A CASE STUDY ON TOCOLYTIC MEDICATION:

PRE-TERM LABOR

By
Demontano, John Brian
Frugalidad, Kathleen
Galfo, Deserie
Gallos, Mary Angeline

BSN 4C GROUP 9
CASE SCENARIO:

Mrs. Jones is a G4T1P1A1L2 at 32 weeks and 3 days. She came into labor triage for contractions that are happening
every 2 to 4 minutes apart and lasting approximately 60 seconds long. Mrs. Jones delivered her last child at 34 weeks.

On admission her assessment is:

BP: 112/67
P: 78R: 16
T: 36.7
Pain: 6/10 for contractions and back pain
SVE: deferred
Medical Diagnosis: Preterm Labor

Mrs. Jones states that her bag of water is still intact, and she has not noticed any vaginal bleeding. The contractions
have been happening since 24 weeks gestation but have become more consistent and regular in the past 8 hours.
Mrs. Jones said that she has been drinking only water and had a large glass before laying down prior to coming in. Mrs.
Jones denies intercourse in the last 24 hours. The triage nurse calls the on-call obstetrician, Dr. Peach, and fills her in
on Mrs. Jones.
 Dr. Peach order a fFN swab and RN to do SVE. Dr. Peach
orders 100-mg dose of Indomethacin for preterm labor,
oral dose of 25 mg every four to six hours, to discontinue
after 48 hours; nifedipine orally in a loading dose of 30 mg,
followed by 20 mg given every four to eight hours for 24
hours, and then a maintenance dose of 10 mg every eight
hours until 35 to 37 weeks

Dr. Peach orders laboratory tests:

History & Physical Assement:
NURSING HISTORY

History of Present Illness:

Presented at the ER with a chief complaint of contractions that

are happening every 2 to 4 minutes and lasting approximately
60 seconds long. She stated that her bag of water is still intact
and no vaginal bleeding was noticed. The contractions are more
consistent and regular in the past 8 hours compared to the
contractions that have been happening since 24 weeks
gestation.
Past Health History:

General Health Status:

Patient is a 35 year old, female. Presented in the ER with chief complaint of contractions every 2 to 4 minutes
and lasting approximately 60 seconds long.
Childhood Illness:
Patient have no known illness since childhood.
Accident or injuries:
Patient have no recent accidents and only have sporting injuries.
Serious/ Chronic Illness:
No history of serious/chronic illnesses
Hospitalization:
Hospitalized during her last delivery of a child.
Operations:
Patient does not undergo any operations.
Immunizations:
Completed
Allergies:
No known allergies.
Current Medication:
Indomethacin
Nifedipine
Family History:
Patient reported that her maternal side has a history of diabetes and
hypertension while the paternal side has a history of hypertension and
alcoholism. No history of allergies, tuberculosis, mental illness, kidney
disease and mental retardation was reported by patient.

Current Medications:
Indomethacin
Nifedipine

Physician Orders: Kath

Dr. Peach order a fFN swab and RN to do SVE
PHYSICAL ASSESSMENT
A. Vital Signs
BP: 112/67
P: 78
R: 16
T: 36.7
Pain: 6/10 for contractions and back pain
SVE: deferred
Medical Diagnosis: Preterm Labor

B. General Appearance
Awake, Alert and oriented to time, place, and person; well-groomed; makes
eye contact; speech clear and appropriate; came into labor triage for
contractions that are happening every 2 to 4 minutes apart and lasting
approximately 60 seconds long.
C. Skin
Skin surfaces are dry and warm to touch. No skin discolorations noted.
Skin is intact with no redness noted.

D. Head and Face

Head is symmetrical, round, in midline and appropriately related to body
size. No lesions are visible. Hair is thin, black and evenly distributed.

E. Eyes
Eyes are symmetrical. Pupils equal, round and reactive to light and
accommodation. Conjunctiva is clear, white and smooth. Sclera is white.
Eyebrows are evenly distributed. No swelling, redness or discharges
noted.
F. Ears
Ears are equal in size bilaterally. The auricle aligns with the corner of each eye.
Earlobes are attached to adjacent skin with no apparent lobe. No lesions,
lumps or nodules noted. Color is consistent with facial color. No discharge
noted

G. Nose
Nasal structure is smooth and symmetric. Normal pink mucosa. No bleeding,
discharges, swelling and lesions noted. Patent airflow on both nostrils.

H.Mouth and Oropharynx

Lips are pink, smooth, and moist without lesions or swelling.
I. Neck
Neck is symmetrical. No masses, lesions and swelling noted.
Trachea positioned at midline.

J. Chest and Breast-Heart

Crackles auscultated in bilateral bases, occasional
cough.Symmetry of clavicle noted. Respiratory rate at 16 bpm.
No heart murmurs noted. Heart rate at 78 bpm

K. Abdomen
L. Back
Normal curvature of the spine. No masses noted.

M. Upper Extremities
Arms are bilaterally symmetric. Fair and even skin tone. Skin is warm to
touch. No clubbing, cyanosis or edema observe. No lesions noted.

N. Lower Extremities
Legs are identical in size and shape bilaterally. No clubbing of extremities,
cyanosis or edema noted. No deformities or wounds noted.

O. Genito-Anal Area
Bag of water is still intact. No vaginal bleeding.
14 PROGRAM OUTCOMES
1. Apply knowledge of physical, social, natural and health sciences, and humanities in
the practice of nursing

Having knowledge in physical, social, natural and health sciences and

humanities in the practice of nursing can detect what is happening to the
patient, what are the problems to be solved and what are the ways to alleviate
them

2.Provide safe, appropriate and holistic care to individuals, families, population group
and community utilizing nursing process.

Utilizing nursing care plans in providing quality care for the patient.
3.Apply guidelines and principles of evidence-based practice in the delivery of care

Preterm delivery is the leading cause of neonatal morbidity and is the most common reason for
hospitalization during pregnancy. The rate of preterm delivery (before 37 weeks' gestation) has been
declining since 2007. Clinical diagnosis of preterm labor is made if there are regular contractions and
concomitant cervical change. Less than 10% of women with a clinical diagnosis of preterm labor will
deliver within seven days of initial presentation. Women with a history of spontaneous preterm
delivery are 1.5 to two times more likely to have a subsequent preterm delivery.

4.Practice nursing in accordance with existing laws, legal, ethical and moral principles

Ethics within healthcare are important because workers must recognize healthcare
dilemmas, make good judgments and decisions based on their values while keeping
within the laws that govern them. To practice competently with integrity, nurses,
like all healthcare professionals, must have regulation and guidance within the
profession. The American Nurses Association (ANA) has developed the Code of
Ethics for this purpose.
5.Communicate effectively in speaking, writing and presenting using culturally-appropriate
language

Our goal as nurses is to provide holistic care to our patients, which is impossible to
achieve if communication is lacking. Patients will eventually reject prescribed drugs if
their actions are not fully explained, as they will believe that it may impair their health.
As a nurse, we must be able to communicate effectively. We should address any
inquiries or clarifications from our patients.

6. Document to include reporting up-to-date client care accurately and

comprehensively

To document honestly and accurately is very important because it is one of

the basis in rendering care to our patients. This is also where we base our
next interventions and monitor the progress of our patients' conditions
while taking the drugs.
7. Work effectively in collaboration with inter-, intra-and multi-disciplinary and
multi-cultural teams

A set of competent professionals collaborating to attain effective patient

care. Delivery room nurses that monitor the patients labor, obstetrician
that took care of the patient in the delivery and after birth, and a
pediatrician who focuses on the infants health and development from birth.

8.Practice beginning management and leadership skills in the delivery of client care using a
systems approach

Team work is an optimal method of delivering exemplary health care. Efficient and
effective teamwork provides benefits for you, your peers and your patients. Your
workplace becomes more enjoyable and productive when you are able to operate as a
team. Safety issues are reduced, while retention rates are increased. At the same time,
patient care improves with seamless collaboration and enhanced communication.
9.Conduct research with an experienced researcher

Conduct research about preterm labors to advance in our field,

stay current, and provide quality patient care.

10. Engage in lifelong learning with a passion to keep current with national
and global developments in general, and nursing and health developments in
particular

Lifelong professional education is considered as a qualitative indicator in

the health discipline, as it can improve health professionals’ knowledge
and skills, as well as nursing care. It is necessary for nurses to be able to
engage in seminars regarding preterm labors in order to provide the
patient with adequate and safe health care.
11. Demonstrate responsible citizenship and pride of being a Filipino

As a nurse, we serve as an advocate for our patients, a caregiver, a communicator, an

educator, a counselor, a change agent and a clinician. Assessing the patient before
giving tocolytic drugs, asking for allergies, and verifying doses and route before
administering tocolytic drugs to patients having preterm labors, and providing health
education. Filipino nurses are known to be the most compassionate nurses worldwide;
instilling the values and morals passed from generations.

12. Apply techno-intelligent care systems and processes in health care delivery

Technology can be used to save and access data from a patient's medical
records. It also improves patient communication by providing a readable
format that anyone may use. As a result, the likelihood of errors is reduced.
13. Adopt the nursing core values in the practice of the profession

Nursing values give a framework for evaluating behavior and

affect practice decisions by guiding norms for action. It can help
the patient by knowing what is right and wrong for the patient.

14. Apply entrepreneurial skills in the delivery of nursing care

Nurse entrepreneurs have the ability to have a huge impact
on the healthcare industry. They can assist establish the
groundwork for moving the notion of care delivery forward in
numerous ways by working individually to develop new and
creative technologies and systematic industry
A comparative study on the efficacy of nifedipine and indomethacin for
prevention of preterm birth as monotherapy and combination therapy: a
randomized clinical trial
Abstract

Introduction: Preterm delivery is an important issue in obstetrics, which is the most common
cause of neonatal mortality and morbidity. Therefore, finding a way to prevent it is always under
serious concern.

Objective: The study aimed to compare the efficacy of two tocolytic agents, nifedipine and
indomethacin, for inhibiting preterm uterine contractions as monotherapy and combination
therapy.

Materials and methods: A double-blind randomized clinical trial was performed on pregnant
women with gestational age of 26-34 weeks of pregnancy who referred to hospital for preterm
labor. They were randomly assigned to three groups. Indomethacin plus placebo, nifedipine plus
placebo, and a combination of indomethacin and nifedipine were administered to the three
groups. Inhibiting contractions for 2 hours and prevention of delivery for 48 hours and 7 days
were evaluated. Also, duration of pregnancy, the number of preterm births, and the interval
between entering the study and delivery were compared between three groups.
Results: One hundred fifty women were eligible for the study. Two women in the
nifedipine group and one woman in the combined group were excluded from the
study because of hypotension. The women of the three groups did not have
significant difference according to age, BMI, gravidity, parity, Bishop score,
gestational age, and the number of contractions at entering the study. Thirty-six
women (72%) in the indomethacin group, 36 women (72%) in the nifedipine group,
and 41 women (89.4%) in the combination group had stopped contractions within
the first 2 hours of intervention (p = .002). Inhibiting contractions for 48 hours (p =
.003), inhibiting contractions for 7 days (p = .021), gestational age at birth (p = .001),
number of pregnancies more than 37 weeks (p = .007), and neonatal weight (p =
.020) were significantly more in the combination group.

Conclusion: Combination therapy with nifedipine and indomethacin was more

effective than monotherapy with either of these two medications for inhibiting
preterm labor, delaying delivery, and prolongation of the duration of pregnancy.