Unit: 6 Pharmacology for

Midwives
Prepared by:
Anita Khadka
M.Sc Nursing
4th Batch
Pregnancy, childbirth and lactation pose
unique challenges in terms of drug therapy.
The pregnant mother and her unborn child
are exceptionally vulnerable from a
physiological, clinical and ethical point of
view.
This warrants careful consideration of a
number of important aspects, which could
influence the decision for drug therapy,
The midwife should have through
knowledge of the indications, actions and
side effects of these drugs as well as the
nursing considerations related to each of
them in order to plan and implement
effective nursing process.
Drugs used in obstetrics have a huge
impact on the outcome of both mother and
baby.
Drug therapy may pose a significant risk
during each of the following vulnerable
periods in the human reproductive cycle:
 Fertilization of the ovum, followed by
complete implantation.
 The fetus.
 The mother and infant.
 The following aspects must be considered:
 Physiological changes during pregnancy that
may affect drug action and kinetics.
 Drug toxicity during pregnancy.
 Cross-placental transfer of drug molecules
and their metabolites.
 Excretion in breast milk.
 Drug safety during pregnancy and lactation
Effects of pregnancy on
pharmacokinetics
Pharmacokinetics means “ what body
does to the drug” .
Includes absorption, distribution,
metabolism and elimination of drugs.
It tells you how and when drug reaches
the site of action
Certain physiological changes during
pregnancy have implications for drug
therapy and may affect any of the four
basic kinetic processes namely:
1. Absorption
2. Distribution
3. Metabolism
4. Elimination /Excretion
1. Absorption
Increased progesterone levels:
 Cause a decrease in gastrointestinal
motility (with resultant constipation)
 Decrease in oesophageal sphincter
pressure (which causes heartburn).
 In addition, placenta-derived human
chorionic gonadotropin (hCG) causes
nausea and vomiting.
 The altered gastrointestinal functioning
caused by these changes could influence
the rate and extent of absorption of orally
administered drugs.
Pregnancy also results in:
Increased lung perfusion and pulmonary
alveolar drug transfer due to improved
cardiac output.
Meaning that the absorption will be
improved for drugs that are administered
via the pulmonary route (i.e. nebulizers
and inhalers).
Absorption from an intramuscular site is
likely to be efficient because tissue
perfusion is increased due to
vasodilatation.
Parenteral drug administration is
preferred in order to obtain a quick
response.
2. Distribution
1. Total body water increases by up to 8 Litres, creating a larger
space within which water soluble drugs may distribute.
2. The increased plasma volume that accompanies pregnancy
and which may result in an increased volume of distribution
(Vd) of certain drugs.
3. Pregnancy brings about a decreased blood albumin level,
which could result in an increased fraction of free drug
molecules.
3. Metabolism
Hepatic metabolism increases, but not the
blood flow to liver.
Hepatic drug metabolizing enzymes are
induced during pregnancy probably by
high concentration of circulating
progesterone.
This can lead to more rapid metabolic
degradation especially of highly lipid
soluble drugs.
4. Drug excretion
During pregnancy the renal plasma flow
increases by 100% and glomerular
filtration rate by 70%.
Hence, drugs which depend for their
elimination mainly on kidney are
eliminated more rapidly than in non-
pregnant stage, e.g. ampicillin, gentamicin
and cephalosporin.
 Increase total blood volume:
This leads to change in cardiac output, blood
pressure and Glomerular filtration rate.
This results in change in volume of
absorption and distribution of drug.
Change in metabolism and excretion of
drug.
Change in protein binding of drugs and
passage of drug through placenta.
Placental transfer of drugs
The placenta is not a perfect barrier to drugs
and chemicals administered to mother.
Thalidomide tragedy, showed that placenta
was capable of transferring drugs ingested by
mother to fetus, with potential for great harm.
On other hand, placental transfer of drugs
administered to mother has been used to treat
fetal arrhythmias, congestive heart failure, &
other conditions.
Factors affecting placental drug transfer
to fetus
Physicochemical properties of drug
Rate at which drug crosses placenta &
amount of drug reaching the fetus
Duration of exposure to drug
Distribution characteristics in different
fetal tissues
Stage of placental & fetal development at
time of exposure to the drug
Effects of drugs used in combination
Risk categories for drugs and
Medications
Food and Drug Administration has
generated a grading system for
medications used during pregnancy. The
categories are A, B, C, D, and X. The
significance of these categories are :-
CATEGORY A
Drugs that have been tested for safety during
pregnancy and have been found to be safe.
Clinical Application
For all practical purposes, there are no
Category A drugs.
Drugs and some multivitamins.
This includes Magnesium sulphate, folic
acid, vitamin B6, and thyroid medicine
classified as Category A.
CATEGORY B
No evidence of risk in humans: Drugs that
have been used a lot during pregnancy and do
not appear to cause major birth defects or
other problems.
Clinical Application
Category B drugs include vitamins,
acetaminophen, famotidine, prednisolone,
insulin (for diabetes), and ibuprofan (inflam)
before third trimester, ibuprofen should not
take during the last three months of pregnancy.
CATEGORY C
Risk cannot be ruled out: Drugs that are
more likely to cause problems for the
mother or fetus. Also includes drugs for
which safety studies have not been
finished. Drugs should be given only if
the potential benefit justifies the potential
risk to the fetus.
Clinical Application
There are some reasons to be more
concerned about these drugs than
Category B drugs.
If the pregnant patient will benefit from a
Category C drug, it is generally used.
These drugs include fluconazole and
ciprofloxacin, some antidepressants are
also included in this group.
CATEGORY D
Positive evidence of risk: Drugs that
have clear health risks for the fetus. but
the benefits from use in pregnant woman
may be acceptable despite the risk (e.g., if
the drug is needed in a life threatening
situation or for a serious disease.)
Clinical Application
Category D drugs includes Tetracycline,
lithium (used to treat manic depression),
phenytoin (eptoin), ACE inhibitor and
most chemotherapy drugs to treat cancer.
They should be used during pregnancy
only when no alternatives available.
CATEGORY X
Contraindicated in pregnancy: Drugs that
have been shown to cause birth defects and
should never be taken during pregnancy.
Clinical Application
These drugs should not be used during
pregnancy.
This includes drugs to treat skin conditions
like cystic acne (Accutane), a sedative
(thalidomide)
Alcohol, Thalidomide, Oral contraceptive
pills, Lithium, Methotrexate,
Mifepristone, Danazol, Isotretinoin,
Radioactive iodine and others are also
from this group.
Commonly used drugs and their
categories
Drug name Category

Analgesics and antipyretics B and C

Acetaminophen B

Aspirin B

Phenacetin C

Antiemetics B and C

Antibiotics B,C and D

Penicillin,ampicillin,amoxicillin B

Cephalosporin B

Erythromycin B

Gentamycin C
Commonly used drugs and their
categories
Drug name Category

Streptomycin ,Tetracycline D

Metronidazole B

Antimalarial C

Antifungal C

Antitubercular B and C

Ethambutol B

Pyrizinamide C

Rifampicin C

Vitamin B,C,D,E and folic acid A

Guideline for using the drugs
If the benefit outweighs the potential
risks, only then can the particular drug be
used with prior counseling.
Only, well tested and reputed drugs are to
be prescribed and that too using the
minimum therapeutic dosage for the
shortest possible duration.
Commonly prescribed drugs in
midwifery
Guidelines for Prescribed Drugs in
Pregnancy
1. Don’t use drug unless it is absolute
necessary— use drug in pregnant patient
only when it is absolutely necessary.
2. Ruling out possibility of pregnancy—
rule out possibility of pregnancy in
every female of reproductive age group
and restrict drug usage.
Magnesium Sulphate
Itis anticonvulsant drug.
Mechanism Of Action:
Decreased acetylcholine release from
motor nerve terminals, which is
responsible for anticonvulsant properties,
thereby reduces neuromuscular irritability.
It also decreases intracranial edema &
helps in diuresis.
Its peripheral vasodilatation effect
improves the uterine blood supply.
Has depressant action on the uterine
muscles & CNS.
Indication
1. Severe pre-eclampsia
2. Eclampsia
3. Used in preterm labor to decrease
uterine activity.
Contraindication
Heart block
Impaired renal function
Pregnant women actively progressing
labor.
Myasthenia gravis
Preparation
Inj- 1amp=2ml contains 1gm Mgso4.
Tablet-64mg
Dose
1. Loading Dose:
Draw up 4gm of MgSo4 50% solution.
Dilute it with 12ml NS making it 20%
solution (20ml)
Give by IV infusion slowly over 5 minutes
Draw up 10gm MgSo4 50%solution (50%)
Draw 1ml 2% lignocane in the same syringe
Give 5gm by deep IM injection in each
buttock.
Ifconvulsion occur after 15 minutes,
Draw up 2gm of MgSo4 50% solution
Give by IV injection slowly over 5 minutes

2. Maintenance dose:
Give 5gm of MgSo4 50% solution,
together with1ml 2% lignocaine in the
same syringe by deep IM into alternate
buttock. (every 4hours)
Monitoring before repeat administration
Count respiration rate for one minute
every hour (=>16/minutes)
Check patellar reflex every hour(present)
Urinary output is atleat 30ml/hr over 4
hours.
Antidote
Calcium gluconate 1gm (10ml of 10%
solution) by IV injection slowly over
10minutes.
Side effects
breathing difficulties, lowered blood
poor reflexes, pressure,
confusion feeling like you might

weakness pass out,

anxiety,
flushing (warmth,
cold feeling,
redness, or tingly
extreme drowsiness,
feeling),
sweating, muscle tightness or
contraction, or
headache
Nursing Consideration
 Assess patients Vital signs every15 min after IV
dose, do not exceed 150 mg/min
Monitor magnesium level If using during labour,
time of contractions, determine intensity.
Urine output should remain 30 ml/hr or more if less
notify physician.
Examine patient Reflexes-knee jerk, patellar reflex.
Administer only after calcium gluconate is available
for treating magnesium toxicity.
Using infusion pump/monitor carefully, IV at less
than 150mg/min, circulatory collapse may occur.
Provide Seizure precautions: place client in single
room with decreased stimuli, padded rails.
Positioning of client in left lateral recumbent
position to decrease hypotension & increased renal
blood flow.
Evaluate patient mental status, memory,
Respiratory status & Reflexes.
Discontinue infusion if respirations are below
12/min, reflexes severely hypotonic, urine below
30ml/hr or in the event of mental confusion/
lethargy/ fetal distress.
Oxytocics in obstetrics
Oxytocics are the drugs of varying chemical
nature that have the power to excite
contractions of the uterine muscles.
Among a large number of drugs belonging to
this group, the following are the important ones
and are extensively used in clinical practice.
 Oxytocin
 Ergot derivatives
 Prostaglandins
1. Oxytocin
It is transported from the hypothalamus to
the posterior pituitary where it is stored
and eventually released.
It causes the contraction of smooth
muscles and therefore has powerful action
on the uterine muscles and act within 2
and ½ minutes when given
intramuscularly.
Mode of action:
Myometrial oxytocin receptor concentration
increases maximum (100-200 fold) during labor.
Oxytocin acts through receptor and voltage-
mediated calcium channels to initiate myometrial
contractions.
It stimulates amniotic and decidual prostaglandin
production.
The uterine contractions are physiological, i.e.
causing fundal contraction with relaxation of the
cervix.
Indications:
Oxytocin may be conveniently used in
pregnancy, labor or puerperium.
The indications are grouped as follows:
1. Therapeutic :Pregnancy, Labor,
puerperium
2. Diagnostic
1. Pregnancy
Early:
To accelerate abortion
Inevitable or missed and to expedite expulsion
of hydatidiform mole
To stop bleeding following evacuation of the
uterus
Used as an adjunct to induction of abortion
along with other abortifacient agents (PGE1 or
PGE2 ).
Late: To induce labor
2. Labor:
To ripen the cervix before induction.
Augmentation of labor
Uterine inertia
Inactive management of third stage of labor
Following expulsion of placenta as an
alternative to ergometrine.
3. Puerperium:
To minimize blood loss and to control
postpartum hemorrhage.
Diagnostic:
1. Contraction stress test (CST):
2. Oxytocin sensitivity test (OST)
Contraction stress test (CST):
 Assess irritability of uterus to oxytocin
 During the antepartum period, oxytocin
induces uterine contractions that transiently
reduce placental blood flow to the fetus.
 The oxytocin challenge test measures the
fetal heart rate response to a standardized
oxytocin infusion and provides information
about placental circulatory reserve.
INDICATION CONTRAINDICATIONS:
Intrauterine growth Compromised fetus
restriction Previous history of
Postmaturity cesarean section
Hypertensive  Complications likely to
disorders of produce preterm labor
pregnancy APH
Diabetes. Multiple pregnancy.
Procedure
0.01U given IV at the end of spontaneous
contraction
Repeated at 1min interval until induced
contraction starts (hardening)
The alteration of the FHR during
contractions is recorded by electronic
monitoring.
Alternatively, clinical monitoring can
effectively be performed using hand to
palpate the hardening of the uterus during
contraction and auscultation of FHR during
contraction and for 1 minute thereafter.
It takes at least 1–2 hours to perform the test.
Inference- failure of ut.contraction after 4 inj
signifies uterus is unlikely to be responsive
to induction.
INTERPRETATION OF CST
Positive — persistent late deceleration of
FHR with 50% or more of uterine
contractions
Negative — no late or significant variable
deceleration
Suspicious — intermittant late or variable
decelerations
Unsatisfactory — 90 seconds or occurring
more frequently than every 2 minutes
Importance:
A negative test is associated with good
fetal outcome.
Whereas a positive CST is associated
with increased incidence of IUD, fetal
distress in labor and low Apagar score.
But there is 50% chance of false-positive
results and as such positive test cases are
subjected to other methods of evaluation.
Contraindication of oxytocin
●
Grand multipara Pregnancy

Pregnancy Contracted pelvis

●

●
Malpresentation
●
History of cesarean section or hysterotomy

●
Obstructed labor
Labour ●

●
Incoordinate uterine contraction
Fetal distress

●
Hypovolemic state
Anytime ●
Cardiac disease
Side effect of oxytocin
Maternal:
Uterine hyperstimulation (overactivity): (> 6 in 10
min time)
Uterine rupture
Water intoxication: is due to its antidiuretic
function when used in high dose (30–40 mIU/min)
and meanifested 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.
Hypotension: Bolus IV injections of
oxytocin cause hypotension especially
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 mIU/min) and continued for
a long time.
Fetal:
Fetal distress, fetal hypoxia or even fetal
death may occur due to uterine
hyperstimulation.
Uterine hypertonia causes reduced
placental blood flow.
Method of administration of oxytocin
1. Controlled intravenous infusion
2. Intramuscular : 10 unit after birth of baby.
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 mIU/min)
and increased gradually.
1. For induction of labor
2. For augmentation of labor
Observation during oxytocin infusion
Rate of flow of infusion by counting the drops per minute or
monitoring the pump.
Uterine contractions—number of contractions per 10 min
duration of contraction and period of relaxation are noted.
‘Fingertip’ palpation for the tonus of the uterus in between
contraction.
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 15 min
interval or by continuous EFM.
Assessment of progress of labor (descent of the head and
rate of cervical dilatation.
Indications of stopping the infusion
1. Nature of uterine contractionn
a) Abnormal uterine contractions occurring
frequently (every 2 minutes or less) or
lasting more than 60 sec
(hyperstimulation) or polysystole.
b) Increased tonus in between contractions.
2. Evidences of fetal distress
3. Appearance of untoward maternal
symptoms.
2. Ergot derivatives
Out of many ergot derivatives, two are
used extensively as oxytocics. These are:
i. Ergometrine
ii. Methergine
Mode OF action:
Ergometrine acts directly on the
myometrium.
It excites uterine contractions which come
so frequently one after the other with
increasing intensity that the uterus passes
into a state of spasm without any
relaxation in between.
Composition of Ergot derivatives
Preparation Ampules Tablets
Ergometrine 0.25-0.5mg 0.5-1mg
Methergine 0.125- 0.125-0.5mg
0.250mg
Syntometrine 0.5mg-
Ergometrine
+
5 unit-
Syntocin
Onset and duration of action
Ergometrine: Methergine

Onset of action Onset of action

 IV: 45-60sec  IV: 1 and 1/2min
 IM: 6-7min  IM: 7min
 Oral: 10min  Oral: 10min

Duration: 3hours Duration: 3hours

Indication
1. Prophylactic : 2. Therapeutic :
Active management To stop the atonic
of third stage of labor uterine bleeding,
Prophylaxis to excess following delivery,
bleeding following abortion or expulsion
delivery. of hydatidiform mole
B.
Contraindication
Prophylactic
(1) Suspected pleural pregnancy: given accidentally with
the delivery of the first baby, the second baby is
compromised by the tetanic contractions of the uterus.
(2) Organic cardiac diseases: Results in sudden squeezing
of blood from the uterine circulation into the systemic
circulation causing overloading of the right heart and
failure.
(3) Severe preeclampsia and eclampsia: Sudden rise of
blood pressure or development of fits (eclampsia).
(4) Rh-negative mother: More risk of fetomaternal
microtransfusion.
Therapeutic
1. Heart disease or severe hypertensive
disorders—because of its
vasoconstrictive effect, it may cause
transient hypertension or cardiac failure
especially when given intravenously.
2. Oxytocin is a better substitute in such
cases
Hazards/ side effect
Common side effects are nausea and
vomiting.
Because of its vasoconstrictive action, it may
precipitate rise of blood pressure,
myocardial infarction, stroke and
bronchospasm.
Prolonged use may lead to gangrene of the
toes due to its vasoconstrictive effect.
Prolonged use in puerperium may interfere
with lactation by lowering prolactin level.
Cautions:
Ergometrine should not be used during
pregnancy, first stage of labor, second
stage prior to crowning of the head and in
breech delivery prior to crowning.
Nurse’s responsibilities:
Assess
Blood pressure, pulse and respiration.
Watch for signs of haemorrhage.

Administer
Orally or IM in deep muscle mass.
Have emergency cart readily available.

Evaluate
Therapeutic effect: decreased blood loss.

Teach
To report increased blood loss, abdominal cramps,
headache, sweating, nausea, vomiting or dyspnoea.
3. PROSTAGLANDINS 
Source: arachidonic acid.

Mechanism of action:
PGF2α promotes myometrial contractility
PGE2 helps cervical maturation
Mechanism of action:
Both PGE2 and PGF2α have got an
oxytocic effect on the pregnant uterus
when used in appropriate dose.
The probable mechanism of action is
change in myometrial cell membrane
permeability and/or alteration of
membrane-bound Ca++.
PGs also sensitize the myometrium to
oxytocin.
PGE2 is at least 5 times more potent than
PGF2α.
PGF2α acts predominantly on the
myometrium, while PGE2 acts mainly on
the cervix due to its collagenolytic
property.
PGE2 causes dissolution collagen bundles
and increases submucosal water content
of the cervix.
Indication
Induction of abortion
Termination of molar pregnancy
Induction of labor
Cervical ripening prior to induction of abortion
or labor
Augmentation (acceleration) of labor
Management of atonic postpartum hemorrhage
Medical management of tubal ectopic
pregnancy
Contraindication
Hypersensitivity to the compound
Uterine scar
Active cardiac, pulmonary, renal or
hepatic disease; hypotension (PGE2)
Bronchial asthma (PGF2α)
Fibroid uterus
PID
Preparation
Tablet- 0.5mg
1. PG E2 – Prostin E2 ( Dinoprostone)
 Gel-0.5mg E2 in 2.5ml gel-comes in pre
loaded syringe.
2. PG F2 alpha- Prostin F2 alpha
( Dinoprostodine)
 Inj- 125 and 250mcg

3. PGE1 – Misoprostol
 Tablet-100mcg,200mcg,600mcg
Dosage & routes of administration
Tablets: containing o.5 mg prostin E2
Vaginal suppository: containing 20 mg
PGE2 or 50 mg PGF2 alpha
Vaginal pessary: 3mg PGE2
Injectable ampoules/vials of prostinE2
1 mg/ml prostin F2 alpha
5mg/ml Misoprostol 50mg given 4 hourly
by oral, vaginal/ rectal route for induction
of labour
Advantages
Powerful oxytocic effect, irrespective of
duration of gestation
Induction of labor (PGE2 , PGE1 ): In cases
with (a) low preinduction score; (b) IUFD
Used in induction of abortion (PGE1 ) with
success
It has got no antidiuretic effect
PGE1 (misoprostol) can be used for
augmentation of labor
Disadvantages
Itis costly compared to oxytocin
Nausea, vomiting, diarrhea, pyrexia,
bronchospasm, tachycardia and chills
Cervical laceration may occur (PGF2α) when
used as an abortifacient
Tachysystole (hyperstimulation) of the uterus,
may occur during induction and may continue
for a variable period
Risk of uterine rupture in cases with previous
scar
Nursing considerations
Assess patient RR, rhythm & depth, vaginal
discharge, itching/ irritation.
Administer Antiemetic/ antidiarrheal preparations
prior to giving this drug, high in vagina, after
warming the suppository by running warm water over
package.
Evaluate patient for length & duration of contractions,
notify physician of contractions lasting over 1 minute
or absence of contractions, fever & chills.
Advised patient to remain supine for 10-15 minutes
after vaginal insertion.
Tocolytic Agents
Tocolytic drugs are those drugs which
decrease the uterine motility.
Preterm labor and delivery can be delayed
by drugs in order to improve the perinatal
outcome.
Short term delay of 48 hours allows the
use of corticosteroids that can reduce the
perinatal mortality and serious morbidity
significantly.
The commonly used drugs are:
Betamimetics, Prostaglandin synthetase
inhibitors, Magnesium sulfate, Calcium
channel blockers, Oxytocin receptor
antagonists, Nitric oxide donors and
progesterone.
1. Betamimetics
Example: Ritodrine, Terbutaline,
Salbutamol.
Effective for 48 hrs to allow time for
steroids and antibiotics to work.
Mechanism of action
Blocks myometrial oxytocin receptors.
It inhibits intracellular Ca++ release,
release of PGs & thereby inhibits
myometrial contractions.
Indication
Generally from 24+ WOG onwards
Until 34+ WOG at the latest
Spontaneous premataure contraction
Contraindication
Cardiac disease especially ventricular outflow
obstruction.
Hyperthyroidism
Uncontrolled insulin-dependent diabetes.
Chorioamnionitis.
Multi-fetal gestation.
Severe obstetrical bleeding.
Severe anemia.
Asthmatic patient already taking beta-adrenergic
agents.
Dose
Ritodrine is given by IV infusion, 50
µg/min and is increased by 50 µg every
10 min until contractions cease. Infusion
is continued for about 12 hrs after the
contractions cease.
Terbutaline has longer half-life and has
fewer side effects. Subcutaneous injection
of 0.25 mg every 3 to 4 hrs is given
Side effects
Maternal:  Cardiac failure
 Headache  Hyperglycemia
 Palpitation  ARDS
 Tachycardia  Hyperinsulinemia
 Pulmonary edema  Lactic acidemia
 Hypotension  Hypokalemia
 Even death.
Fetal: Neonatal:
Tachycardia Hypoglycemia
Heart failure Intraventricular
IUFD. hemorrhage
Nursing Intervention
Monitor blood pressure and pulse during
treatment.
Assess intensity of uterine contraction.
Assess FHR and maternal heart rate
during infusion.
Fluid intake should be monitored to
prevent fluid overload and development
of pulmonary edema, discontinue if it
occurs.
Evaluate the therapeutic response:
Reduce uterine contraction
Absence of preterm labour
Increase pulse volume

Teach:
Avoid hazardous activities until stabilized on
medication.
Making position change slowly to prevent fainting.
Notify physician if rash, palpitation or severe flushing
occurs.
Remain in bed during infusion.
2. Magnesium sulphate
Magnesium sulphate is used mainly for
patients who have contraindications to
beta-adrenergic agents.

Mechanism of action:
Inhibition to calcium ion.
Direct depresent action on uterine muscle.
Dose:
Loading dose: 4-6 gm I.V. over 20-30
min. followed by an infusion of 1-2 gm/hr
to continue tocolysis for 12 hours after
contarctions have stopped.
Serum magnesium levels of 4–7 mEq/L
are considered therapeutic for inhibiting
myometrial activity.
Contraindications:
Absolute contraindications
Myasthenia gravis
Heart block
Relative contraindications
Impaired renal function
Recent myocardial infarction.
Side effects
Itis relatively safe. Neonatal side effects
Common maternal Lethargy
side effects Hypotonia
Flushing Rarely respiratory
Perspiration depression
Headache and muscle
weakness,
Rarely pulmonary
edema.
Caution:
Concurrent use of calcium channel
blockers and magnesium sulfate can
theoretically result in profound
hypotension and probably should be
avoided.
3. Prostaglandin synthesis inhibition:
Iindomethacin: Cyclo-oxygenase inhibitor
Sulindac another NSAID is also used as it
has less placental transfer.
Mechanism of action
Reduces synthesis of PGs, thereby
reduces intracellular free calcium,
activation of MLCK and uterine
contractions.

Dose:
Loading dose 50 mg PO or PR followed
by 25 mg every 6 hrs for 48 hrs.
Side effects
1.Maternal II. Fetal
Heartburn Oligohydraminios,
Asthma Fetal renal
GI bleeding impairment
Thombocytopenia Premature closure of

Renal injury ductus arteriosus

Intraventricular
Platelet dysfunction.
hemorrhage
Nursing Intervention
Avoid aspirin, alcohol during therapy
(increases risk of GI bleeding)
GI upset occurs, so take with food or
milk.
Avoid task that require alertness motor
skill until response to drug is establish.
If dizziness present, assist to ambulate.
4. Calcium Channel Blocker
Nifedipine
Nicadipine
Verapamil
Mechanism of action: Nifedipine blocks
the entry of calcium inside the cell. It is
equally effective to MgSO4.
Dose: Oral (not sublingual) 10–20 mg
every 3–6 hrs
Side effect
Maternal:
 Hypotension
 Headache
 Flushing and nausea
Neonatal side effects
 Lethargy
 Hypotonia
 Rarely respiratory depression.
Caution:
Combinedtherapy with β mimetics or
MgSO4 should be avoided.
5. Oxytocin antagonists: Atosiban
Mechanism of Action
It blocks myometrial oxytocin receptors.
It inhibits intracellular calcium release,
release of prostaglandin secretion and
thereby inhibits myometrial contractions.
Dose: iv infusion 300 µg/min. Initial bolus
may be needed.
Side Effect: Nausea, vomiting, chest pain
(rarely).
Nursing Intervention:
 Assess general condition, respiratory status.
 Continuously monitor intake and output
records.
 Position comfortably.
6. Nitric oxide (nO)
Nitric oxide (nO) donors Glyceryl
trinitrate (GTN)
Mechanism of action: Smooth muscle
relaxant
Side effect: headache, nausea,
hypotension
Teratogenic
A teratogen is defined as any agent that
results in structural or functional
abnormalities in the fetus, or in the child
after birth, as a consequence of maternal
exposure during pregnancy.
The teratogenic mechanism for most drugs
remains unclear(idiosyncratic), but may be
due to the direct effects of the drug on the
fetus and/or as a consequence of indirect
physiological changes in the mother or fetus.
Pathophysiology
Teratogenic risk is determined largely by
timing of drug exposure.
Establishment of full implantation of the
fertilized egg takes 1 to 2 weeks.
Teratogenic exposure during this stage
elicit an ‘all-or-nothing’ response, leading
either to death of the embryo or
completely normal development of the
fetus.
Embryonic stage (weeks 3-8 post-
conception) :
The critical time for organogenesis is during the
first 8 weeks of pregnancy.
Exposure to drugs during this critical period
therefore represents the greatest risk of major birth
defects.
For this reason, women are often advised to avoid
or minimize all drug use in the first trimester
whenever possible.
After 8 weeks, most teratogenic effects are related
to fetal growth restriction or functional deficits
such as mental retardation.
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:
(i) Amount of the drug reaching the fetus, (ii)
Gestational age at the time of exposure, (iii) Duration
of exposure.
After D 71 development of other organs
continues. Diethylstilbestrol (DES) related
uterine anomalies occur with exposure
around 20 weeks.
Brain continues to develop throughout
pregnancy and neonatal period. Fetal
alcohol syndrome occurs in late
pregnancy.
Fetal or neonatal affection caused by
maternal medication
Cytotoxic drugs: Teratogenic, Abortion, FGR,
IUFD, Myelosuppression
Diethylstilbestrol: Vaginal adenosis, cervical
hoods, uterine hypoplasia of the female offspring
Androgenic steroids: Masculinization of the
female offspring
Lithium: Cardiovascular (Ebstein’s) anomalies,
fetal diabetes insipidus, polyhydramnios,
neonatal goitre, hypotonia and cyanosis, prenatal
diagnosis with echocardiography needed
Anticonvulsants: Phenytoin, Valproate,
Carbamazepine:
Benefits of treatment outweigh the risks to the
fetus.
Polytherapy should be avoided
 Fetal hydantoin syndrome
Includes microcephaly, IUGR, mental retardation,
craniofacial abnormalities, hypertelorism,
hypoplasia of the nails and distal phalanges
 Increased risk of neural tube defects, ASD cleft
palate, polydactyly, hypospadias,
craniosynostosis
Aspirin
High doses in the last few weeks cause
premature closure of ductus arteriosus,
Persistent pulmonary hypertension and
kernicterus in newborn.
Risk of prolonged pregnancy and
maternal bleeding due to platelet
dysfunction.
Cocaine:
 Congenital anomalies (cardiac, CNS),
abortion, placental abruption,
microcephaly
Antimalarials: Chloroquine, Quinine:
 No evidence of fetal toxicity in
therapeutic doses; benefits outweigh the
risk
Aminoglycosides:
 Nephrotoxicity, ototoxicity in preterm infants

Chloramphenicol :
“Gray baby” Syndrome (peripheral vascular
collapse)
Tetracycline:
 Dental discoloration (yellowish)
Chelate calcium and deformity
Inhibition of bony growth, hypoplasia of the
enamel
Long-acting sulfonamides:
 Neonatal hemolysis(G6PD deficiency),
Jaundice and kernicterus
Nitrofurantoin:
 Hemolysis in newborn with G6PD
deficiency, if used at term. No congenital
defects noted.
Metronidazole:
 No evidence of teratogenic risk, high-dose
regimens should not be used
Cimetidine, omeprazole Ranitidine:
No known teratogenic risk
Isotretinoin: external ear malformations, cleft
palates, undersized jaws (micrognathia), a
variety of heart defects, hydrocephalus 
Efavirenz: Known to be teratogenic, risks of
NTD
ACE inhibitor
Hypotension, renal dysplasia,
anuria/oliguria, oligohydramios,
intrauterine growth retardation,
pulmonary hypoplasia, unclosed ductus
arteriosus, incomplete ossification of the
skull, intrauterine or neonatal death.
Vitamin A large dose: Birth defect such as
malformations to fetuses' skulls, faces, limbs, eyes, central
nervous system.
All live viral vaccines: Potentially dangerous to the fetus
Narcotics:

Maternal: abortion, FGR.

Fetal: Depression of CNS (apnea, bradycardia and
hypothermia)
Smoking: Placental abruption, placenta previa,
prematurity and IUGR increased
Alcohol: Fetal alcholoh syndrome, growth restriction,
fetal anomalies, CNS dysfunction.
Analgesic
Pain during labor results from a combination
of uterine contractions and cervical dilatation.
Relief of pain during labor and delivery is an
essential part in good obstetric care.
Drugs have an important part to play in the
relief of labor pain but it must not be
supposed that they are of greater importance
than proper preparation and training for
childbirth.
The intensity of labor pain depends on the
intensity and duration of uterine
contractions, degree of dilatation of
cervix, distension of perineal tissue, parity
and the pain threshold of the subject.
Choice of anesthesia depends upon the
patient’s conditions and the associate
disorders.
The Physiology of Pain in Labor
1st stage of labor
Mostly visceral
Dilation of the cervix and distention of
the lower uterine segment
Dull, aching and poorly localized
Slow conducting, visceral C fibers, enter
spinal cord at T10 to L1
2nd stage of labor
Mostly somatic
Distention of the pelvic floor, vagina and
perineum
Sharp, severe and well localized
Rapidly conducting A-delta fibers, enter
spinal cord at S2 to S4.
Analgesia for Labor and
Delivery
Always controversial
“Birth is a natural process”
Women should suffer
Concerns for mother’s safety
Concerns for baby
Concerns for effects on labor
Types of Labor Analgesia
Non-pharmacological analgesia
Pharmacological
Regional Anesthesia/Analgesia
Method of pain relief
Psychoprophylaxis
Sedatives and analgesics
Inhalation agents
Patient controlled analgesia (PCA)
Transcutaneous electric nerve stimulation
(TENS)
Regional (neuraxial) analgesia
General anesthesia
Psychoprophylaxis
Relaxation and motivation can reduce the fear and
apprehension to a great extent.
Patient is taught about the physiology of pregnancy
and labor in antenatal (mothercraft) classes.
Relaxation exercises are practiced.
Husband or the partner is also involved in the
management.
His presence in labor would encourage the bearing
down efforts.
Need of analgesia would be less.
This avoids the huge emotional stress and
negative feelings of failure that some women
are left with when they decide to use
medications for pain relief.
Lamaze method- The Lamaze method
teaches women to respond positively to the
pain of labor. Mothers are taught to relax
during the contraction with the help of a
birth partner, contributing to the process of
labor without the use of drugs. 
Sedatives
Do not possess analgesic qualities.
Used early in labour to relieve anxiety or
to aid in sleep.
Cross the placenta freely.
Barbiturates, Phenothiazines, and
Benzodiazepines.
Barbiturate and benzodiazepines are not
used
For the purpose of selecting a general analgesic drug,
labor has been divided arbitrarily into two phases.
The first phase corresponds up to 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 up to 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
Systemic Opioid analgesics:
Morphine-like pharmacological activity.
Natural- morphine and codeine
Semisynthetic- hydromorphone and
heroine
Synthetic- meperidine and fentanyl
Provide sedation and a sense of euphoria.
Analgesic effect in labour is limited.
Primary mechanism of action is sedation
Advantages-
Easy administration.
Inexpensive.
Avoids complications of regional block.
Does not require skilled personnel.
Few serious maternal complications.
Disadvantages-
All drugs easily cross placenta.
Pain relief inadequate in most cases
Maternal sedation
Nausea, vomiting, gastric stasis
Fetal heart rate effects:
Loss of beat-to-beat variability
Sinusoidal rhythm
Dose-related maternal / neonatal depression
Newborn neurobehavioral depression
Pethidine:
For a long time pethidine has been used
as an analgesic in labor.
It has got strong sedative but less
analgesic efficacy.
Pethidine is generally used in the early
first stage of labor.
Indicated when the discomfort of labor
merges into regular, frequent and painful
contractions.
The initial dose is 100 mg (1.5 mg/kg body
weight) IM and repeated as the effect of the
first dose begins to wane, without waiting
for the reestablishment of labor pain.
Pethidine dose: 0.25-0.5mg-kg IV and 1.0-
2.0 mg-kg IM.
The side effects of pethidine to the mother
are nausea, vomiting, delayed gastric
emptying.
Pethidine crosses the placenta and
accumulates in fetal tissues.
Pethidine reduces baseline variability,
depresses respiration and suckling of the
newborn when administered before delivery.
Ranitidine should be given to inhibit gastric
acid production, and emetic effect is
counteracted by metoclopramide (10 mg
IM).
Tramadol
Centrally acting opioid analgesic used in
treating severe pain.
Route- IV or IM
Dose- 50 mg
Emetic: Should be given with antiemetic.
Maximum respiratory depression and low
apgar score occur in newborns that are
delivered within3 hours after an IM
administration 2 hours after an IV
administration.
Meperidine
Compared to morphine, analgesic effect is
one tenth, but respiratory depression
effect is less.
 Meperidine is the most commonly used
parenteralopioid analgesic during labor.
Im dose ranges from 50 to 100 mg with a
peak onset of effect at 40 to 50 minutes
Iv doses of 25 to 50 mg start to act within
5 to 10minutes.
Analgesic effect lasts up to 3 to 4 hours.
Fetal exposure to meperidine is highest
between 2 and 3 hours after maternal
administration.
Side effects- tachycardia, nausea and
vomiting, and a delay in gastric emptying.
Fentanyl
Fast-onset, short-acting synthetic opioid.
Requires frequent redosing or the use of a
patient controlled intravenous infusion
pump.
Fewer neonatal effects and less maternal
sedation and nausea.
It provides reasonable levels of analgesia
with minimal neonatal depression.
The usual dose of fentanyl for labor
analgesia is 25 to50 µg intravenously.
The peak effect occurs within 3 to 5
minutes and has a duration of 30 to 60
minutes.
Phenothiazines
Promethazine (Phenargan) commonly used in
labor in combination with an opioid.
Dose- 25 mg
Antagonists are not available.
Weak antiemetic and causes sedation in the
mother.
Routine use of promethazine is unnecessary.
It does not cause major neonatal depression.
Narcotic antagonists
Narcotic antagonists are used to reverse
the respiratory depression induced by
opioid narcotics.
Naloxone is given to mother 0.4 mg IV in
labor.
It may have to be repeated.
It is given to the newborn 10 μg/kg IM or
IV and is repeated if necessary when the
infant is born with narcotic depression.
Naloxone is given to a newborn born of a
narcotic addicted mother, with proper
ventilation arrangement only otherwise
withdrawal symptoms are precipitated.
Sedative/tranquiliser 
Benzodiazepines (Diazepam):
It is well tolerated by the patient.
It does not produce vomiting and helps in
the dilatation of cervix.
It is metabolized in the liver.
The usual dose is 5–10 mg.
It may be used in larger doses in the
management of preeclampsia.
However, diazepam is avoided in labor.
Major disadvantages are: Loss of beat to
beat variability in labor, neonatal
hypotonia and hypothermia.
Flumazenil is a specific benzodiazepine
antagonist.
It can reverse the respiratory depression
effect of benzodiazepines.
Combination of narcotics and
antiemetics:
Narcotics may be used in combination with
promethazine, metoclopramide or
ondansetron.
The advantages 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
labor.
Inhalational analgesia
Easy to administer (no needles)
Nitrous oxide is administered in subanaesthetic
concentrations. (N2O 30-50%)
Analgesia without loss of consciousness.
Crosses the placenta but is eliminated
efficiently, no untoward neonatal effects.
No effects on uterine contractions.
Most effective for short term (1-2 hrs) pain
relief.
Most beneficial in late first stage of labour.
Premixed nitrous oxide and oxygen
Cylinders contain 50% nitrous oxide and
50% oxygen mixture.
Entonox apparatus has been approved for
use by midwives.
This agent is used in the second phase
(from 8 cm dilatation of cervix to delivery).
It can be self administered.
Entonox is most commonly used inhalation
agent during labor in the UK.
Hyperventilation, dizziness, hypocapnia
are the side effects.
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.
Commonly used local anesthetic agents
in obstetrics
Lignocaine
Usual dose: 7 mg/kg
Onset: Rapid
Duration (Min): 60–90 min
Use in obstetrics: Local or pudendal block
and also for epidural or spinal for
cesarean delivery
Bupivacaine
Dose: 3 mg/kg
Onset: Slow
Duration: 90–150 min
Use in obstetric: Epidural or spinal for
cesarean delivery
Toxicity
Central nervous system: Depression,
dizziness, tinnitus, metallic taste,
numbness of tongue, slurred speech,
muscle fasciculation. Rarely generalized
convulsions and loss of consciousness.
Cardiovascular toxicity: Hypotension,
cardiac arrythmias and fetal distress due
to impaired placental circulation
Regional (neuraxial) anesthesia
Pudendal block
Paracervical block
Paravertebral (lumbar sympathetic block)
Epidural - lumbar (caudal)
Spinal
Combined spinal-epidural (CSE)
Pudendal block
Itis a safe and simple method of analgesia during
delivery.
Pudendal nerve block does not relieve the pain of
labor but affords perineal analgesia and relaxation.
Pudendal nerve block is mostly used for forceps
and vaginal breech delivery.
Simultaneous perineal and vulval infiltration is
needed to block the perineal branch of the
posterior cutaneous nerve of the thigh and the
labial branches of the ilio-inguinal and
genitofemoral nerves (vide supra).
This method of analgesia is associated
with less danger, both for mother and
baby than general anesthesia.
Technique: The pudendal nerve may be
blocked by either the transvaginal or the
transperineal route.
Using a 20-gauge needle, inject 5 to 10
ml of local anesthetic just below the
ischial spine.
The potential for local anesthetic toxicity
is higher with pudendal block compared
with perineal infiltration because of large
vessels proximal to the injection site.
Aspiration before injection is particularly
important.
Side effect
Hematoma formation, infection and rarely
intravascular injection or allergic reaction.
Toxicity may affect:
 CNS: excitation, ringing in the ears and
convulsions.
 Cardiovascular: tachycardia, hypotension,
arrythmias, even cardiac arrest. Spinal
anesthesia:
Paracervical nerve block:
Is useful for pain relief during the first
stage of labor.
Following the usual antiseptic safe
guards, a long needle (15 cm or more) is
passed into the lateral fornix (cervical
mucosa), at the 3 and 9 o’clock positions.
Five to ten milliliter of 1% lignocaine are
injected at the site of the cervix and the
procedure is repeated on the other side.
This dose is quite sufficient to relieve
pain for about an hour or two, and
injections can be given more than once if
necessary.
Bupivacaine is avoided due to its
cardiotoxicity.
Paracervical block should not be used
where placental insufficiency is present.
Fetal bradycardia that follows in 2 to 70
percent of applications.
Fetal acidosis and death have been
reported.
Paracervical block should be used
cautiously at all times and should not be
used at all in mothers with fetuses in
either acute or chronic distress.
Epidural - lumbar (caudal)
When complete relief of pain is needed
throughout labor, epidural analgesia is the
safest and simplest method for procuring it.
It provides sensory as well as various degrees
of motor blockadge over a region of the body.
But anesthetists/obstetricians have to be
trained properly to make use of this very
valuable method in normal and abnormal
labor.
Guidelines American College of Obs &
gynae
Primary indication is the patient's desire
for pain relief.
Medical indications during labor- selected
forms of cardiovascular and respiratory
disease, and prevention or treatment of
autonomic hyperreflexia in parturients
with a high spinal cord lesion.
Epidural analgesia prevents increases in
both cortisol and 11-
hydroxycorticosteroid levels during labor,
but systemically administered opioids do
not.
Epidural analgesia also reduce elevations
of epinephrine, norepinephrine, and
endorphin levels.
Continuous lumbar epidural block:
A lumbar puncture is made between L2 and L3 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.
A local anesthetic agent (0.5% bupivacaine) is injected
into the epidural space.
Full dose is given after a test dose when there is no
toxicity. For complete analgesia a block from T10 to the
S5 dermatomes is needed.
For cesarean delivery a block from T4 to S1 is
needed.
Repeated doses (top ups) of 4–5 mL of 0.5%
bupivacaine or 1% lignocaine are used to
maintain analgesia.
Epidural analgesia, as a general rule should be
given when labor is well established.
Maternal hydration should be adequate with
normal saline or Hartmann’s solution (crystalloid)
infusion prior commencing the blockade.
The patient’s blood pressure, pulse and
the fetal heart rate should be recorded at
15 minutes interval following the
induction of analgesia and hypotension, if
occurs, should be treated immediately.
The woman is kept in semilateral position
to avoid aortocaval compression.
Benefits
Pregnancy-induced hypertension
Breech presentation
Twin pregnancy
Preterm labor.
 Previous cesarean section is not a contraindication.
 Epidural analgesia when used there is no change in
duration of first stage of labor.
 But second stage of labor appears to be prolonged by
15–30 minutes.
 This might lead to frequent need of instrumental
delivery like forceps or ventouse.
Contraindications-
Maternal Coagulopathy or anticoagulant Therapy
Supine hypotension
Hypovolemia
Neurological disease
Spinal deformity or chronic low back pain
Patient’s refusal
Skin infection at injection site
Fixed cardiac output disease
History of allergy to local anaesthetics
Thrombocytopenia
Side effect
Hypotension due to sympathetic blockade
(vasodilatation)
Pain at insertion site (back pain)
Local anesthetic toxicity
Allergic reaction
High or total spinal anesthesia
Neurologic injury
Post spinal headache
Fetal bradycardia
Complication
Hypotension due to sympathetic blockade
(vasodilatation).
Pain at the insertion site. Back pain
Postspinal headache due to leakage of
cerebrospinal fluid through the needle
hole in the dura
Injury to nerves, convulsions, pyrexia
 Ineffective analgesia
Spinal anesthesia:
Spinal anesthesia is obtained by injection of local
anesthetic agent into the subarachnoid space.
It has less procedure time and high success rate.
Spinal anesthesia can be employed to alleviate the
pain of delivery and during the third stage of labor.
For normal delivery or for outlet forceps with
episiotomy, ventouse delivery, block should extend
from T10 (umbilicus) to S1.
For cesarean delivery level of sensory block
should be up to T4 dermatome.
Hyperbaric bupivacaine (5–10 mg) or
lignocaine (25–50 mg) is used.
Addition of fentanyl (to enhance the onset
of block) or morphine (to improve pain
control) may be done.
Brief or minimal spinal anesthesia is far
safer than prolonged spinal anesthesia.
The advantages of spinal anesthesia are:
Less fetal hypoxia unless there is
hypotension and
Minimal blood loss.
The technique is not difficult and no
inhalation anesthesia is required, but
postspinal headache occurs in 5–10% of
patients.
Side effects of Spinal anesthesia
Hypotension due to blocking of sympathetic bers
leading to vasodilatation and low cardiac output.
Respiratory depression may occur due to paralysis of
respiratory muscles including diaphragm (C3 –C5 )
Failed block, chemical meningitis, epidural abscess
Total spinal—due to excessive dose or improper
positioning.
Postspinal headache—due to low or high CSF
pressure and leakage of CSF.
Meningitis due to faulty asepsis
Transient or permanent paralysis
Toxic reaction of local anesthetic drugs
Paralysis and nerve injury
Nausea and vomiting are not uncommon
Urinary retention (bladder dysfunction)
Nursing Consideration
Spinal anesthesia can be obtained by injecting the
drug into the subarachnoid space of the third or
fourth lumbar interspace with the patient lying on
her side with a slight head uptilt.
The blood pressure and respiratory rate should be
recorded every 3 minutes for the first 10 minutes
and every 5 minutes thereafter.
Oxygen should be given for respiratory depression
and hypotension.
Sometimes vasopressor drugs may be required if a
marked fall in blood pressure occurs.
Combined spinal-epidural analgesia
(CSE):
Opioids ± LA
Rapid onset of intense analgesia.
Ideal in late or rapidly progressing labour.
 Very low failure rate.
Less need for supplemental boluses.
Minimal motor block (“walking epidural”)
Walking epidural- Use of opioid only to allow
parturients to ambulate during labour because
there is little or no interference with motor
function.
An introducer needle is first placed in the
epidural space.
A small gauge spinal needle is introduced
through the epidural needle into the
subarachnoid space (needle through needle
technique).
A single bolus of 1 mL 0.25% bupivacaine
with 25 μg fentanyl is injected into the
subarachnoid space.
The spinal needle is then withdrawn.
An epidural catheter is thus sited for
repeated doses of anesthetic drug.
The method gives rapid and effective
analgesia during labor and cesarean
delivery.
It allows women to move (walking
epidural) during labor.
Infiltration Analgesia/ Perineal
Infiltration
Direct infiltration of 1% lignocaine is used for
perineal and lower vaginal lacerations.
 Advance the needle and inject and aspirate to avoid
intravascular injection.
Dose of lignocaine is 3-4 mg/kg plain solution, and
7-8 mg/kg with added epinephrine.
1% solution = 10 mg/ml
For 6O kg woman total dose should not exceed 200
mg or 20 ml.
After local infiltration one should wait 3 minutes
before proceeding.
For episiotomy
Perineal infiltration anesthesia is extensively used prior
to episiotomy.
A 10 mL syringe, with a fine needle and about 8–10 mL
1% lignocaine hydrochloride (Xylocaine) are required.
The perineum on the proposed episiotomy site is
infiltrated in a fanwise manner starting from the middle
of the fourchette.
Each time prior to infiltration, aspiration to exclude
blood is mandatory.
Episiotomy is to be done about 2–5 minutes following
infiltration.
For outlet forceps or ventouse: (Perineal
and labial infiltration):
The combined perineal and labial infiltration is
effective in outlet forceps operation or ventouse
traction.
A 20 mL syringe, a long fine needle and about 20
mL of 1% lignocaine hydrochloride are required.
The needle is inserted just posterior to the
introitus.
About 10 mL of the solution is infiltrated in a
fanwise manner on both sides of the midline (as
for episiotomy).
The needle is then directed anteriorly
along each side of the vulva as far as the
anterior-third to block the genital branch
of the genitofemoral and ilioinguinal
nerve.
Five milliliter is required to block each
side.
Local abdominal for cesarean delivery:
This method is rarely used where regional block is
patchy or inadequate.
Technique:
The skin is infiltrated along the line of incision with
diluted solution of lignocaine (2%) with normal
saline.
The subcutaneous fatty layer, muscle, rectus sheath
layers are infiltrated as the layers are seen during
operation.
The operation should be done slowly for the drug
to become effective.
Patient controlled analgesia (PCA):
Narcotics are administered by mother herself
from a pump at continuous or intermittent
demand rate through intravenous route.
Total dose is limited as there is a lockout
interval.
This offers better pain control than high doses
given at a long interval by the midwife.
Maternal satisfaction is high with this method.
Drugs commonly used are fentanyl, meperidine
or remifentanil
Transcutaneous electric nerve stimulation
(TENS):
It is a noninvasive procedure and is preferred
by many women during labor.
Electrodes are placed over the level of T10 –
L1 and S2 – 4.
Current strength can be adjusted according to
pain.
It works by inhibiting transmitter release
through interneuron level.
However, no change in pain score was
observed when TENS was switched on.
GENERAL ANESTHESIA FOR
CESAREAN SECTION
Uterine contractility may be diminished by
volatile anesthetic agents like ether, halothane
Halothane, isoflurane cause cardiac depression,
hepatic necrosis and hypotension
Hypoxia and hypercapnia may occur
Time interval from uterine incision to delivery
is related directly to fetal acidosis and hypoxia
Longer the exposure to general anesthetic
before delivery the more depressed is the
Apgar score
Preoperative preparations:
Preoperative medication with sedatives or
narcotics is not required as they cause
respiratory depression of the fetus.
Fasting of about 6 hours is preferable for an
elective surgery.
High-risk women in labor should preferably
not be allowed to eat.
Ryel’s tube aspiration of gastric contents is to
be done when the stomach contains food
materials.
H2 -blocker (Ranitidine 150 mg orally)
should be given night before (elective
procedure). H2 receptor blocking agent and
metoclopramide is to be given IM especially
to women with high risks (obesity).
Non-particulate antacid (0.3 molar sodium
citrate 30 ml) is given orally before
transferring the patient to theater to
neutralize the existing gastric acid.
While on the theater table, left lateral tilt of
the woman is maintained with a wedge on the
back. This is to avoid autocaval compression
as it is detrimental to both mother and fetus.
Metoclopramide (10 mg IV) is given after
minimum 3 minutes of preoxygenation to
decrease gastric volume and to increase the
tone of lower esophageal sphincter.
Intubation with adequate cricoid pressure
following induction should be done.
Uterine incision — Delivery (U-D) interval is
more predictive of neonatal status (Apgar score).
Prolonged U-D interval of more than 3 minutes
results in lower Apgar scores and neonatal
acidosis.
Awake extubation should be a routine.
Preoxygenation with 100% oxygen is administered
by tight mask fit for more than 3 minutes.
Induction of anesthesia is done with the injection
of thiopentone sodium 200–250 mg (4 mg/kg) as a
2.5% solution intravenously.
Anesthesia is maintained with 50% nitrous
oxide, 50% oxygen and a trace (0.5%) of
halothane.
Relaxation is maintained with
nondepolarizing muscle relaxant (vecuronium
bromide 4 mg or atracurium 25 mg).
Intubation: An assistant is asked to apply
cricoid pressure as soon as the consciousness
is lost. Intubation is done with a cuffed
endotracheal tube and the cuff is inflated.
After delivery of the baby, the nitrous
oxide concentration should be increased
to 70% and narcotics are injected
intravenously to supplement anesthesia.
Complications of general anesthesia:
Aspiration of gastric contents
(Mendelson’s syndrome)tachycardia,
Clinical presentation: tachypnea,
bronchospasm, rhonchi, rales, cyanosis,
decreased PaO2 and hypotension.
X-ray chest reveals right lower lobe
involvement.
Immunization in pregnancy
Immunization
The administration of vaccines during
pregnancy poses a number of concerns
about the risk of transmitting a virus to a
developing fetus.
The risk of transmitting a virus to a
developing fetus is Primarily Theoretical.
Theoretic risks of vaccination must be
weighed against the risks of the disease to
mother and fetus.
Routine vaccines that generally are Safe
during pregnancy include:
1. Diphtheria
2. Meningococcal
3. Tetanus
4. Rabies.
5. Influenza
6. Hepatitis 
Vaccines that are contraindicated Live
virus vaccine include:
1. Measles, Mumps, and Rubella ( MMR )
2. Varicella
3. (BCG) Bacille Calmette-Guérin
4. Yellow vaccine
5. Polio.
If a live-virus vaccine is inadvertently given
to a pregnant woman, or if a woman
becomes pregnant within four weeks after
vaccination, she should be counseled about
potential effects on the fetus.
 Measles, mumps, and rubella vaccine
should not be given to pregnant women,
because of potential adverse effects on the
fetus. But should be vaccinated post partum.
Influenza
Fever, malaise, myalgia, and upper
respiratory tract symptoms or infections
characterize influenza infection.
Most severe complications are the result
of pneumonia secondary to influenza
infection.
The inactivated influenza vaccine one dose should
be administered to all pregnant women who will
be in the second or third trimester of pregnancy
(27-36 WOG) during the influenza season.
Women in their second or third trimesters have
higher morbidity, from influenza infection.
Immunization should be avoided in most patients
during the first trimester to avoid a coincidental
association with spontaneous abortion, which is
common in the first trimester.
2. Tetanus and Diptheria
Diphtheria is an infection of the nasal,
pharyngeal, laryngeal, or other mucous
membranes that can cause neuritis,
myocarditis, thrombocytopenia, and
ascending paralysis.
 Tetanus infection can cause production of
a neurotoxin, leading to tetanic muscle
contractions.
According to CDC guidelines : 1ST dose
between 16 -20 weeks & 2nd dose after 4-
6 weeks apart.
Previously vaccinated pregnant women
who have not received a Td vaccination
within the past 10 years should receive a
booster dose. O.5 ml Intramuscular in
upper arm. 
In Nepal
1stdose 0.5ml Td is given at 1st ANC visit
and 2nd dose a month apart.
3. Rabies
 Rabies is a viral infection transmitted most
commonly by the saliva of infected animals.
Dysregulation of the autonomic nervous
system and involvement of the brainstem
and cranial nerves lead to the classic
"foaming at the mouth" appearance.
Nonspecific prodromal symptoms progress
to encephalitis marked by confusion,
hallucinations. 
 In patients who have not been immunized
previously, 20 IU per kg of HRIG (human
rabies immune globulin) is given at the wound
site for high-risk bites or if testing is positive.
Patients with previous vaccinations do not
need HRIG but do require revaccination on a
modified schedule.
There have been no identified associations
between rabies vaccination and fetal
abnormalities 
4. Hepatitis B
Risk factors for a pregnant woman include:
1. Having multiple sexual partners
2. Using or abusing intravenous drugs
3. Having occupational exposure, and
4. Being a household contact of acutely infected
persons or persons with a chronic carrier state.
Because it contains noninfectious hepatitis B
surface antigen particles and it cause no risk to
the fetus, neither pregnancy nor lactation is a
contraindication to vaccination.
5. Meningococcal (MenB)
May be given in pregnancy or in the
postpartum setting
Should any meningococcal disease
outbreak place a woman at risk for
infection.
6. Tetanus, Diphtheria, and Pertussis
(Tdap)
a dose of Tdap= tetanus toxoid, reduced
diphtheria toxoid, and acellular pertussis
vaccine.
During each pregnancy
To all pregnant women: irrespective of the
patient’s prior history of receiving between 27
and 36 w
If Tdap is not administered during pregnancy
it should be administered immediately
postpartum.
7. Pneumococcal
Risk factors for pneumococcal infection in
pregnant women include
Diabetes
Cardiovascular disease,
Immunodeficiency,
Asthma. 
 The current vaccine includes purified capsular
polysaccharide.
 Women at high risk should be given this
vaccination before, but not during, pregnancy. 
8. Measles, Mumps and rubella
Measles, mumps, and rubella vaccine
should not be given to pregnant women,
because of potential adverse effects on the
fetus.
But should be vaccinated post partum. 
9. Varicella ( Chicken Pox )
Varicella vaccination is a live attenuated
virus and is contraindicated during
pregnancy.
Women who are vaccinated should avoid
becoming pregnant for one month
following each injection. 
10. HPV VACCINE
Not recommended for use in pregnancy.
If patient becomes pregnant - Delay
remaining doses till delivery.
If vaccinated during pregnancy - No
intervention (MTP) needed.
Lactating women can receive the HPV
vaccine (Gardasil) and still continue
breastfeeding as it is a vaccine without
live viral DNA.
SAFE MEDICATION TO TREAT
DURING PREGNANY
Allergy : Benadryl (diphenhydramine).
Cold and Flu:
 Tylenol (acetaminophen)
 Saline nasal drops or spray
 Warm salt/water gargle
Constipation:
 Colace
 Metamucil
Analgesics & antipyretics –Paracetamol [Cat
B] is safe in normally recommended doses.
Nausea & vomiting – Meclizine & cyclizine
[Cat B] - safe
 Metoclopramide [Cat B] used in labour &
during anaesthesia
 Ondensetron [Cat B]
Antidiarrheal Medications: Loperamide
[Cat B]
Heartburn & dyspepsia –Non-absorbable
antacids like aluminium hydroxide [Cat B] If
taken in early pregnancy - ↑ risk of congenital
malformations
 Sucralfate [Cat B], H2 blockers [Cat B] are safe
 All PPIs – Cat B except Omeprazole [Cat C]
 Lansoprazole – Safest PPI in pregnancy
Constipation – Bulk laxatives [Cat B]
containing bran, isapghula or methylcellulose
are best for simple constipation
First Aid Ointment
 Bacitracin J&J
 First-Aid Cream Neosporin
 Polysporin.
Rashes
 Benadryl cream
 Caladryl lotion or cream
 Hydrocortisone cream or ointment.
Some antibiotics namely Amoxycillin,
Ampicillin, Cephalosporins,
Erythromycin.
Levothyroxine.
Acetaminophen.
Folic Acid and Vitamin B6.
Methyldopa, and hydralazine.
Insulin.
Heparin.
MEDICATIONS CONTRAINDICATED IN
PREGNANCY
 Some drugs in category contraindicated
in pregnancy and their effects on the fetus
are listed below:-
Vitamin A and its derivatives -
Accutane(Isotretinoin), can cause Birth
defects.
Thalidomide – Seal like limbs and other
defects.
Diethylstilbestrol : Causes cancer of the
vagina or cervix in female children during
their teenage years.
Warfarin (Warin): Causes multiple birth
defects.
Danazol (Danzol): Causes malformations
in sex organs of female fetus.
Simvastatin (Avastin)and other statins:
Cholesterol is needed for fetal growth and
its reduction by statins could harm the
fetus.
Finasteride (pronor): affect the sex
organ of fetus.
Testosterone (Testanon): Can cause birth
defects.
Oral contraceptives: Can cause birth
defects.
Dutasteride (Urodart): Affects the sex
organ development of the fetus.
Methotrexate (Trexonate): Causes cleft
palate along with multiple defects.
Aspirin: during pregnancy, especially
during the last three months.
May make a pregnancy last longer and
may cause severe bleeding before and
after delivery.
(PDA)- failure of closure of ductus
Arteriosus usually present in every fetus
before birth, infants after birth.
Lithium Salt : Ebstein's anomaly
(Congenital heart defect in which the
opening of the tricuspid valve is displaced
towards the right)
Thalidomide causes Phocomelia (limb
deformity)
Valproic acid(epilim) causes decreased
absorption of Folic acid and leads to
deficiency of folic acid which may results
in neural tube defects in the fetus.
Valproic acid induced Fetal Valproate
Syndrome. Valproate syndrome include
facial features, tall forehead, medial
deficiency of eyebrows, flat nasal bridge,
broad nasal root.
Carbamazepine can cause birth defects
that include:- cardiovascular and urinary
tract anomalies, cleft palate, fingernail
hypoplasia, developmental delays, and
intrauterine growth restrictions.
Paroxetine (oxat) (Selective serotonin re-
uptake inhibitor): Causes cardiac defects.
Phenytoin induced Fetal Hydantoin
Syndrome Fetal hydantoin syndrome, also
called fetal dilantin syndrome is a group of
defects caused to the developing fetus by
exposure to the teratogenic effects of
phenytoin or carbamazepine.

Opoid analgesic induced Drug withdrawal

syndromes.
Effects of drug on Developing fetus
Cephalosporins: Primarily cardiac and
oral cleft defects
Fluoroquinolones: Cartilage damage
Cytotoxic drugs: Teratogenic, Abortion,
FGR, IUFD, Myelosuppression
Accutane (Vitamin A derivative)

Microcephaly/hydrocephaly
CHD
Microtia
Cleftlip/palate
Risk of spontaneous abortion- 25
Risk of stillborn
Diethylstilbestrol: Vaginal adenosis,
cervical hoods, uterine hypoplasia of the
female offspring
Androgenic steroids: Masculinization of the
female offspring
Lithium: Cardiovascular (Ebstein’s)
anomalies, fetal diabetes insipidus,
polyhydramnios, neonatal goitre, hypotonia
and cyanosis, prenatal diagnosis with
echocardiography needed
Anticonvulsants: Phenytoin, Valproate,
Carbamazepine:

 Fetal hydantoin syndrome

Includes microcephaly, IUGR, mental
retardation, craniofacial abnormalities,
hypertelorism, hypoplasia of the nails and
distal phalanges
 Increased risk of neural tube defects, ASD
cleft palate, polydactyly, hypospadias,
craniosynostosis
Aspirin
High doses in the last few weeks cause
premature closure of ductus arteriosus,
Persistent pulmonary hypertension and
kernicterus in newborn.

Cocaine:
 Congenital anomalies (cardiac, CNS),
abortion, placental abruption,
microcephaly
Anticoagulant: Fetal warfarin syndrome,
Hemorrhage, Depressed nasal bridge,
Spontaneous abortion / stillbirth.
Quinolone: Fetal death, neonatal death,
preterm delivery, IUGR
Zidovudine: neonatal anemia
Nevirapine: hepatotoxicity and rash
Fluconazole gt 400mg/day : cranio-
facial abnormalities
Ketoconazole: impair cortisol synthesis
Ergots(Dihydroergotamine,
ergotamine): chronic exposure result in
IUGR by vascular disruption or increased
uterine tone.
Nicotine: Cell damage and deficits in cell
number, Impaired synaptic activity
Aminoglycosides:
 Nephrotoxicity, ototoxicity in preterm infants

Chloramphenicol :
“Gray baby” Syndrome (peripheral vascular
collapse)
Tetracycline:
 Dental discoloration (yellowish)
Chelate calcium and deformity
Inhibition of bony growth, hypoplasia of the enamel
Hepatotoxicity
Long-acting sulfonamides:
 Neonatal hemolysis(G6PD deficiency),
Jaundice and kernicterus
Nitrofurantoin:
 Hemolysis in newborn with G6PD
deficiency, if used at term. No congenital
defects noted.
Isotretinoin: external ear malformations,
cleft palates, undersized jaws
(micrognathia), a variety of heart defects,
hydrocephalus 
Efavirenz: Known to be teratogenic, risks
of NTD
ACE inhibitor
Hypotension
Renal dysplasia, anuria/oliguria,
Oligohydramios
Intrauterine growth retardation
Pulmonary hypoplasia
Unclosed ductus arteriosus
Incomplete ossification of the skull,
Intrauterine or neonatal death.