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Triage Medications

Leah Pirman
Drug name: Dinoprostone (Prepidil Gel, Cervidil vaginal insert)
Dose, route, frequency:
o Cervical ripening: Endocervical gel: 0.5 mg: if response is unfavorable may repeat in 6 hr (not to exceed 1.5 mg/24
hr); Vaginal insert: one 10 mg insert
Indications for OB use:
o Endocervical gel, vaginal insert: used to ripen the cervix in pregnancy at or near term when induction of labor is
indicated
o Action: Produces contractiosn similar to those occurring during labor at term by stimulating the myometrium. Initiates
softening, effacement, and dilation of the cervix. Also stimulates GI smooth muscle
o Therapeutic effects: Initiation of labor & expulsion of fetus
Common Side Effects: Uterine contractile abnormalities, warm feeling in the vagina, back pain, amniotic fluid embolism, and
fever
Contraindications: This is contraindicated in hypersensitivity to prostaglandins or additives in the gel. The gel/insert should
be avoided in situations in which prolonged uterine contractions should be avoided including previous c-section or uterine
surgery, cephalopelvic disproportion, traumatic delivery or difficult labor, multiparity, hyperactive or hypertonic uterus, fetal
distress, vasa previa, active herpes genitalis, ob emergency requiring surgical interventions, situations in which vaginal
delivery is contraindicated; presence of acute pelvic inflammatory disease or ruptured membranes; concurrent oxytocic therapy
(wait for 30 min after removing insert before using oxytocin)
Effects/Implications for pregnancy or breastfeeding: This is a category C drug in pregnancy
o Possible fetal distress & hypoxia
o Should only be used during labor or to induce labor, not used during pregnancy unless wishing to induce labor or expel
products
o This has not been measured in human milk after exogenous administrations, but it is a normal component of breast milk
in small amounts where it may help protect the infants GI tract
o It can suppress lactation but research suggests it should probably not be used postpartum in mothers who wish to
breastfeed
Nursing Actions as applicable:
o Monitor frequency, duration, and force of contractions & uterine resting tone
o Monitor vitals throughout therapy
o Auscultate breath sounds (watch for hypersentivity)
o Monitor amount and type of vagianl discharge
o Monitor uterine status, fetal status, and dilation and effacement of cervix

Triage Medications
Leah Pirman
o Inform patient she may experience a warm feeling in her vagina
Drug name: Misoprostol (Cytotec)
Dose, route, frequency:
o Antiulcer: PO 200 mcg 4 x daily with or after meals at bedtime or 400 mcg twice daily, with the last dose at bedtime.
o Termination of pregnancy: PO 400 mcg single dose 2 days after mifepristone if abortion has not occurred (<49 days in
conjunction with mifepristone)
o Misoprostol is available either as a 100 or 200 mcg tablet. Therfore, tablets mustbe broken to prepare correct dose.
Recommended initial dose is 25 mcg intravaginally into the posterior vaginal fornix using the tips of index and
middle finger without use of lubricant. Repeat every 3-6 hours up to 6 doses in a 24 hour period or until an
effective contraction pattern is established, the cervix ripens, or significant adverse effects
o Used PP to prevent hemorrhage
1000 mg rectally or 200 mg orally with 400mg Sublingually
o PP hemorrhage prophylaxis (not as useful as oxytocin, but used as last alternative)- 600 mg oral dose at time of delivery
of fetal shoulder
o Tx: incomplete abortion (off labeled use) oral 600 mc as single
o induction of labor before oxytocin when Bishop score is <4 (prepartum),
o cervical ripening before surgical procedures (preoperative)
Indications for OB use: Prevention of gastric mucosal injury from NSAIDs, including aspirin, in high-risk patients. Used with
mifepristone for termination of pregnancy. Unlabeled use: treatment of duodenal ulcers, cervical ripening, and labor induction.
o Action: acts as a prostaglandin analogue, decreasing gastric acid secretion, and increasing the production of protective
mucus. Causes uterine contractions
Common Side Effects: headache, abdominal pain, diarrhea, nausea, vomiting, constipation, miscarriage
o Shivering is a common side effect with rectal or SL
Black Box Warning: use during pregnancy may cause abortion, birth defects, or premature birth. Not to be used to decreased
NSAID induced ulcers in a woman of childbearing potential unless she is capable of complying.
Contraindications: Contraindicated in hypersensitivity to prostaglandins.
o Avoid concurrent use with oxytocin
o In patients with history of c-section or major uterine surgeries
o Maternal infection, fever, vaginal bleeding
o OB: Should not be used to prevent NSAID-induced gastric injury because of potential for fetal harm or death

Triage Medications
Leah Pirman
o Use extreme caution when used for cervical ripening, may cause uterine rupture
Effects/Implications for pregnancy or breastfeeding: This is a pregnancy category X drug. It is contraindicated during pregnancy.
Cases of congenital malformation has been reported. Following an unsuccessful abortion: teratogenic producing limb, skull defects,
gastroschisis (congenital defect in abdominal wall that doesnt close), bilateral palsy of cranial nerves, cleft lip and palate, fetal
vascular disruption
o Lactation: May cause severe diarrhea in the nursing infant
o It is excreted in human breast milk, no reports of severe adverse effects
Nursing Actions as applicable:
o Assess patient routinely for epigastric of abdominal pain, and for frank or occult blood in stool, emesis, or gastric
aspirate
o Monitor uterine cramping and bleeding during therapy
o Assess dilation of cervix periodically during therapy
o Advise patient to avoid alcohol and foods that may cause an increase in GI irritation
o Teach appropriate lifestyle and diet if used to prevent ulcers
o Assess maternal-fetal unit, before each insertion and during treatment following agency protocol for frequency. Assess
maternal vital signs and health status, FHR and pattern, and status of pregnancy, including indications for cervical
ripening or induction or labor, signs of labor or impending labor, and the Bishop score. Recognize that an abnormal
FHR and pattern; maternal fever, infection, vaginal bleeding, or hypersensitivity and regular, progressive, uterine
contractions contraindicate use.
o Use in caution with patients with history of asthma, glaucoma, and renal, hepatic, and CV disorders.
o Have woman void prior to insertion
o Assist woman to maintain a supine position with a lateral tilt or side lying position for 30-40 minutes after insertion
o Prepare to swab the vagina to remove unabsorbed medication using a saline soaked gauze wrapped around finer or to
administer terbutaline 0.25 mg SQ if significant adverse effect occurs.
o Initiate oxytocin for induction of labor no sooner than 4 hours after last fose of misprostol was administered, following
agency protocol, if ripening has occurred and labor has not begun
o Document all assessment findings and administration procedures
Drug name: Terbutaline (Bricanyl)
Dose, route, frequency: IV 2.5-10 mcg/min infusion; increase by 5 mcg/min q 10 min until contractions stop (not to exceed
30 mcg/min). After contractions have stopped for 30 min, decrease infusion rate to lowest effective amount and maintain for 48 hours

Triage Medications
Leah Pirman

o SQ: 0.25 mg every 20 minutes to 3 hours; hold for pulse >120 beats per minute. Terbutaline has not yet been approved
for and should not be used for prolonged tocolysis (beyond 48-72 hours)
Indications for OB use: Management of preterm labor (tocolytic) unlabeled use
Common Side Effects: Nervousness, restlessness, tremor, nausea, vomiting, hypokalemia, tachycardia, palpitations, headache
Contraindications: Contraindicated in hypersensitivity to adrenergic amines. Use cautiously in those near term in pregnancy
and lactation
Effects/Implications for pregnancy or breastfeeding: This is a pregnancy category B drug
o It is shown to cross the placenta and the fetus may experience the general adverse effects reported in the mother
o Myocardial necrosis is expected to be related to terbutaline use
o It is excreted in small amounts into human milk
It is considered to be compatible with breast-feeding by the American Academy of Pediatrics
Nursing Actions as applicable:
o Monitor maternal pulse and BP, frequency and duration of contractions, and FHR
o Assess maternal respiratory symptoms of pulmonary edema
o Monitor mother and neonate for symptoms of hypoclycemia and mother for hypokalemia
o Monitor maternal serum glucose and electrolytes
o Monitor neonates serum glucose

Drug name: Nifedipine (Adalat cC, Adalat XL, Afeditab CR, Nifedical, Procardia)
Dose, route, frequency: PO 10-30 mg 3 times daily (not to exceed 180 mg/day) or 10-20 mg twice daily as immediate-release
form, or 30-90 mg once daily as sustained-release form (not to exceed 90-120 mg/day)
Indications for OB use: It is used in OB for treatment of preeclampsia and preterm labor
o Other: Management of hypertension, angina pectoris, vasopastic angina and unlabeled uses include prevention of
migraine headache management of HR or cardiomyopathy
Common Side Effects: headache, dizziness, dorwisness, peripheral edema, flushing
Contraindications: Contraindicated in hypersensitivity; sick sinus syndrome; second-or-third degree AV block; systolic BP
<90 mm Hg; coadministration with grapefruit juice, rifampin, rifabutin, Phenobarbital, phenytoin, carbamaxepine, or St. Johns
wort
Effects/Implications for pregnancy or breastfeeding: This is a pregnancy category C drug.
o Animal studies have revealed evidence of teratogenicity, embryotoxicity, pacentotoxicity, and fetotoxicity; it is
recommended for use during pregnancy when benefits outweighs risk

Triage Medications
Leah Pirman

o Nifedipine is excreted into human milk. Manufacturer recommends that due to the potential for serious adverse
reactions in nursing infants, a decision should be made to discontinue nursing or discontinue the drug
Delay breast-feeding 3-4 hours after a dose significantly decreases the amount of nifedipine to which a nursing
infant may potentially be exposed
Nursing Actions as applicable:
o Monitor BP and pulse before therapy
o Monitor intake and output ratios and daily weight
o Assess for signs of HR
o Assess rash periodically during therapy
o Monitor serum potassium periodically
o Monitor renal and hepatic functions
o Nifedipine may cause positive antinuclear antibody and direct Coombs test results
o Instruct patient to avoid grapefruit or grapefruit juice during therapy
o Nifedipine has also been evaluated for treatment of PTL. Tocolytics may be used for short term (48 hour_ prolongation
of pregnancy to allow for administration of antenatal steroids and should not be used prior to fetal viability or when
risks to fetus or mom are greater than risk of PTL. Ensure effective maintenance.
o Encourage fluids to reduce hypotension; and educate patient on signs and symptoms of hypotension

Drug name: Zolpidem (Ambien)


Dose, route, frequency: PO 5 mg orally once daily immediately (immediate release) before bedtime (maximum dose 10 mg
orally daily) ; Extended release PO 6.25 mg once daily immediately before bedtime (max dose 12.5 mg orally once daily
immediately before bedtime)
Indications for OB use: It is a sedative (hypnotic). It is used to treat insomnia
Common Side Effects: Drowsiness, headache, muscle aches, sleepiness, drowsiness, back ache, diarrhea,
Contraindications: Allergic reaction, if sensitive to lactose, kidney disease, sleep apnea, lung disease, history of depression or
history of drug addiction
Effects/Implications for pregnancy or breastfeeding: This is a FDA pregnancy category C medication. There are no
controlled data in human pregnancy. Chronic use of hypnotics during late pregnancy may be associated with neonatal
withdrawal symptoms. Only given if benefits outweigh the potential risks
o The excretion of zolpidem in human milk is very low and most of it takes place during the first 3 hours following drug
intake. The effects in the nursing infant are unknown.

Triage Medications
Leah Pirman

Nursing Actions as applicable:


o Monitor LOC
o Assess drowsiness, side effects from lack of sleep

References
Dinoprostone. Retrieved from http://www.drugs.com/breastfeeding/dinoprostone.html
Misoprostol. Retrieved from http://www.drugs.com/pregnancy/misoprostol.html
Nagtalon-Ramos, J. (2014). Maternal-newborn nursing care (1st ed.). Philadelphia, PA: F. A. Davis Company.
Nifedipine. Retrieved from http://www.drugs.com/pregnancy/nifedipine.html
Terbutaline. Retrieved from http://www.drugs.com/pregnancy/terbutaline.html
Zolpidem. Retrieved from http://www.drugs.com/pregnancy/zolpidem.html