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Magnesium Sulphate Infusion for the Obstetrical Patient in Labour Grey Nuns and Misericordia Community Hospitals – Initiation and Maintenance of - PROCEDURE Approved by: Director, Women’s Health, Covenant Health, GNH/MCH Site Leads, Obstetrics/Gynecology, GNH/MCH Labour and Delivery Manual Original Date January 2004 Revised Date June 2011 Next Review: July 2014 Page 1 of 5 1.0 PURPOSE To reduce the risk of and/or control seizure activity associated with preeclampsia and eclampsia. 2.0 GENERAL INFORMATION 2.1 Physician Responsibilities General Practitioner will have obtained a transfer of care to Obstetrician prior to initiation of infusion. 2.2 3.0 Registered Nurse Responsibilities 2.2.1 Obtain premixed solution from Pyxis (or prepare solution as per procedure if premix not available). 2.2.2 Administer and maintain infusion. 2.2.3 Monitor condition of mother and/or fetus. 2.2.4 One to one nursing is recommended. Constant attendance is required during the loading dose. EQUIPMENT 3.1 3.2 3.3 3.4 3.5 3.6 3.7 IV Solution 1000mL Ringers Lactate for control Premixed Magnesium Sulphate (MgSO4) Solution 50g/500mls 2/3 – 1/3 Alaris IV tubing x 2 Alaris Pump with minimum of 2 channels IV tray / IV equipment Fetal monitor BP cuff (mechanical preferred) HAVE TOXEMIA TRAY AVAILABLE AT BEDSIDE CONTAINING: MgSO4 ANTIDOTE – CALCIUM GLUCONATE 10% 1g (10mL) solution Dosage: 1 gram slow IV over 3 minutes REFLEX HAMMER 4.0 PROCEDURE Grey Nuns and Misericordia Community Hospital Procedure Name: Magnesium Sulphate Infusion for the Obstetrical Patient in Labor Initiation and Maintenance of 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9 4.10 4.11 4.12 Check the chart to ensure physician’s order is written. Explain the procedure to the patient. Ensure oxygen and suction available at bedside and functional. Prepare Control solution of 1000mL of Ringer’s Lactate. Control solution should be primed through Alaris tubing. Prime a second Alaris IV tubing with the pre-mixed MgSO4 solution supplied by Pharmacy. Attach tubing to Alaris pump. Label tubing above and below pump. Establish IV and attach control tubing directly to IV catheter. Once IV is established attach control solution tubing to Alaris pump. Run Control infusion at 50mL/hour until MgSO4 infusion is started. Perform baseline assessment of mother and fetus. Document in progress notes. - BP, pulse, respirations - Deep tendon reflexes - Contractions - Fetal heart rate Position patient preferably in left lateral position. Piggyback MgSO4 solution to lowest port of control solution IV line. Program Alaris pump for MgSO4 infusion with a second Registered Nurse present to verify pump setting is correct. Initiate MgSO4 solution loading dose of 4 grams as ordered. Run pump over 20 minutes. How to Program the Alaris Pump for a Magnesium Sulphate Infusion. To set maintenance dose: ▪ Press Guardrail Drugs on Alaris panel. ▪ Choose MgSO4 Continuous (magnesium sulphate continuous) ▪ Concentration – choose 50 gm/500mls ▪ Under Continuous Infusion, input maintenance dose to run at ordered 1-2 grams. To set bolus dose: ▪ At bottom of panel, choose bolus. ▪ Input dose of 4 grams, duration 20 minutes (120 mL/hr). 2 Grey Nuns and Misericordia Community Hospital Procedure Name: Magnesium Sulphate Infusion for the Obstetrical Patient in Labor Initiation and Maintenance of 3 4.13 NURSING ALERT: Continuous fetal monitoring is necessary while administering Magnesium Sulphate. 4.14 5.0 At completion of 4 gm bolus Loading Dose, Alaris pump will automatically switch to the set maintenance dose as ordered. MONITORING PARAMETERS DURING MAGNESIUM SULPHATE INFUSION 5.1 To assess patient as per chart below and document parameters on appropriate records. Frequency Parameter* Signs of Toxicity Action Respirations less than 14 or greater than 26 Stop MgSO4 Notify house staff/ physician/ resident Q 1 Hour Should be co-checked at shift change Absent patellar reflexes Loss of deep tendon reflexes Stop MgSO4 Notify house staff/ physician/resident Intake and Output (Insert foley catheter) Q 1 hour Use of urinary Urometer is recommended Less than 30ml (CHA Regional Pharmacy 2005) Notify house staff or physician Urine Protein Test urine hourly with dipstick Loading Dose Maintenance dose BP Q 15 minutes Pulse Q15 minutes Q15 minutes for first hour then Q1h X 4 then Q4h or as ordered Q 30 minutes Respirations Q15 minutes Q 30 minutes Breath sounds Prior to start of loading dose Q 2 hours Deep Tendon Reflexes (DTRs) Prior to start of loading dose Level of Consciousness Q 15 minutes Grey Nuns and Misericordia Community Hospital Procedure Name: Magnesium Sulphate Infusion for the Obstetrical Patient in Labor Initiation and Maintenance of 5.2 4 Signs of MgSO4 toxicity NURSING ALERT: Stop MgSO4 and notify Primary Care Provider if any signs of MgSO4 toxicity are present. SIGNS OF MgSO4 TOXICITY: altered level of consciousness decreased respirations (less than 14) absent deep tendon reflexes urinary output is less than 30 mL/hour 6.0 DOCUMENTATION 5.1 5.2 5.3 5.4 5.5 Partogram and/or Patient Care Record. I.V. Therapy Sheet Medication Sheet (MAR) Hourly Intake and Output Sheets Blood Pressure Printout Record (if NIBP used) NURSING ALERT: Nursing Management of Seizure Activity Protect the woman from harm (bedrails, falling, glasses, sharp objects) – current practice is not to introduce an airway or tongue depressor into the mouth. Call for help. Ensure the suction and O2 are ready. Prepare the medications that are likely to be needed. Start IV lines when the seizure ends (if not already done – beware volume overload). Position in left lateral when the seizure ends. Restart EFM when the seizure ends. Communicate with the family. Document In the event that premixed bags are not available: Draw up 25g MgSO4 (50mL) (use filter straw for glass ampoules) (see Fluid Therapy Manual “Use of Filter Straw”). Add 25g (MgSO4) to 200mL Normal Saline (N/S) (concentration – 1g/10mL). Grey Nuns and Misericordia Community Hospital Procedure Name: Magnesium Sulphate Infusion for the Obstetrical Patient in Labor Initiation and Maintenance of 7.0 REFERENCES Alberta Health Servcies Regional Parenteral Manual – Edmonton Zone. Retrieved June 21, 2011 from www.intranet2.capitalhealth.ca/pharmacy/pm/index.asp American Hospital Formulary Service Drug Information ’92 Guide to Parenteral Admixtures, 1990 Handbook on Injectable Drugs 6th edition, L. Trissel (1990) JOGC Kennedy, B.B., Ruth, D.J., Martin, E.J., (2009) Intrapartum Management Modules. A Perinatal Education Program . (p.240) Philadelphia: Wolters Kluwer Health, Lippincott Williams and Wilkins. 4th edition. MOREOB Program. Retrieved on Hypertensive Disorders in Pregnancy. June 21, 2011 from www. moreob.com U.S.P.D.I. 12th edition, 1992 5