Medications during labour

Question 1

what are the management options for PPH?

Answer 1

Rubbing up a contraction
Bimanual compression

Pharmacological:

• IV oxytocin (30IU infusion w/ 500ml NaCl, 136ml/hr)
• Syntometrine (IM injection, prostaglandin + ergometrine)
• 3rd line: Carbaprost (250mcg 15 min intervals - max 2g)
• Tranexamic acid (anti fibrinolytic)
• Misoprostol

Surgical management

Question 2

what type of drug is syntometrine? what is its indication and dose?

Answer 2

prostaglandin + ergometrine

• causes uterine contractions
• used in active 3rd stage labour and PPH
• 50IU syntocinon + 500mcg ergometrine IM injection

Question 3

what type of drug is carbaprost and what is it used for?

Answer 3

prostaglandin F2 alpha

• used in PPH when syntometrine and oxytocin haven’t worked

Question 4

what are contraindications to the use of syntometrine and why?

Answer 4

pre eclampsia
hypertension
cardiac problems

• ergometrine is a alpha agonist which causes smooth muscle contraction therefore would worsen hypertension

Question 5

what are contraindications to the use of carbaprost and why?

Answer 5

asthma

- causes bronchospasm

Question 6

what is the dose and mode of delivery of oxytocin?

Answer 6

30IU IV infusion with 500ml NaCl

136ml/hr

Question 7

if a woman is at risk of pre term labour or presents in pre-term labour, what dose of steroids would you give?

Answer 7

betamethasone or dexamethasone IM 2 x 12mg doses 12 hourly

Question 8

what are options for pain relief during labour?

Answer 8

non-pharmacological

• TENS
• accupuncture
• breathing
• massage

pharmacological

• entonox
• morphine (IV)
• remifentanil (self-administered IV)
• epidural
• spinal anaesthesia
• general anaesthetic

Question 9

what are the benefits and side effects of morphine during labour?

Answer 9

good pain relief in about 30 mins

respiratory depression in neonate

Question 10

what are the benefits side effects of entonox use?

Answer 10

immediate effect but moderate effect

nausea and vomiting
feeling spaced out

Question 11

what are the benefits and side effects of the use of remifentanil during labour?

Answer 11

self administered, effective, short half life so is quickly metabolised by both mother and baby

nausea and vomiting

Question 12

at what gestation would you give steroids if the woman went into preterm labour?

Answer 12

between 24-36 weeks

up to 39 weeks if planned c-section

Question 13

what is the antidote for opioids?

Answer 13

naloxone

Question 14

describe induction of labour and how it is carried out.

Answer 14

ripen cervix with cook balloon

perform amniotomy with amniohook

IV infusion of oxytocin (30IU with 500ml NaCl 136ml/hr)

Question 15

what are possible side effects of oxytocin?

Answer 15

hypotension (fluids - NaCl infusion)
hyponatraemia (NaCl infusion)
uterine hypertonicity (monitor baby with continuous CTG)

Question 16

what is involved in the active third stage of labour?

Answer 16

cord traction and delivery of placenta
cut and clamping of cord
syntometrine to prevent PPH (500mcg ergometrine + 50IU syntocinon IM injection)

Question 17

why is ibuprofen contraindicated as pain relief during labour?

Answer 17

premature closure of PDA
oligohydramnios, oliguria
increased risk of bleeding in neonate

Question 18

if there is foetal distress what tocolytic medication is preferred?

Answer 18

terbutaline (b2 agonist) or GTN

- causes smooth muscle relaxation

Question 19

what antihypertensive medications are contraindicated in pregnancy?

Answer 19

ACE inhibitors
angiotensin receptor blockers
spironolactone

Question 20

what is the 1st line and 2nd line management for hypertension during labour?

Answer 20

1st line: labetalol
(alpha+beta blocker)

2nd line: hydralazine

poorly controlled hypertension during labour - can give labetalol via slow IV injection followed by slow IV infusion

Question 21

what are contraindications to an epidural?

Answer 21

thrombocytopenia
coagulopathy
raised ICP
anticoagulants within 12 hours of insertion 
local sepsis, septic shock 
allergy to local anaesthesia

Question 22

what are signs of allergic reaction to local anaesthesia?

Answer 22

personal tingling 
paraesthesia
tingling 
drowsiness
coma 
light headed
seizures

Question 23

what are the advantages and disadvantages of an epidural?

Answer 23

advantages

• best for baby
• effective pain relief
• can be topped up if require transfer to theatre for assisted delivery or c-section
• effective after delivery if require sutures for tears/episotomy
• can prevent further raised BP in pre-eclampsia

disadvantages

• post dural headache
• causes hypotension
• epidural haematoma/abscess
• risk of respiratory depression
• reduces women’s mobility

Question 24

what are the advantages and disadvantages of a spinal anaesthetic?

Answer 24

advantages

• patient can stay awake and meet baby
• effective bilateral pain relief
• able to maintain airway

disadvantages

• risk of nerve damage
• hypotension
• risk it wears off if surgery takes long
• post dural puncture headache
• nausea, vomiting or pruritus
• require catheterisation