POLICY BC.

29
Use of Tocolytic BIRTH CENTER
Agents in Pregnancy Patient Care
Issue Date:
Last Approval: Jan 2018

I. PURPOSE
To provide guidelines for administration of tocolytic agents in high risk pregnancy
II. DEFINITIONS
Commonly Used Medications: **No one tocolytic has been proven to be more effective than
another.
A. Magnesium Sulfate is the first line IV medication currently used for tocolysis at UCSF in
part due to the neuroprotection that magnesium provides in preterm birth.
B. Nifedipine is a commonly administered calcium channel blocker used in preterm labor
treatment. Nifedipine is more efficacious than betamimetics (terbutaline) and has fewer
side effects. Small studies have shown Nifedipine to be as effective a tocolytic agent as
IV magnesium sulfate.
 Nifedipine and magnesium are not usually administered concurrently due to a
risk of neuromuscular blockade
C. Terbutaline may be administered to quiet uterine activity while magnesium sulfate IV or
Nifedipine PO is initiated or to treat uterine tachysystole or tetanic contractions.
D. Indomethacin is a commonly used prostaglandin synthetase inhibitor. Indomethacin may
be used alone or with another tocolytic, usually prior to 32 weeks gestation.
Indomethacin is commonly used for a limited time during the fetal surgery perioperative
period or may be used as a routine tocolytic. Prolonged use of indomethacin may have
significant fetal side effects such as oligohydramnios and/or premature closure of the
ductus arteriosis but these are usually reversible when stopped. Because of these side
effects, more frequent AFIs or fetal echocardiograms may be done.
E. Nitroglycerin: Is a powerful tocolytic agent that is useful for acute uterine relaxation and
can be useful during procedures such as removal of a retained placenta, fetal head
entrapment and uterine tetany. Nitroglycerin is not used for long-term tocolysis.
Nitroglycerin has a rapid onset and short half-life which makes it particularly useful in
emergent situations that may require subsequent surgical intervention.
III. POLICY
An RN experienced in the care of antepartum patients may administer tocolytic medication(s)
with a provider order, and monitor maternal and fetal effects.
A goal of tocolytic use is to delay preterm birth by at least 48 hours so that glucocorticoids
can achieve maximum effect. Randomized controlled trials have demonstrated tocolytics are
effective in reducing uterine activity associated with cervical change for 48-72 hours, but
continued use does not result in a reduction in overall incidence of preterm births.
A. Patients with preterm contractions that result in cervical change, and patients remote from
term considered at significant risk for preterm delivery, are candidates for tocolysis.
B. During this 48-72 hour window, corticosteroids can be administered and a prospective
plan of care can be determined. After 48-72 hours, routine tocolysis is generally
discontinued.

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 POLICY BC.29
Use of Tocolytic BIRTH CENTER
Agents in Pregnancy Patient Care
Issue Date:
Last Approval: Jan 2018

1. The exception to this is patients who have undergone an open fetal surgery (i.e.
in utero myelomeningocele repair) who are generally tocolized until delivery by
36 weeks)
C. Once IV tocolysis has been terminated, patients may require no additional medications or
may be started on PO tocolytics depending on condition and provider preference.
Randomized controlled trials show PO tocolytics have no demonstrable efficacy in
preventing preterm delivery (PTD) but may be effective in reducing preterm contractions.
D. In patients with preterm premature rupture of membranes (PPROM) and preterm labor,
tocolysis may be used for 48-72 to allow for corticosteroids to be administered, and then
tocolysis is generally discontinued.
Activity modification, hydration (500-1000 ml crystalloid) and sedation (morphine or
lorazepam) may be used individually, or in combination, for patients with preterm
contractions/preterm labor. The combination of these interventions is associated with a
reduction in symptoms in patients with preterm contractions (non-randomized studies).
Tocolytics may be used to stop or slow uterine activity, though the efficacy of these
medications is uncertain. Tocolytics may be used in the management of complications e.g.
preterm labor, placenta previa, and placental abruption. Tocolytics may also be used to
control uterine activity or relax the uterus during or following specific procedures, such as:
A. Cerclage
B. Intrauterine transfusion
C. Fetal surgery
D. Abdominal, uterine, or other surgery during pregnancy
E. External cephalic version
Relative contraindications: When maternal/fetal risks are greater than the risk of preterm
birth.
A. Intrauterine fetal demise
B. Lethal fetal anomaly
C. Severe intrauterine growth restriction
D. Severe preeclampsia
E. Chorioamnionitis
F. Maternal hemorrhage with hemodynamic instability
IV. PROCEDURES
A. Weigh patient upon admission, or check most recent weight (within 1 week) and
document on admission record. (The baseline weight is important for the assessment of
fluid retention, as excessive weight gain may precede other clinical signs of fluid
overload.)
B. Apply external fetal monitor and tocolytic. Establish fetal heart rate (FHR) baseline and
uterine activity. Monitor patient per provider orders.

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 POLICY BC.29
Use of Tocolytic BIRTH CENTER
Agents in Pregnancy Patient Care
Issue Date:
Last Approval: Jan 2018

C. Place patients on bed rest with uterine displacement, as ordered.

D. Obtain and document baseline temperature, pulse, respiration, blood pressure and pain
score. Repeat vital signs (VS) as needed per patient’s condition.
E. Foley catheters are not required for patients on tocolytics for preterm labor. Transport
patients commonly arrive with a foley catheter in place. Consult with physician team
about discontinuation of the catheter unless continued catheterization is medically
indicated. Offer bedpan to empty bladder if on bedrest.
F. The provider performs a sterile vaginal or speculum exam on admission and as needed
with change in uterine activity/preterm labor symptoms.
1. Five or more contractions in 60 minutes, with cervical change is the threshold used to
consider further intervention in a singleton gestation.
2. For multiple gestations, the baseline uterine activity may be six contractions per hour.
3. Rupture of membranes.
G. Dip the patient’s urine sample to check for specific gravity, ketones, leukocytes and
nitrites as ordered to assess need for PO or IV hydration. If the patient is on magnesium
sulfate, urine specific gravity may be altered.
H. If a tocolytic is ordered, explain procedure to patient, initiate appropriate nursing and
medical care:
1. Place #18 or #16 gauge IV, obtain blood lab specimens and initiate IV fluids as
ordered.
2. Gather additional equipment as needed specific for the tocolytic agent used.
3. Maintain strict bed rest until activity orders are received from provider.
4. Monitor strict intake & output (I&Os). Minimize IV fluids and maximize PO fluid
intake. This may reduce the likelihood of iatrogenic fluid overload.
5. Encourage patient to empty bladder frequently to reduce uterine activity.
6. Suggest docusate sodium 250mg BID or TID PO while on bed rest.
7. Provide emotional support to patient and family.
*** See the nursing care relative to the specific tocolytic in the appendices, which follow.
V. REFERNCES
Flood Chez, B., Harvey, C. J., Hess-Eggleston, N, Troiano, N. H.(2013) Guidelines for the
Care of Patients with Preterm Labor: appendix E. High-Risk and Critical Care Obstetrics 3rd
Edition. Pp. 3384-386. Philadelphia: AWONN/Lippincott.
Glock, J. L., & Morales, W. J. (1993). Efficacy & safety of nifedipine versus magnesium
sulfate in the management of preterm labor: A randomized study. American Journal of
Obstetrics and Gynecology, 169(4), 960-964.
Iams, J. D. (2002). Preterm birth, in S. G. Gabbe, J. R. Niebyle, & J. L. Simpson (Eds.).
Obstetrics: Normal and Problem Pregnancies, 4th Ed. pp. 782-792. Philadelphia: Churchill
Livingston.

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 POLICY BC.29
Use of Tocolytic BIRTH CENTER
Agents in Pregnancy Patient Care
Issue Date:
Last Approval: Jan 2018

Katz, V. L., & Farmer, R. M. (1999). Controversies in tocolytic therapy. Clinical Obstetrics
and Gynecology, 42(4):802-819.
King J. F., Flenady, V. J., Papatsonis D. N. M., Dekker G. A., Carbonne B. (2003). Calcium
channel blockers for inhibiting preterm labor (Cochrane Review). In: The Cochrane Library,
Issue 3, 2003. Oxford: Update Software.
Norton, M. E., Merrill, J., Cooper, B. A., Kuller, J. A., & Clyman, R. I. (1993). Neonatal
complications after the administration of indomethacin for preterm labor. The New England
Journal of Medicine, 329(22), 1602-1607.
Simpson, K. R. & Knox, G. E. (2004). Obstetrical Accidents Involving Intravenous
Magnesium Sulfate: Recommendations to Promote Patient Safety. The American Journal of
Maternal-Child Nursing, 29, 161-169
VI. RESPONSIBILITY
For questions regarding this policy contact The Birth Center Clinical Nurse Specialist.
VII. HISTORY OF POLICY
Author:
Issue Date:
Reviewed and Revised Dec 2017, N, Manke, RN, B. Li MD, M. Killion RN CNS
Last Revision/Review: Jan 2018, M. Killion RN CNS
VIII. APPENDIX
Appendix A: Magnesium Sulfate
• Actions, relative contraindications, dosage & administration
• Side effects, interventions, antidote, & fetal/neonatal effects
• Nursing care
• Initiating Magnesium Sulfate Infusion
Appendix B: Nifedipine (Procardia)
• Actions, relative contraindication, dosage & administration
• Side effects, nursing interventions, antidotes, & fetal /neonatal effects
• Nursing care
Appendix C: Betamimetics (Terbutaline/Brethine)
• Actions, relative contraindications, dosage & administration
• Side effects, interventions, antidote, & fetal/neonatal effects
• Nursing care
Appendix D: Indomethacin (Indocin)
• Actions, relative contraindications, dosage & administration
• Side effects, interventions, antidote, & fetal/neonatal Effects

This guideline is intended for use by UCSF Medical Center staff and personnel and no representations or
warranties are made for outside use. Not for outside production or publication without permission. Direct
inquiries to the Office of Origin or Medical Center Administration at (415) 353-2733.

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 POLICY BC.29
Use of Tocolytic BIRTH CENTER
Agents in Pregnancy Patient Care
Issue Date:
Last Approval: Jan 2018

APPENDIX A

MAGNESIUM SULFATE: Actions, Relative Contraindications, Dosage & Administration

Action:
Magnesium decreases the frequency of depolarization of smooth muscle by modulating calcium uptake, binding, and distribution in smooth muscle
cells. The net result is inhibition of uterine contractions.
Relative Contraindications:
1. Heart block
2. Myocardial damage
3. Impaired renal function (UO < 30 ml/ hr; creatinine > 0.9 mg/dl)
4. Myasthenia gravis
5. Uncontrolled maternal bleeding
6. Chorioamnionitis

***This dosing should also be used when administering Magnesium Sulfate for neonatal neuroprotection.

DILUTION LOADING DOSE MAINTENANCE DOSES MAXIMUM

4 GM in 50ml sterile water (1 gram
= 12.5ml)
Main Line: LR @ TKO (30ml/hr)
4 grams magnesium sulfate in
50ml sterile water is available in medication delivery set
Pyxis.
Using Buretrol infusion tubing
prime line through an infusion
pump with the Guardrails
settings activated.
Label the line per the IV labeling
policy.
Infuse 4-6 grams per
order (50-75 ml) via
over 20-30 min. The RN
must remain with the
patient for the duration of
the loading dose.
DOSE
Usual maintenance dose
= 1-4 gms/hr
Infuse via
infusion device until 4-6 gms/hr
order is discontinued.
Infuse main line at a
rate so that total IV fluids =
50-70 ml/hr (Magnesium
Sulfate dose included).
If patient is NPO, total IV
rate may be increased
to 100-125 ml per hr.

Obtain independent 2 RN check of

initial pump settings
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 POLICY BC.29
Use of Tocolytic BIRTH CENTER
Agents in Pregnancy Patient Care
Issue Date:
Last Approval: Jan 2018

MAGNESIUM SULFATE: Side Effects, Nursing Interventions, Antidote, & Fetal/Neonatal Effects

SIDE EFFECTS/TOXICITY NURSING INTERVENTIONS ANTIDOTE FETAL/NEONATAL EFFECTS

Signs & Symptoms of Toxicity: Remain at the bedside for the duration of the Calcium
bolus or loading dose infusion. Gluconate 10%
Decreased mental status Obtain independent RN double-check of initial 10-20 ml IV
concentration and pump settings. (Push slowly
Profound muscle weakness IV pump is a critical alarm for the duration of the over 1-2 min)
infusion.
Significant nausea/vomiting Stop infusion and notify provider when s/sx of
magnesium toxicity are present. Consider
Markedly decreased or absent drawing magnesium level.
deep tendon reflexes Monitor urine output closely as magnesium
sulfate is excreted exclusively in the urine. Output
Respiratory depression. of <30 ml/hr may lead to magnesium sulfate
toxicity. Notify provider for decreased urine
Cardiac arrhythmias including output
arrest. Disconnect and take down the magnesium bag
and tubing immediately upon discontinuation of
magnesium therapy.
Fetal: Neonatal:
Pulmonary edema Strict I&O. Fluid intake management is based on May cause Hypotonia
Diuresis I&O’s. Auscultate lung fields at least q 2 hours decreased Plethoric
FHR variability. Weak cry
and fetal Respiratory
movement. depression
Hypocalcemia(rare)

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 POLICY BC.29
Use of Tocolytic BIRTH CENTER
Agents in Pregnancy Patient Care
Issue Date:
Last Approval: Jan 2018

MAGNESIUM SULFATE: Nursing Care

VITAL SIGNS BLOODS I&O/WT ACTIVITY/DIET ELECTRONIC FETAL HEART DOCUMENTATION

RATE/TOCO MONITORING

Baseline: T.P.R., BP Labs per Strict I&O during Bed rest, lateral Continuous monitoring during Document infusion,
Lung Assessment, provider and for 24 hr position, modified bolus and maintenance assessments and
DTRs prior to order after D/C Trendelenburg, if therapy. changes in APeX
initiation of magnesium needed.
therapy sulfate
Routine serum . May have BRP if Ensure monitoring frequency is
Respiratory rate, magnesium stable and consistent with patient
depth, and oxygen levels are not Daily to weekly w/provider order condition.
saturation, vital necessary. weights as
signs, level of ordered Regular diet.
consciousness,
fetal heart rate, Bedrest exercises.
and uterine
activity:
Q 15 min x 1 hour
Q 30 min x 1 hour
Then per attached
magnesium
sulfate protocol

DTRs & breath

sounds Q2 hrs
and as indicated
by maternal
symptoms.
.

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 POLICY BC.29
Use of Tocolytic BIRTH CENTER
Agents in Pregnancy Patient Care
Issue Date:
Last Approval: Jan 2018

INITIATING MAGNESIUM SULFATE INFUSION

 RN REMAINS AT THE BEDSIDE FOR THE DURATION OF THE BOLUS INFUSION

VS/O2 sat/LOC/FHR/Uterine activity/Patient tolerance of infusion:

 Q 15 minutes for the first hour
 Q 30 minutes for the second hour
 Then as listed below:
ASSESSMENTS AT ALL PATIENT HANDOFFS ANTEPARTUM POSTPARTUM
& LABOR
Nurse: Patient Ratios Labor 1:1 1:2-4 depending on acuity
1:1 for the duration of the bolus AP 1:2-3
Pump Settings & Buretrol 2 RN Independent check is required Q 1 hour Q 1 hour
Volume
Independent RN double-check
at initiation and all dosage
changes
IV lines including set-up and 2 RN independent check is required
labeling
Respiratory Rate/Depth Q 1 hour Q 1 hour
Oxygen saturation Q 1 hour Q 1 hour
Urine output Q 1 hour Q 1 hour
Vital signs Q 1 hour Q 2 hours
Level of consciousness Q 1 hour Q 2 hours
DTRs Q 2 hours Q 2 hours
Lung sounds Q 2 hours Q 2 hours
*INCREASE FREQUENCY OF ASSESSMENTS AS INDICATED BY PATIENT CONDITION*

DISCONTINUATION VITAL SIGNS, O2 SAT, LOC, URINE OUTPUT, RR Q 2 HRS X 2

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 POLICY BC.29
Use of Tocolytic BIRTH CENTER
Agents in Pregnancy Patient Care
Issue Date:
Last Approval: Jan 2018

APPENDIX B

NIFEDIPINE (Procardia): Actions, Relative Contraindication, Dosage & Administration

Actions: Calcium channel blockers or calcium antagonists are non-specific smooth muscle relaxants, predominantly used for the treatment of
hypertension in adults. They exert their tocolytic effect by preventing the influx of extracellular calcium ions into the myometrial cell. Nifedipine
effectively and rapidly reduces uterine activity, decreasing both amplitude and frequency of contractions, and reduces basal tone.

Relative Contraindications:
1. CHF
2. Aortic stenosis
3. Impaired liver function
4. Heart block

LOADING DOSE MAINTENANCE DOSE MAXIMUM DOSE

Obtain baseline vital signs Initiate maintenance dose: Maximum dose:

Initiate loading dose:
1. Usually 10-20 mg PO.
2. May give additional 10mg PO every 15
minutes until uterine activity subsides or
maximum dose of 40 mg is given (4
capsules).
Take BP:
 prior to administering each nifedipine
capsule
 every 15 min x 1 hr after loading dose.
Usual maintenance dose is 10-20 mg PO Not to exceed 30mg in a single dose (except
every 4 to 6 hrs. when loading) or 180 mg per day.
Begin maintenance therapy by administering *No fluid restriction is necessary with
oral Nifedipine 10-20 mg 2 hrs after last Nifedipine.
loading dose or as ordered.
Then give 10-20 mg every 4-6 hr as ordered
Obtain BP/P prior to each dose. Once
stabilized, check BP every 4 to 6 hrs.
Notify provider for hypotension

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 POLICY BC.29
Use of Tocolytic BIRTH CENTER
Agents in Pregnancy Patient Care
Issue Date:
Last Approval: Jan 2018

NIFEDIPINE (Procardia): Side Effects, Nursing Interventions, Antidotes, & Fetal/Neonatal Effects

SIDE EFFECTS NURSING INTERVENTIONS ANTIDOTE FETAL/NEONATAL

EFFECTS

Common: Inform patient of common and occasional side None Unknown

Hypotension: Infrequent but most common in pts who effects.
are hypertensive and/or hypovolemic. Fetal Monitoring: continuous
***Use cautiously in hypertensive or hypovolemic Provider Notification during stabilization, then
patients Notify provider if systolic < 90 or per provider order.
diastolic < 50 (maintenance dose usually held
Facial flushing (usually within 15 min of when patient is hypotensive).
administration)
Increased maternal heart rate
10 to 25 BPM If clinically significant hypotension develops:
 Notify provider and/or anesthesia.
Occasional:  Increase IV fluids.
Light headedness  Consider ephedrine if fluid bolus is
Headache unsuccessful and significant changes in
Dizziness FHR occur
Edema
Heart burn
General weakness
Pruritus
Tinnitus
Nausea

Rare
Precipitation of angina
Myocardial infarction
Congestive heart failure
Leg cramps

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 POLICY BC.29
Use of Tocolytic BIRTH CENTER
Agents in Pregnancy Patient Care
Issue Date:
Last Approval: Jan 2018

APPENDIX C
BETAMIMETICS: Actions, Relative Contraindication, Dosage & Administration

Action: Terbutaline (Brethine) stimulates beta-adrenergic receptors which activate an enzyme (adenylate cyclase) that causes an increase in
intracellular concentration of cyclic adenosine monophosphate (cAMP). Elevated cyclic AMP levels result in a reduction of intracellular calcium,
decreasing smooth muscle contraction.
Two types of Beta-adrenergic receptors exist in varying ratios in cell membranes throughout the body. Beta-1 receptors dominate the intestines
and heart. Beta-2 receptors dominate the myometrium, blood vessels, and bronchioles. Their stimulation leads to uterine relaxation,
vasodilatation, bronchdilation, and glycogenesis. Terbutaline shows some degree of selectivity for Beta 2 receptors though they also affect Beta 1.

Relative Contraindications:
1. Severe preeclampsia
2. Moderate to severe maternal cardiac disease
3. Uncontrolled antepartum hemorrhage
4. Pulmonary hypertension
5. Severe anemia
6. Uncontrolled diabetes
7. Chorioamnionitis
8. Hyperthyroidism.
9. Tachycardia (>120 bpm)

ORAL DOSE (RARELY USED) SQ TERBUTALINE

1 amp = 1mg/ml
USUAL MAXIMUM DOSE 5 mg PO every 2-4 hrs 0.25 mg q 2-4 hours PRN
(occasionally 2.5 mg every 2-4 hrs)

BETAMIMETICS: Side Effects, Interventions, Antidote, Fetal/Neonatal Effects

SIDE EFFECTS NURSING INTERVENTIONS ANTIDOTE NEONATAL/FETAL

EFFECTS
Tachycardia, bounding pulse, Check Apical pulse (AP) prior to dose. Propranolol Intraventricular
palpitation, tremor. Hold medication for AP > 120 bpm and notify provider. (Inderal) hemorrhage
0.25mg IV
Hypocalcemia
Transient elevation of blood Avoid large infusions of glucose containing IV solutions. Hypoglycemia
glucose Betamimetics are generally avoided when possible in patients with

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 POLICY BC.29
Use of Tocolytic BIRTH CENTER
Agents in Pregnancy Patient Care
Issue Date:
Last Approval: Jan 2018

Glycosuria: occasional diabetes. Notify provider for random BG over 140mg/dl.

BETAMIMETICS: NURSING CARE

VITAL SIGNS BLOODS I&O/WT FLUID ACTIVITY/DIET ELECTRONIC
LABS MANAGEMENT FHR/TOCO
MONITORING
VS and complete Per provider Mainline TKO Bedrest with modified
SQ THERAPY assessment prior order. May (30 ml/hr) or saline lock trendelenberg if Continuous
to initiation of need weekly Strict I&O. ordered. (HOB up 20-
drug. HCT, metabolic Weigh prior to initiation of 30 degrees).
panel treatment and weekly NPO or clear liquids.

Nurse to check Per provider No I&O or fluid Per provider order Per provider order
PO
vital signs & order. May restriction
pain prior to need weekly necessary
each dose. HCT, metabolic
panel Weekly wt.

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 POLICY BC.29
Use of Tocolytic BIRTH CENTER
Agents in Pregnancy Patient Care
Issue Date:
Last Approval: Jan 2018

APPENDIX D

INDOMETHACIN (INDOCIN): Actions, Relative Contraindications, Dosage and Administration

Actions: Indocin is a prostaglandin synthetase inhibitor. Its action as a tocolytic is thought to be related to inhibition of the synthesis of
prostaglandins which are released from cervical and uterine tissues and are associated with uterine activity.

Relative Contraindications:
1. Renal or hepatic disease
2. Active peptic ulcer disease
3. Poorly controlled hypertension
4. Asthma
5. Coagulation disorders
6. Use after 32 weeks gestation

LOADING DOSE MAINTENANCE DOSE MAXIMUM DOSE

50mg PO 25-50 mg PR or PO q 4-6 hrs, usually limited to 2-
50 - 100mg rectal suppository 4 days due to concerning side effects 300mg/24 hrs
(PR)

SIDE EFFECTS NURSING INTERVENTIONS ANTIDOTE FETAL/NEONATAL EFFECTS

(with prolonged administration of indomethacin)
Gastric irritation Best tolerated (regardless of route) None Fetal
with meals or antacids. Decreased amniotic fluid 2o to decreased fetal renal blood flow
Nausea Premature closure of the ductus arteriosis/Tricuspid regurgitation
Patient may need periodic AFIs. Neonatal (if born < 28 wks)
Renal toxicity  Increased risk of intraventricular hemorrhage
(Creatinine) Avoid concomitant use of ASA.  Decreased renal blood flow and decreased urine output
 Increased risk of necrotizing enterocolitis
Inhibits platelet  Pulmonary hypertension
aggregation

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 POLICY BC.29
Use of Tocolytic BIRTH CENTER
Agents in Pregnancy Patient Care
Issue Date:
Last Approval: Jan 2018

VITAL SIGNS BLOODS I&O/WT ACTIVITY/DIET ELECTRONIC FHR/TOCO MONITORING

T, P, R, BP baseline Creatinine prior to Per provider order 1. Per provider order.

then therapy and Weigh weekly 2. AFI measurements at least weekly.
q 12 hrs weekly. 3. Possible fetal echo to determine tricuspid regurgitation.

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