension
— Hypoxia and hypercapnia may occur
— Time interval from uterine incision to delivery is related directly to fetal acidosis and hypoxia
— Longer the exposure to general anesthetic before delivery the more depressed is the Apgar score.

General anesthesia:
Complications of general anesthesia:
Aspiration of gastric contents (Mendelson’s syndrome) is a serious and life threatening one.
 Delayed gastric emptying due to high level of serum progesterone,and maternal apprehension during
labor is the predisposing factor.
 The complication is due to aspiration of gastric acid contents (pH < 2.5) with the development of
chemical pneumonitis, atelectasis and bronchopneumonia.
 Right lower lobe is commonly involved as the aspirated food material reach the lung parenchyma
through the right bronchus.

Clinical presentation:
tachycardia, tachypnea, bronchospasm, ronchi, rales, cyanosis and hypotension. X-ray chest reveals right
lower lobeinvolvement.

Prevention:
The following safety measures should be taken to prevent this complication:
1. Patient should not be allowed to eat during labor.
2. H2-blocker (Ranitidine 150 mg orally) should be given night before (elective procedure) and to be
repeated (50 mgIM/IV) one hour before the administration of general anesthetic, to raise the gastric
pH.
3. Metoclopramide (10 mg IV) is given after minimum 3 minutes of pre-oxygenation to decrease
gastric volume and to increase the tone of lower esophageal sphincter.
4. Non-particulate antacid (0.3 molar sodium citrate 30 mL) is given orally before transferring the
patient to theatre to neutralize the existing gastric acid.
5. Intubation with adequate cricoid pressure following induction should be done.
6. Awake extubation should be a routine.
Management:
Immediate suctioning of oropharynx and nasopharynx is done to remove the inhaled fluid.
 Bronchoscopy may be needed if there is any large particulate matter.
 Continuous positive pressure ventilation to maintain arterial oxygen saturation of 95% is done. Pulse
oximeter is a useful guide.
 Antibiotics are administered when infection is evident.

Other complications of general anesthesia are:

(i) Failure in intubation and ventilation
(ii) Nausea, vomiting and sore throat.
SUMMARY:-
Childbirth is one of the most painful experiences a woman is likely to encounter in her lifetime. Fortunately,
analgesic techniques exist that reduce or ameliorate labor pain. Neuraxial labor analgesia offers the most
complete analgesia and is safe and reliable.
Anesthesia-related maternal morbidity and mortality have decreased steadily in recent years. This may be a
result of the more widespread use of neuraxial analgesia and anesthesia in obstetric patients.

CONCLUSION:-
Analgesic techniques are the gold standards for pain relief during labour and delivery. Despite the increased
use and known benefits of neuraxiallabour analgesia, there has been significant controversy regarding the
impact of neuraxial analgesia on labour outcomes. Review of the evidence suggests that effective
neuraxiallabour analgesia does not increase the rate of Caesarean delivery, even when administered early in
the course of labour; however, its use is associated with a prolonged second stage of labour. Effective
second-stage analgesia might also be associated with an increased rate of instrumental vaginal delivery.
SUMMARY
Today we have discussed about the topic under the following headings-
 Introduction of the topic
 Drugs used in pregnancy
 Drugs used in labour
 Drugs used in puerperium

CONCLUSION
 No drug should be administered to a woman during pregnancy, labor and birth, unless the woman is
fully informed of the known risks and the relevant areas of uncertainty regarding the effects of the drug
on the physiologic and neurologic development of the woman or her baby
 The drugs that are used daily in obstetric can have a huge impact on the outcome of both mother and
child.
 Therefore, obstetric providers need to have a very clear understanding of the mechanism of action, doses
and side-effects of the most commonly used drugs.
BIBLIOGRAPHY

1. Annamma Jacob “A Comprehensive Textbook of Midwifery & Gynecological Nursing” 3rd edition.
Jaypee Brothers Medical Publishers (P) Ltd page no. 604-619
2. D.C.Dutta’s “Textbooks of Obstetrics” 7th edition. New Central Book Agency (P) Ltd page no.666.
3. A.KDebdas “Drug handbook in Obstetrics”,3rd edition.Jaypee brothers and medical publishers private
limited, New Delhi.
4. wolter Kluwer “Drug handbook”32 edition.lippincot William &Wilkinson publisher ,London.
5. www.medicine.tcd.ie/pharmacology_therapeutics/.... Obs&Gyn.pd 

INTERNET SOURCES-
https://www.slideshare.net/golden4host/drugs-in-pregnancy

https://www.drugs.com/condition/labor-augmentation.html

https://emedicine.medscape.com/article/796379-medication

https://www.ncbi.nlm.nih.gov/pubmed/11432320