P

INDEX
S.NO CONTENT PAGE NUMBER
1 INTRODUCTION
2 DRUGS UED IN OBSTETRICS 3-9
 OXYTOCICS IN OBSTETRICS. 9-11
 ERGOT DERIVATIVES. 11-14
 PROSTAGLANDINS. 1415
 ANTI HYPERTENSIVES 15-16
 MATERNAL DRUGS INTAKE AND BREAST
FEEDING 16-20
 FETAL HAZARDS ON MATERNAL
3 MEDICATION DURING PREGNANCY 24
4 SUMMARY 24
5 CONCLUSION. 24
BIBLIOGRAPHY.
1
PHARMACO DYNAMICS IN OBSTETRICS
INTRODUCTION
Most women are exposed to drugs of one type or another during pregnancy. These may
be prescribed drugs are those bought over the counter. They may be given as part of
the management of the pregnancy itself or that of a coincidental medical problem.
However, when considering the use of any drugs in a pregnant or the women herself,
but also on the fetus or neonate. Many drugs have undesirable effects on the fetus and
should therefore be avoided during pregnancy. On the other hand, some drugs are
given to the woman because of their therapeutic effects on the fetus. Ex;-
Betamethasone or Dexamethasone are given to women at risk of preterm birth
because of their effects on fetal lung maturation. It is therefore important to have a
working knowledge of the issues surrounding the use of drugs.
In pregnancy and puerperium so that women can be correctly informed and advised
regarding the potential benefits and risks.
Many drugs have a undesirable effects on the fetus and should therefore be
avoided during pregnancy. On the other hand, some drugs are given to the women
because of therapeutic effects on the fetus. for example Betamethasone or
Dexamethasone are given to women at risk of preterm birth because of their therapeutic
effects on fetal lung maturity. It is therefore important to have a working knowledge of
the issues surrounding the use of drugs in pregnancy and puerperium.
DRUGS USED IN PREGNANCY
Most of the available information on pharmacokinetics of drugs during pregnancy

has obtained from animal experiments and may not be directly applicable to humans.
Precautions while prescribing drugs to a pregnant women
 Treat minor ailments with out drugs. Avoid drugs if possible, especially in the first
3months.
2
 If a drug must be prescribed, it should be one which is know to be safe during
pregnancy.
 Avoid recently introduced drugs if possible. Prefer a drug which has been in use
for long periods of time to a newly introduced drug as the safety of the later for
the fetus is not likely to be know completely.
 Adjust the dose of the drug to the pregnant state. However because of
pharmacokinetic factors (increased body weight and more rapid clearance)
Transfer of drugs across the placenta
Some of the fetal blood vessels are contained in tiny hair like projections (villi)of
the placenta that extend into the wall of the uterus. The mother blood passes through
the space surrounding the villi(intervillous space). Only a thin membrane (placental
membrane) separates the mother’s blood in intervillous space from the fetus’s blood in
the villi. Drugs in the mother blood can crosses this membrane in to blood vessels in
villiand pass through the umbilical cord to the fetus.
I. OXYTOCICS IN OBSTETRICS:-
a).DEFINITION:-
Oxytocic are the drugs of varying chemical nature that have the power to excite
contractions of the uterine muscle.
According to D.C.DUTTAOxytocin is a
naturally occurring hormone that exerts a stimulatory effecton myometrial contractility.
The effect of oxytocin on the myometrium is mainly dependent on the concentration of
oxytocin receptors present.
According to MYLES
b).PHARMACOLOGY:-
Oxytocin is nano peptide. In 1950, de Vigneaud and coworkers did the Nobel prize
winning work on structure of oxytocin. It is synthesized in the supraoptic and
paraventricular nuclei of thehypothalamus. By nerve axons it is transported from the
3
hypothalamus to the posterior pituitary where it is stored and eventually released.
Oxytocin has a half life of 3-4 mts and a duration of action of approximately 20mts. It is
rapidly metabolized and degraded by oxytocinase.
c).MODE OF ACTION:-
Myometrial oxytocin receptors concentration increases maximum (100-200) during

labour. Oxytocin acts through receptors and voltage mediated calcium channels to
initiate myometrial contractions. It stimulates amniotic and decidual prostaglandin
production. Bound intracellular calcium eventually mobilized from the sarcoplasmic
reticulum to activate the contractile protein. The uterine contractions are physiological
i.e. causing fundal contraction with relaxation of the cervix.
d).PREPARATIONS USED:-1).Synthetic oxytocin (Syntocinon-sandozor pitocin-parke-

Davis) is widely used.It has only got oxytocic effect with out any vasopressor action.
The syntocinon is available in ampoules containing 5 IU/m;Pitocin 5IU/ml.
2).Syntometrin (Sandoz)-A combination of Syntocinon 5 units and ergometrine 0.5mg.
3).Desamino oxytocin-It is not inactivated by oxytocinase and is 50-100 percent more

effective than oxytocin. It is used as buccal tablets containing 50IU.
4)Oxytocin nasal solution contains 40 units/ml.
e).EFFECTIVENESS:-
In the trimester, the uterus is almost refractory to oxytocin. In the second trimester
Relative refractoriness persists and as such, oxytocin can only supplement other
abortifacient agents in induction of abortion. In later months of pregnancy and during
labour in particular, it is highly sensitive to oxytocin even in small doses. Oxytocin loses
its effectiveness unless preserved at the correct temperature( between 2& 8c)
f).INDICATIONS:-
Oxytocin may be conveniently used in pregnancy, labour or puerperium.The indications

are group.
4
g). THERAPEUTIC;-Pregnancy
Labour
Puerperium
Pregnancy;-Early—
 To accelerate abortion—inevitable or missed and to expedite expulsion of

hydatidiform mole.
 To stop bleeding following evacuation of the uterus.
 Used an adjunct to induction of abortion along with other abortifacient agents
(PGE1 or PGE2)
LATE;-
To induce labour
To ripen the cervix before induction
LABOUR;-
Augmentation of labour.
Uterine inertia.
Inactive management of 3 rd stage of labour
Following expulsion of placenta as an alternative to ergometrine.
PUERPERIUM;-To minimize blood loss and to control postpartum haemorrhage.
h) DIAGNOSTIC;-
o Contraction stress test(CST)

o Oxytocin sensitivity test ( OST)
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CONTRAINDICATIONS OF OXYTOCIN
PREGNANCY LABOUR ANYTIME
 Grand multipara  All the contra-  Hypovolemic state

indication in
pregnancy
 Contractedpelvis  Obstructed labour  Cardiac disease
 History of caesarean  Incoordinate uterine

section or contraction
hysterotomy
 Malpresentation  Fetal distress
III.DANGERS OF OXYTOCIN:-
The dangers are particularly noticed when the drug is administered late in pregnancy or
during labour.
a).MATERNAL:-
uterine hyperstimulation (overactivity)- is a frequently observed side effect. There

may be excessive duration of uterine contraction(hypertonia) or increased frequency (>
6 in 10 min time) of contractions (polysystole). It is often associated with abnormal FHR
patternuterine rupture – may be seen with violent uterine contractions common. High
risk cases are: grand multipara, malpresentation, contracted pelvis, prior uterine scar
(hysteromony) and excessive oxytocin use.
Water intoxication is due to its antidiuretic function when used in high dose. Water
intoxication is manifested by hyponatremia, confusion, coma, convulsions, congestive
cardiac failure and death. It is prevented by strict fluid intake and output record, use of
salt solution and by avoiding high dose oxytocin for a long time.
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Hypertension:-Bolus IV injections of oxytocin causes hypotension specially when
patient is hypovolemic or with a heart disease. Occasionally oxytocin may produce
anginal pain.
Antidiuresis :-Antidiuretic effect is observed when oxytocin infusion rate is high (40-50
mlU/min) and continued for along time.
b).FETAL:-
fetal distress, fetal hypoxia or even fetal death may occur due to uterine
hyperstimulation. Uterine hypertonia or polysystole causes reduced placental blood
flow.
c).ROUTES OF ADMINISTRATION:-
 Controlled intravenous infusion is the widely used method

 Bolus IV or IM – 5-10 units after the birth of the baby as an alternative to
ergometrine
 Intramuscular – the preparation used is syntometrine
 Buccal tablets or nasal spray – limited use on trail basis
IV.METHODS OF ADMINISTRATION OF OXYTOCIN;-
a).CONTROLLED INTRAVENOUS INFUSION:-
oxytocin infusion should be ideally by infusion pump. Fluid load should be minimum. It is
started at low dose rates (1-2 mLU/min) and increasedgradually.
(i).FOR INDICATION OF LABOUR
Principles :
1) Because of safety, the oxytocin should be started with low dose and is escalated at
an interval of 20-30minutes where there is no response. When the optimal response is
achieved(uterine contraction sustained for about 45seconds and numbering 3
contractions in 10 minutes),the administration of the particular concentration in mU/per
minute is to be continued. This is called oxytocin titration technique.
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(2) the objective of oxytocin administration is not only to initiate effective uterine
contractions but also to maintain the normal pattern of uterine pattern of the uterine
activity till delivery and at least 30-60 minutes beyond that.
Calculation of the infused dose: Nowadays the infusion is expressed in terms of

milliunits per minute. This can give an accurate idea about the exact amount
administered per minute irrespective of the concentration of the solution.
Regulation of the drip: The drip is regulated by – (1) Manually, counting the drops
per minute commonly practiced (2) oxytocin infusion pump which automatically controls
the amount of fluid to be infused.
Convenient regime:-Because of wide variation in response, it is a sound practice to

start with a low dose (1-2 mIU / min at every 20 min. intervals upto 8 mU /min. the
patient should preferably lie on one side or in semi-fowler’s position to minimize
venacaval compression.
High dose oxytocin begins with 4mU/min and increased 4mU/min at every 20-30 min.
interval, it is a mainly used for augmentation of labour and in active management of
labour. Risks of uterine hyperstimulation and fetal hart irregularities are more with high
dose regime.
In majority of cases, a dose of less than 16 millions per minute (2units in 500ml ringer
solution with drop rate of 60/minute) is enough to achieve the objective. Conditions
where fluid overload is to be avoided, infusion with high concentration and reduced drop
rate is preferred.
(ii).FOR ARGUMENTATION OF LABOUR;-
Oxytocin infusion is used during labour in uterine inertia or for augmentation of labour or
in the active management of labour. The procedure consists of low rupture of the
membranes followed by oxytocin infusion when the liquor is clear. Feto-pelvic
disproportion must be ruled out before hand.
 Observation during oxytocin infusion.
8
 Rate of flow of infusion by counting the drops per minute or monitoring the
pump.
 Indications of stopping the infusion.
 Uterine contractions – number of contractions per 10min duration of contraction
and period of relaxation are noted. ‘finger tip’ palpation for the tonus of the uterus
in between contractions may be done where gadgets are not available.
 Peak intrauterine pressure of 50-60 mm Hg with a resting tone 10-15 mm Hg is
optimum when intrauterine pressure monitoring is used.
 FHR monitoring is done by auscultation at every 15min interval or by
continuous EFM.
 Assessment of progress of labour (descent of the head and rate of cervical
dilatation)
 Indications of stopping the infusion
(1) Nature of uterine contractions – (a) abnormal uterine contractions occurring
(hyperstimulation) or polysystole. (b) increased tonus in between contractions.
(2) Evidences of fetal distress. (3)Appearance of untoward maternal symptoms.
V.DIAGNOSTIC USE OF OXYTOCIN;-
a).CONTRACTION STRESS TEST (CST)(syn; oxytocin sensitivity test ;ost)
It is an invasive method to assess the fetal wellbeing during pregnancy. When there is
alteration in FHR in response to uterine contractions, it suggests fetal hypoxia.
PRINCIPLES;-The test is based on determination of the respiratory function of the feto-

placental unit during induced contractions when the blood flow through the unit is
controlled. The objective is to detect the degree of fetal compromise so that a suitable
time can be selected to terminate the pregnancy.
Candidates for CST;-
1.Intra uterine growth restriction.
2.Postmaturity.
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3.Hypertensive disorders of pregnancy.
4.Diabetes
Contraindications;-
1.Compromised fetus.
2.Previous history of caesarean section.
3.Complicatios likely to produce preterm labour.
4.APH
5.Multiple pregnancy
PROCEDURE;-The oxytocin infusion is started in the same manner as mentioned

earlier. The initial rate of infusion is 1mU/minute which is stepped up at intervals
Of 20mts until the effective uterine contractions are established .The alteration of the
FHR during contractions are recorded by electronic monitoring. Alternatively, clinical
monitoring can effectively be performed using hand to palpate hardening of the uterus
during contraction and auscultation of FHR during contraction and for 1mt thereafter. It
takes at least 1-2hrs to perform the test.
IMPORTANCE;- A negative test is associated with good fetal outcome. Whereas a

positive CST is associated with increased incidence of IUD, fetal distress in labour and
low Apgar score. But there is 50% chance of false positive results and as such positive
test cases are subjected to other methods of evaluation. For the wellbeing of the fetus
suspicious. CST should have a n induces uterine contractions for CST by massaging
the repeat test in 24 hours.
NIPPLE STIMULATION TEST:-The woman induces uterine contractions for CST by

massaging thenipple through her clothes for 10 minutes. It takes less time compared to
CST.
VI.ERGOT DERIVATIVES;-
10
Out of many ergot derivatives, two are used extensively as oxytocics . There are; ;
 Ergometrine (Ergonovine in USA)

 Methergin(Methyl ergonovine in USA)
a).CHEMISTRY;- Ergometrine is an alkaloid by Dudley and Moir in 1935 from ergot, a

fungus Claviceps purpureal that develop commonly in cereals like rye, wheat, etc. The
alkaloids are detoxified in the liver and eliminated in the urine. Methergin is a
semisynthetic protect derived from lysergic acid.
b).MODE OF ACTION : Ergometrine acts directly on the myometrium. It excites

uterine contractions which come so frequently one after the other which increasing
intensity that the uterus passes intoa state of spasm without any relaxation in between.
c).EFFECTIVENESS ; Keeping the physiological functions in mind, it should not be

used in the induction of abortion or labour. On the contrary, it is highly effect. E in
hemostasis to stop bleeding from the uterine sinuses , either following delivery or
abortion. Methergin is some what slower in producing uterine response taking 96
seconds, in contrast to 55 seconds by ergometrine when administered intravenously.
d).MODE OF ADMINISTRATION ; Ergometrine and methergin can be used

parenterally or orally. As it produces titanic uterine contractions, the preparation should
only be used either in late second stage of labour (after the delivery of the anterior
shoulder) or following delivery of the baby. Syntometrine should always be
administered intramuscularly.
e).USES OF ERGOMETRINE METHERGIN
f).HAZARDS: (1) Common side effects are nausea and vomiting.
(2)Because of this vasoconstrictive action, it mayprecipitate rise of blood pressure,

myocardial infarction,stroke and bronchospasm
(3) prolonged use may lead to gangrene of the toes due to its vasoconstrictive effect
11
(4) prolonged use in puerperium may interfere with lactation by loweringprobation
level
g).CAUTIONS
Ergometrine should not be used during pregnancy, first stage of labour, second stage
prior to crowning of the head and in breech delivery prior to crowning.
h).COMMENTS
As a haemostatic in uterine haemorrhage following expulsion of the fetus irrespective of

duration of pregnancy, ergometrine or methergin is the drug of choice. On the contrary,
oxytocin is predominantly used to initiate uterine (induction) and to accelerate uterine
contractions in labour.
VII.PROSTAGLANDINS(PGs);-
Prostaglandins area the derivatives of prostanoic acid from which they derive their
names. They have the property of acting as “local harmones”. Prostaglandins were
described and named by voneuler in 1935.
a). CHEMISTRY
Prostaglandins are 20-carbon carboxylic acids with a cyclopentane ring which are
formed from polyunsaturated fatty acids. Of many varieties of prostaglandins, PGE2 and
PGF2a are exclusively used in clinical practice. The subscript numeral after the letter
indicates the degree of unsaturation. Inactivation is done in lungs and liver.
b).SOURCES
Prostaglandins 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
menstrual fluid, endometrium, decidua and amniotic membrane.
c). PROSTAGLANDINS
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Increased biosynthesis of PGs of E and F series in the uterus is a prerequisite for labour
both term and preterm. PGs are paracrine/autocrine hormones as they act on locally at
their site of production. Their half life in the peripheral circulation is about 1-2 mts.
Decidua is the main sources of PGF2fetal membranes (amnion)produce PGE2and the
myometrium mainly produce PGI2.In vivo,PGF2 promotes myometrial
contractility,PGE2 helps cervical ripening.PGs promotemyometrial contraction
irrespective of the duration of gestation, where as oxytocin acts predominantly on the
uterus at the term or in labour. This has helped the widespread use of PGs to effect 1 st
trimester medical termination of pregnancy and also for induction of labour at term.Side
effects of PGs are less when used vaginally. Locally application of PGE2 gel is the gold
standard for cervical ripening.
d).USES IN OBSTETRICS:
 Induction of abortion (MTP&Missed abortion)

 Termination molar pregnancy
 Induction of labour
 Cervical ripening prior to induction of abortion or labour
e).CONTRAINDICATIONS
Hypersensitivity to the compound
Uterine scar
Active cardiac, pulmonary, renal or hepatic disease;hypotension(PGE2
Bronchial asthma(PGF2)
f).MECHANISM OF ACTION
Both PGE2 ,PGF2 have got oxytocic effect on the pregnant uterus when used in
appropriate dose.The probable mechanism of action is change in myometrial
cellmembrane permeability and/ or alteration of membrane –bound Ca++.PGs also
13
sensitive the myometrium to oxytocin.PGE2is atleast 5 times more potent than
PGF2 .PGF2 acts predominantly on the myometrium,while PGE2 acts mainly on the
cervix due to its collagenolytic property.
g). ADV&DIS ADVANTAGES & SIDE EFFECTSPROSTAGLANDINS(PGs);-
ADVANTAGES DISADVANTAGES&SIDEEFFECTS
1.Powerful oxytocic effect, irrespective 1. It is costly compareto oxytocinOf duration of

gestation
2.Induction of labour (PGE2,2. Nausea,vomiting,diarrhea,pyrexia,In cases with
(a) low preinduction score bronchospasm,tachycardia andchills.
(b)IUFD3.Cervical laceration may occur(PGF2)
3.Used in inductionof abortion(PGE1)with when used as an abortifacient.
Success
4.It has got no anti diuretic effect(of oxytocin)4. Tachysystole(hyperstimulation)of

theuterus,mayoccurduringinductionand maycontinue for a variable period.
5.PGE1(misoprostol)can be used for 5.Risk of uterine rupture in case with
augmentation of labouruterine scar
b).PREPARATIONS;-
 PROSTAGLANDIN E2is widely usedbecause it is less toxic and more effective

than PGF2α. It is however more costly.
1. Vaginal tablet – Contains 3mg dinoprostone (prostin E2 ). In the posterior fornix
followed by 3 mg after 6-8 hour maximum 6 mg.
2. Vaginal pessary (with retrival device) releasing dinoprostone approximately 10
mg over 24 hours. It is removed when cervical ripening is adequate.
3. Prostin E2(Dinoprostone) gel – 500 μg into cervical canal, below the level of
internal os or 1-2 mg in the posterior fornix.
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4. Parental:-
a. PGE2 (I.V) – Prostin E2 containing mg/ml
b. PGF2α – Prostin F2α (Dinoprost tromethamine) containing 5mg/ml
c. Methyl analogue of PGF2α (Carboprost- containing 250 μg/ml).
 METHYLESTER OF PGE1(misoprostol). It is rapidly absorbed and is more
effective than oxytocin or dinoprostone for induction of labour.
 MISOPROSTOL(PGE1) has been used for cervical ripening. Primarily it has
been used for peptic ulcer disease. Transvaginal misoprostol is misoprostol is
used for induction of labour. A dose of 50 μg every 3 hours to a maximum of six
doses or 25μg every 4 hours to a maximum of eight doses or orally 50 μg every 4
hours has been used. Misoprostol has been gound to be as effective as PGE2
for cervical ripening and induction of labour. The optimum dose of misoprostol is
yet to be determined. To date no evidence of teratogenic or carcinogenic effects
has been observed.
 ADVANTAGES& OF PGE1 over PGE2:- Misoprostol is cheap, stable at room
temperature, long self life, easily administered (oral or vaginal or rectal) and has
less side effects. Induction delivery interval is short. Need of oxytocin
augmentation is less. Failure of induction is less.
 RISKS:- Incidence of tachysystole (hyperstimulation), meconium passage are
high. Rupture of uterus though rare, has also been observed. It should not be
used for cases with previous caesarean birth because the risk of the rupture is
high. Misoprostol is not yet approved for use in pregnancyby FDA. Use of
misoprostol for induction of abortion has been discussed.
a) Hyperstimulation:- Contractions > 5 in 1min time is lasting for atleast 2 minutes.
Fetal heart rate (FHR) change may or may not be present.
b) Tachysystole is the hyperstimulation without FHR changes.
c) Hyperstimulation syndrome is the hyperstimulation or tachysystole with FHR
abnormalities (ACOG-2003).
i).REMARKS ABOUT OXYTOCICS:-All the oxytocins have got their places in obstetrics
15
 To arrest haemorrhage following delivery (PPH) or abortion, ergot preparation
(methergin, ergometrine) is the life saving drug. In refractory cases of atonic PPH,
PGF2α (IM/intra-myometrial) or PGE1(misoprostol) 1000μg (rectal)is an effective
choice.
 For induction of labour – either prostaglandins or oxytocin can be used. With
favourable preinduction cervical score, there is very little to choose between oxytocin
and prostaglandin, but when the score is a distinct advantage over oxytocin.
Misoprostol has certain advantages over PGE2.
 In augmentation or acceleration of labour, oxytocin still enjoys its popularity although
prostaglandins are equally effective.
 For induction of abortion – prostaglandins (misoprostol – PGE1)has got a distinct
advantage over oxytocin. Oxytocin may supplement the effects of PGs in the
process.
VIII.ANTIHYPERTENSIVE THERAPY;-
Antihypertensive drugs are essential when the BP is 160/110mm of hg to protect the

mother from eclampsia, cerebral hemorrhage, cardiac failure and placental abruption.
Aim is to reduce BP to a mean, 125mm hg. Their benefit in mild or moderate
hypertension is not yet known. If there is any risk of target organ damage (kidney)
antihypertensives are given to maintain BP ≤ 140 mm of hg. First line therapy is either
methyldopa or labetalol. Second line drug is nifedipine. ACE inhibitors are avoided in
pregnancy. The following are the drugs with their pharmacological property and clinical
use:-
 In pre-eclampsia and eclampsia

 Chronic hypertension
IX.DIURETICS
The diuretics are used in the following conditions during pregnancy:-
 Pregnancy induced hypertension with pathological edema

 Severe anaemia in pregnancy with heart failure
16
 As an adjunct to certain antihypertensive drugs such as hydralazine or diazoxide.
 Eclampsia with pulmonary edema
 Prior to blood transfusion in severe anaemia
 COMMON PREPARATIONS USED:- Frusemide (loop diuretic) – dose -40mg tab

daily following breakfast for 5 days a week. In acute conditions, the drug is
administered parentally in doses of 40-120 mg daily. Mode of action – it directly
prevents reabsorption of sodium and potassium mainly from the loop of Henle.
Hazards :
(a) .Maternal complications include – weakness, fatigue, muscle cramps, hypokalaemia

and postural hypotension. These can be corrected by potassium supplement during
therapy.
(b). Fetal – In pre-eclampsia, its routine use should be restricted, as it is likely to cause
further reduction of maternal plasma volume, which is already lowered. This may result
in diminished placental perfusion leading to fetal compromise. Other hazards include
thrombocytopenia and hyponatraemia.
Thiazide diuretic is often used in conjunction with other antihypertensives. It is safe in

pregnancy.
Dose:- 12.5 mg twice daily maximum up to 50mg daily may be used. Side effects are:-
Maternal and fetal hyponatraemia, acute pancreatitis, rise in uric acid levels, and
neonatal thrombocytopenia. In a diabetic patient, it may cause hyperglycemia.
Spironolactone potentiates thiazide or loop diuretics by antagonizing aldosterone. It is a

potassium sparing diuretic. It is contraindicated in hyperkalaemia. Drospirenone is an
analog of Spironolactone. It has antiandrogenic and antimineralocorticoid properties.
The dose used in COCs is usually not associated with hyperkalaemia.
XIII.MATERNAL DRUGS INTAKE& BREAST FEEDING:
17
Maternal drugs intake during nursing may have adverse effect not only on lactation but
also on the baby through the ingested breast milk. Any drug ingested by a nursing
mother may be present in her breast milk, but its any clinical significance to the infant.
However, milk concentrations of some drugs (e.g.iodides) may exceed those in the
maternal plasma so that therapeutic doses in the mother may cause toxicity to the
infant. Common side effects from maternal medication on breast fed infants are :
diarrhea (antibiotics), irritability (antihistaminics), drowsiness (sedatiues,
antidepressants, antiepileptics).
 GUIDELINES FOR MEDICATION DURING LACTATION

Benefits of medication must outweigh the risks .
Select drugs that are most widely tested and with short half life.
Monitor the infant during e course of therapy.
Non-ionised, low molecular weight, lipid soluble compounds are usually excreted
through breast milk.
 MATERNAL MEDICATION
 EFFECTS ON LACTATION& THE NEONATES
Maternal medication Effects on lactation and the neonate
Oral pill (combined) Suppression of lactation

Bromocriptine - do –
Ergot Vomiting, diarrhea, convulsions in infant
Progesterone (only pill) It is ideal for breast-feeding mother
Metronidazole (single dose regimen) No adverse effects have been reported
Temporary cessation of lactation(12-24 Hours) is advised.
Anti-thyroid drugs, radioactive iodine Hypothyroidism, goitre, agranlocytosis
Warfarin
a). TERATOLOGY & PRESCRIBING IN PREGNANCY
Teratogen causes permanent alteration in the structure and or function of an

organ,acting during the embryonic or fetal life.Theteratogens may be chemical agents
18
(drugs) or physical agents (radiation, heat).The dose (amount) and duration of
teratogen exposure may cause variable response from on effect level to lethal
level.Final results of an abnormal development are :death, malformation, growth
restriction and functional disorder.
The term placental barrier is a contradiction as many drugs cross the barrier with
the exception of large organic ions such as heparin and insulin. Approximately 25% of
human development defects are genetic in origin, 2-3% are due to drug exposure and
about 65% ore either unknown or from combination of genetic and environmental
factors.
MECHANISM OF TERATOGENECITY:
The actual mechanism is unknown.Teratogens may affect through the following ways:
1) Folic acid deficiency leads to deficient methionine production and RNA, DNA
synthesis. Folic acid is essential for normal meiosis and mitosis.
Periconceptional folate deficiency leads to neural tube defects, cleft lips and
palate .
2) Epoxides or arena oxides are the oxidative inter metabolites of many drugs like
hydantoin and carbamazepine.This intermediary metabolites have carcinogenic
and teratogenic effects unless they are detoxified by fetal epoxide hydrolase.
3) Environment and Genes.Abnormalities that are multi factorial depends on the
ultimate interaction between the environment and fetal gene mutation.
Genotype of the embryo and their susceptibility to teratogens are the important
determinants.Homozygous gene mutations are associated with more
anomalies.
4) Maternal disease and drugs (epilepsy and anticonvulsants) have an increased
risk of fetal anomalies.Paternal exposure to drugs or mutagens (polycyclic
hydrocarbons) can cause genemutation and chromosomal abnormality in
sperm.
5) Homeobox genes are groups if regulatory genes that control the expression of
other genes involved in the normal development of growth and
19
differentiation.Teratogens like retinoic acid can dysregulate these genes to
causes abnormal gene expression.
b).TIMING OF TERATOGEN EXPOSURE AND THE HAZARDS:
Before D 31:Teratogen produces an all or none effect.The conceptus either does not
survive or survives without anomalies.In early conception only few cells are there.So
any damage at that phase, is irreparable and is lethal.
D 31-D 71 is the critical period for organ formation.Effects of teratogen depend on the
following factors:
 Amount of the drug reaching the fetus

 Gestational age at the time of exposure
 Duration of exposure.
After D 71 development of other organs continues.Diethyl stilboesterol (DES) related

uterine anomalies occur with exposure around 20 weeks-
c).ALCOHOL
Heavy drinkers have major risk to the fetus. Fetal Alcohol Syndrome (FAS) is defined
as the presence of at least one characteristics from each of the following 3 categories:
1. Growth restriction before and or after birth.

2. Fetal anomalies : Small palpebral fissures, indistinct or absent philtium,
epicanthic folds, flattened nasal bridge, short length of nose, thin upper lip, low
set and unparallel ears and retarded midfacial development.
3. CNS dysfunction : Microcephaly, mental retardation, abnormal development
(attention deficit with hyperactivity)
4.
ANALGESIA DURING LABOUR AND DELIVERY
20
The pain during labor results from a combination of uterine contractions and cervical
dilatation. Drugs have an important part to play in labor but it must not be supposed that
they are of greater importance than proper preparation and training for child birth .
METHOD OF PAIN RELIEF
1. Sedatives and analgesics.

2. Inhalation agents.
3. Regional analgesics.
4. General anesthesia.
SEDATIVES AND ANALGESICS
For the purpose of selecting a general analgesic drug, labor has been divided
arbitrarily into two phases . the first phase corresponds up to 8cm dilatation of the cervix
in primigravidae and 6cm in case of multipara . the second phase corresponds to
dilatation of the cervix beyond the above limits up to delivery . the first phase is
controlled by sedatives and analgesics and the second phase is controlled by inhalation
agents.
PETHIDINE (MEPERIDINE) :
It is synthetic narcotic analgesic agent, well absorbed by all routes of

administration .
ACTION
 Inhibits ascending pain pathways in central nervous system, increases pain

threshold and alters pain perception.
INDICATIONS
 Moderate to severe pain in labor , postoperative pain, abruption placentae,

pulmonary edema.
21
DOSAGEAND ROUTE OF ADMINISTRATION
 Injectable preparation contains 50 mg/dl can be administered SC,IM ,IV. Its dose
is 50 to 100mg IM combined with promethazine 25mg.
CONTRAINDICATION
Pethidine should not be used intravenously within 2 hours and intramuscularly

within 3 hours of the expected time of delivery of the baby , for fear of birth asphyxia . it
should not be used in cases of preterm labor and when the respiratory reserve of the
mother is reduced.
SIDE EFFECTS/ADVERSE REACTIONS
MOTHER
 Drowsiness , dizziness , confusions, headache, sedation, euphoria, nausea and

vomiting.
FETUS
 Respiratory depression , asphyxia.
FENATANYL: Fentanyl is a synthetic narcotic analgesic agent.
ACTION
 Inhibits ascending pain pathways in CNS , increases pain threshold and alters
pain perception.
INDICATIONS
 Moderate to severe pain in labor , postoperative pain and as adjunct to general

anesthetic.
DOSAGE AND ROUTES
 0.05 to 0.1mg IM
22
CONTRAINDICATIONS
 Hypersensitivity to opiates.
SIDE EFFECTS/ ADVERSE REACTIONS
 Dizziness , delirium, euphoria, nausea, vomiting, muscle rigidity, blurred vision.
INHALATION METHODS
PREMIXED NITROUS OXIDE AND OXYGEN:
Cylinders contain 50 percent nitrous oxide and 50 percent oxygen mixture.

Entonox apparatus has been approved for use by midwives .This agent is used in the
2nd phase . entonox is most commonly used inhalation agent during labor
SIDE EFFECTS -Hyperventilation.
-dizziness
-hypocapnia
The woman is to take slow and deep breaths before the contractions and to stop
when the contractions are over . The woman should be monitored with pulse oximetry.
REGIONAL ANAESTHESIA
The methods so far considered cannot ensure a painless delivery n or can they
make labor tolerable when the pain is very severe. When complete relief of pain is
needed throughout labor , epidural analgesia is the safest and simplest method for
procuring it.
ADVANTAGES OF REGIONAL ANAESTHESIA
 The patient is awake and can enjoy the birth time.

 Newborn apgar score generally good.
23
 Lowered risk of maternal aspiration.
 Post operative pain control is better.
EPIDURAL ANALGESIA IS SPECIALLY BENEFICIAL in cases like pregnancy

induced hypertension , breech presentation , twin pregnancy labor . previous caesarean
section is not a contraindication. Epidural analgesia when used there is no exchange in
duration of first stage of labor. But second stage of labor appears to be prolonged . this
might lead to frequent need of instrumental delivery like forceps or ventouse.
CONTRAINDICATIONS OF EPIDURAL BLOCK
 Maternal coagulopathy or anticoagulant therapy.

 Supine hypotension.
 Hypovolaemia.
 Neurological diseases.
 Spinal deformity or chronic low back pain
 Skin infection at the injection site.
COMPLICATIONS OF EPIDURAL ANALGESIA
 Hypotension due to sympathetic blockade.

 Pain at the insertion site. Back pain.
 Post spinal headache due to leakage of cerebrospinal fluid .
 Total spine due to inadvertent administration of the drug in the subarachnoid
space.
 Injury to nerve , convulsions , pyrexia.
24
 Ineffective analgesia.
PUDENDAL NERVE BLOCK
It is a safe and simple method of analgesia during delivery. Pudendal nerve block
doesnot relieve the pain of labor but affords perineal analgesia and relaxation.
Puedendal nerve block is mostly used for forceps and vaginal breech delivery. 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.
TRANSVAGINAL ROUTE
Transvaginal route is commonly preferred. A 20ml syringe, one 15cm 22guage

spiral needle and about 20ml of 1% lignocaine hydrochloride are required. The index
and middle finger 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 the ischial spine and
thereafter to push a little to pierce the sacro-spinous ligament just above the ischial
spine tip. After aspiratingto exclude blood , about 10ml 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 and rarely intravascular injection.
SPINAL ANAESTHESIA
25
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.
Procedure
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 1 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 caesarean section.
SIDE EFFECTS OF SPINAL ANAESTHESIA
 Hypotension
 Respiratory depression.
 Post spinal headache.
 Permanent paralysis.
 Paralysis and nerve injury.
 Nausea and vomiting are not uncommon.
 Urinary retention .
XVII.GENERAL ANAESTHESIA FOR CAESAREAN SECTION
The following ae the important considerations of general anesthesia

for cesarean section:
26
 Caesarean 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 throughthe placental barrier and may depress the baby.
 Uterine contractility may be diminished by volatile anaesthetic 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 to fetal acidosis and
hypoxia.
 Longer the exposure to general anaesthetic before delivery the more depressed
is the apgar score.
GENERAL ANAESTHESIA:
Preoperative medication with sedatives or narcotics is not required as

they may cause respiratory depression of the fetus.
 100% oxygen is administered by tight mask fit for more than 3 minutes .
induction of anaesthesia is done with the injection of thiopentone sodium
200 to 250 mg (4mg/kg) as a 2.5 percent solution intravenously, followed by
refrigerated suxamethonium 100mg .
 The assistant applies cricoids pressure as consciousness is lost. The patient
is intubated with a cuffed endotracheal tube and the cuff is inflated.
 Anaesthesia is maintained with 50 percent nitrous oxide, 50 percent oxygen
and a trace (0.5%) of halothane. Relaxation is maintained with
nondepolarizing muscle relaxant. After delivery of the baby , the nitrous
oxide concentration should be increased to 70% and narcotics are injected
intravenously to supplement anaesthesia.
COMPLICATIONS OF GENERAL ANAESTHESIA
27
 Aspiration of gastric contents is a serious and life threatening one.
 Delayed gastric emptying due to high level of serum progesterone , decreased
motilin and maternal apprehension during labor is the predisposing factor.
 The complications is due to aspiration of gastric acid contents with the
development of chemical pneumonitis , atelectasis and bronchopneumonia .
 Right lower lobe is commonly involved as the aspirated food material reach the
lung parenchymathrough the right bronchus.
Clinical presentation :
Tachycardia , tachynoea, bronchospasm, bronchi, rales, cyanosis and

hypotension. X-ray chest reveals right lower lobe involvement.
PREVENTION:
The following safety measures should be taken to prevent complication:
 Patient should not be allowed to eat during labour.

 H2-blocker (rantidine 150mg orally ) should be given night before and to be
repeated (50mg IM/IV) one hour before the administration of general
anaesthetic , to raise the gastric PH.
 Metoclopramide (10mg IV) is given after minimum3 minutes of pre-oxygenation
to decrease gastric volume and to increase the tone of lower oesophageal
sphincter.
 Non- particulate antacid is given orally before transferring the patient to theatre to
neutralize the existing gastric acid.
 Intubation with adequate cricoids pressure following induction should be done.
 Awake extubation should be a routine.
MANAGEMENT: Immediate sutioning of oropharynx and nasopharynx is done to

remove the inhaley be needed if there is any large pad fluid. Bronchoscopy may be
needed if there is any large particular 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. Role of corticosteroid is doubtful.
28
Other complications of general anaesthesia are :
1) failure in intubation and ventilation.
2) nausea and vomiting and sore throat.
SUMMARY
Till now we have discussed regarding drugs used in obstetrics.
CONCLUSION
By the end of seminar students will be able to gain knowledge regarding drugs
used in obstetrics.
XXII. BIBLIOGRAPHY
1. D.C DUTTA; ‘’A TEXT BOOK OF OBSTETRICS;’’7TH EDITION; NEW CENTRAL

BOOK AGENCY (P) LTD, LONDON;2011;498—521
2. WILLIAMS, ‘F’. GARY GUNNINGHAM MD;”A TEXT BOOK OF WILLIAMS
OBSTERRICS”;22nd; MGGRAW – HILL ; MEDIAL PUBLISHING DIVISION USA ;
2005 ;341 – 364.
3. SABARATNAM ARUN KUMARAN ; V.SIVAKESARATNAM ; A TEXT BOOK OF
ESSENTIALS OFOBSTETRICS; 1ST EDITION ; JAYPEE BROTHERS MEDICAL
PUBLISHERS (P) (LTD) NEW DELHI ; 2004 ; 250 – 257.
4. MUDILAR & MENON’S ;” A TEXTBOOK OF CLINICAL OBSTETRICS”;10TH
EDITION ; ORIENT LONGMAN (P) (LTD) CHENNAI ; 2005; 74-76.
5. MYLES ; “A TEXTBOOK FOR MIDWIVES”;14TH EDITION, CHURCHILL LIVING
STONE ELSEVIER LIMITED ; 2003; 903 – 916.
6. IANDONALDS ;”A TEXTBOOK OF PRACTICAL ESSENTIALS OF
OBSTETRICS”; 6TH EDITION ; BL PUBLICATIONS NEW DELHI; 2006; 671-
681.
29
30
DRUGS USED COMMONLY
Folic acid
It is named as folic acid because it is commonly presenting green leaves. It is

recommended that all women planning a pregnancy should taken folic acid in a dose of
400ug daily and that this continue through out the first trimester.
Transport, Storage
Given orally folic acid appears in the blood with in 30min and excretion is
completed with in 24hours. The amount of folic acid excreted in the urine is depend
upon the dose. Vitamin C protects folic acid, from oxidative destruction.
Adverse reactions
Folic acid is almost non toxic and no adverse effects have been reported except
a rare and doubtful allergic reaction to parenteral preparations.
Preparation and dosage
The recommended dose in the general population is 4 mg daily, but in women at

risk of neural tube defects (eg : with a previously affected fetus, or on carbomazepine or
sodium valporate) should receive 5 mg daily.
Therapeutic uses
Daily requirement of folic acid in non pregnant – 50-100 µg/day and during
pregnancy increased 400 µg/day.
1. Inadequate intake due to

a. Nausea, vomiting and loss of appetite.
b. Dietary insufficiency
2. Increased demand due to
c. Increased maternal tissue including red blood cell volume.
d. Development product of conception
31
3. Diminished absorption - Intestinal malabsorption a syndrome is responsible for
its recurrence.
4. Abnormal demand a. Twins b. infection (reduce the life span of red cells) c.
Hemorrhagic states such as peptic ulcer, hook worm infestation, hemorrhoids
and hemolytic states (Chronic malaria, sickle cell anemia or Thelassmia).
5. Anemia due to impaired utilization certain anti epileptic drugs like
phenobarbitone, phenytoin and primidone may cause folic acid deficiency
anemia probably by impairing its absorption and its utilization.
6. Prevention of neutral tube defects (N.T.D) Any woman who can become
pregnant should be prescribed 400 mcg of folic acid daily as other wise the
conceptus might develop N.T.D. which are liable to occur during the first week of
gestation, even before the subject knows that she is pregnant.
IRON
Iron deficiency anemia is common in pregnant iron preparations are frequently

prescribed.
Iron is present in the human body chiefly as a component of haemoglobin in

blood (2/3) and the rest (1/3) in bone marrow spleen and muscle.
Iron deficiency essentially results in a fall in blood haemoglobin content which

causes a variety of symptoms like poor general well being. Early fatigability,
neuropathic symptoms cloudiness of intellectual process, breath less ness, vague
muscle and body aches.
Requirement :
Daily iron requirement for adult 1-1.5 mg/day. In pregnant and lactation iron
requirement 2-2.5 mg/day.
Dose :
Daily administration of 200 mg of ferrous sulphate (containing 60 mg of element

iron) along with 1 mg folic acid is a quite effective prophylactic procedure.
(Supplementary iron therapy).
32
Indications
 Iron deficiency due to chronic blood loss.

 Pregnancy, foetus takes up to 600 mg of iron from the mother even if she is iron
deficient.
 During the treatment of severe pernicious anemia.
Choice of therapy depends on : (i) Severity of anaemia (2) Duration of pregnancy
(time available before delivery) (3) Associated complicating factors.
Iron therapy: 1. Oral therapy 2. Parenteral therapy
1. Oral therapy: Iron is best absorbed in the ferrous form and as such any of the
ferrous preparations available either in tablets or capsules may be conveniently
prescribed. The preparations available are ferrous gluconate, ferrous fumarate or
ferrous succinate. In spite of claims about the superiority of one preparation over
the other, ferrous sulphate is widely used. Green coated fersolate tablet contains
200mg (3 gr) ferrous sulphate which contains 1 gr (60 mg) of element iron, trace
of copper and managenese. The initial dose is one tablet to be given thrice daily
with or after meals. If bigger dose in necessary (maximum six tablets a day), it
should be stepped up gradually in three to four days. The treatment should be
continued till the blood picture becomes normal; thereafter a maintenance dose
of one tablet daily is to be continued till at least three months following delivery.
2. Drawbacks: (1) Intolerance – The intolerance is evidenced by epigastric pain,
nausea, vomiting diarrhea or constipation. It may be related to increased dose of
iron or to some preparation. To avoid intolerance, it is preferable to start the
therapy with a smaller dose-one tablet daily and then to increase the dose to a
maximum three tablets a day. If such procedure fails to stop the symptoms an
alternate preparation should be prescribed.
3. unpredictable absorption rate – Because of various unforeseen factors which
are involved in the iron absorption and its utilization, the therapy cannot be
instituted confidently when rapid response is needed. Antacids, oxalates and
phosphates will reduce absorption while ascorbic acid, lactate and various
33
(3) With the therapeutic dose, the serum iron may be restored but there is difficulty if
replenishing the store iron.
 Response of therapy is evidenced by : (1) Sense of well being (2) Increased

appetite (3) Improved outlook of the patient (4) Haematotogical examination : (a)
Rise in haemoglobin level (b) Haematocrit value returning to normal (c)
Reticulocytosis within 7-10 days. If no significant improvement is evident
clinically and haematologically within three weeks, diagnostic reevaluation is
needed.
 Rate of improvement : The improvement should be evident within three weeks
of the therapy. After a lapse of ten days, the haemoglobin concentration is
expected to rise at the rate of 0.1-0.25 gm/100 ml per day until it reaches to a
near normal level by 4-10 weeks depending upon the severity.
 Causes of failure of improvement : (1) Improper typing of anaemia (2)
Defective absorption due to associated gastrointestinal disorders (3) The patient
fails to take iron. (4) Concurrent blood loss as in hook worm infection or bleeding
piles (5) Inhibition of erythropoiesis by infection.
 Contraindications of oral therapy : The following are the contraindications of
oral therapy : (1) Intolerance to oral iron (2) Severe anaemia where rapid need
for iron is very pressing as in advanced pregnancy - beyond 30 weeks.
Considering the unpredictable absorption and utilization following oral therapy,
parenteral therapy is the preferred choice.
II. Parenteral therapy :Parentera) therapy includes :
(A) Intravenous route : (i) Repeated injections (B) Intramuscular route
(ii) Total dose infusion (TDI)
Indications of parenteral therapy :
The following are the indications of parenteral therapy :
(1) Contraindications of oral therapy as previously mentioned.
(2) Patient is not co-operative to take oral iron.
34
It is now widely recognized that there is no significant acceleration in
haemoglobin concentration following parenteral therapy as compared with oral
medication (oral administration under ideal circumstances). As such the parenteral route
should not_ be used just because a quicker response can be obtained.
The main advantage of parenteral therapy is the certainty of its administration to

correct the haemoglobin deficit and to fix up the store iron.
(A) Intravenous route :
 Interrupted therapy : Saccharated oxidfi-oi iron was first introduced tor

interrupted intravenous therapy. Because of high toxicity even to the extent of
occasional death, it was replaced promptly as soon as suitable parente'al
preparations were available in the market,
 Total dose infusion (TDI) : The deficit of iron is first calculated and the total
amount of iron required to correct the deficit is administered by a single sitting
intravenous infusion. The compound used is iron dextrancompound. 1 ml of
which contains 5Q_rng element inning one ampoule containsdose vial contains
10 ml.
Advantages : (1) It eliminates repeated and painful intramuscular injections. (2) The
treatment is completed in a day and the patient may be discharged much earlier from
the hospital. (3) It is less costly compared to the repeated intramuscular therapy.
Limitations : (1) As the maximum haemoglobin response does not appear before four
to nine weeks, the method is unsuitable if at least four weeks time is not available, to
raise the hemoglobin to a sate level of 10 gm% before delivery. Thus, it is mostly
suitable during 30-36 weeks of pregnancy where the patient is unwilling or unable to
complete the course of intramuscular" injections. (2) History of allergy and previous
history of reaction to potential therapy are contraindicated for its use.
Estimation of the total requirement: The manufacturers usually give the necessary"
information as to how the calculation, is to be made. However, the following methods
are useful :
35
1. Assuming that 200 mg of element iron will raise the haemoglobin by 1 gm per
100 ml in female, the total milligrams of element iron required is estimated to be
the deficiency of haemoglobin in grams multiplied by 200. An additional 50% is to
be added for partial replenishment of the store iron.
2. Calculation based on a formula 0.3 X W (100-Hb%) mg of element iron. Where
W = patient's weight in pounds, Hb% = observed haemoglobin concentration in
percentage. Additional 50% is to be added for partial replenishment of the body
store iron.
Example : The total element iron required in an anaemic patient weighing 100 Ib with
haemoglobin 50% is calculated as follows : 0.3X10(){100-50)=3/10X100X50=I500mg.
Add50% = 50mg.TotaIelementironrequired2250mg.
Pre-requisites :The following pre-requisites are to be fulfilled for TDI
(1) Correct diagnosis of true iron deficiency anaemia
(2) No history of allergy
(3) Adequate supervision
(4) Facilities for management of anaphylactic reaction
Procedures
1. Overnight admission in the hospital is not required. The patient may be admitted
in the morning for infusion.
2. The required iron is mixed with 500 ml of 5% dextrose. If the required amount of
iron is more than 50 ml (1 ml = 50 mg of element iron), then the total dose is to
be infused on two consecutive days, infusing half the total amount in each day.
3. Usual precautions like those of blood transfusion are to be taken both prior to
and during the infusion process.
4. The drip rate should be 10 drops per minute during the first 20 minute and
thereafter the drip rate may be increased to 40 drops per minute depending
upon the severity of anaemia.
36
5. Any adverse reaction like rigor, chest pain or hypotension calls for omission of
the drip.
(B) Intramuscular therapy : The compounds used are
 Iron-dextran (Imferon)
 Iron iorbitol- complex in dextrin (Iron sorbitol complex-Jectofer)
Both the preparations contain 50 mg of element iron in one millilitre. Total dose to
be administered is calculated as that previously mentioned in intravenous therapy. Total
dose of iron sorbitol complex is to be adjusted because of it> 30% excretion in urine.
Iron dextran compound (Imferon) : It is absorbed mainly through lymphatics and

hence there is chance of lymph-adpnopathy. Absorption is slower because of its bigger
molecules. Excretion is practically nil.
Iron loroitol Complex (Jectofer) : It is absorbed mainly through the blood stream and
about one-third is excreted in the urine following each injection. Therefore, it should not
be given in case with impaired renal function. It produces an unpleasant metallic
tasteanda loss of ability to taste food. As fraction of iron sorbitol becomes bound with
siderophilin, it is important that adequate free Siderophilin be available and as such
oral iron should be suspended at least 24 hours prior to the sorbitol therapy,
otherwise there may be reaction. This is not applicable to iron dextran compound
therapy.
Procedure of injections '. After an initial test dose of 1 ml, the injections are given daily
or on alternate days in doses of 2 ml intramuscularly.
To prevent dark staining of the skin over the injection sites and to minimise pain,
the injections are given with a two inch needle deep into the upper outer quadrant of the
buttock using a 'Z' technique (pulling the skin and subcutaneous tissues to one side
before inserting the needle). An additional precaution is to inject small quantity of air or
saline down" the needle before withdrawing it. These procedures prevent even a slight
drop of the solution to come beneath the skin surface so as to stain it.
ANTIEMETICS
37
If a vomiting is significant problem then it is preferable to use an antiemetic drugs
rather than risk dehydration, in the most severe cases it will cause malnutrition.
Antihistamine
Eg : cyclizine (marzine) the dose 50 mg.
The most common side effects is drowsiness.
 They block the histaminergic signals from the vestibular nucleus to the vomiting
centre.
Anticholergic drugs
Eg : prochlor perazine. It is a less sedative 10-30 mg.
Other wise : Anti psychotic, Antiemetic.
Side effects : It cause “dystonic reaction” or “Occulogyric crisis” where there is a

uncontrolled spasm of the muscles of the face and neck.
Other is diphenyl hydramine.
Anti dopaminenergic drugs Metocloprimide.
Is safe in the third trimister and it is mostly prescribed in resistant cases.
Action : It is acts central
It action is increases the resting tone of the gastro esophagus spincter and
stimulates co-ordinated gastric motility to speed up gastric emptying.
Adverse reaction
It is a relatively safe drug.
In some cases drowsiness, dystonic reaction will be present.
Dose : - 5-10 mg Tablet – TID
38
10-20 mg IV or IM.
ANTACID DRUGS
Antacids are alkalis that act by reducing the acidity of stomach acid. Modern
antacid drugs are mostly based on calcium, magnesium and albumin salts which are
relatively non-absorbable. They are often combined with alginates, which coat the lining
of oesophagus and stomach and therefore reduce contact with stomach acid. Because
they are relatively non absorbable, they are safe for use in pregnancy.
 Aluminium hydroxide gel 4-8 ml every 2-4 hrs.

 Aluminium hydroxide 0.5 g Tablets.
 Magnesium trisilicate – 2-4g every 1-4 hrs.
 Calcium carbonate – 1 g of calcium carbonate 2-4g.
ANTIBIOTICS
Antibiotics are one of the most commonly prescribed groups of drugs in

pregnancy. Betalactum antibiotics are safe during pregnancy.
Antibiotics that are considered safe in pregnancy
 Penicillins (benzyl penicillin, phenoxymethyl penicillin, ampicillin, amoxicillin, Co-

amoxyclav (Augmentin, flucloxacillin) cuphalosporins (cephradine, cuphalexim,
cefuroxime, cephotaxime) – alternative it allergic.
 Benzyl penicillin in – 200,000 – 400,000 units 4th hourly.
 Trimethoprim : avoid in first trimester.
Ampicillin : achieves very high concentration in the fetal circulation and amniotic fluid
and is very suitable for treatment of utensil infector during pregnancy. 250-500 mg 6 th
hourly.
Erythromycin : Base is safe but erythromycin isolate should be avoided for fear or
hepatotoxicity 250 -500 mg.
If one is needed to treat a serious systemic infection in the mother gentamycin or

tobramycin should be preferred.
39
Antibiotics that may causes adverse effects in pregnancy.
Tetracycline (Tetracycline, Oxytetracycline, doxycycline) Risk : Discoloration

and dysplasia of fetal bones and teeth, cataracts when used in second and third
trimester.
Aminioglycosides (Gentamin, ex: Netilmicin) Risk of ototoxicity but often used in

serious maternal infection where benefit out weight risk.
Chloramphenicol : Grey baby syndrome when used in second and third trimester.
Nitrofurantoin Haemolysis in fetus at term avoid during labour and delivery but
safe at other times.
Quinolones (Cliprofloxacin, Ofloxcin) Astrhopathy infetus – most of the evidence

for this obtained from animal studies.
ANALGESIA
It is relatively common for a pregnant woman to require analgesia during

pregnancy. This may be for something as simple as a headache or a more significant
problem such as rheumatoid arthritis, or for a pregnancy related conditions.
Paracetamol This is one of the drugs which has a long and un blemished safety record
when taken in therapeutic doses. It should be recommended first line analgesic agent in
pregnancy. However, in over dose it can be potentially lethal to the month or fetus, or
both, as it causes liver failure.
NSAID’S eg: Ibuprofen, Indometacin, voltarol. These drugs may be relatively safe in
the first trimester but have the potential to cause renal dysnfuncitn, premature closure of
the ductus arteriosis, necrotising enterocolitis and intracerebral haemorrahage.
Indometacin has been used on a short term basics as a tocolytic agent and to reduce
liquor volume in poly hydraminios, but should not be used in the longterm because of
the above risks.
40
A possible problem with inbuprofen is that is available widely as an over – the
counter preparation.
These drugs are safe in breast feeding.
Opiate Analgesics : eg: Pethidine, morphine, diamorphine, codine, dihdro codine.
When used in analgeric closes there is no clear evidence of teratogenesis with these
drugs.
For acute episodes there is probably little risk with the use of these drugs.
The neonatal with drawl can be demonstrated even in women using relatively
moderates doses of codine such as those available in over the counter preparation.
When gives in large doses in labor there is a risk of respiratory depression.
ASPIRIN
In analgeric doses, aspirin has been shown to increase the risk of natural, fetal and
neonatal bleeding because of its effects as an antiplatelet agent. Aspirin at an analgeric
dose is contra indicated in pregnancy.
A common analgeric dose is 600 mg every 6 hours.
However, in low doses (75 mg daily) aspirin used in pregnancy for treatment of
women with recurrent miscarriage, thrombophilias (inherited risk of
throboembolism), and prevention of pre-elapria and intra utensil growth
rutrification.
In low dose there is evidence to suggest that there is no increased risk of maternal
or neonated haemorrhase.
Aspirin exerts in its antiplatelet effect for around 10 days after administration and
may prolong the bleeding time. Some clinicians therefore prefer to discontinue
aspirin 3-4 week’s prior to delivery to prevent complications.
ANTIHYPERTENSIVE DRUGS
41
Antihypertensive drugs are used in hypertensive disorders of pregnancy. The commonly
used drugs are:
 Adrenergic inhibitors—Methyldopa
 Adrenergic blocking agents—Labetalol, propranolol
 Vasodilators—Hydralazine, Diazoxide, sodium nitroprusside
 Calcium channel blockers—Nifedipine.
Methyldopa Preparations
Aldomet, Dopamet.
Action
Stimulates central oadrenergic receptors or acts as false transmitter, resulting in

reduction of arterial pressure.
Indications
Hypertension.
Contraindications
Active hepatic disease, congestive cardiac failure, blood dyscrasias, psychiatric dis-
orders.
Side Effects/Adverse Reactions
Nausea, vomiting, diarrhea, constipation
Bradycardia, orthostatic hypotension, angina, weight gain
Drowsiness, dizziness, headache, depression
Leukopenia, thrombocytopenia coomb's test may be positive.
Dosage and Route of Administration
 Orally—250 mg BID-1 gmTID

 IV infusion—250-500 mg.
42
NursingConsiderations
Assess
Blood values—Neutrophils, platelets
Renal studies—Protein, BUN, creatinine
Liver function tests
Blood pressure before beginning treatment and periodically thereafter.
Perform / Provide
 Storage of tablets in tight containers.

Evaluate
 Decrease in blood pressure (therapeutic response)

 Allergic reaction—Rash, fever, pruritis, urticaria
 Symptoms of congestive heart failure (edema, dyspnea, wet rales)
 Renal symptoms—Polyuria, oliguria, frequency.
Teach Client I Family
 To avoid hazardous activities

 Administer one hour before meals
 Not to discontinue drug abruptly or withdrawal symptoms may occur
 Not to use over the counter (OTC) medications (non-precription) for cough, cold
or allergy, unless directed by physician
 Compliance with dosage schedule even if feeling better
 To rise slowly to sitting or standing position to minimize orthostatic hypotension
 Not to skip or stop drug unless directed by physician
 Notify physician of untoward signs and symptoms.
Labetalol
Preparations
43
Trandate, Normodyne.
Action
Nonselective (3 blocker.)
Indication
Hypertension.
Contraindications
Hepatic disorders, sinus bradycardia, bronchial asthma.
Orthostatic hypotension, bradycardia, chest pain, ventricular dysrhythmias,

drowsiness, headache, nightmares, lethargy, agranulo-cytosis,
thrombocytopenia, sore throat, dry burning eyes.
Dosage and Routes of Administration
Orally—100 mgTID up to 800 mg daily
IV infusion (Hypertensive crisis)—1-2 mg/ min until desired effect.
Nursing Considerations
Assess
 Intake output and weight daily

 Blood pressure and pulse check q4h
 Apical or radial pulse before administration.
Administer
PO, before food and after.
IV, keep client recumbent for 3 hours.
Perform /Provide
44
• Storage in dry area at room temperature.
Evaluate
• Therapeutic response—Decreased BP after 1-2 weeks
• Edema in feet, legs daily
• Skin turgor and dryness of mucous membranes for hydration status.
Teach Client/Family
• Not to discontinue drug abruptly, taper over 2 weeks
• Not to use over the counter medications containing a-adrenergic stimulants, such as
nasal decongestants and cold medications, unless directed by physician
• To report bradycardia, dizziness, confusion or depression
• To avoid alcohol, smoking and excess sodium intake
• Take medication at bedtime to prevent the effect of orthostatic hypotension
• Wear support hose to minimize effects of orthostatic hypotension.
Propranolol (Inderal)
Action
• (3-adrenergic blocker—Decreases preload, afterload, which is responsible for decrea-

sing left ventricular end diastolic pressure and systemic vascular resistance.
Indications
• Hypertension, prophylaxis of angina pain.
Contraindications
• Bronchial asthma, renal insufficiency, diabetes mellitus, cardiac failure.
45
Maternal
• Severe hypotension, sodium retention, bradycardia, bronchospasm, cardiac failure.
Fetal
• Bradycardia and impaired fetal responses to hypoxia, IUGR with prolonged therapy,
neonatal hypoglycemia.
• Orally 80-240 mg in divided doses.
Assess
• BP, pulse and respirations during therapy
• Weight daily and report excess weight gain
• Intake output ratio.
Administer
• Administer with 240 ml of water on empty stomach.
Evaluate
• Tolerance if taken for long period
• Headache, light-headedness, decreased BP.
Teach Client /Family
• That there may be stinging sensation when the drug comes in contact with mucous
membranes
• The drug may be taken before stressful activity exercise
• Client compliance with treatment regimen
46
• To make position changes slowly to prevent fainting.
Hydralazine
Preparations
• Apresoline, Hydralyn, Rolazine.
Action
• Vasodilates arteriolar smooth muscles by direct relaxation, reduction in blood pressure

with reflex increase in cardiac function.
Indication
• Essential hypertension.
Contraindications
• Coronary artery disease, mitral valvular rheumatic heart disease.
AdverseEffects
Maternal
• Hypotension, tachycardia, arrythmia, palpitation, acute rheumatoid state, muscle cra-

mps, headache, dizziness, depression, anorexia, diarrhea, pruritis.
• Orally—100 mg/day in 4 divided doses
• IV/IM bolus 20-40 mgq4-6h.
Assess
47
• BP every 15 minutes initially for 2 hours then every hour for 2 hours, and then q4h,
pulse q4h
• Blood studies—Electrolytes, CBC and serum glucose
• Intake—Output and weight daily.
Administer
• To patient in recumbent position, keep in that position for one hour after administration.
Evaluate
• Edema in feet and legs daily
• Skin and mucous membrane for hydration
• Rales, dyspnea, orthopnea
• Joint pain, tachycardia, palpitation, headache and nausea.
Teach Client/Family
• To take with food to increase bio-availability
• To notify physician if chest pain, severe fatigue, muscle or joint pain occurs.
Nifedipine
Preparations
• Adalat, procardia.
Action
• Calcium channel blocker
• Produces direct arteriolar vasodilatation by inhibition of inward calcium channels in .

vascular smooth muscles.
Indications
48
• Hypertension, angina pectoris.
Contraindications
° Simultaneous use of magnesium sulphate could be hazardous due to synergistic effect
• Second or third degree heart block.
SideEffects/Adverse Reactions
• Flushing, hypotension, palpitations, brady-cardia, inhibition of labor, headache, fatigue,

drowsiness, nausea, vomiting.
• Orally—5-10 nig, tid.
Assess
• Blood levels of the drug, therapeutic levels 0.025-0. Install.
Administer
• Before meals, and hs.
Evaluate
• Therapeutic response, cardiac status, BP, „ pulse, respiration and EGG.
Teach Client/Family
• To limit caffeine consumption
• To avoid OTC drugs unless directed by the physician
• Stress patient compliance to all aspects of drug use.
Diazoxide
49
Preparation
• Hyperstat.
Action
• Vasodilator.
Indication
• Hypertensive crisis when urgent decrease of diastolic pressure is required.
Contraindications
• Diabetes, heart disease
• Diuretics should be used simultaneously.
Side Effects
Maternal
• Fluid and sodium retention
• Inhibition of uterine contraction
• Hyperglycemia
• Severe hypotension
• Palpitations.
Fetal
• Hypoxia.
• TV—30-50 mg, may be repeated every 10-15 minutes or continuous infusion.
50
Assess
• BP Smin for 2 hours, then lhr for 2 hours and then q4h
• Pulse, jugular venous distention q4h
• Serum electrolytes, CBC, serum glucose
• Weight daily and intake output.
Administer
• To patient in recumbent position, keep in that position for one hour after administration.
Perform /Provide Protection from light.
Evaluate
• Therapeutic response—Primarily decreased diastolic pressure
• Edema in feet and legs
• Hydration status
• Dyspnea and orthopnea
• Postural hypotension—Take BP sitting and standing.
Teach Patient /Family
• To limit caffeine consumption
• To report side effects if present
• To comply with the regimen.
Sodium Nitroprusside
Preparations
51
• Nipride, Nitropress
Action
• Peripheral vasodilator, directly relaxes arteriolar, venous smooth muscle, resulting in

reduction of cardiac preload and afterload.
Indications
• Hypertensive crisis
• To decrease bleeding by creating hypotension during pregnancy.
Contraindications
• Should be used in critical care unit for short time
• Compensatory hypertension is possible.
Maternal
• Nausea, vomiting, severe hypotension
• Restlessness, decreased reflexes, loss of consciousness.
Fetal
• Toxicity due to metabolites—Cyanide and thiocyanate.
• IV infusion 0.5-10 mg/kg/minute.
Assess
52
• Serum electrolytes, BUN and creatinine
• Hepatic function (AST, ALT and alkaline phosphatase)
• BP and ECG
• Weight and intake output.
Administer
• Using an infusion pump only
• Wrap bottle with aluminum foil to protect from light.
Evaluate
• Therapeutic response—Decreased BP, absence of bleeding
• Edema—Feet and legs
• Hydration status.
Diuretics are used in the following conditions during pregnancy.
• Pregnancy induced hypertension with massive edema
• Eclampsia with pulmonary edema
• Severe anemia in pregnancy with heart failure
• Prior to blood transfusion in severe anemia
• As an adjunct to certain antihypertensive drugs, such as hydralazine or diazoxide.
Common Preparations Used Furosemide (Lasix)
Action
• A loop diuretic: Acts on loop of Henle by increasing excretion of sodium and chloride.
53
Dosage
40 mg tab, daily following breakfast for 5 days a week. In acute conditions, the drug is
administered parenterally in doses of 40-120 mg daily.
Side Effects
Maternal
• Side effects include weakness, fatigue, muscle cramps, hypokalemia, hyponatre-mia,

hypocalcemia, hypochloremic alkalosis and postural hypotension.
Fetal
• May occur due to decreased placental per-fusion leading to fetal compromise. Throm-
bocytopenia and hyponatremia are other hazards.
Contraindications
• Hypersensitivity to sulphonamides, hypo-volemia.
Interactions/Incompatibilities
• Increased toxicity—Lithium, skeletal muscle relaxants, and digitalis
• Decreased effects of antidiabetics 8 Increased anticoagulant activity
• Increased action anticoagulants.
Assess
• Weight, intake and output daily to determine fluid loss
• Respiration—Rate, depth and rhythm
• BP—Lying and standing
54
• Electrolytes—Sodium, chloride, potassium, BUN, blood sugar, CBC, serum creatinine,
blood pH and ABGs
• Glucose in urine, if patient is diabetic.
Administer
• In AM to avoid interference with sleep.
• Potassium replacement, if serum potassium is less than 3.0
• With food, if nausea occurs, absorption may be decreased slightly.
Evaluate
• Improvement in edema of feet, legs and sacral area
• Signs of metabolic acidosis—Drowsiness, restlessness
• Signs of hypocalcemia, postural hypotension, malaise, fatigue, tachycardia and leg

cramps
• Rashes and temperature elevation.
Teach Patient I Family
• To increase fluid intake 2-3 L/day unless contraindicated
• To rise slowly from lying or sitting position
• To report adverse reactions, such as muscle cramps, nausea, weakness or dizziness
• To take with food or milk
• To take early in day to prevent nocturia.
Hydroch loroth iazide
Preparations
• Esidrex, hydrodiuril, hydrozide.
55
Action
• Sulphonamide derivative
• Acts on distal tubule by increasing excretion of water, sodium, chloride and potassium.
Uses
• Edema, hypertension.
Dosage and Route
• PO, 25-100 mg/day.
• Polyuria, glycosuria, frequency
• Nausea, vomiting, anorexia
• Rash, urticaria, fever
• Increased creatinine, decreased electrolytes.
Contraindications
• Hypersensitivity to thiazides or sulphona-mides.
Assess
• Weight, intake and output to determine fluid loss
• Rate, depth and rhythm of respiration
• BP—lying and standing
• Electrolytes—Potassium, sodium and chloride
• BUN, blood sugar, CBC, serum creatinine, blood pH and ABGs
56
• Glucose in urine, if patient is diabetic.
Administer
• In AM to avoid interference with sleep
• With food if nausea occurs.
Evaluate '
• Improvement in edema
• Improvement in CVP
• Signs of metabolic acidosis, drowsiness and restlessness
• Signs of hypokalemia, postural hypotension, malaise, fatigue, tachycardia, leg cramps

and weakness
• Rashes and temperature elevation.
• To increase fluid intake to 2-3 L/day unless contraindicated
• To notify physician of muscle weakness, cramps, nausea and dizziness
• Drug may be taken with food or milk
• To take early in day to avoid nocturia.
Spironolactone (Aldactone)
Mode of Action
• The drug antagonizes aldosterone by competitive inhibition in the distal tubules, thereby
preventing the potassium excretion and decreasing the sodium reabsorption.
Dose
57
• Initially 25 mg PO may be increased to 100 mg in divided doses.
Advantages
• There is no potassium loss. It has some hypotensive action.
Assess
• Weight, intake and output daily to determine fluid loss
• Blood pressure—Lying and standing as postural hypotension may occur
• Serum electrolytes (sodium, potassium, chloride), BUN, blood glucose, serum creatinine
and CBC.
Administer
• In AM to avoid interference with sleep
• With food—if nausea occurs.
Evaluate
• Improvement in edema—Feet, legs and scral area daily
• Signs of metabolic acidosis—Drowsiness, restlessness
• Signs of hypokalemia—Postural hypotension, fatigue, tachycardia, leg cramps and

weakness.
Teach Client I Family
• To increase fluid intake
• To rise slowly from lying or sitting position
• To take with food or milk for Gl symptoms
58
• To take early in day to prevent nocturia.
TOCOLYTIC DRUGS
These drugs can inhibit uterine contractions and used to prolong the pregnancy. In
women who develop premature uterine contractions, in addition to putting them to
absolute bed rest and sedating, tocolytic drugs are administered in an attempt to inhibit
uterine contractions. The commonly used drugs are—Isoxsuprine (duvadilan), ritodrine
hydrochloride (yutopar) and magnesium sulphate.
Isoxsuprine (Duvadilan)
Action
• Acts directly on vascular smooth muscle, causes cardiac stimulation and uterine
relaxation.
Dosage and Routes
Initial
IV drip 100 mg in 5 percent dextrose. Rate 0.2 ug per minute. To continue for at least
two hours after the contractions cease.
Maintenance
• IM 10 mg six hourly for 24 hours, Tab 10 mg 6-8 hourly.
Side Effects
• Hypotension, tachycardia, nausea, vomiting, pulmonary edema, cardiac arrhythmias,

adult respiratory distress syndrome, hyper-glycemia, hypokalemia, lactic acidosis.
Contraindications
59
• Hypersensitivity, postpartum.
Assess
• BP and pulse during treatment
• Take BP—Lying and standing—orthostatic hypotension is common
• Intensity and length of uterine contractions
• Fetal heart tones.
Administer
• With meals to reduce G 1 upset.
Perform /Provide
• Storage at room temperature.
Evaluate Therapeutic response:
• Reduced uterine contractions
• Absence of preterm labor
• Increased pulse volume.
• To avoid hazardous activities until stabilized on medication. Dizziness may occur
• To make position changes slowly, or fainting may occur
• To notify physician if rash, palpitations or severe flushing develops.
Ritodrine Hydrochloride (Yutopar)
Action
60
• Uterine relaxant—Acts directly on vascular smooth muscle. Causes cardiac stimulation
and uterine relaxation.
Dosage and Routes
Initial
• IV drip 100 mg in 5 percent dextrose. Rate, 0.1 mg per minute gradually increased by
0.05 mg per minute l0 min until desired response. To continue for at least 2 hours after
the contractions cease.
Maintenance
• Tab 10 mg 6-8 hourly
• PO 10 mg given half hour before termination of IV, then 10 mg q2h x 24 hrs, then 10-20
mg q4h, not to exceed 120 mg/day.
• Hyperglycemia, headache, restlessness, sweating, chills, and drowsiness
• Nausea, vomiting, anorexia and malaise
• Altered maternal and fetal heart tone and palpitations.
Contraindications
• Hypersensitivity, eclampsia, hypertension and dysrhythmias.
Assess
• Maternal and fetal heart tones during infusion.
• Intensity and length of uterine contractions.
61
• Fluid intake to prevent fluid overload, discontinue if this occurs.
Administer
• Only clear solutions
• After dilution 150 mg in 500 ml D5W or NS, give at 0.3 mg/ml
• Using infusion pumps or monitor carefully.
Perform I Provide
• Positioning of patient in left lateral recumbent position to decrease hypotension and

increase renal blood flow.
Evaluate Therapeutic response
• Decreased intensity
• Length of contraction
• Absence of preterm labor
• Decreased BP.
• To remain in bed during infusion.
ANTICONVULSANTS
The commonly used anticonvulsant is magnesium sulphate. Diazepam, phenytoin and

phenobarbitone are also used.
Magnesium Sulphate
Action: Decreases acetylcholine in motor nerve terminals, which is responsible for anti-
convulsant properties, thereby reduces neuromuscular irritability. It also decreases
intracranial edema and helps in diuresis. Its peripheral vasodilatation effect improves
the uterine blood supply. Has depressant action on the uterine muscle and CNS.
62
Use
• It is a valuable drug lowering seizure threshold in women with pregnancy-induced

hypertension. The drug is used in preterm labor to decrease uterine activity.
Dosage and Route
• For control of seizures, 20 ml of 20 percent solution IV slowly in 3-4 minutes; to be

followed immediately by 10 ml of 50 percent solution IM, and continued 4 hourly till 24
hours postpartum. Repeat injections are given only if the knee jerks are present, urine
output exceeds 100 ml in previous 4 hours and the respirations are more than
10/minute. The therapeutic level of serum magnesium is 4-7 mEq/L.
• 4 gm IV slowly over 10 min., followed by 2 gm/hr, and then 1 gm/hr in drip of 5 percent
dextrose for tocolytic effect.
Side Effects
• Maternal: Severe CNS depression (respiratory depression and circulatory collapse),

evidence of muscular paresis (diminished knee jerks).
• Fetal: Tachycardia, hypoglycemia.
Antidote
• Injection calcium gluconate 10 percent 10 ml IV.
Nursing Considerations Assess
• Vital signs q 15 min. after IV dose. Do not exceed 150 mg/min
• Monitor magnesium levels
• If using during labor, time contractions, determine intensity
• Urine output should remain 30 ml/hr or more, if less notify physician
• Uterine contractions when used as tocolytic agent
63
• Reflexes—knee jerk, patellar reflex.
Administer
• Only after calcium gluconate is available for treating magnesium toxicity
• Using infusion pump or monitor carefully; IV at less then 150 mg/min; circulatory
collapse may occur
• Only dilutions.
Perform IProvide
Seizure precautions—Place client in single
room with decreased stimuli, padded side
rails
• Positioning of client in left lateral recumbent position to decrease hypotension and

increase renal blood flow.
Evaluate
• Mental status, sensorium, memory
• Respiratory status—Respiratory depression, rate and rhythm: Hold drug if respirations

are less than 12/min
• Hypermagnesemia—Depressed patellar reflex, flushing, confusion, weakness, flaccid

paralysis, dyspnea
• Respiratory rate, rhythm and reflexes of newborn if drug was given within 24 hours prior
to delivery
• Reflexes—Knee jerk and patellar reflex decrease with magnesium toxicity.

Discontinue infusion if respirations are below 12/minute, reflexes severely hypotonic,
urine output below 30 ml/hour or in the event
64
of mental confusion or lethargy or fetal distress.
Teach Client/Family
• On all aspects of the drug—Action, side effects and symptoms of hypermagnesemia
• To remain in bed during infusion.
Diazepam (Valium)
Action
Depresses subcortical levels of CNS, anti-convulsant, and antianxiety.
• PO, 2 to 10 mg tid—qid
• IV, 5 to 20 mg (bolus), 2 mg/min, may repeat q5—lOmin, not to exceed 60 mg, may
repeat in 30 min if seizures reappear.
Side Effects
• Mother: Hypotension, dizziness, drowsiness, headache.
• Fetus: Respiratory depressant effect, which may last for even three weeks after birth.
Hypotonea and thermoregulatory problems in newborn.
Assess
• BP in lying and standing positions; if systolic pressure falls 20 mmHg, hold drug and
inform physician
• Blood studies—CBC
• Hepatic studies.
Administer
65
• IV into large vein to decrease chances of extravasation.
• PO with milk or food to avoid GI symptoms.
Provide
• Assistance with ambulation during beginning therapy since drowsiness and dizziness
may occur.
• Safety measures include side rails.
Evaluate Therapeutic response:
• Mental status, sensorium, sleeping pattern
• Physical dependence, headache, nausea, vomiting
Teach Patient / Family
• That drug may be taken with food
• To avoid alcohol ingestion
• Not to discontinue medication abruptly
• To rise slowly as fainting may occur.
Phenytoin (Dilantin)
Action
• Inhibits spread of seizure activity in motor cortex.
• Eclampsia—10 mg/kg IV at the rate not more than 50 mg/minute, followed 2 hours later
by 5 mg/kg
• Epilepsy—300-400 nig daily orally in divided doses.
Side Effects
66
Maternal
• Hypotension, cardiac arrhythmias and phlebitis at injection site.
Fetal
• Prolonged use by epileptic patients may cause craniofocal abnormalities, mental re-
tardation, microcephaly and growth deficiency.
• Blood studies—CBC, platelets every 2 weeks until stabilized
• Discontinue drug if neutrophils < 1600/mm2.
Administer
• After diluting with normal saline, never water.
Evaluate
• Mental status, sensorium, affect, memory
• Respiratory depression
• Blood dyscrasias—Sore throat, bruising.
Teach Patient I'Family
• All aspects of drug administration, when to notify physician.
Phenobarbitone (Luminai)
Action
• Decreases impulse transmission and increases seizure thresholds at cerebral cortex

level.
Dose and Route of Administration
• 120-240 mg/day in divided doses.
67
Side Effects
Maternal
• Sedation, drowsiness, hangover headache, hallucinations.
Fetal
• Withdrawal syndrome.
Assess
• Blood studies, liver function tests during long term treatment
• Therapeutic level 15-40 mg/ml.
Evaluate
• Mental status, mood, senorium, affect and memory
• Respiratory depression
• Blood dyscrasias—Fever, sore throat bruising, rash.
• All aspects of drug administration and when to notify physician.
ANTICOAGULANTS
Heparin Sodium
Action
• Prevents conversion of fibrinogen to fibrin.
Indications
68
• Deep vein thrombosis, thromboembolism, disseminated intravascular coagulation,
patients with prosthetic valves in the heart.
Dosage and Routes
• Administered parenterally; only 5,000-7,000 IU to be administered initially as IV push,

followed by 2,500 units subcutaneously every 24 hours.
Side Effects
Leukopenia, thrombocytopenia, osteoporosis, hemorrhage, alopecia.
Nursing Considerations Assess
• Blood studies—Hematocrit, platelets, occult blood in stools
• Partial prothrombin time
• Blood pressure—Signs of hypertension.
Administer
• At same time each day to maintain steady blood levels
• Avoid all I M injections that may cause bleeding.
Evaluate
• Therapeutic response—Decrease of deep vein thrombosis
• Bleeding gums, petechiae, ecchymosis, black tarry stools, hematuria
• Fever, skin rash, urticaria.
• To avoid use of drugs unless prescribed by physician
• To use soft bristle toothbrush to avoid bleeding gums
69
• To comply with instructions .To recognize and to sign of bleeding—gums, under skin,
urine, stool.
Warfarin Sodium (Cumadin)
Action
• Interferes with blood clotting by indirect means—depresses hepatic synthesis of vitamin

K—dependent coagulation factors (II, VII, IX, X).
Indications
• Deep vein thrombosis, pulmonary embolism.
Dosage and Route
• 10-15 mg orally daily for 2 days, followed by 2-10 mg at the same time each day depen-
ding upon the prothrombin time.
Side Effects
Maternal
• Hemorrhage.
Fetal
• Skeletal and facial deformities, optic atrophy, microcephaly.
Assess
• Blood studies—Hematocrit, platelets, occult blood in stools
• Prothrombin time
• BP—Watch for signs of hypertension.
70
Administer
• At same time each day to maintain steady blood levels
• Alone—do not give with food
• Avoid all IM injections that may cause bleeding.
Perform I Provide
• Storage in tight container.
Evaluate
• Therapeutic response—decrease of deep vein thrombosis
• Bleeding gums, petechiae, ecchymosis, black tarry stools, hematuria
• Fever, skin rash, urticaria.
• To avoid over the counter (OTC) preparations unless prescribed by physician
• Drug may be held during menstruation
• To use soft—bristle tooth brush
• Stress client compliance
• To report any sign of bleeding.
Pethidine(Meperidine)
It is synthetic narcotic analgesic agent, well absorbed by all routes of administration.
Action
71
• Inhibits ascending pain pathways in central nervous system, increases pain threshold
and alters pain perception.
Indications
• Moderate to severe pain in labor, postoperative pain, abruptio placenta, pulmonary

edema.
• Injectable preparation contains 50 mg/ml, can be administered SC, IM, IV. Its dose is
50-100 mg IM combined with pro-methazine 25 mg.
Contraindication
Pethidine should not be used intravenously within 2 hours and intramuscularly within 3
hours of the expected time of delivery of the baby, for fear of birth asphyxia. It should
not be used in cases of preterm labor and when the respiratory reserve of the mother is
reduced.
Mother
• Drowsiness, dizziness, confusion, headache, sedation, euphoria, nausea and vomiting.
Fetus
• Respiratory depression, asphyxia,
Assess
• Urinary Output—may cause urinary retention.
Administer
• With antiemetic (promethacin) to prevent nausea and vomiting
72
• When pain is beginning to return—determine dosage interval by patient response.
Perform I Provide
• Storage in light—Eesistant container at room temperature
• Assistance with ambulation
• Safety measures—Side rails, night light, call bell within easy reach.
Evaluate
• Therapeutic response—Decrease in pain
• CNS changes—Dizziness, drowsiness, euphoria
• Allergic reactions—Rash, urticaria
• Respiratory depression, notify physician if respirations are <12/minute.
• To report symptoms of CNS changes, allergic reactions.
Fentanyl
Fentanyl is a synthetic narcotic analgesic agent.
Action
• Inhibits ascending pain pathways in CNS, increases pain threshold and alters pain
perception.
Indications
• Moderate to severe pain in labor, postoperative pain and as adjunct to general anes-
thetic
Dosage and Routes
• 0.05-0.1 mg IM q 1-2 hours prn. Available in injectable form, 0.05 mg/ml.
73
Contraindications
• Hypersensitivity to opiates.
• Dizziness, delirium, euphoria, nausea, vomiting, muscle rigidity, blurred vision.
Assess
• Vital signs
• Note muscle rigidity.
Administer
• By injection (IM-IV), give slowly to prevent rigidity
• Only with resuscitative equipment available.
Perform I Provide
• Storage in light resistant container at room temperature
• Coughing, turning and deep breathing for postoperative patients
• Safety measures—Side rails, night light, call bell within reach.
Evaluate
• CNS changes—Dizziness, drowsiness, hallucination, euphoria, LOG, pupil reaction
• Allergic reaction—Rash, urticaria
• Respiratory dysfunction—Respiratory depression: Notify physician if respirations are

>12/minute.
74
• To report any symptoms of CNS changes, allergic reactions.
Promethazine (Phenergan)
Promethazine is an antihistamine, Hi—receptor antagonist belonging to the

phenothiazine group.
Action
• Decreases allergic response by blocking histamine, sedative and antiemetic.
Indications
• Treatment of vomiting in pregnancy
• Sedation during labor
• Pregnancy induced hypertension
• Combined with pethidine to prevent vomiting
• In Rh isoimmunization to decrease the production of antibodies
• Allergic reactions.
• Available for oral use as 12.5,24 and 50 mg tablets and for parenteral use as 25 and 50
mg/ml solutions. The dose is 25 mg, 8 hourly orally and 25 mg intramuscularly, to be
repeated as necessary.
Contraindications
• Acute asthma attack
• Lower respiratory tract disease.
75
• Drowsiness, dizziness, poor coordination, fatigue, anxiety, confusion, neuritis, paras-
thesia.
Assess
• Urinary output—Be alert for urinary retention, frequency, dysuria; drug should be dis-
continued if these occur.
Administer
• Coffee, tea and cola (caffeine) to decrease drowsiness
• With meals if GI symptoms occur when given orally
• Deep IM in large muscle; rotate site.
Perform I Provide
• Hard candy or gum, frequent rinsing of mouth for dryness
• Storage in light resistant container.
Evaluate
• Therapeutic response
• Respiratory status—Wheezing, chest tightness
• Cardiac status—Palpitation, hypotension, increased pulse.
• That drug may cause photosensitivity, to avoid prolonged sunlight
• To notify physician if confusion, or hypotension occurs
• To avoid concurrent use of alcohol or other CNS depressants
• To avoid drinking or other hazardous activity, if drowsiness occurs.
76
CORTICOSTEROIDS
Corticosteroids may be administered in pregnancy for pre existing maternal

disease such as asthma, rheumatoid arthritis and other inflammatory disease. In these
patent the most used agent in prednisolane, which Gosses placenta in relatively small
quantity. It is considered safe for use in pregnancy as there is no evidence of adverse
effect on the developing fetus.
If corticosteroids are administered ever in moderate doses, throughout

pregnancy then there is a risk of maternal adrenal suppression.
This results in a failure of normal mechanism of increased endogenous

corticosteroid production in labour. Women who are on long term steroid treatment
should therefore receive extra --- in labour to compensate for this.
The other use of corticosteroids in pregnancy is for fetal lung maturation in actual
or threatened preterm delivery. In this case beta ethane or --- is used, both of which
cross the placenta in higher concentrating than prediniedance. Betanetholmae and
dexamethanol are generally gives as intramuscular injections in divided doses over 24-
48 hours.
Different units use widely differing regimens.
 Treatment with antennal corticosteroids has been shown to be associated with a

substantial reduction in the incidence of respiratory distress syndrome.
 The most significant effect is noticed if 48 hours has elapsed between
administration of the drug and delivery.
 There is no clear evidence of adverse effects on the fetus or on long-term follow
up of children exposed to steroids.
 There is a significant reduction in pinnate morality and intraventicular
haemorrhage.
77
DRUGS IN OTHER DISORDERS
 Deep vein thrombosis may be treated with heparin. The use of streptolainase is
associated with the risk of bleeding.
 Allergichinitis: This may be treated either locally (with glucocorticoids or
deconestants) or systematically with antihistamines (dipheshydramine,
dimenshydirinate, tripelenamine).
 Cough :Diphehydramine, codeine and dextromethorphan may be used safety to
treat cough during pregnancy.
 Prusitus :This may be treated locally (with tropical moisturizing (reans or lotial,
calamitine lotion, zinc oxide cream or ointment or glucocorticoids) or
systematically (with hydroxyzine, diphenych---- or glucocorticoide).
 Headache: May be treated with paracetamol, codeine and benzodiazepines,
Aspirin and NSAID may be used in the first and second but not in the third
trimesters.
 Migraine :May be treated with Analgerics, propranolol, dimenhydrinate and
demitryptiline.
 Thyrotoxicosis : Thioamides are the therapy of choice for thylotoxicosis during
pregnancy. Propylthiouracil is preferred to carbimazole. The does should be
kept as low as possible. Stable iodine and radioactive iodins are contraindicated.
DRUGS USED IN POST PARTUM AND NEWBORN
 Nearly all agents received by the Mother are likely to be found in her milk and
could theoretically harm the infant. The advantages of breast feeding for both a
mother and her body are well known.
 The safety of breast feeding while a mother intaking medication may be
assessed by wishing the risks of adverse effects occurring in the body due to
drug, against the beneficial effects of the drug for the mother. The benefits to the
baby of breast feeding must also be considered.
78
Methods of minimizing drug transfer to the infant
 Using an alternative route of administration. Eg. Use a nasal spray instead of oral
bronchodilator
 Using the lowest appropriate dose.
 Timing the feed to minimize the --- drug in milk. Eg. Taking maternal dose
immediately after a feed or before babies longest sleep period.
 Choosing and alternative drug therapy if possible.
 Expressing and discarding milk if drug treatment only short term.
In the puerperium iron and vitamins and mild analgesics were taken routinely by
the population and antibiotics, laxatives are frequently prescribed.
In the puerperium
 Drugs used Routingly (Iron, Vitamins, Mild analgesics)

 Drugs used frequently antibiotics, laxativety.
 Drugs used in the complications.
Iron therapy
Majority of the women in the troping remain in an anemic state following delivery.
Supplementary iron therapy (ferrous sulphate 200mg) is to be given daily for a minimum
period of 4-6 weeks.
COMMONLY USED DRUGS :A
Analgesics – aches and pain
The drugs ibuprofen, diclofenac, indomethacin and naproxen have an acceptably

low infant dose and are considered safe to use. Aspirin in contra indicated only because
of the theoretical risk of --- syndrome. Both paracetamol and codeine are safe
alternatives, although combinations containing codeine 30 mg should be used
continuously.
79
Anthelmintics – Worms
Pyratel and mebendazole are considered safe artery are poorly absorbed from
the gastrointestinal tract and are unlikely to be transferred to breast milk in clinically
significant amounts.
Cold and flu
Body aches and pain (Analgerics)
Nasal symptoms,
Steams inhalations and saline (sodium chlorides nasal spray may provide symptomatic
relief. Decongestial sprays (oxymetazoline, xylometa---) may be used. However, oral
preparations containing psudoephedrine should be avoided as it may be reduce milk
production, and may cause irritability in a breast fed body.
Cough
Usually self limiting. If treatment is required, use guaifenerin, brambexine or

senega and ammonia mixture for chesty cough, pholcodine or dextromethorphase for
chesty cough, pholcodine or dextromethorphase for dry cough.
Sore throat
Lozenges or threat gargles containing amylmetracresol, dichlorobezyl alcohol or

cetylpyridinium may be used. Avoid products containing iodine.
Antihistamines – allegories and has fever
Sedating antihrtamines such as – or diphenyldramine may be used but the body

should be observed for sedation or irritability of the non-sedating anti histamines,
loratdine and derloradine are transferred into breast milk in very small amounts and are
considered safe.
Anti infectives
80
Pencillins (Amoxycillin, flucloxacillis) apahlorporis and macrolides (erythromycin
and Roxythromycin) are considered safe.
Metronidazole is considered safe in dose is 400 mg three times a day.
Although it may give the milk a bitter taste with a single high dose of metronidazole milk
should be expressed and discarded for 24 hours furthers dose.
Amplcillin (Roscillin, Ampilin) It is highly effective against a variety of Grams-

negative bacteria.
Adverse reactions however skin rashes are more common (meculo popular, Diarrhea.
Usually dose is 250-500 mg 6th hourly. Dose are large as 1 g.
Erthyromycin It is a Antibacterial spectrum resembles that of penicillin.
Allergic reactions include – fever, eosinophilia, urticaria, dermatitis,

lymphadenopathy.
Dose is 1-2gm. The tablet coated contain 250 mg of erythromycin base.
Immunization
 Un immunized Rh-negative mothers who delivered Rh-positive babies are given

anti D gammaglobulin.
 Women how are susceptible to rubella, infection must be vaccinated and
instructed about post potent of pregnancy for at least 2 months.
 The booster dose of tetanus toxoid should be given at the time of discharge, if it
is not given during pregnancy.
Administration
 It should be administered with in 72 hrs of preferably early following delivery or

abortion.
 In case where the specific time limit is over (72 hrs) she may be given upto 14 –
28 days after delivery to avoid sensitization.
 Doses :
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 Anti D Gamma globulin IM 300 μg following delivery.
 All Rh negative un senstitized women IM- 50μg Rh- immuno globulin within 72
hrs of induced abortion, spontaneous abortion, ectopic pregnancy are chorion
villus biopsy in the first trimester.
 Women with pregnancy beyond 12 weeks should have full dose of 300 μg.
 Approximate volume of fetal blood entering in to the maternal circulation is to be
estimated.
 The technique is to note that number of fetal red cells (dark, refractile bodies) per
50 low power fields.
 If there are 80 fetal erythrocytes in 50 low power fields, in maternal peripheral
blood films. It represents transplacental haemorrhage to the extent of 4 ml of fetal
blood.
Suppression of lactation
Suppression becomes necessary
 If the baby is born dead or dies in the neonatal period.

 When the women does not want to breastfeed her baby or if breast feeding is
contraindicated.
Drugs
 Bromocriptine (Paralodel) 2.5 mg orally twice daily for two weeks. This inhibits prolactin
secretion. Early return of ovulation. Contraceptive advises has to give.
 Ethynyl estradiol 0.05 mg twice daily for five days. Combination of estrogen and
testosterone preparation (mixogen), intramuscularly soon after delivery. Use of parlodel
may be associated with early return of ovulation and hormonal preparation carry the risk
of thromboembolic complication.
 Metaclopramide increases milk product stimulate the prolactin secretion.
Other breast complication are
Breast engorgement It is due to exaggerated normal venous and lymphatic

engorgement of the breast which proceeds lactation.
 To administer analgesics for pain.
82
 To administer stilboestrol 5 mg – 1 tab – 4th hourly for 24 hours in obstinate cases.
 Where the breast remain tight inspite of sucking and expression.
Cracked nipples
The nipple may become painful due to 1. Loss of surface epithelium with the
formation of a raw area on the ripple. 2. Due to fissure situated either at the tip are the
base of the nipple.
Treatment
Application of tincture benzoin after the night feeding and the fissure ie. Likely to
be healed with in 8-12 hours.
The nipple is to be kept dry and exposure to air.
Acute mastritis
Infection follows a cracked nipple to involve the breast parenchymal tissues

leading to cellulites.
Supplementary stilboestrol 5 mg tablet given 4 th - 6th hourly may be an effective

temporary palliation.
Bromocriptive (Parlodel) 2.5 mg if availability twice daily for 2 weeks.
The risk of using oestrogenic preparation to the puerperal mother –

thromboembolic manifestation or late post partum blood loss, should be kept in mind.
Use of bromocriptine may be associated with early return of ovulation and hence
necessary contraception precaution should be advised.
Early institution of appropriate antibiotic gives better result as late administration

fails to secure full resolution.
Penicillin 5 lacs units twice daily may be given IM.
 The Antibiotic therapy is to be continued for at least 10 days.

 Analgesic and sedative are given as required.
83
Flucloxacillin (penicillinase resistant penicillin) is the drug of choice. A dose of 500 mg
every 6 hrs orally is started till the sensitivity report available.
Puerperal sepsis
An infection of the genital tract which occurs as a complication of delivery is

termed puerperal sepsis.
Antibiotic include
Pending sensitivity report, intra muscular administration of crystalline penicillin

one million units 6 hours along with streptomycin 1 gm daily is quite effective
alternatively, ampicillin 500 mg may be administered IM at 6 hours interval. However, in
severe cases, intramuscular gentamycin 3-5 mg per kg body weight daily in divided
doses or chloramphenicol 500 mg 6th hourly is given along with 0.5 gm of metronidazole
IV at 8 hours interval.
The treatment should be continued until the infection is controlled for at least 10 days.
Puerperal Venous Thrombosis
Thrombosis of the leg veins and pelvic veins is are of the common and important
complications in puerperium specially in the western countries.
In this cases this drugs has to administer
 Tab – phenobarbitone 30-60 mg or diazepam 5 mg to ensure sleep. Phenobarbitone

peripherally inhibit the reticular activity system.
 Appropriate antibiotics are to be administered.
 Anticoagulants
o Heparin 15,000 units are administered intravenously followed by 10,000 units, 4-6 hours
for four to six injections when the blood coagulation is likely to be depressed to the
therapeutic levels.
o A drug of coumarin series – warfarin is commonly used orally when the first dose of
heparin is injected.
84
o This initial daily single dose varies from 30-50 mg followed by a maintenance dose of
5-10 mg daily.
The anticoagulant therapy should be continued till all evidences of the disease
have disappeared which takes at least three weeks.
Lactation should be suppressed during the period of therapy.
Pulmonary embolism
While deep venous thrombosis in the leg or in the pelvis is most likely the cause
of pulmonary embolism, but in about 80-90 %, it occurs with out any previous clinical
manifestations deep vein thrombosis.
Active treatment includes 1. Intravenous administration of morphine 15 mg and

heparin 25,000 units.
 In general, whenever there is reasonable suspicious of pulmonary embolism, it is much

safer to initiate the therapy as outline, rather than to have a risk of second embolism
which may prove fetal.
 Heparin therapy is to be continued upto 40,000 IU/ day so as to maintain the clotting
time to over 12 minutes for the first 48 hours.
 Heparin level is maintained at 0.2 to 0.4 units /ml or the activated partial thromboplastin
time (APTT) about twice the normal.
 IV fluid support is continued and BP is maintained if needed by dopamine or adrenaline.
Thrombolytic therapy : Streptokinase with loading dose of 600,000 IV can be given

and continued with 100,000 per hour. It does not cross the placenta when used during
pregnancy.
Tachycardia is a counteracted by digitalis.
EFFECTS OF MATERNAL MEDICATIONS ON FETUS AND BREAST FEEDING

INFANTS
85
During early embryogenesis, the drugs taken by the mother reach the conceptus
through the tubal or uterine secretions by diffusion. The harmful effect on the blastocyst
is usually death. In case of survival, there is chance of congenital anomalies.
From 2nd-12th week (period of organo-genesis), drugs taken by the mother can
cause serious damages. Gross congenital malformations and even death of the fetus
may result, depending on the route, length of time and dose of exposure.
From the second trimester onwards, transfer of drugs takes place through the utero-
placental circulation. The drug transfer across the placenta is increased due to the
lowered serum albumin concentration, which results from hemodilution. As the albumin-
binding capacity of the drugs is decreased, more free drug is available for placental
transfer. In addition, the metabolism of the drugs may be hampered by the increase in
plasma steroids. Increased utero-placental blood flow, increased placental surface area
and decreased thickness of the placental membrane are the additional causes for
increased drug transfer.
Fetotoxic or teratogenic drugs are prescribed only when the benefits outweigh the
potential risks. Prior counseling is mandatory and minimum therapeutic dosage is used
for shortest possible duration.
Maternal Medications with Established Teratogenic Properties and their Effects
• Cytotoxic drugs—Multiple fetal malformations and abortion
• Androgenic steroids, Hydroxy progesterone—Masculinization of the female offspring
• Lithium—Increased congenital malformations when used in the first trimester, neonatal

goiter, hypotonia and cyanosis
• Diethyl stillbestrol—Vaginal stenosis, cervical hoods and uterine hypoplasia in female

fetuses.
Possible Teratogens
• Antithyroid drugs—Goiter, mental retardation
86
• Oral antidiabetic drugs—Abnormalities in the eyes, central nervous system, skeletal
system and neonatal hypoglycemia
• Vitamin D—Cardiopathies, hypercalcemia and mental retardation
• LSD (lysergic acid diethylamide)—Chromosomal abnormality and stunted growth
9
Anticonvulsants (- Phenytoin, valproate)— Mental retardation, cardiac abnormalities,
limb defects, neonatal bleeding, epilepsy.
Fetotoxic Drugs
• Aspirin—High doses in the last few weeks can cause premature closure of ductus
arteriosus, persistent pulmonary hypertension and kernicterus in the newborn.
• Corticosteroids (prednisolone)—Doses above 10 mg daily may produce fetal and

neonatal adrenal suppression.
• Aminoglycosides (antibiotics, e.g. amikacin, streptomycin)—Auditory or vestibular da-

mage
• Chloramphenicol—Peripheral vascular collapse (gray baby syndrome)
• Tetracycline—Dental discoloration (yellowish) and deformity, inhibition of bony growth
• Long acting sulphonamides—Neonatal hemolysis, jaundice and kernicterus
• Nitrofurantoin (furadantin)—Hemolysis in newborn with G6 PD deficiency, if used at term
• Vitamin K (large doses)—Hyperbilirubi-nemia and kernicterus
• Alcohol and smoking—Intrauterine growth retardation, pre-term labor, mental retar-

dation.
• Narcotics—Depression of CNS—Apnea, bradycardia and hypothermia.
• Anesthetic agents—Convulsion, bradycardia, acidosis, hypoxia, hypertonia.
• Antihistamines—Tachycardia, vomiting, diarrhea.
87
• Anticoagulants—Optic atrophy, microcephaly, chondrodysplsia punctate.
• Diuretics—Fetal compromise due to diminished placental perfusion.
• Beta-blockers (antihypertensive drugs)— IUGR, fetal bradycardia and impaired fetal

responses to hypoxia.
Maternal Drug Intake and Breastfeeding
Maternal drug intake of nursing mothers have adverse effects on lactation and also on
the baby as it may be present in the breast milk.
Milk concentration of some drugs such as iodides may even exceed those in the
maternal plasma so that therapeutic doses in the mother may cause toxicity to the
infant. Certain drugs in breastmilk may cause hypersensitivity in the infant when used in
therapeutic doses. Transfer of drugs through breast milk depends on the following
factors:
• Chemical properties
• Molecular weight
• Degree of protein binding
• Ionic dissociation
• Lipid solubility
• Tissue pH
• Drug concentration
• Exposure time.
Drugs that are non-ionized, of low molecular weight and lipid soluble compounds are
usually excreted through breastmilk. Drugs identified as having effects on lactation and
the neonate are listed below:
• Bromides—Rash, drowsiness and poor feeding.
88
• Iodides—Neonatal hypothyroidism.
• Chloramphenicol—Bone marrow toxicity.
• Oral pill (combined preparations)—Suppression of lactation.
• Bromocriptine (parlodel)—Suppression of lactation.
• Ergot—Suppression of lactation.
• Metronidazole (Flagyl)—Anorexia, blood dyscrasias, irritability, weakness, neurotoxic

disorders.
• Anticoagulants—Hemorrhagic tendency (warfarin appears safe in therapeutic doses).
• Isoniazid—Anti-DNA activity and hepato-toxicity.
• Antithyroid drugs and radioactive iodine— Hypothyroidism and goiter, agranulocytosis.
• Antimetabolites (methotraxate)—Anti-DNA activity, immunosuppression.
• Diazepam, opiates, phenobarbitone—Sedation effect with poor sucking reflex.

Breastfeeding is discouraged for mothers on
medications that are harmful for the infant.
DRUGS USED IN NEW BORN
The transition from intrauterine life is a dramatic one and demands considerable
and effective physiological alternatives by the body in order to ensure survival.
Care of the umbilical cord : The cord is to be inspected once more for evidence of
slipping of ligature. Dressing with bland power and cord binder are not favoured in
places where the baby is placed in a clean in places where the baby is placed in a clean
environment.
If the cord is left exposed to the air, with out any application of dusting powder, it
dries up and falls off much earlier.
89
 However, Chlorhexidine powder (Hibitone) 0.5% may be applied after the stump is
swabbed with surgical spirit.
Alternatively, bland powder consisting of Zinc oxide, boric acid and starch is
proportion of 1:1:2 may be applied to the stump.
In severe hypothermia
Stared IV 10% dextrose, give injectable vitamin k (1 mg for term baby, 0.5 mg for
preterm baby) and provide oxygen.
Intramuscular administration of vitamin K 1 mg is given as routine to minimize

haemorrhagic disease.
Care of eyes
As a prophylaxis against ophthalmic neonatorum, Instillation of 1% silver nitrate

solution to each eye followed by saline wash has been practiced in some centres as a
routine or in selected cases.
 Tetracycline ointment may be used as an alternative, being non irritant and equally
effective.
 Instillation of eyedrops as prophylaxis against gonococcal infection. It is suggested that,
to be effective, such treatments should be administered with in one hour of birth.
 Localized reactions to silver nitrate drops have been shown to impair eye to eye contact
with the mother and it has been noted that these may interfere with early mother –baby
relationships.
MINOR DISORDERS OF THE NEW BORN AND DRUGS
Sticky eyes It may due to a chemical irritant or bacterial conjunctivitis due to

stephylococus. Use of sulphacetamide 10 % drop cures the condition.
Through : It produces a rash in the subcutaneous area. The buttocks and the innerside
of the thight are also affected. Treatment with
90
1.1 Generation violet solution or nystatin cream is of help
Constipation : It is commonly met in artificially fed babies. It is better not to use any
laxation. Correction of the dietetic error or extra water is usually effective. If it fails, milk
of magnesia 4 ml by month is effective.
DRUGS USED IN RESUSCITATION
AIMS of r---- : These are to
 Establish and maintain a clear air way, by ventilation and oxygenation.

 Ensure effective circulation
 Correct acidosis
 Prevent hypothermia, hypoglycemia and haemorrhage.
The drugs are
 Nalaxone hydro chloride 1 ml ampoules 40 mcg/ml.

 Adrenaline (Epinephrine) 1: 10000 and 1:1000.
 Human albumin solution 4.5%.
 THAM (tril –hydroxymethyl – aminomethanus 7%)
Sodium bicarbonate 4.2%
 Dextrose 10%
 Vitamin K, 1 mg ampouler
 Normal saline 0.9%
If the baby’s response is slow or be remains hypotonic after ventilation is achieved,
consideration will be given to the use of drugs.
In specialist obstetric units, pulse oscimetry may be employed to monitor hypoxia

and blood obtained through the umbilical arthey orvien to as certain biochemical status.
Results will enable appropriate administration of runs citationalize.
Nalaoxone hydrochloride
This is not an emergency drug purse and should be used with cantina and only
inspecific circumstances. It is a powerful antiopioid drug used to reverse the effects of
91
maternal narcotic drugs given in the preceding 3 hours. Ventilation should be
established prior to issue.
 It must not be given to apnocic babies adose of upto 100 micrograms per kilogram body
weight may be administered intra muscularly for prolonged action.
 As opioid action may persist for many hours the mid wife must be alert for signal for
replace when a repeat dose may be required.
Sodium Bicarbonate
This is not recommended for brief periods of cardiopulmonary recurcitation.
 Once the tissues are oxygenated by lump inflation with 100% oxygen and cardiac
compression, the --- will self-correct unless asphyxia is very severe.
 If the heart rate is less than 60 despite effective ventilation, chest compression and two
intra venous doses of adrenaline (epinephroid), then sodium bicarbonate 4.2% solution
(0.5 ---) can be administered using 2-4 ml/kg (1-2 mmol/kg) by slow intravenous
injection at a rate of 1 ml / min in orders to avoid rapid elevation of serum osmolatity
with the attendant risk of intracranial haemorrhage.
 It should not be given prior to ventilation being established.
 Tham: 7% (Trie – hydroxyethyl-amino methal)0.5 m.mol/kg may be used in preference
to sodium bicarbonate.
Adrenaline (epinephrine)
This is indicted if the heart rate is less than 60 despite 1 minute of effective
ventilation and chest compression. An initial dose of 0.1-0.3 ml.kg of 1:10,000 solution
(10-30 mcg/kg) can be given intravenously this can be repeated after 3 minutes for a
further two days.
 It is reasonable to try giving our choice via the endotracheal tube of adrenaline
(eqiuphrine) 0.01 ml/kg of 1:1000 – sanction has an immediate effect.
Human albumin 4.5%
92
This is infrequently needed in practice. If pulmonary haemorrhage or sign of 8U
shock persists despite adequate resuscitation them 4.5% human albumin 10-20 ml/kg
as a volume expander should be administered as Quickly as possible.
Hypoglycemia is not usually a problem unless resuscitation has been prolonged. A

solution of dextrole 10% 3ml/kg may be given intravenously to correct a blood sugar of
less than 2.5 mmol/L.
ANALGESIA AND ANAESTHESIA IN OBSTETRICS
The following factors are important to control the dose of sedative and
analgesics.
(1) The threshold of pain : The threshold of pain varies from patient to patient, so that
each mother must be assessed individually. Some patients experience severe pain
though the uterine contractions are relatively weak. In such cases, it is preferable to
control the pain adequately even if this involves a temporary depression of uterine
action.
(2)Primigravidaeor&multiparae — The multiparous women needless analgesia

dueto addedrelaxation ofthebirth canal and rapid delivery.
13) Maturity of the foetus — Minimal doses of drugs are indicated while the foetus is
thought to be premature to avoid the risk of neonatal asphyxia.
For the purpose of selecting a general analgesic drug", labour has been divided
arbitrarily into two phases. The first phase corresponds upto 8 cm dilatation of the cervix
in primigravidae and 6 cm in case of multipara. The second phase corresponds to
dilatation of the cervix beyond the above limits upto delivery. 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.
Sedatives : Chloral hydrate, barbiturates, benzodiazepines etc. may be employed in the

early part of the first phase.
93
Chloral hydrate : It is excreted by the kidneys. It can produce vomiting and so should
be used well diluted to prevent vomiting. A safe dose is 2 gm given orally along with
equal amount of potassium bromide. It provides mild sedation in early labour.
Barbiturates : Pentobarbitone, butobarbitone, quinal barbitone and sodium amytal are

commonly used. They are less depressing to the foetal respiration than morphine but
their effects are uncertain. They can produce restlessness and delirium. The drugs are
detoxicated in the liver. The initial dose is 200 mg and given by mouth when labour is
well established. Additional doses of 100 mg are given every 3-4 hours in 12 hours not
exceeding 600 mg.
Diazepam : It is well tolerated by the patient. It does not produce vomiting and helps in
the dilatation of cervix. It is metabolised in the liver. The usual dose is 10-15 mg. It may
be used in larger doses in the management of pre-eclampsia and to supress premature
labour. In labour pain a total dose of 30 mg to the mother has little effect on the foetus
but larger doses are associated with low Apgar scores at birth. It is administered
parenterally.
Pethidine : Pethidine is generally used in the first phase of labour and indicated when
the discomfort of labour merges into regular, frequent and painful contractions. The
initial dose is 100 mg (1.5 mg/kg body wt) I.M. and repeated as the effect of the first
dose begins to wane, without waiting for the re-establishment of labour pain.
Pethidine with its antagonists : Formerly, a combination of pethidine with

levallorphan (100 mg pethidine and 1.25 mg levallorphan) was very popular, and
nalorphine was considered to be an equal antagonist in a dose of 5 mg. It is now
accepted that the combination of pethidine with a narcotic antagonist produces no less
respiratory depression than pethidine given alone.
To antagonise the effect of narcotics given to mothers when the labour proceeds
more rapidly than anticipated, naloxone in a dose of 0.4 mg should be given
intravenously and may be repeated at 3 minute intervals until the desired effect is
obtained. A dose of 0.01 mg/kg is injected into the umbilical vein and repeated if
necessary when the infant is born with narcotic depression.
94
Pentazocin (Fortwin) : It also causes drug dependence and is given intramuscularly
in a dose of 30-40 mg. Its duration is shorter and causes some respiratory depression.
Naloxone is an efficient and reliable antagonist.
Combination of narcotics and tranquillisers : Narcotics may be used in combination

with promethazine, chlorpromazine or promazine (Sparine). The advantages are
claimed that the combination potentiates the action of narcotic, produces less
respiratory depression and prevents vomiting. But there are also disadvantages like
hypotension and delay of second stage of labour.
James Simpson, Professor of Midwifery in Edinburgh, Scotland (Fig. :10rla) is

credited with the first use of inhalation analgesia in obstetrics in 1847, when he
introduced ether for vaginal delivery (1). Although it met with/considerable resistance
from church leaders of the time, acceptance of the principle of abolishing pain during
childbirth was assured when Queen Victoria was administered chloroform to good effect
by Dr. John Snow (RgrAOrW) during the birth of her 8th and 9th children in 1853 and
1857. Since then, almost every new inhalation anesthetic agent has at some time been
studied for obstetric analgesia for labor.
The first use of nitrous oxide dates from 1881, when Stanislav KliRevich a Polish
physician working in Russia, studied the effects of premixed 80% nitrous oxide in
oxygen on laboring women. He concluded it was safe and effective, and that uterine
contractions were unaffected (2). It is interesting that despite his work, administration of
the more dangerous nitrous oxide/air mixtures was the technique adopted in the early
1900s. Indeed, although nitrous oxide/oxygen was rein- troduced in the 1940s through
1950s, it was not until 1961 that Tunstall described the use of premixed nitrous
oxide/oxygen for labor (3)
It is important to define the terms inhalation analgesia and inhalation anesthesia.

Inhalation analgesia refers to the inhalation of subanesthetic concentrations of
anesthetic agents to provide pain relief for labor and/or delivery. The mother remains
awake wirifprotective laryngeal reflexes intact. It is administered by an anesthesiologist
or other qualified persons or by the patient herself, and may be used alone or to
95
supplement other methods of analgesia. Inhalation anesthesia refers to the
administration of inhalation agents to produce general anesthesia.
INDICATIONS FOR INHALATION ANALGESIA AND ANESTHESIA
"Some women choose not to have regional analgesia because of a fear of

needles and complications, or they believe they will be unable to participate in the
delivery. In such cases the choice of analgesic techniques for the first stage of labor
includes psychoprophylactic techniques; use of inhalation agents, opioids, or other
systemic drugs; or paracervical block. Although opioids and other systemic drugs are
easily administered, they have the potential to cause neonatal respiratory and
neurobehavioral depression. The relatively high incidence of fetal brady-cardia after
inhalational analgesia has led to the infrequent use of this technique. Inhalation
techniques are often seen as an acceptable alternative (4rT2), and it is critical that
those administering paracervical block are specifically educated in the technique and its
potential hazards.
Finally, the effects of an inhalation agent on the fetus and conate should be
considered. First, the amount passing to the fetus is affected by its solubility and means
of administration. For example, an insoluble agent breathed intermittently is rapidly
expired by the mother with little cumulation into the fetus, whereas fetal transfer is
greater whenever blood levels are maintained continuously, e,g., by continuous
administration of a soluble agent. For each agent, greater placenta! transfer is likely with
prolonged administration and with the use of higher inspired concentrations. Second,
the side effects of the particular agent are important. These may be indirect (on
maternal cardiac output and uteroplacental blood flow, maternal respiration, uterine
activity, etc.) or direct (on the fetal cardiovascular system, neonatal neurobehavior,
etc.). Fetal side effects may thus be apparent before delivery or manifest in the early
postpartum period. An interesting early observation was that the parturient offered
inhalation analgesia might hyperventilate in an attempt to maximize its benefit, with the
potential risk of hypocapnia and placental vasoconstriction (17). However, this
phenomenon may be no different than that seen with hyperventilation during painful
labor. Third, the neonatal excretion of any drug that has transferred during labor is
96
important; this also depends on the agent's solubility and the ability of the neonate to
achieve adequate ventilation following delivery.
Equipment and Methods of Administration
Inhalation agents may be delivered using standard anesthetic equipment (Table

10.3) or using devices specifically designed for intermittent inhalation (Table 10.4). A
standard anesthetic machine can be used to deliver nitrous oxide or volatile agents (or
both). It produces continuous flow of gases and therefore results in continuous
inhalation if the face mask is kept applied to the patient's face, and may result in
environmental pollution if used for intermittent inhalation. The anesthesia machine pro-
vides continuous delivery and higher concentrations of inhalation agents, and results in
higher blood concentrations of agents compared with intermittent inhalation. Anesthetic
machines are therefore usually reserved for relatively short, intense periods, e.g., for
delivery of the baby or forceps delivery. A suggested technique is outlined in Table 10.3.
Nitrous Oxide
Nitrous oxide is often used as a premixed 1:1 mixture with oxygen (in several
countries including the United Kingdom, Canada, Australia, South Africa, and the United
States), available commercially as Entonox®. In the United States, a 50% nitrous oxide
in oxygen mixture is administered using a blending device (Nitronox®). Entonox® is
manufactured utilizing the Poynting effect (named after the English physicist who de-
scribed it), by which gaseous oxygen is bubbled through liquid nitrous oxide with
vaporization of the liquid to form a gaseous mixture. Entonox® is supplied in cylinders
that may be connected to a central manifold and then to a piped gas supply or supplied
freestanding to the delivery suite. Three sizes of Entonox® cylinders are available,
containing 500, 2000, or 5000 L of gas; they are colored blue with blue/white shoulders.
At temperatures above —7°C (pseudocritical temperature), both nitrous oxide and
oxygen remain in the gaseous phase, but at temperatures below this the nitrous oxide
may liquify, resulting in liquid nitrous oxide at the cylinder's base with gaseous oxygen
above. Use of a normal cylinder in this condition results in a high concentration of
oxygen initially followed by almost pure nitrous oxide as the oxygen is exhausted.
97
Cylinders may therefore contain an internal tube from the outlet, which draws gas from
the lower part of the cylinder, so that in case of liquifaction, liquified nitrous oxide
containing about 20% dissolved oxygen is delivered. Warming and repeated inversion
of the cylinders can be used to reconstitute the gaseous mixture. In climates where tem-
peratures commonly fall below the pseudocritical temperature, special precautions
should apply to the storage and handling of the cylinders.
Most use of Entonox® is with intermittent "on-demand" systems, reflecting the

noncontinuous nature of labor pain, although continuous administration using simple
face masks or nasal cannulae has also been used. The most common device consists
of a two-stage pressure-reducing valve incorporated into a single housing (Figure 10.3).
The first-stage pressure reduction delivers a lower pressure to the second-stage valve;
when the parturient creates a negative pressure by breathing in, the large diaphragm
moves upwards and tilts a rod, which constitutes the second-stage valve. Gas is thus
delivered as long as the parturient makes inspiratory efforts. The valve is adjusted so
that minimal negative pressure is required to activate gas flow. An expiratory valve is
placed at the distal end of the delivery tubing so that the mouthpiece or face mask does
not have to be removed from the face between breaths (Figure 10.4). Nasal cannulae
have been used to provide a background level of gas in between contractions,
supplemented by intermittent inhalation via a mouthpiece during contractions (18),
although this is not routine practice.
For intermittent inhalation of nitrous oxide, given its low blood-gas solubility
(0.47), it should be possible to achieve maximal blood levels of the gas within a short
time of beginning inhalation. Interestingly, Klikovich reported in 1881 that the best
results were obtained by inspiring the gas 30 to 60 seconds before each contraction,
with an inspiratory pause before exhaling (2). Theoretical calculations by Waud and
Waud suggest that a 50-second period of inhalation is required before each contraction,
continuing until halfway between contractions (19). Given the unpredictable pattern of
most women's contractions, a compromise is usually reached whereby inspiration of the
gas begins the moment each contraction is initially felt, continuing until the peak has
passed. Maximal analgesia may thus not be obtained. Slow deep breaths are more
98
efficient than short shallow ones. This technique is something that many parturients find
difficult to do, and it is therefore helpful if they have practiced the breathing technique
beforehand, or at least during early labor when contractions are not so painful. Nitrous
oxide concentration delivered is limited by the fixed performance of the delivery device,
which is, however, an inherent safety feature of this technique. If administered by an
anesthetist with an anesthesia machine, a faster onset of analgesia may be achieved by
temporarily increasing the inspired concentration but with the risk of increased side
effects.
Volatile Agents
Specific devices for intermittent inhalation of volatile agents during labor and
vaginal delivery have been designed, although these are rarely used now. In the United
Kingdom, the best known of these were the Emotril and Tecota trichloroethylene
vaporizers and the Cardiff methoxyflurane inhaler. All three were temperature-
compensated draw-over vaporizers suitable for self-administration by the mother and
were popular for a time, although their respective agents were withdrawn for reasons
unrelated specifically to obstetric practice. Other draw-over vaporizers have been used,
including the hand-held Duke and Cyprane devices. To be suitable for draw-over
inhalation analgesia, such a vaporizer should be unaffected by temperature and the
parturient's minute volume and peak flow, both of which may vary widely during labor.
Trichloroethylene and methoxyflurane were administered in air in concentrations of
0.2% to 0.5%. Since both agents had high blood-gas partition coefficients (9 and 13,
respectively), analgesia was relatively slow in onset with cumulation even if inhaled
intermittently. More recently, Entonox® has been inhaled from a standard on-demand
Entonox® valve and passed through an isoflurane draw-over vaporizer to produce 0.2%
to 0.25% isoflurane and 50% nitrous oxide in oxygen (Fig. 10.5) (20, 21). A similar
concentration of isoflurane has been added to a nitrous oxide/oxygen mixture in a single
cylinder and has been reported as being effective when inhaled through a standard
Entonox® valve'- (22) .vDesflurane and -sevoflurane have particularly low blood-gas
solubilities (0.42 and 0.69, respectively), which might make them especially suited for
intermittent inhalation. Desflu-rane requires a special vaporizer because of its low
99
boiling point (23°C) and is thus unsuitable for draw-over use, although use of desflurane
delivered using an anesthetic machine has been described (23).
Maternal Effects
Analgesia
Nitrous Oxide. Surprisingly, it is difficult to find clear objective evidence of nitrous

oxide's analgesic efficacy. Westling etal. found improved analgesia with intermittent
70% nitrous oxide compared with 40%, supporting a dose-related analgesic effect (24).
However, a comparison of 50% and 70% nitrous oxide by intermittent inhalation
performed 30 years ago found little difference in efficacy between the two
concentrations (12). Approximately 70% of parturients rated their analgesia as good or
better, while 90% reported the gas "helped." McAneny and Doughty found that self-
administration of between 50% and 80% nitrous oxide produced complete pain relief in
8% to 14% of parturients, unrelated to inspired concentration (25). Using Entonox®,
Rosen et al. obtained complete relief of pain in 11% of women, with 30% reporting little
or no relief (26). A more recent report involving several thousand women using
intermittent Entonox® found that 40% described die gas as helpful while 38% described
it as unhelpful (27). Carstoniu et al. have recently challenged accepted wisdom by
comparing premixed nitrous oxide/oxygen with compressed air in a double-blind,
randomized, crossover study (28). There was no difference in visual analog pain scores
over five successive contractions between the two gas mixtures, although most subjects
were able to distinguish nitrous oxide and chose to continue with it. A study from Oulu,
Finland, also found little benefit as demonstrated by visual analog pain scores from a
variety of analgesic techniques, including intermittent inhalation of 50% nitrous oxide
and meperidine (Figure 10.6), despite 72% and 83% of users, respectively, reporting
good or moderate pain relief (29). This finding suggests that nitrous oxide, like opioids,
may make parturients feel better without necessarily reducing objectively measured
pain (30). Continuous administration may provide more consistent analgesia than
intermittent inhalation (24). One possible reason for this might be the relatively low
arterial concentrations of nitrous oxide achieved with intermittent inhalation. The mean
concentration required for analgesia without loss of consciousness has been found to
100
be 41.2% using continuous administration (31), whereas 50% nitrous oxide given
intermittently only achieves an arterial concentration equivalent to breathing 26.4% (32).
Inte; mit-tent inhalation of Entonox® achieves analgesic levels of nitrous oxide faster
when 5 L/min is also administered continuously via nasal cahnulae, compared to
intermittent inhalation alone or together with continuous administration of oxygen (18).
(Environmental contamination remains a problem with this technique.
Taken together, these studies suggest that about a third of parturients gain no
benefit from self-administered inhalation of nitrous oxide, with the remainder deriving
variable benefit. Few data exist on the use of higher concentrations administered by an
anesthesiologist using an anesthetic machine. Despite its use for over 100 years, we do
not appear to be any closer to quantifying nitrous oxide's analgesic effects in labor (33).
Volatile Agents. Most volatile agents in common use have relatively poor
analgesic qualities, limiting their usefulness. Other problems include their uterine
relaxant effects at high inspired concentrations, and the risk of accidental overdosage
and induction of general anesthesia, with its attendant hazards. If the agent is a poor
analgesic, high concentrations must be administered to achieve an analgesic effect,
increasing the risk of uterine relaxation and induction of anesthesia. Anesthetic re-
quirements are reduced in pregnancy (15, 16), which makes mothers more susceptible
to inhalation analgesia but also makes inadvertent induction of general anesthesia more
likely. Two agents with powerful analgesic properties were trichloroethy-lene (Trilene®)
and methoxyflurane (Penthrane®), which, despite being relatively soluble in blood, both
enjoyed popularity as inhalation analgesics during the 1960s and 1970s but are no
longer available, and are thus of historic interest only. Their high potency compensated,
to a degree, for their other, less desirable properties.
The use of halothane in obstetric anesthesia has declined in recent years with
the advent of newer agents. Halothane is considered too potent to be useful for
inhalation analgesia without producing anesthesia. Although it has been useful for
general anesthesia when rapid, profound uterine relaxation is needed, itjs doubtful
whether halothane is a better myometrial relaxant than the other inhalation agents.
Furthermore, its slower elimination and potential for causing cardiac arrhythmias are
101
also disadvantages. It has been safely used for cesarean section, although it is
increasingly superseded by the newer inhalation agents.
Studies of enflurane have produced conflicting results, some suggesting a useful

analgesic effect (34-36) and others finding unacceptable depression of consciousness
with little analgesia (-57), Neonatal condition appears unaffected by brief maternal
inhalation of low concentrations of enflurane (34). Like halothane, enflurane causes
dose-dependent uterine relaxation; thus, enflurane and halothane share many
characteristics, and indications for their use in obstetric anesthesia are similar. An
advantage of enflurane over halothane is thatits effects are more rapidly reversible
because of its lower blood solubility. On the other hand, a potential disadvantage of
enflurane is its increased biotransformation and production of fluoride ions in morbidly
obese subjects (38), although this has not been described in obstetrics (34).
Isoflurane has become popular in obstetrics because of its low blood-gas

solubility (1.4), cardiovascular stability, and lack of hepatic and renal toxicity. At
equipotent concentrations, its effect on uterine contractility is similar to that of halothane
and enflurane (39). Isoflurane has been found to provide useful analgesia during labor
comparable to that produced by nitrous oxide without producing adverse effects as long
as concentrations under 0.7% are used (34, 40, 41). At higher concentrations,
increased drowsiness occurs (41). During the second stage of labor, concentrations of
0.2% to 0.7% isoflurane result in analgesia similar to that produced by 30% to 60%
nitrous oxide, with high rates of acceptance by patients, obstetricians, and
anesthesiologists, low incidence of amnesia, similar amounts of blood loss, and similar
neonatal outcomes (40). Wee et al. have described the use of Entonox® with isoflurane
0.2%, which resulted in lower pain scores than Entonox® alone although with greater
drowsiness (20). Similar results have been obtained by Tunstall et al. (21, 22).
Isoflurane is also widely used for general anesthesia performed for cesarean section
(see Chapter 11) and would thus appear to be suitable for inhalation anesthesia for
operative vaginal delivery if indicated.
Desflurane and sevoflurane have received surprisingly little attention in the

literature despite their low blood-gas solubility and potential suitability for obstetrics.
102
One study compared 1.0% to 4.5% desflurane and 30% to 60% nitrous oxide, both
delivered continuously using an anesthetic machine during the second stage of labor
(42). Concentrations of 2% desflurane produced comparable analgesia to 46% nitrous
oxide, with no maternal or fetal adverse effects in either group other than a 23%
incidence of amnesia in the desflurane group. This high incidence of amnesia may limit
desflurane's usefulness in labor. Desflurane and sevoflurane have been used for
cesarean section with maternal and fetal effects comparable to enflurane (42) and
isoflurane (43), respectively. Preliminary work indicates that sevoflurane has less
uterine relaxant action than isoflurane and halothane at equivalent minimum alveolar
concentration (MAC) doses (44), although whether this has clinical significance is
debatable. Preliminary results of studies in the pregnant sheep model suggest that
sevoflurane preserves maternal hemodynamic stability, while causing greater increases
in uterine blood flow than does isoflurane (45). Apart from these studies and individual
case reports of sevoflurane for cesarean section (46, 47), there has been little other
published work on sevoflurane in clinical obstetric practice despite its attractive
properties of low blood-gas solubility, pleasant smell, and low irritability. Concerns about
interaction between sevoflurane and soda-lime in circle systems at low-gas flows (48)
are controversial and not reflected in the United Kingdom, where no restriction on use of
low flows exists in the product license sheet, unlike in the United States.
Other Maternal Effects
Maternal Consciousness. Even nitrous oxide's weak anesthetic properties may

be enough to induce loss of consciousness in some parturients, especially at higher
concentrations- Thus, 3% to 5% of women may become unconscious breathing intermit-
tent 70% to 80% nitrous oxide compared with 1 % or less at 50% gas (12,25). In
addition, "inadequate cooperation" has been reported in 9% of parturients at 50%
nitrous oxide increasing to 17% of women at 80% gas (25). Despite this potential risk,
use of Entonox® appears to be safe, as experience of its use over many years would
testify (12, 25, 49-53). Depressed consciousness and induction of anesthesia is more of
a concern with the volatile agents, which are much more potent as anesthetic agents
103
than nitrous oxide. Thus, careful attention must be paid when administering these
agents, firstly to ensure low concentrations are delivered and secondly to monitor the
mother's level of consciousness.
Maternal Oxygenation. Studies into maternal oxygenation during intermittent

nitrous oxide inhalation have produced conflicting results. While some have found no
evidence of hypoxemia between contractions (28) or mild hypoxemia only (54), others
have found frequent episodes of arterial desaturation, in some cases to less than 70%
using pulse oximetry (55). It would appear that the respiratory depressant effect of
opioids is additive (56); thus, studies not controlled for concurrent opioid administration
are more likely to observe hypoxemia (54, 55, 57). It is interesting that only one of these
studies that was randomized and double-blind found no hypoxemia and even a higher
arterial saturation in the nitrous oxide/oxygen group than in the control group given
compressed air.
Uterine Relaxation. Uterine relaxation resulting from use of inhalational agents may
prolong labor and, more importantly, may result in increased blood loss following
delivery. Nitrous oxide is devoid of uterine effects, as originally demonstrated by
Klikovich, who inserted a tube into the uterus and measured in-trauterine pressure.
Cardiovascular Effects. Although traditionally held to have on cardiovascular effects

when used for labor and vaginal de-livery a recent study of intermittent 40% and 70%
nitrous oxide and continuous 40% nitrous oxide in labor found a dose-related reduction
in heart rate, cardiac output, and blood pressure that was greatest with continuous
administration and that persisted between contractions (59). Since pain relief was also
dose-dependent and greatest with continuous inhalation, it is possible that these
cardiovascular effects were related to relief of pain rather than to a direct effect of the
gas, although this could not be excluded. The volatile agents have well-known car-
diovascular-effects, hut in the' low concentrations used for labor and vaginal delivery
these are unlikely. Neonatal Effects
Placental transfer of all inhalation agents occurs rapidly, because they are highly
lipid soluble, nonionized, and of fairly low molecular weight. Anesthetic levels increase
104
rapidly in the fetal brain, and in general the degree of fetal and neonatal depression is
directly proportional to the depth and duration of maternal anesthesia (64). Neonatal
depression may result from direct drug effects or from physiologic changes induced in
the mother, such as hypoventilation or hypotension.
Early studies suggested adverse effects of nitrous oxide on the fetus, although
most involved cesarean section under general anesthesia, in which the deleterious
effects probably arose from catecholamine production associated with light anesthesia
in the absence of volatile agents rather than from the nitrous oxide itself (65, 66).
Inhalation of nitrous oxide for analgesia during labor has not been associated with
adverse effects including depression of neurobehavioral scores, despite rapid passage
into the fetus and the theoretical risk of neonatal diffusion hypoxia, and limitation of the
available space in the lung for oxygen (34, 67). Intermittent administration of 50%
nitrous oxide results in negligible maternal (and presumably fetal) arterial levels by the
start of the next contraction (32), unliie the situation in which nitrous oxide is inhaled
continuously.
Inhalation analgesia and anesthesia for labor
Regional Anaesthesia
The methods so far considered cannot ensure a painless delivery nor can they make
labour tolerable when the pain is very severe. When complete relief of pain is needed
throughout labour, epidural analgesia is the safest and simplest methods for procuring
it. But very few anaesthetists have the time to make use of this very valuable method in
normal and abnormal labour.
Continuous lumbar epidural block : A lumbar puncture is made between L2 and L/5
with the epidural needle (Tuohy needle). 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. Repeated doses of 4 to 5 ml of 0.5 percent bupivacaine or 1 percent
lignocaine are used to maintain analgesia. Epidural analgesia, as a general rule should
be given when labour is well established. The patient's blood pressure, pulse and the
105
foetal heart rate should be recorded at 15 minutes following the induction of analgesia
and hypotension, if occurs, should be treated immediately.
Contraindications to epidural analgesia :
(1) Sepsis at the site of injection
(2) Haemorrhagic disease or anticoagulant therapy
(3) Supine hypotension
(4) Neurological diseases
Caudal epidural analgesia : With the patient in left lateral position and after full aseptic
precautions, the sacral hiatus is identified and a malleable needle is pushed through it,
first piercing the skin and the sacro-coccygeal ligament at right angle and
then'depressing the needle towards the natal cleft so that the needle Ijes at an angle of
40° to the skin. The needle is gently advanced into sacral canal. The stylet is withdrawn
and an aspiration test is carried out to ensure that the dura or vein is not punctured. An
epidural catheter (a fine nylon catheter) is then passed through the needle and the
needle is then withdrawn, 16 ml to 20 ml of 1 percent lignocaine is passed and relief of
pain becomes established within 10-20 minutes. Bupivacine (0.5%) can be used for
prolonged analgesia. Caudal analgesia is rapidly falling into disuse because the
approach to the epidural space through sacral hiatus is dirtier, harder and fails more
often.
Per cervical nerve block
Following the usual antiseptic safe guards, a long needle (15 cm or more) is passed
into the lateral fornix, at the three and nine o'clock positions. 4 to 5 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 (0.25
percent) may also be used and its effects last for about 3 hours^~" In order to avoid
106
complications, a specially constructed guard tube is used. A needle is insetted through
the tube and isof such a length that it protrudes not more than 7 mm beyond its tip
(Fig.33/4).
Although paracervieal block may be used from 5 cm dilatation of the cervix, it is most
useful towards the end of the f irst stage of labour to remove the desire to bear down
earlier.
Paracervieal block can only relieve the pain of uterine contraction, and the perinea!
discomfort is removed by pudendal
nerve block. Because of the short lived effect and the rapid demoralisation in a patient,
a considerable interest in a
continuous epidural analgesia has been shown. •
Perineal infiltration
For episiotomy — Perineal infiltration anaesthesia is extensively used prior to

episiotomy, A10 ml. syringe, with a fine needle and about 8-10 ml 1% lignocaine
hydrochloride (Xylocaine) are required. The perineum on the proposed epi* epsiotomy
site is infiltrated in a fan-wise manner Fig.36/6 starting from the middle of the fourchette.
Each time prior to infiltration, aspiration to exclude blood is mandatory, fepisiotomy is
tote done about 2-5 minutes following infiltration.
For outlet forceps or ventouse — (Perineal and labial infiltration) : The combined
perinea! And labial infiltration is
effective in outlet forceps operation or ventouse traction. A 20 ml syringe, along 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 f anwise manner on both sides of the midline (as for episiotomy).The
needleis 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 (Fig.33/5). ...
107
Pudendal nerve block . .
Pudendal nerve block does not relieve the pain of labour but affords perinea!
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 anaesthesia.
Technique : The pudendal nerve may be blocked by either the transvaginal or the
transperineal route.
Transvaginal route : Transvaginal route is commonly preferred. A20 ml syringe, one

15cm (6'') 17-20gauge 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. Trie needle is passed along
the groove of the f ingejs and guided to pierce the vaginal wall on ^he apex of ischial
spine and thereafter to push a little to
pierce the sacrospinous ligament just above the ischial spine itjp. 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 .
(Eig.33/6).
Spinal Anastasia
The pain relief from an epidermal is obtained by blocking the condition of

impulses along sensory nerves as they enter the spinal cord.
When epidural block in labor was first introduced in the 1970s most attention was
focused on the technical and less as the problems it caused in relation to normal birth.
108
In those early years, as well as providing the required sensory block, the blockade of
motor and sympathetic nerves caused lose of bladder sensation and function, complete
number of the legs, significant hypotensian, relaxation of pelvic floor muscles and
impairment of expulsive efforts in the second stage of labour.
The percentage of units providing a 24 hours epidermal service has risen from
78% in 1991 to 90% in 1999.
Definition Spinal anesthesia can be employed to alleviate the pair of delivery and
during the third stage of labour.
 Brief or minimal spinal anesthesia is far safer than prolonged spinal anesthesia.
Advantages and Disadvantages
Goes and Mander, Howell cities cause of advantages and disadvantages.
 To eradicate pain,
 It can be converted to anesthesia to facilitate operative delivery.
 Less foctel hypomia
 Minimal blood loss.
The motor paralyst that used to because, and was divided by women and mid wives is
being reminded by the use of low dose infection epidural.
Other advantages
 The tendency of lower blood pressure can be an advantage incase of PIH.

 If labour is prolonged, gives effective pain relief allowing mother to rest.
 Does not depress the respiratory centre of the fetus.
Disadvantages
 In effective blocks
 More frequent monitoring of vital signs
 Lengthen first stage of labour.
 Lessable to adopt different birth positions.
109
 Less sensation of expulsulsive efforts and lengthen second stage of labour, increase in
instrumental vaginal delivery.
Contra indications and risk
 Un corrected anticoagulation or coagulopathy.

 Vertebral canal haemetoa
 Local or systemic sepsis (Pyresia above 380c not treated with antibiotics)
o Risk – Vertebral canal absence
 Hyporalaemia or active haemorrhage risk – cordiac collapse.
 Lack of sufficient trained midwives for continuous care and monitoring of mother and
fetus for the duration of epidural blockade.
Risk
 Maternal collapse, convulsions

 Respiratory arrest
 Fetal compromise
Preprocedure nursing care
 The women and her partner must have a clear explanation of the procedure and the
women consent must be obtained.
 An intravenous infusion of crystalloid fluids is commercial prios to procedure.
 Select the low dose epidural blockades.
 Mother is positioned in the left lateral for the procedure. (This is party because of the
risk of spine hypothesis and also because the mother may well be more comfortable in
this position when in labour.
 Some Anesthetists may find it easier or may prefer to ask the mother to sit up and flex
the spine, in an effort to supports the vertebral, the facilitating the management of the
procedure.
 The fetal heart rats and the woman’s blood pressure must be recorded throughout,
especially in the case of pregnancy induced hypertension, or in any case of suspicious
of fetal compromise.
Procedure
110
A local anesthetic is injected into the epidural space of the lumber region, usually
between vertebral L1 and L2 or between L2 and L3, or between L3 and L4.
 The procedure is carried out by an experienced (obstetric) anesthetist, under strict

aseptic conditions.
 The usual aseptic technique is employed, the area disinfected and the region draped.
 A small amount of local anesthetic is used before inserting a Thohy needle into the
epidural space.
 To locate the epidural space the anesthetist advances the needle usually, 16g, is
introduced little by little until the resistance of the ligament flavour is encountered.
 At this point a syringe is attached to the – needle, after removal of the stilette.
 The needle is then inserted further, continuously, until it enters the epidermal space.
This is recognized by the loss of resistance when pressure is applied to the plunger of
the syringe (loss of resistance to saline is lanctines is preferred).
 It is particularly important that the woman keeps very still at this stage as the
subrachnoid space is a few millimeter deeper.
 A slight movement of the women could result in the tuohy needle in adherently
puncturing the meninges and causing a “dural tap”.
 Once confident that the tuohy needle is in the epidural space and there has been no
leakages of blood of CSF, a Cachets is threatened throughout needle to facilitates bolus
top-ups or a continous infusion. A test dose of the local anesthetic ludicrous(lingacaing)
of about 4ml, may then be given –although same anesthetist prefer to inject the first
dose of bupi vaccine (Marcain) very slowly whilest observing for any adverse reactions
continuous infusion of dilutes bupivaccines and opioids (urenal fentany 1) has permitted
significant reductions in the amount of local anesthetic used whilst encoring rapid
analgesia.
 A further advantage of this region lies in the mother ability to move about and bear
down in the second stage at labour because of the minimal motor block effect.
 Low dose infusion in a lower incidence of instrumental vaginal deliveries compared with
traditional bolus epidurals.
111
 An antibacterial filter is attached to the end of the cache. The cachet is then secured to
the mother’s back with strapping (ensuring that she is not allergic to plaster) and a
syringe pump set up by the anesthetist if there is to be a continuous infusion.
Post Procedure Nursing Care
After the administration of first dose of bupivacacine and any subsequent top-up
doses of local anesthetic the blood pressure and pulse should be measured and
recorded every 5 minutes for 20-30 minutes then every 3 minutes.
 The mother may sit up in bed once it has become established that her blood pressure is
stable, titled to our side to prevent aortocaval compression.
 Throughout labour the months should be assisted to changer her position regularly to
avoid soft tissue damage.
 The fetal heart is usually monitored electronically.
 The month may be un aware of a full bladder, so the midwife ensure that the woman is
encouraged to empty her bladder regularly.
 She will not feel utensil contraction, or a desire to beardown in the second stage of
labour, so close observation is necessary. Utensil activity may be electronically
monitored.
 The spread of the block should be checked regularly
 Units vary in whether they use a cold object or ethyl chloride spray to test the extent to
which the mother has lost seculation.
The epidural top up
Midwives top up the epidural block giving a further dose as prescribed by the
anaesthetist. The prescription should indicate clearly the dosage and frequency of the
drug to be given, the positioning of the women.
 The midwife is personally responsible for ensuring that she is competent to carry out the
procedure.
 Identification of complications.
 The midwife has an important enabling and facilitating role to help the women maintain
control of pain during child birth.
112
 Accurate and detailed records of all records given will provide a good basis from which
proper decisions may be made concurring the progress and the needs of the women.
Complications
The use of low dose bupivacanie solutions for analgeria in labour has limited the
risk of hypotensions and local anesthetic toxicity.
Complications are
 Dural puncture and consequent headache

 Total spinal : Respiratory arrest
 Local anesthetic toxicity : Cardiac carets
 Fetal compromise cruting from hypotension or local analgesic toxicity.
 Loss of bladder secretion (need for catechization)
 Increased need for assisted vaginal birth
 Neurological sequels (serious damage extremely rare, weakness / sensory loss is
uncommon bat -- resolves.
Headache
For most woman the side effects following epidermal are minimal and backache
is more likely to be due to localized brining and immobility than epidermal analgesia.
Postdural puncture headache and duraltap
If there has been “dural tap” during the procedure, women are likely to develop a
severe portal headache caused by leakage of CSF. Headache from a dural tap can also
follow spinal anesthesia for operative deliveries.
 However, needles used for deliberate spiral injection are much finer than to tucohy
needles and the use of smaller gange “Pencil point” needles has greatly reduced the
leakage of CSF.
 Severe headache following a dural tap is treated by epidermal injection of 10-20 ml of
matural blood ( a blood patch) to seal the puncture and relieve the headache.
Increased in assisted vaginal birth
113
According to Throp et intervention is much less likely to occur if the epidermal has
been sited after 5 cm of dilation of the cervical. According to the birth process
necessitated the opening of the mother back . By this is meat the lifting up of the lower
lumber vertebral to facilitates the pallage and birth of the baby.
OBSTETRIC EMERGENCIES
Vasa praevia
The term vasa praevia is used when a fetal blood vessel lies over the os, in front
of the presenting part. This occurs when fetal vessels from a velamentous insertion of
the cord cross the area of the internal os to the placenta. The fetus is in jeopardy, owing
to the risk of rupture of the vessels, which could lead to exsan-guination.
Vasa praevia may sometimes be palpated on vaginal examination when the

membranes are still intact. It may also be visualised on ultrasound. If it is suspected a
speculum examination should be made.
Ruptured vasa praevia
When the membranes rupture in a case of vasa praevia, a fetal vessel may also
rupture. This leads to exsanguina-tion of the fetus unless birth occurs within minutes.
Diagnosis
Slight fresh vaginal bleeding, particularly if it commences at the same time as

rupture of the membranes, may be due to ruptured vasa praevia. Fetal distress dis-
proportionate to blood loss may be suggestive of vasa praevia.
Management
The midwife should call for assistance, requesting urgent medical aid. The fetal
heart rate should be monitored. If the mother is in the first stage of labour and the fetus
is still alive, an emergency caesarean section is carried out. If in the second stage of
labour, delivery should be expedited and a vaginal birth may be achieved. Caesarean
114
section may be carried out but mode of delivery will be dependent on parity and fetal
condition.
A paediatrician should be present at delivery and, if the baby is alive,

haemoglobin estimation will be necessary after resuscitation. The baby will require a
blood transfusion but there is a high mortality associated with this emergency.
Presentation and prolapse of the umbilical cord (BOX32.1)
Predisposing factors
These are the same for both presentation and prolapse of the cord. Any situation
where the presenting part is neither well applied to the lower uterine segment nor well
down in the pelvis may make it possible for a loop of cord to slip"down in front of the
presenting part. Such situations include:
 high or ill-fitting presenting part

 high parity
 prematurity
 malpresentation
 multiple pregnancy
 polyhydramnios (Mesleh et al 1993, Murphy & MacKenzie 1995).
High head. If the membranes rupture spontaneously when the fetal head is high, a loop
of cord may be able to pass between the uterine wall and the fetus, resulting in its lying
in front of the presenting part. As the presenting part descends the cord becomes
occluded.
Multiparity. The presenting part may not be engaged when the membranes rupture and
malpresentation is more common.
Prematurity. The size of the fetus in relation to the pelvis and the uterus allows the cord
to prolapse. Babies of very low birth weight (less than 1500 g) are particularly
vulnerable (Mesleh etal 1993).
115
Malpresentatior. (See Ch. 30). Cord prolapse is associated with breech presentation,
especially complete or footling breech. This relates to the ill-fitting nature of the
presenting parts and also the proximity of the umbilicus to the buttocks. In this situation
the degree of compression may be less than with a cephalic presentation, but there is
still a danger of asphyxia.
Cord presentation
This is diagnosed on vaginal examination when the cord is felt behind intact
membranes. It is, however, rarely detected but may be associated with aberrations in
fetal heart monitoring such as decelerations, which occur is the cord becomes
compressed.
Management
Under no circumstances should the membranes be ruptured. The midwife should

discontinue the vaginal examination, in order to reduce the risk of rupturing the
membranes. Help should be summoned, including medical aid. If continuous electronic
fetal monitoring is available, a recording may be commenced to assess fetal well-being.
The mother should be helped into a position that will reduce the likelihood of cord
compression. In the absence of continuous fetal monitoring the fetal heart should be
auscultated as continuously as possible, particularly during contractions.
Caesarean section is the most likely outcome.
Cord prolapse
Diagnosis
The diagnosis of cord prolapse is made when the cord is felt below or beside the
presenting part on vaginal examination. A loop of cord may be visible at the vulva. The
cord is more commonly felt in the vaginor, in cases where the presenting part is very
high, it may be felt in the cervical os.
Whenever there are factors present that predispose to cord prolapse, a vaginal
examination should be performed immediately on spontaneous rupture of membranes.
116
An abnormal heart rate, particularly bradycardia, may indicate cord prolapse.
Suspected cord prolapse may be the result of a suspicious CTG. Variable decelerations
and prolonged decelerations of the fetal heart are associated with cord compression,
which may be caused by cord prolapse.
If an oxytocin infusion is in progress this should be stopped. The midwife carries

out a vaginal examination and assesses the degree of cervical dilatation. She identifies
the presenting part and station. The time should also be noted. If the cord can be felt
pulsating, it should be handled as little as possible. Spasm of the cord may occur
through handling or be due to reduction in temperature. If the cord lies outside the
vagina, then it should be gently replaced to try to maintain temperature. An assistant
should be asked to auscultate the fetal heart and a record of the fetal heart rate is
made.
Management
The risks to the fetus are hypoxia and death as a'result of cord compression. The
risks are greatest with prematurity and low birth weight (Murphy & MacKenzie 1995).
Delivery must be expedited with the greatest possible speed to reduce the mortality and
morbidity associated with this condition. Caesarean section is the treatment of choice
in those instances where the fetus is still alive and delivery is not imminent, or vaginal
birth cannot be indicated.
In the second stage of labour the mother may be able to push and the midwife
may perform an episiotomy to expedite the birth. This may be possible with a
multifarious mother. Where the presentation is cephalic, assisted birth may be achieved
through ventouse or forceps.
Definition
The term 'shoulder dystocia is used in this chapter to describe failure of the
shoulders to traverse the pelvis spontaneously after delivery of the head (Smeltzer
1986). However, a universally accepted definition of shoulder dystocia has yet to be
produced (Roberts 1994).
117
Risk factors
Although it would be useful to identify those women : risk from a delivery

complicated by shoulder dystocia, most risk factors can give only a high index of
suspicion (Al-Najashi et al 1989). Antenatally these risk factors include post-term
pregnancy, high parity, maternal age over 35 and maternal obesity (weight over 90 kg at
delivery).
Warning signs and diagnosis
The delivery may have been uncomplicated initially (Morris 1955), but the head
may have advanced slowly and the chin may have had difficulty in sweeping over the
perineum. Once the head is delivered it may .look as if it is trying to return into the
vagina, which is caused by reverse traction.
Shoulder dystocia is diagnosed when manoeuvres normally used by the midwife

fail to accomplish delivery (Resnik 1980).
Management
Vipon diagnosing shoulder dystocia the midwife must summon help immediately.
An obstetrician, an anaesthetist and a person proficient in neonatal resuscitation should
be called,Shoulder dystocia is a frightening experience for the mother, for her partner
and for the midwife. The midwife should keep calm and try to explain as much as
possible to the mother to ensure her full cooperation for the manoeuvres that may be
needed to complete the delivery.
The purpose of all these manoeuvres is to disimpact the shoulders and

accomplish delivery. The principle of using the most simple manoeuvres first should be
applied.
The midwife will need to make an accurate and detailed record of the type of
manoeuvre(s) used and the time taken, the amount of force used and the outcome of
each maneuver attempted.
Non-invasive procedures
118
Change in maternal position. Any change in the matern'al position may be useful
to help release the fetal shoulders. However, certain manoeuvres have proved useful
and are described below. It is anticipated that following the use of one or more of these
manoeuvres the midwife should be able to proceed with the delivery.
The McRoberts manoeuvre. This manoeuvre involves helping the woman to lie
flat and to bring her knees up to her chest as far as possible (Fig. 32.5).
This manoeuvre will rotate the angle of the symphysis pubis superiorly and use
the weight of the mother's legs to create gentle pressure on her abdomen, releasing the
impaction of the anterior shoulder (Gonik et al 1983, 1989). It is the manoeuvre
associated with the lowest level of morbidity and requires the least force to accomplish
delivery (Bahar 1996, Gross et al 1987, Nocon et al 1993).
Suprapubic pressure. Pressure should be exerted on the side of the fetal back
and towards the fetal chest. This manoeuvre may help to adduct the shoulders and
push the anterior sboulder away from the symphysis pubis (Fig. 32.6).
Rupture of the uterus
Rupture of the uterus is one of the most serious complications in midwifery and
obstetrics. It is often fatal for the fetus and may also be responsible for the death of the
mother. With effective antenatal and intrapartum care this complication should be
avoided; however, it remains a significant problem worldwide.
Rupture of the uterus is defined as being complete or incomplete.
 Complete rupture – involves a tear in the wall of the uterus with or without expulsion of
the fetus
 Incomplete rupture – involves tearing of the uterine wall but not the promethium.
Management
An immediate caesarean section is performed, in the hope of delivering a live

baby. Following the delivery of the fetus and placenta, the extent of the rupture can be
assessed. Choice between the options to perform a hysterectomy or to repair the
119
rupture depends on the extent of the trauma and the mother’s condition. Further clinical
assessment will include evaluation of the need for the blood replacement and
management of any shock.
Amniotic fluid embolism/ anaphylactoid syndrome of pregnancy
This rare but potentially catastrophic condition occurs when amniotic fluid enters
the maternal circulation via the uterus or placental site. The presence of amniotic fluid in
the maternal circulation triggers an anaphylactoid response and the term ‘embolus’ is a
misnomer.
Emergency action
Any one of the above symptoms is indicative of an acute emergency. As the

mother is likely to be in a state of collapse, resuscitation needs to be commenced at
once. An emergency team should be called, since the midwife responsible for the care
of the mother requires immediate help. If collapse occurs in a community setting, basic
life support should be commenced prior to the arrival of emergency services.
Despite improvements in intensive care the outcome of this condition is poor.

Specific management for the condition is life support, and high levels of oxygen are
required. Mothers who survive are likely to have suffered a degree of neurological
impairment.
Acute inversion of the uterus
This is a rare but potentially life-threatening complication of the third stage of

labour. It occurs in approximately 1 in 2250 births (Brar et al 1989).
In the most serious cases the inner surface of the fundus appears at the vaginal
outlet, as in total inversion. In less severe cases the fundus is dimpled, which is known
as a partial inversion.
A midwife’s awareness of the precipitating factors enables her to take preventive

measures to avoid this emergency.
120
Classification of inversion
Inversion can be classified according to severity as follows:
 First degree – the fundus reaches the internal os

 Second degree – the body or corpus of the uterus is inverted to the internal os
 Third degree – the uterus, cervix and vagina are inverted and are visible.
Management Immediate action
A swift response is needed to reduce the risks to the mother.
1. Help is summoned, including appropriate medical support.

2. The midwife in attendance should immediately attempt to replace the uterus. This may
be achieved by pushing the fundus with the palm of the hand, along the direction of the
vagina, towards the posterior fornix. The uterus is then lifted towards the umbilicus and
returned to position with a steady pressure (Johnson's manoeuvre). This, if successful,
will reduce the risk to the mother.
3. An intravenous cannula should be inserted and fluids commenced. Blood should be
taken for cross-matching prior to starting the infusion.
4. If the placenta is still attached, it should be left in situ as attempts to remove it at this
stage may result in uncontrollable haemorrhage.
5. Once the uterus is repositioned, the operator should keep the hand in situ until a firm
contraction is palpated. Oxytocics should be given to maintain the contraction
(Cunningham et al 1997).
Medical management
If manual replacement fails, then medical or surgical intervention is required. The

use of the hydrostatic method of replacement involves the instillation of warm saline
infused through a giving set into the vagina. The pressure of the fluid builds up as
several litres are run into the vagina and restores the uterus to the normal position,
while the operator seals off the introits by one hand inserted into the vagina.
121
If the inversion cannot be manually replaced, it may be due to the development
of a cervical constriction ring. Drugs can be utilised to relax the constriction and facilitate
the return of the uterus to its normal position.
Throughout the events the mother and her partner should be kept informed of
what is happening. Assessment of vital signs, including level of consciousness, is of
utmost importance.
Basic life-support measures
Standards of basic life support have been agreed for health professionals and lay
people throughout Europe. Basic life support refers to the maintenance of an airway and
support for breathing, without any specialist equipment other than possibly a pharyngeal
airway. Before starting any resuscitation, assessment of any risk to the career and the
patient is needed. The space available, size of patient* and her condition may place
those undertaking resuscitation in danger of injury. Slide sheets should be available to
move patients. The position of the patient may result in the midwife being unable to
undertake chest compression or ventilation effectively and cause personal injury as a
result of. twisting, or straining back muscles (Resuscitation Council UK 2001). Tire basic
principles are:
A - airway
B - breathing
C - circulation.
1. The level of consciousness is established by shaking the woman's shoulders and

enquiring whether she can hear.
2. Assistance is called for by ringing the emergency bell or asking the partner to call for
help and then return to the midwife who must remain with the woman.
3. The woman is laid flat, removing pillows. A pregnant woman should be further
positioned with a left lateral tilt to prevent aortocaval compression. This can be achieved
by the use of pillows or a wedge under the right side.
122
4. The head is tilted back and the chin lifted upwards to improve the patency of the airway
(Fig. 32.12).
5. The airway is cleared of any mucus or vomit. Any well-fitting dentures are left in place.
6. The chest is observed for signs of respiratory effort. The midwife listens for breathing
sounds and feels for breath being exhaled from the mouth and nose. An or pharyngeal
airway of the correct size is inserted if available.
7. If no breathing is detected, the midwife will pinch: he nose closed, take a deep breath in
and exhalejn to the woman's mouth, so that her chest can be seen to air is then allowed
to escape and the chest should be observed to fall. She repeats this to achieve two
effective breaths. If after five attempts the woman remains unresponsive the signs of
circulation should be assessed.
8. The midwife should quickly check for a carotid pulse. If there is no pulse, external chest
compression is needed. The xiphisternum is located. The hands are placed palm
downwards one on top'-of the other with the fingers interlinked. The heel of the lower
hand is positioned on the lower two-thirds of the sternum. With arms straight, the
midwife leans on to the sternum, depressing it 4-5 cm, and releases it slowly at the
same rate as compression. The action should be repeated 100 times a minute. The
midwife may need to kneel over the woman or find something to stand on to ensure that
she is suitably positioned to carry out resuscitation (Fig. 32.13). The surface under the
woman must be firm for the manoeuvre to succeed.
9. Chest compression and rescue breathing should be continued until help arrives and
until those experienced in resuscitation are able to take over. A rate of 15 chest
compression to 2 breaths is carried on if only one person is present; if two people are
available the rate is 15 compressions to 2 breaths (Resuscitation Council UK 2000).|
Shock
Shock is a complex syndrome involving a reduction in lilood flow to the tissues

with resulting dysfunction of organs and cells. It entails progressive collapse of the
circulatory system and, if left untreated, can result in death. Shock can be acute but
prompt treatment results in recovery, with little detrimental effect on the mother.
However, inadequate treatment or failure to initiate effective treatment can result in a
123
chronic con dition ending in multisystem organ failure, which may be fatal. Shock can be
classified as follows:
 hypovolaemic - the result of a reduction in intra-vascular volume

 cardiogenic - impaired ability of the heart to pump blood
 distributee"-an abnormality in the vascular system that produces a maldistribution of the
circulatory i system; this includes septic and anaphylactic shock/ (Rice 1991).
Hypovolaemic shock
This is caused by any loss of circulating fluid volume that is not compensated for,
as in hemorrhage, but may also occur when there is severe vomiting. The main causes
and management of both these conditions are dealt with elsewhere.
The body reacts to the loss of circulating fluid in stages as follows:
Initial stage. The reduction in fluid or blood decreases the venous return to the
heart. The ventricles of the heart are inadequately filled, causing a reduction in stroke
volume and cardiac output. As cardiac output and venous return fall, the blood pressure
is reduced. The drop in blood pressure decreases the supply of oxygen to the tissues
and cell function is affected.
Compensatory stage. The drop in cardiac output produces a response from the
sympathetic nervous system through the activation of receptors in the aorta and carotid
arteries. Blood is redistributed to the vital organs. Vessels in the gastrointestinal tract,
kidneys, skin and lungs constrict. This response is seen by the skin becoming pale and
cool. Peristalsis slows, urinary output is reduced and exchange of gas in the lungs is
impaired as blood flow diminishes. The heart rate increases in an attempt to improve
cardiac output and blood pressure. The pupils of the eyes dilate. The sweat glands are
stimulated and the skin becomes moist and clammy. Adrenaline (epinephrine) is
released from the adrenal medulla and aldosterone from the adrenal cortex. Ant diuretic
hormone (ADH) is secreted from the posterior lobe of the pituitary. Their combined
effect is to cause vasoconstriction, an increased cardiac output and a decrease in
124
urinary output. Venous return to the heart will increase but, unless the fluid loss is
replaced, will not be sustained.
Progressive stage. This stage leads to multi system failure. Compensatory

mechanisms begin to fail, with vital organs lacking adequate perfusion. Volume
depletion causes a further fall in blood pressure and cardiac output. The coronary
arteries suffer lack of supply. Peripheral circulation is poor, with weak or absent pulses.
Final, irreversible stage of Hock. Multi system failure and cell destruction are
irreparable. Death ensues.
Management
Jorgen resuscitation is needed to prevent the mother's condition deteriorating

and causing irreversible damage.
The priorities are to:
1. Call for help - Shock is a progressive condition and delay in correcting hypovolaemia
can lead ultimately to maternal death.
2. Maintain the airway - if the mother is severely collapsed she should be turned on to her
side and 40% oxygen administered at a rate of 4-6 litres per minute. If she is
unconscious an airway should be inserted.
3. Replace fluids - two wide-bore intravenous cannulae should be inserted to enable fluids
and drugs to be administered swiftly. Blood should be taken for cross-matching prior to
commencing intravenous fluids. A crystalloid solution such as Hartmann's or Ringer's
lac-tate is given until the woman's condition has improved. A systematic review of the
evidence found that colloids were not associated with any difference in survival and
were more expensive than crystalloids (Alderson et al 2001). Crystalloids are, however,
associated with loss of fluid to the tissues, and therefore to maintain the intravascular
volume colloids are recommended after 2 litres of crystalloid have been infused. No
more than 1000-1500 ml of colloid such as Gelofusine or Haernocell should be given in
a 24 hour period. Packed red cells arid-fresh frozen plasma are infused when the
condition of the woman is stable and these are available.
125
4. Warmth - it is important to keep the woman warm, but not over warmed or warmed too
quickly as this will cause peripheral vasodilatation and result in hypotension.
5. Arrest haemorrhage - the source of the bleeding needs to be identified and stopped.
Any underlying condition needs to be managed appropriately.
126

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INDEX

S.NO CONTENT PAGE NUMBER

DRUGS USED IN PREGNANCY

Most of the available information on pharmacokinetics of drugs during pregnancy

Precautions while prescribing drugs to a pregnant women

Myometrial oxytocin receptors concentration increases maximum (100-200) during

d).PREPARATIONS USED:-1).Synthetic oxytocin (Syntocinon-sandozor pitocin-parke-

2).Syntometrin (Sandoz)-A combination of Syntocinon 5 units and ergometrine 0.5mg.

3).Desamino oxytocin-It is not inactivated by oxytocinase and is 50-100 percent more

4)Oxytocin nasal solution contains 40 units/ml.

Oxytocin may be conveniently used in pregnancy, labour or puerperium.The indications

 To accelerate abortion—inevitable or missed and to expedite expulsion of

PUERPERIUM;-To minimize blood loss and to control postpartum haemorrhage.

o Contraction stress test(CST)

PREGNANCY LABOUR ANYTIME

 Grand multipara  All the contra-  Hypovolemic state

 Contractedpelvis  Obstructed labour  Cardiac disease

 History of caesarean  Incoordinate uterine

 Malpresentation  Fetal distress

uterine hyperstimulation (overactivity)- is a frequently observed side effect. There

 Controlled intravenous infusion is the widely used method

IV.METHODS OF ADMINISTRATION OF OXYTOCIN;-

a).CONTROLLED INTRAVENOUS INFUSION:-

(i).FOR INDICATION OF LABOUR

Calculation of the infused dose: Nowadays the infusion is expressed in terms of

Convenient regime:-Because of wide variation in response, it is a sound practice to

(ii).FOR ARGUMENTATION OF LABOUR;-

 Observation during oxytocin infusion.

V.DIAGNOSTIC USE OF OXYTOCIN;-

a).CONTRACTION STRESS TEST (CST)(syn; oxytocin sensitivity test ;ost)

PRINCIPLES;-The test is based on determination of the respiratory function of the feto-

Candidates for CST;-

1.Intra uterine growth restriction.

2.Previous history of caesarean section.

3.Complicatios likely to produce preterm labour.

PROCEDURE;-The oxytocin infusion is started in the same manner as mentioned

IMPORTANCE;- A negative test is associated with good fetal outcome. Whereas a

NIPPLE STIMULATION TEST:-The woman induces uterine contractions for CST by

 Ergometrine (Ergonovine in USA)

a).CHEMISTRY;- Ergometrine is an alkaloid by Dudley and Moir in 1935 from ergot, a

b).MODE OF ACTION : Ergometrine acts directly on the myometrium. It excites

c).EFFECTIVENESS ; Keeping the physiological functions in mind, it should not be

d).MODE OF ADMINISTRATION ; Ergometrine and methergin can be used

e).USES OF ERGOMETRINE METHERGIN

f).HAZARDS: (1) Common side effects are nausea and vomiting.

(2)Because of this vasoconstrictive action, it mayprecipitate rise of blood pressure,

As a haemostatic in uterine haemorrhage following expulsion of the fetus irrespective of

 Induction of abortion (MTP&Missed abortion)

Hypersensitivity to the compound

Active cardiac, pulmonary, renal or hepatic disease;hypotension(PGE2

g). ADV&DIS ADVANTAGES & SIDE EFFECTSPROSTAGLANDINS(PGs);-

1.Powerful oxytocic effect, irrespective 1. It is costly compareto oxytocinOf duration of

2.Induction of labour (PGE2,2. Nausea,vomiting,diarrhea,pyrexia,In cases with

(a) low preinduction score bronchospasm,tachycardia andchills.

(b)IUFD3.Cervical laceration may occur(PGF2)

3.Used in inductionof abortion(PGE1)with when used as an abortifacient.

4.It has got no anti diuretic effect(of oxytocin)4. Tachysystole(hyperstimulation)of

5.PGE1(misoprostol)can be used for 5.Risk of uterine rupture in case with

augmentation of labouruterine scar