Labory and Delivery and Lactation Flashcards
PPROM
what is it
in general, what treatment is used to improve outcomes of PPROM
Preterm premature rupture of membranes
rupture of the amniotic sac before labor beings
ABX, tocolytics, corticosteroids
preterm labor
tocolytics therapy
purpose:
examples:
purpose:
a. prolong pregnancy between 48 hours to 1 week; not utilized beyond 34 weeks.
b. allow transportation of mother to a facility equipped to deal with high risk deliveries
c. prolongation of pregnancy when there are underlying, self limited conditions that can cause labor
examples: beta agonists (terbutaline), magnesium, CCBs,
prostaglandin inhibitors (NSAIDS such as indomethacin)
PROSTALGANDIN I- AND CCBs preferred
preterm labor
ABX
when are the used
examples:
when is it used:
a. prophylactics/ treatment for PPROM. PPROM along with tocolytics and corticosteroids to improve outcomes.
b. maternal infection with Group B Strep (GBS): Given if woman previously gave birth to child with inprevous GBS disease or in presence of GBS in bacteriuria.
penecillin/ampicilllin (cefazolin or clindamycin if allergic)
preterm labor
corticosteroids
when given:
examples:
when given: antenatal corticosteroids for fetal lung maturation to prevent respiratory distress syndrome, intraventricular hemmorhage, and death in infants
examples: betamethasone 12 mg IM q24 hours for 2 doses
or dexamethasone 6 mg IM q 12 hours for 2 doses
cervical ripening and labor induction
Non pharm:
pharm:
Agents: their job
a. pros.
b. cons
non pharm:
- balloon
a. as effective as pharm:
b. should not be used in ruptured membranes - hydroscopic dilator
a. as effective as pharm:
b. should not be used in ruptured membranes
pharm:
- Misoprostol (PGE1): cervical ripening and labor induction
a. can be combined with mechanical method for better efficacy
b. difficult to reverse in cases of adverse effects - Dinoprostol (PGE2):cervical ripening
a. can be combined with mechanical method for better efficacy
b. difficult to reverse in cases of adverse effects - oxytocin: begin or improve contractions
a. infusion can be held if AE
b. may not be as effective as other methods:
c. MOST COMMONLY USED
Labor analgesia
non pharm:
Pharm
non pharm: massage, water immersion, acupuncture, relaxation, and hypnotherapy
pharm:
1. parenteral (systemic analgesia)
2. epidural and spinal analgesia
3. nitrous oxide
4. general anesthesia
parenteral anestesia
pearls:
cons
pearls: fentanyl, morphine, nalbuphine, butorphanol, may be used
cons: variable pain relief, increased risks to fetus due to respiratory depression, decreased muscle tone, and mother AE like hypotension or placental transfer of opioids
epidural analgesia
pearls:
ex used:
cons:
pearls:
- injection of catheter in epidural space.
- most common bupivacaine and ropivacaine
- can be intermittent bolus, continuous infusion or both
cons: minor AE associated with neuraxial blocking. HTN, N&V, urinary retention, shivering, fever, rectal and oral herpes, respiratory depression.
postural puncture headache with continuous spinal analgesia
nitrous oxide
Pearls
cons
pearls: inhaled anesthetic. limited CI, no additional monitoring, quick termination.
cons: less readily available in the us
General anesthesia
pearls:
cons:
pearls: used for vaginal or cesarean delivery and only in emergencies when other methods cant be performed.
cons: standard risks associated with general anesthetic administration
PPH
what is it
treatment:
post partu hemorrhage
what is it: loss of 1000 mL or more (regardless of delivery method) +s/s of hypovolemia
treatment: oxytocin infusion to reduce maternal bloodloss
PPD
treatment:
post partum depression
treatment: first line. SSRI’s, consider breastfeeding status
Brexanolone: IV infusion for PPD. requires hospital stay
current breast feeding recommendations
- exclusive breast feeding for about the first 6 monhts
- breast feeding in combo with introduction of complementary foods until atleast 12 months
- continuation of breast feeding for as long as mutually desired by mother and baby
common barriers to breastfeeding. why ppl stop or don’t try
lack of experience
not enough opportunities to communicate with other breast feeding mothers
lack of up to date info and instruction from health care professionals
hospital practices that make it hard to get started with successful breast feeding
racial disparities (black infants less likely to breastfeed than other racial/ethnic groups)
what hormones control breast feeding
prolactin: causes alveoli to take nutrients from the blood and turn them into breast milk
oxytocin: causes cells around alveoli to contact and eject milk ducts (let down)
composition of breast milk
1.colostrum “liquid gold” first 3 days; rich in nutrients. high in protein, low in fat and sugar
- mature milk: 3-5 days after birth
just the right amount of fat, sugar, water, and protein
a. foremilk: first milk baby receives at start of breast feeding. thin and watery
b. hind milk: released after several minutes of nursing . similar in texture to cream and has highest conc. of fat.
breast feeding benefits
for mom;
for baby:
formom: burn up to 500 calories
lower rates of T2DM, HTN, CVD
lower rates of breast and ovarian cancer
produces oxytocin, reduce risk of bleeding after birth
for baby: has right amount of ft, sugar, water, protein, and minerals
easier to digest than formula
contains antibodies that protect infants
lower risk of SIDS
reduce risk of short and long term health problems in preterm babies
drug properties that increase likelihood of transfer into breast milk
low protein bound drugs low molecular weight drugs high lipid solubility higher concentration in mothers serum longer half-life weak bases
Relative infant dose
what does it tell you
what does it not tell you
estimates infant drug exposure via breast milk
does NOT communicate safety of the medication in breast feeding
to calculate RID
- FIRST
take the dose given and divide it by her weight in kg to get the maternal dose of the drug
(in units mg/kg/day)
- next, multiple the drug concentration in breast milk (mg/mL) by the volume of milk ingested (mL/kg/day) to get the estimated daily infant dose (mg/kg/day. NOTE: IF VOLUME INGESTED IS UNKNOWN, USE 150 mL/kg/day
- calculate RID:divide estimated daily infant dose by maternal dose, multiple x 100 to get percentage.
which RID PERCENTAGes are generally considered safe
<10%
WHICH RID percentages are generally not considered safe
> 25%
most drugs have a RID of what
<1%
main strategy for reducing the risk to the infant
select of drugs that would be considered safe to the infant
infant factor s effecting their drug exposure
- drugs unstable in gastric acid, (aminoglycosided, PPIs, heparin, and insulin) are less likely to be absorbed by infants
- frequency and amount of milk
- exclusive vs non exclusive breast feeding
resources for patient for breast feeding
- la leche league
- kellymom.com
- nursing mothers advisory counsil
- Breast feeding USA
- the office on women’s health
- the lactation pharmacist
lactation medication considerations
consider drug/disease risk/ benefits on mother and brest fed child
in general, if med is commonly prescribed, it is considered safe
never assume a medication that was safe in pregnancy is safe for breast feeding
always counsel on risk/benefits to mother and potential side effects for the child
meds that inhibit breast milk productoin
anti estrogens
antiviral
dopamine agonists
decongestants (pseudoephedrine, propylhexedrine, phenylephrine
ergots
ergots derivatives
ethanol
nicotine (cigarettes)
Selective estrogen reuptake inhibitors (tamoxifen, raloxifene)
galactagogues
metoclopramide
domperidone
herbal and nutritional products purported to assist with breast milk production
fenugreek fennel alfalfa oatmeal beer/brewers yeast lactation tea or cookies containing combinations of above
