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Oct.28.2020

Labetalol (Maternal-Newborn) - CE

ALERT

Labetalol has been identified as a high-alert medication with a heightened risk of causing significant patient harm when used in error.undefined#ref7">7

Remember to route tubes and catheters having different purposes in different, standardized directions (e.g., IV lines routed toward the head; enteric lines toward the feet).9

Take steps to eliminate interruptions and distractions during medication preparation.

OVERVIEW

Medications should be diluted or compounded in the pharmacy before dispensing and only when recommended by the manufacturer and approved by the organization’s practice.6 Some organizations will allow medication compounding in a specific area of practice.

If dilution or reconstitution of an IV push medication becomes necessary outside of the pharmacy, the nurse should perform these tasks immediately before medication administration in a clean, uncluttered, and functionally separate location.6 The nurse should use organization-approved, readily available drug information resources and sterile equipment and supplies to dilute or reconstitute IV push medications.6

Labetalol is used to treat maternal blood pressure (BP) elevations that accompany preeclampsia, eclampsia, acute hypertension, and chronic hypertension during pregnancy. A combined alpha- and beta-adrenergic blocking agent, labetalol reduces BP by dilating arterioles and decreased total peripheral resistance, resulting in decreased BP without a substantial decrease in cardiac output.3 Labetalol has a rapid onset and is less likely than other BP medications to cause excessive hypotension, tachycardia, and rebound hypertension.

IV labetalol is a first-line medication for the management of acute-onset, severe hypertension in pregnant women and women in the postpartum period.2 The medication may be administered orally, but it is generally administered in the inpatient setting via continuous infusion or by slow IV push. IV labetalol’s onset of action is 2 to 5 minutes, its peak action occurs in 5 to 15 minutes, and its duration is 2 to 4 hours.10 Oral labetalol’s onset of action is 30 minutes; the peak effects occur in 1 to 4 hours, and the duration of action is 8 to 24 hours.10 The half-life of labetalol is 2.5 to 8 hours.10

Do not attempt to lower the patient’s BP to normal because doing so may decrease uteroplacental perfusion, causing harm to the fetus. Try to lower the systolic BP to between 140 and 160 mm Hg and the diastolic BP to between 90 and 100 mm Hg.2 Decreased uteroplacental perfusion may lead to decreased fetal oxygenation, producing a change in fetal heart rate (FHR) variability and the onset of late decelerations. Asthma, overt heart failure, greater than first-degree heart block, cardiogenic shock, severe bradycardia, or other conditions that can cause severe, prolonged hypotension, and hypersensitivity to labetalol are contraindications to its administration.3

The recommended labetalol dosing is:

  • Oral dosage: For acute-onset, severe hypertension when IV access is not available. The patient may be given 200 mg of labetalol orally if immediate-release nifedipine is not available; this labetalol dose may be repeated in 30 minutes if sufficient improvement is not observed.2 The usual oral dosage is 200 to 400 mg twice daily.3
  • Intermittent IV dosage: Administered according to the practitioner's order. IV push labetalol is given over 2 minutes.3 One regimen is to escalate or layer the doses for severe hypertension:1,2
    • 20-mg initial dose
    • 40-mg dose 10 minutes later
    • 80-mg dose 10 minutes later (The cumulative IV-administered dose should not exceed 300 mg/24 hr.)
    • 10-mg dose of hydralazine 10 minutes later
    • Get emergency consultation from specialist in maternal-fetal medicine, internal medicine, anesthesiology, or critical care if BP remains elevated 20 minutes later and give additional antihypertensive medication as recommended by the specialist.
  • Continuous IV infusion: Administered at a rate of 0.5 to 2 mg/min and adjusted every 15 minutes according to the BP response until the goal BP is reached.3

The patient should be supine for IV labetalol administration.3 A pregnant patient should have a wedge pillow placed under one side to relieve compression of the aorta and inferior vena cava and avoid supine hypotension.11 Maternal labetalol treatment may cause bradycardia in the neonate.2

Adverse effects of labetalol that should be reported immediately include:

  • Allergic reaction (itching; rash; hives; swelling of face, lips, or tongue)
  • Slow, fast, or irregular heart rate
  • Shortness of breath or trouble breathing
  • Chest pain

Adverse effects of labetalol that are generally mild and temporary include:10

  • Dizziness
  • Depression
  • Fatigue
  • Diarrhea
  • Headache
  • Nausea
  • Vomiting
  • Orthostatic hypotension

Tubing or catheter should be traced from the patient to the point of origin before connecting or reconnecting any device or infusion.9 Tubing should be labeled at the connection site closest to the patient and at the connection site closest to the source when there are different access sites or several bags.9 Labeling reduces the chance of misconnection, especially in circumstances where multiple IV lines or devices are in use. Connections should not be forced, and equipment should only be used for its intended purpose.9 Forced connections or workarounds could indicate that the connection should not be made.

If the mother and support person express concern regarding the accuracy of a medication, the medication should not be given. The concern should be explored, the practitioner notified, and the order verified.

EDUCATION

  • Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
  • Educate the mother and support person regarding the purpose of the medication and the mode of administration.
  • Instruct the mother and support person regarding the potential side effects and adverse reactions to the medication.
  • Allow the mother and support person an opportunity to ask questions or discuss any unresolved concerns about the medication.
  • Explain safety measures that will be taken to monitor the patient.
  • Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment

  1. Perform hand hygiene before patient contact.
  2. Introduce yourself to the mother and support person.
  3. Verify the correct patient using two identifiers.
  4. Assess the patient's baseline vital signs, medication history, and any drug allergies.
  5. Assess the patient for specific contraindications to receiving labetalol and advise the practitioner accordingly. Contraindications may include:3
    1. Beta-blocker hypersensitivity
    2. Cardiogenic shock
    3. Bradycardia
    4. Atrioventricular (AV) block
    5. Heart failure
    6. Hypotension
    7. Asthma
    8. Diabetes mellitus
    9. Pheochromocytoma
  6. Assess the FHR pattern.

Preparation

  1. Obtain the medication, check the practitioner’s order, verify the expiration date, and inspect the medication for particulates, discoloration, or other loss of integrity.
    Do not use medication that is cloudy or precipitated unless such is indicated by its manufacturer as being safe.
  2. Verify any premixed medication provided by pharmacy services.
  3. With a second nurse, verify that pharmacy-prepared solutions follow the practitioner's order, using applicable components of the medication safety steps.
  4. Review medication reference information pertinent to the medication’s action, purpose, onset of action and peak action, normal dose, and common side effects and implications.
  5. Establish cardiac and respiratory monitoring as indicated by the ordered route of administration and the assessment of the patient.
  6. Verify the patient’s actual admission weight in kilograms. Reweigh the patient if appropriate.8 Stated, estimated, or historical weight should not be used.8

PROCEDURE

Oral Administration

  1. Perform hand hygiene.
  2. Verify the correct patient using two identifiers.
  3. Explain the procedure to the mother and support person and ensure that the mother agrees to treatment.
  4. Ensure the six rights of medication safety: right medication, right dose, right time, right route, right patient, and right documentation. Use a bar code system or compare the medication administration record (MAR) to the patient’s identification band.
  5. Prepare the prescribed amount of medication per the manufacturer’s recommendations.
  6. Administer the medication to the patient.
  7. Discard supplies and perform hand hygiene.
  8. Document the procedure in the patient’s record.

IV Administration

  1. Perform hand hygiene and don gloves.
  2. Verify the correct patient using two identifiers.
  3. Explain the procedure to the mother and support person and ensure that the mother agrees to treatment.
  4. Ensure the six rights of medication safety: right medication, right dose, right time, right route, right patient, and right documentation. Use a bar code system or compare the MAR to the patient’s identification band.
  5. Confirm the right dilution or fluid compatibility, the right flow rate, and the monitoring needed.
  6. Use commercially available or pharmacy-prepared prefilled syringes to flush and lock vascular access devices (VADs).6
  7. Disinfect vials by cleansing the access diaphragm using friction and sterile 70% isopropyl alcohol, ethyl alcohol, an iodophor, or other approved antiseptic swab and allow to dry at least 10 seconds.6
  8. Prepare the medication in the syringe.
  9. Label all syringes of IV push medications or solutions unless the syringes are prepared at the patient’s bedside and the medication is immediately administered without any break in the process.6 Use barcode scanning or similar technology immediately before administration.6
  10. Trace tubing or catheter from the patient to the point of origin.9
  11. Label the tubing at the connection site closest to the patient and the source.9
  12. Select the IV tubing injection port closest to the patient. Use a needleless port or adaptor.
  13. Access and flush the VAD.
    1. If using a disinfecting port protector or cap, remove the protector or cap from the needleless connector. Discard the protector or cap in the appropriate receptacle.
      Rationale: The port protector or cap is never reused.
      The effective length of time for exposure depends on the product. Consult the manufacturer’s instructions for use.
    2. Disinfect the needleless connector using vigorous mechanical scrubbing for a minimum of 5 to 60 seconds,4 according to the organization’s practice with an appropriate disinfecting agent (e.g., 70% isopropyl alcohol, an iodophor such as povidone-iodine, greater than 0.5% chlorhexidine in alcohol solution), and allow the solution to dry.4
      Specific guidelines directing the appropriate technique, disinfectant, or amount of time required to clean various devices have not been determined. 4
      There is moderate quality evidence to support the recommendation to apply mechanical friction for no less than 5 seconds. 4
  14. Assess and confirm line patency using, at a minimum, a 10-ml syringe filled with preservative-free 0.9% sodium chloride solution.6
  15. Administer IV push medication using an appropriate-size syringe for the required dose (i.e., a syringe smaller than 10 ml).6
    1. Intermittent IV lock
      1. Administer IV push labetalol over 2 minutes per the manufacturer’s recommendations and the practitioner’s orders.3
      2. Remove the needleless syringe tip and discard it in the proper sharps receptacle.
      3. Flush the VAD using, at a minimum, a 10-ml syringe for a central VAD or a 5-ml syringe for a peripheral VAD filled with preservative-free 0.9% sodium chloride solution.5,6
    2. Infusing IV line
      1. Connect the syringe to the IV line by inserting the needleless tip of the syringe containing the medication through the center of the port.
        Rationale: Puncturing the center of the diaphragm prevents damage to the diaphragm and possible leakage from the site.
      2. Connect the IV solution or prepared syringe to a mainline infusion access port and administer it by a volume-controlled infusion pump.
      3. Program the volume-controlled infusion pump at the infusion rate ordered by the practitioner.
      4. Administer the medication in the amount of time recommended by the organization’s practice, pharmacist, medication reference manual, or manufacturer.
      5. After the medication has been infused, withdraw the syringe and recheck the IV fluid infusion rate or set the fluid infusion pump to the prescribed rate.
  16. Encourage the patient to report any symptoms, including discomfort at the IV site.
  17. Observe the IV site during injection or infusion for sudden swelling.
  18. Perform a vigorous mechanical scrub before each access of the needleless connector or hub with an antiseptic swab and then allow the connector to air-dry completely.4
  19. Flush the injection port using preservative-free 0.9% sodium chloride solution. Attach the 0.9% sodium chloride solution flush syringe and administer the solution at the same rate that the medication was delivered.
    Rationale: Flushing the IV line with preservative-free 0.9% sodium chloride solution prevents IV access device occlusion and ensures that all medication is delivered. Flushing the IV site at same rate as the medication was infused ensures that medication remaining in the IV needle is delivered at the correct rate.
  20. Lock the catheter or resume the ordered infusion. Lock the catheter port with the appropriate solution per the organization’s practice or the manufacturer’s instructions.
  21. Discard supplies, remove gloves, and perform hand hygiene.
  22. Document the procedure in the patient’s record.

MONITORING AND CARE

  1. Follow the organization's practice regarding maternal cardiac monitoring.
  2. For IV push dosing, follow the organization's practice or:
    1. Monitor the patient's BP and heart rate before administration and 10 minutes after administration.2
    2. If additional doses are needed, assess the BP 10 minutes after each dose.2
    3. When the desired BP threshold is achieved, repeat BP measurement every 10 minutes for 1 hour, then every 15 minutes for 1 hour, then every 30 minutes for 1 hour, then every hour for 4 hours.2
      Rationale: The usual target BP for patients with preeclampsia ranges from 140 to 150 mm Hg systolic and from 90 to 100 mm Hg diastolic. 2
  3. Continuously monitor the FHR pattern via electronic monitoring per the practitioner's order or per the organization's practice.
  4. Monitor the patient for adverse and allergic reactions to labetalol. Recognize and immediately treat respiratory distress and circulatory collapse, which are signs of a severe anaphylactic reaction. Follow the organization’s practice for emergency response.
  5. Assess, treat, and reassess pain.

EXPECTED OUTCOMES

  • Medication administered per the six rights of medication safety
  • Maintenance of target BP
  • No adverse effects to patient, fetus, or newborn

UNEXPECTED OUTCOMES

  • Medication not administered per the six rights of medication safety
  • Uncontrolled BP
  • Adverse effects to or death of patient, fetus, or newborn
  • Infusion site phlebitis, infiltration

DOCUMENTATION

  • Verification of the six rights of medication safety (in the patient's record or MAR)
  • Patient's response to medication, including any adverse reactions
  • Patient's vital signs, peripheral oxygen saturation, and changes in cardiac status
  • FHR pattern, including changes in baseline, variability, accelerations or decelerations, or uterine activity
  • IV infusion site
  • IV patency and primary fluid
  • Education
  • Unexpected outcomes and related interventions
  • Patient's weight in kilograms per the organization's practice

REFERENCES

  1. American College of Obstetricians and Gynecologists (ACOG). (2020). Labetalol algorithm. Retrieved September 2, 2020, from https://www.acog.org/-/media/project/acog/acogorg/files/forms/districts/smi-hypertension-bundle-labetalol-algorithm.pdf (Level VII)
  2. American College of Obstetricians and Gynecologists (ACOG) Committee on Obstetric Practice. (2019). Committee opinion no. 767: Emergent therapy for acute-onset, severe hypertension during pregnancy and the postpartum period [Interim update]. Obstetrics and Gynecology, 133(2), e174-e180. Retrieved September 2, 2020, from https://www.acog.org/-/media/project/acog/acogorg/clinical/files/committee-opinion/articles/2019/02/emergent-therapy-for-acute-onset-severe-hypertension-during-pregnancy-and-the-postpartum-period.pdf doi:10.1097/AOG.0000000000003075 (Level VII)
  3. Gold Standard. (2020). Labetalol. Retrieved August 9, 2020, from http://www.clinicalkey.com
  4. Infusion Nurses Society (INS). (2016). Infusion therapy standards of practice. Standard 34: Needleless connectors. Journal of Infusion Nursing, 39(Suppl. 1), S68-S70. (Level VII)
  5. Infusion Nurses Society (INS). (2016). Infusion therapy standards of practice. Standard 40: Flushing and locking. Journal of Infusion Nursing, 39(Suppl. 1), S77-S81. (Level VII)
  6. Institute for Safe Medication Practices (ISMP). (2015). ISMP safe practice guidelines for adult IV push medications: A compilation of safe practices from the ISMP Adult IV Push Medication Safety Summit. Retrieved September 2, 2020, from https://www.ismp.org/sites/default/files/attachments/2017-11/ISMP97-Guidelines-071415-3.%20FINAL.pdf (Level VII)
  7. Institute for Safe Medication Practices (ISMP). (2018). High-alert medications in acute care settings. Retrieved September 2, 2020, from https://www.ismp.org/sites/default/files/attachments/2018-08/highAlert2018-Acute-Final.pdf (Level VII)
  8. Institute for Safe Medication Practices (ISMP). (2020). 2020-2021 Targeted medication safety best practices for hospitals. Retrieved September 2, 2020, from https://www.ismp.org/sites/default/files/attachments/2020-02/2020-2021%20TMSBP-%20FINAL_1.pdf (Level VII)
  9. Joint Commission, The. (2014). Sentinel event alert 53: Managing risk during transition to new ISO tubing connector standards. Retrieved September 2, 2020, from https://www.jointcommission.org/assets/1/6/SEA_53_Connectors_8_19_14_final.pdf (classic reference)* (Level VII)
  10. Skidmore-Roth, L. (2021). Mosby’s 2021 nursing drug reference (34th ed.). St. Louis: Elsevier.
  11. Spain, R.O. (2020). Chapter 19: Nursing care of the family during labor and birth. In D.L. Lowdermilk and others (Eds.), Maternity & women’s health care (12th ed., pp. 376-416). St. Louis: Elsevier.

*In these skills, a “classic” reference is a widely cited, standard work of established excellence that significantly affects current practice and may also represent the foundational research for practice.

Elsevier Skills Levels of Evidence

  • Level I - Systematic review of all relevant randomized controlled trials
  • Level II - At least one well-designed randomized controlled trial
  • Level III - Well-designed controlled trials without randomization
  • Level IV - Well-designed case-controlled or cohort studies
  • Level V - Descriptive or qualitative studies
  • Level VI - Single descriptive or qualitative study
  • Level VII - Authority opinion or expert committee reports