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Classification: Ergot alkaloid, uterine stimulant

Action: Stimulates sustained contraction of the uterus and causes arterial vasoconstriction.

Indications: Used for the prevention and treatment of postpartum or postabortion hemorrhage caused by uterine atony or subinvolution.

Dosage and Route: Usual dosage is 0.2 mg intramuscularly (IM) every 2 to 4 hours for a maximum of five doses. Change to the oral route 0.2 mg every 6 to 8 hours for a maximum of 7 days. Intravenous use not recommended; use in life-threatening emergency only and give over at least 60 seconds with close monitoring of blood pressure (BP) and pulse; may cause severe hypertension.

Absorption: Well absorbed after oral or IM route.

Excretion: Metabolized by the liver; excreted in the feces and urine.

Contraindications and Precautions: Methylergonovine should never be used during pregnancy or to induce labor. Do not use if the mother is hypersensitive to ergot. Contraindicated for women with hypertension, severe hepatic or renal disease, thrombophlebitis, coronary artery disease, peripheral vascular disease, hypocalcemia, or sepsis or before the fourth stage of labor.

Adverse Reactions: Nausea, vomiting, uterine cramping, hypertension, dizziness, headache, dyspnea, chest pain, palpitations, peripheral ischemia, seizure, and uterine and gastrointestinal cramping.

Nursing Considerations: Before administering the medication, assess the blood pressure. Follow facility protocol to determine at what BP level medication must be withheld. Caution the mother to avoid smoking, because nicotine constricts blood vessels. Remind her to report any adverse reactions.
Nurses are with the mother during the hours after childbirth and are responsible for assessments and initial management of uterine atony. If the uterus is not firmly contracted, the first intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus. One hand is placed just above the symphysis pubis to support the lower uterine segment while the other hand gently but firmly massages the fundus in a circular motion. Figure 28-2 illustrates fundal massage.

Clots that may have accumulated in the uterine cavity interfere with the ability of the uterus to contract effectively. They are expressed by applying firm but gentle pressure on the fundus in the direction of the vagina. It is critical that the uterus is contracted firmly before attempting to express clots. Pushing on a uterus that is not contracted could invert the uterus and cause massive hemorrhage and rapid shock (see Chapter 27).

If the uterus does not remain contracted as a result of uterine massage, or if the fundus is displaced, the problem may be a distended bladder. A full bladder lifts the uterus, moving it up and to the side, preventing effective contraction of the uterine muscles. Assist the mother to urinate, or catheterize her to correct uterine atony caused by bladder distention. Note urine output then reassess the uterus.

Pharmacologic measures also may be necessary to maintain firm contraction of the uterus. A rapid intravenous (IV) infusion of dilute oxytocin (Pitocin) often increases uterine tone and controls bleeding (see Drug Guide: Oxytocin, p. 417). Methylergonovine (Methergine) may be given intramuscularly (IM), but it elevates blood pressure and should not be given to a woman who is hypertensive. The usual route of administration is IM; IV use is reserved for life-threatening emergencies only (see Drug Guide: Methylergonovine). Analogs of prostaglandin F2-alpha (PGF2α; carboprost tromethamine [Hemabate; Prostin/15M]) are very effective when given IM or into the uterine muscle if oxytocin is ineffective in controlling uterine atony (Kim, Hayashi, & Gambone, 2010). (See Drug Guide: Carboprost Tromethamine.) Prostaglandin E2 (dinoprostone [Prostin E2]) or misoprostol (Cytotec) given rectally may also be used to control bleeding.

If uterine massage and pharmacologic measures are ineffective in stopping uterine bleeding, the physician or nurse-midwife may use bimanual compression of the uterus. In this procedure, one hand is inserted into the vagina, and the other compresses the uterus through the abdominal wall (Figure 28-3). A balloon may be inserted into the uterus to apply pressure against the uterine surface to stop bleeding (Belfort & Dildy, 2011; Thorp, 2009). Uterine packing may also be used. It may be necessary to return the woman to the delivery area for exploration of the uterine cavity and removal of placental fragments that interfere with uterine contraction.

A laparotomy may be necessary to identify the source of the bleeding. Uterine compression sutures may be placed to stop severe bleeding. Ligation of the uterine or hypogastric artery or embolization (occlusion) of pelvic arteries may be required if other measures are not effective. Hysterectomy is a last resort to save the life of a woman with uncontrollable postpartum hemorrhage.

Hemorrhage requires prompt replacement of intravascular fluid volume. Lactated Ringer's solution, whole blood, packed red blood cells, normal saline, or other plasma extenders are used. Enough fluid should be given to maintain a urine flow of at least 30 mL/hour and preferably 60 mL/hour (Cunningham et al., 2010). Typically, the nurse is responsible for obtaining properly typed and cross-matched blood and inserting large-bore IV lines that are capable of carrying whole blood.
Priority assessments for uterine atony include the fundus, bladder, lochia, vital signs, skin temperature, and color. Assess the consistency and the location of the uterine fundus. The fundus should be firmly contracted, at or near the level of the umbilicus and midline. If the fundus is above the level of the umbilicus and displaced, a full bladder may be the cause of excessive bleeding. A full bladder lifts the uterus and impedes contraction, which allows excessive bleeding. An accumulation of clots also expands the uterus, making contraction difficult and resulting in continued bleeding. (See Procedure: Assessing the Uterine Fundus in Chapter 20 on p. 442 for assessing the fundus.)

Obese women have an increased risk for uterine atony with subsequent postpartum hemorrhage (Blomberg, 2011), however, assessment of the fundus is difficult in this population. Monitor these women frequently for other signs of uterine atony and attempt to assess the uterine fundus while watching for increased lochia flow or clots to be expelled.

Also remember to check under the woman's legs, buttocks, and back for lochia drainage by asking the woman to turn on her side. This allows visibility of any blood that may not be obvious from the front. Although bleeding may be profuse and dramatic, a continuing small but steady trickle or oozing may also lead to significant blood loss that becomes increasingly life threatening.

It is difficult to estimate the volume of lochia by visual examination of peripads. More accurate information is obtained by weighing peripads, linen savers, and, if necessary, bed linens, before and after use and subtracting the difference. One gram (weight) equals approximately 1 mL (volume).

Measure vital signs at least every 15 minutes or more often, if necessary. Apply a pulse oximeter to determine oxygen saturation levels. This helps to detect trends, such as tachycardia or a decrease in pulse pressure that may reveal a deteriorating status in a woman with significant blood loss. Initially, the body compensates for excessive bleeding by constricting the peripheral blood vessels and shunting blood to vital organs. This can be misleading because the vital signs may remain normal even when the woman is becoming hypovolemic. The skin should be warm and dry, mucous membranes of the lips and mouth should be pink, and capillary return should occur within 3 seconds when the nails are blanched. These signs confirm adequate circulating volume to perfuse the peripheral tissue.
Women who have had a previous DVT or PE are at risk for another. These women and others at high risk may receive prophylactic heparin, which does not cross the placenta. Either standard unfractionated heparin (UH) or a low-molecular-weight heparin (LMWH), such as enoxaparin (Lovenox) or tinzaparin (Innohep), may be used. LMWH is longer acting and can be given less frequently and with less laboratory testing. It has fewer side effects and is less likely to cause bleeding. However, it is more expensive than UH and must be given subcutaneously. UH is given IV or subcutaneously.

Women receiving LMWH during pregnancy are changed to UH at approximately 36 weeks of gestation. The change is necessary because UH has a shorter half-life, and epidural anesthesia, which may be needed in labor, is contraindicated within 24 hours of the last dose of LMWH. Heparin is discontinued during labor and birth and resumed approximately 6 to 12 hours after uncomplicated birth and 12 hours after the epidural catheter is removed (American College of Obstetricians and Gynecologists [ACOG], 2011).

If stirrups must be used during the birth, risks of thrombus development can be reduced by placing the woman's legs in stirrups that are padded to prevent prolonged pressure against the popliteal angle during the second stage of labor. If possible, the time in stirrups should be no more than 1 hour.

To prevent thrombus formation after childbirth, all new mothers are encouraged to ambulate frequently and as early as possible. Ambulation prevents stasis of blood in the legs and decreases the likelihood of thrombus formation. If the woman is unable to ambulate, range-of-motion and gentle leg exercises, such as flexing and straightening the knee and raising one leg at a time, should begin within 8 hours after childbirth. In addition, the mother should not use pillows under her knees or the knee gatch on the bed. These devices may cause sharp flexion at the knees and pressure against the popliteal space, leading to pooling of blood in the lower extremities.

Graduated compression stockings or sequential compression devices are used for mothers with varicose veins, a history of thrombosis, or a cesarean birth. Sequential compression devices should be applied preoperatively for a woman undergoing a cesarean birth who is not on anticoagulant therapy and should be continued until she begins to ambulate postpartum (ACOG, 2011). Compression stockings should be applied before the mother gets out of bed to prevent venous congestion, which begins as soon as she stands. It is important that she understands the correct way to put on the stockings. Improperly applied stockings can roll or bunch and slow venous return from the legs.
Depression responds best to a combination of psychotherapy, social support, and medication. Psychotherapy may be helpful to assist the woman to cope with changes in her life. The woman's partner and immediate family must be included in counseling sessions so they can develop an understanding of what the woman feels and needs. In one study, support from trained peers demonstrated some success (Dennis, Hodnett, Reisman, et al., 2009; Morrell, Slade, Warner, et al., 2009). However, a more recent study (Letourneau, Stewart, Dennis, et al., 2011) did not support this finding.

If psychotherapy alone is not effective, it should be combined with medication. Selective serotonin reuptake inhibitors and tricyclic antidepressants are the most commonly prescribed medications. It may take up to 4 weeks for the medications to be fully effective, and they may be continued for 9 to 12 months after remission of symptoms (Beck, 2008).

Whether the woman is still pregnant or is breastfeeding must be considered when any drugs are prescribed as some are safer than others for use in pregnancy and lactation. Women who discontinue medications for depression during pregnancy are more likely to have a relapse during pregnancy or postpartum (Haskett, 2011). In addition, women who have depression and do not take medication during pregnancy are more likely to have inadequate prenatal care and preterm delivery (Dossett, 2008). Electroconvulsive therapy may also be necessary for mothers who are suicidal. It is used when the woman has not improved with other treatment.
Postpartum anxiety disorders include panic disorder, postpartum obsessive-compulsive disorder (OCD), and posttraumatic stress disorder. Panic disorder manifests as episodes of tachycardia, palpations, shortness of breath, chest pain, and fear of dying or of "going crazy." Episodes are repetitive and interfere with the woman's daily life. Antianxiety and antidepressant medications and counseling are the treatment for this condition.

Postpartum OCD is a condition where the woman has consuming thoughts that she might harm the baby and fears being alone with the baby. Anxiety and depression occur, and the woman may perform compulsive behaviors to avoid acting on her thoughts. Some mothers avoid their infants while others obsessively check on the infants frequently day and night (O'Hara & Segre, 2008). Treatment includes antianxiety and antidepressant medications and counseling.

In posttraumatic stress disorder, women perceive childbirth as a traumatic event. They have nightmares and flashbacks about the event, anxiety, and avoidance of reminders of the traumatic event; some have depression after giving birth. Feeling a lack of caring or communication or having a birth very different from what they expected may contribute to this disorder. Women need to talk about their experiences and how they perceived them and often search for answers about their experiences. They may feel isolated from their infants and have prolonged difficulty feeling close to them. Celebrating the child's birthdays may be distressing as they are anniversaries of the trauma experienced when the child was born