Labetalol (Maternal-Newborn) - CE/NCPD

The content in Clinical Skills is evidence based and intended to be a guide to clinical practice. Always follow your organization’s practice.

ALERT

Labetalol has been identified as a high-alert medication with a heightened risk of causing significant patient harm when used in error.^{undefined#ref13">13}

Route tubes and catheters having different purposes in different, standardized directions (e.g., IV lines routed toward the head; enteric lines toward the feet).¹¹

Take steps to eliminate interruptions and distractions during medication preparation.

OVERVIEW

Labetalol is used to treat blood pressure (BP) elevations that accompany hypertensive disorders of pregnancy. A combined alpha- and beta-adrenergic blocking agent, labetalol reduces systemic vascular resistance without reducing total peripheral blood flow and has very little effect on cerebral circulation. This results in decreased BP without a substantial decrease in cardiac output.⁶ 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 patients and patients 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.

Maternal vital signs and the fetal heart rate (FHR) pattern should be closely and frequently monitored after labetalol administration. The patient’s response to antihypertensive medication should be monitored closely. Antihypertensive therapy should not decrease arterial pressure too significantly or too rapidly because uteroplacental perfusion may be compromised,^1,7 resulting in an interruption of fetal oxygenation with Category II (indeterminate) or Category III (abnormal) FHR characteristics.⁵ Antihypertensive treatment is indicated for systolic BP of 160 mm Hg or greater, diastolic BP of 110 mm Hg or greater, or both, confirmed as persistent (lasting 15 minutes or more).^1,2 The target range is systolic BP of 140 to150 mm Hg and diastolic BP of 90 to 100 mm Hg.⁴

Contraindications to labetalol administration are active asthma, overt heart failure, greater than first-degree heart block, cardiogenic shock, and severe bradycardia.⁶ Active asthma is defined as:³

• Symptoms at least once a week, or
• Use of an inhaler or corticosteroids for asthma during the pregnancy, or
• History of intubation or hospitalization for asthma

Additional contraindications include conditions that can cause severe, prolonged hypotension, and hypersensitivity to labetalol.⁶

Continuous labetalol IV infusions should be adjusted per the BP response. When the goal BP is reached, the infusion should be stopped.⁶ Oral labetalol should be started when the supine BP begins to rise.⁶

Adverse effects of labetalol that should be reported immediately include:

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

Some adverse effects of labetalol that are generally mild include (Table 1):⁶

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

When a secondary antihypertensive medication is given (e.g., nifedipine followed by labetalol or labetalol followed by hydralazine) and BP remains elevated, initiation of an emergency consultation from a specialist in maternal-fetal medicine, internal medicine, anesthesiology, or critical care is recommended.^1,3,4

Labeling the tubing reduces the chance of misconnection, especially in circumstances where multiple IV lines or devices are in use.¹⁰

If the patient or support person expresses 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.

SUPPLIES

See Supplies tab at the top of the page.

EDUCATION

• Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
• Educate the patient and support person regarding the purpose of the medication and the mode of administration.
• Instruct the patient and support person regarding the potential side effects and adverse reactions to the medication.
• Educate the patient about proper positioning during labetalol administration.
• Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment

1. Perform hand hygiene before patient contact. Don appropriate personal protective equipment (PPE) based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Introduce yourself to the patient and support person.
3. Verify the correct patient using two identifiers.
4. Assess the patient’s baseline vital signs (including BP).
5. Assess the patient’s medication history, including any drug allergies.
6. Assess the patient for specific contraindications to receiving labetalol and advise the practitioner accordingly.
7. Assess FHR pattern and uterine activity using electronic fetal monitoring as appropriate for the clinical situation and per the organization’s practice.

Preparation

1. Verify the patient’s actual admission weight in kilograms. Reweigh the patient if appropriate.¹⁴ Do not use stated, estimated, or historical weight.¹⁴
2. 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.

3. Utilize high-alert medication administration practices per the organization’s practice.
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. Ensure that all appropriate antidotes, reversal agents, and rescue agents are readily available.¹⁴

PROCEDURE

Oral Administration

1. Perform hand hygiene and don gloves. Don additional PPE based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Verify the correct patient using two identifiers.
3. Explain the procedure to the patient and support person and ensure that the patient agrees to treatment.
4. Ensure the rights of medication safety.
5. Prepare the prescribed amount of medication.
6. Administer the medication to the patient.
7. Monitor the patient’s vital signs and BP per the organization’s practice.
8. Discard supplies, remove PPE, and perform hand hygiene.
9. Document the procedure in the patient’s record.

IV Push Administration

1. Perform hand hygiene and don gloves. Don additional PPE based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Verify the correct patient using two identifiers.
3. Explain the procedure to the patient and support person and ensure that the patient agrees to treatment.
4. Ask the patient to lie in the side-lying position, if possible during IV labetalol administration.⁶ If supine, a pregnant patient should have a wedge pillow placed under one side to relieve compression of the aorta and inferior vena cava and to avoid supine hypotension.¹⁵
5. Ensure the rights of medication safety.
6. Use commercially available or pharmacy-prepared prefilled syringes to flush and lock vascular access devices (VADs).⁹
7. Disinfect vials by cleaning 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.¹²
8. Draw the prescribed amount of medication into the syringe and prepare the syringe for IV administration; read the medication label for a second check of correct name and dose against the medication administration record (MAR).
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.¹² Use bar code scanning or similar technology immediately before administration.¹²
10. Remove gloves, perform hand hygiene, and don clean gloves.
11. Monitor BP before IV administration.⁶
12. If using a disinfecting port protector or cap, remove it from the needleless connector and discard.
13. Disinfect the connection surface and sides of the needleless connector using vigorous mechanical scrubbing for 5 to 15 seconds using 70% isopropyl alcohol or alcohol-based chlorhexidine suitable for use with medical devices.⁸ Allow the solution to dry.⁸
14. Confirm patency of the VAD by aspirating for blood return and flushing the VAD using a 10-ml syringe filled with preservative-free 0.9% sodium chloride solution.⁹ Use a minimum volume of solution that is equal to twice the internal volume of the catheter and add-on devices or a larger volume (e.g., 5 ml).⁹

    Rationale: A 10-ml syringe generates lower injection pressure.⁹

15. Administer IV push medication using an appropriate-size syringe for the required dose (i.e., a syringe smaller than 10 ml).⁹
16. Connect the syringe or insert the needleless adapter in the IV push port.
17. Administer the IV push medication within the amount of time recommended by the organization’s practice, the pharmacist, the medication reference manual, or the manufacturer.
18. Monitor the patient’s vital signs per the organization’s practice.
19. For IV push dosing, monitor the patient’s BP per the organization’s practice or:
    1. Monitor the patient’s BP 10 minutes after administration.^1,3
    2. If additional doses of labetalol are needed, assess the BP 10 minutes after each dose.^1,3
    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.^1,3
20. Remove the syringe and discard it in the proper receptacle.
21. If using a disinfecting port protector or cap, apply a new one.
22. Discard supplies, remove PPE, and perform hand hygiene.
23. Document the procedure in the patient’s record.

Continuous Infusion

1. Perform hand hygiene and don gloves. Don additional PPE based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Verify the correct patient using two identifiers.
3. Explain the procedure to the patient and support person and ensure that the patient agrees to treatment.
4. Ask the patient to lie in the side-lying position, if possible during IV labetalol administration.⁶ If supine, a pregnant patient should have a wedge pillow placed under one side to relieve compression of the aorta and inferior vena cava and to avoid supine hypotension.¹⁵
5. Ensure the rights of medication safety.
6. Monitor BP before IV administration.⁶
7. When there are multiple access sites or multiple solutions connected to a VAD, label the tubing with the route and medication or solutions at the connection sites closest to the patient and at the container.¹⁰
8. Trace tubing or catheter from the patient to the point of origin.¹¹
9. If using a disinfecting port protector or cap, remove it from the needleless connector and discard.
10. Disinfect the connection surface and sides of the needleless connector using vigorous mechanical scrubbing for 5 to 15 seconds using 70% isopropyl alcohol or alcohol-based chlorhexidine suitable for use with medical devices.⁸ Allow the solution to dry.⁸
11. Connect the medication solution tubing to the mainline infusion access port.
12. Administer medication infusions using a programmable infusion pump with a dose error-reduction software system, when available.¹⁴
13. Flush the VAD using a 10-ml syringe filled with preservative-free 0.9% sodium chloride solution.⁹ Use a minimum volume of solution that is equal to twice the internal volume of the catheter and add-on devices or a larger volume (e.g., 10 ml for central VADs; 5 ml for peripheral IV catheters).⁹

    Rationale: A 10-ml syringe generates lower injection pressure.⁹

14. Encourage the patient to report any symptoms, including discomfort at the IV site.
15. Observe the IV site during infusion for sudden swelling.
16. If using a disinfecting port protector or cap, apply a new one.
17. Monitor the patient’s vital signs and BP per the organization’s practice.
18. Discard supplies, remove PPE, and perform hand hygiene.
19. Document the procedure in the patient’s record.

MONITORING AND CARE

1. Monitor the patient for adverse and allergic reactions to the medication. 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.
2. Assess FHR pattern and uterine activity using electronic fetal monitoring as appropriate for the clinical situation and per the organization’s practice.
3. Institute fall risk precautions per the organization’s practice.

EXPECTED OUTCOMES

• Medication administered per the rights of medication safety
• Target BP achieved after medication administration
• No adverse reactions in the patient or fetus

UNEXPECTED OUTCOMES

• Medication not administered per the rights of medication safety
• Target BP not achieved or BP remains elevated after medication administration
• Adverse reactions in the patient or fetus
• Death of patient or fetus
• Infusion site phlebitis, infiltration

DOCUMENTATION

• Medication administration (high-alert medication documentation per organization’s practice)
• Patient’s response to medication, including any adverse reactions
• Patient’s vital signs, BP, peripheral oxygen saturation, and changes in cardiac status
• FHR pattern (if indicated) including changes noted after administration
• IV infusion site
• IV patency and primary fluid
• Education
• Unexpected outcomes and related interventions
• Patient’s weight in kilograms

REFERENCES

1. American College of Obstetricians and Gynecologists (ACOG). (2019). Practice bulletin no. 203: Chronic hypertension in pregnancy. Obstetrics & Gynecology, 133(1), e26-e50. doi:10.1097/AOG.0000000000003020 (Level I)
2. American College of Obstetricians and Gynecologists (ACOG). (2020, reaffirmed 2023). Practice bulletin no. 222: Gestational hypertension and preeclampsia. Obstetrics & Gynecology, 135(6), e237-e260. doi:10.1097/AOG.0000000000003891 (Level I)
3. American College of Obstetricians and Gynecologists (ACOG). (2020). Safe motherhood initiative: Labetalol algorithm. Retrieved November 30, 2023, from https://www.acog.org/-/media/project/acog/acogorg/files/forms/districts/smi-hypertension-bundle-labetalol-algorithm.pdf (Level I)
4. American College of Obstetricians and Gynecologists (ACOG). (2020). Safe motherhood initiative: Maternal safety bundle for severe hypertension in pregnancy. Retrieved November 30, 2023, from https://www.acog.org/-/media/project/acog/acogorg/files/forms/districts/smi-hypertension-bundle-slides.pdf (Level I)
5. Cashion, K. (2024). Chapter 18: Fetal assessment during labor. In D.L. Lowdermilk and others (Eds.), Maternity & women’s health care (13th ed., pp. 356-374). St. Louis: Elsevier.
6. Clinical Pharmacology powered by Clinical Key. (2023). Labetalol. Retrieved November 6, 2023, from https://www.clinicalkey.com
7. Dix, D. (2024). Chapter 27: Hypertensive disorders. In D.L. Lowdermilk and others (Eds.), Maternity & women’s health care (13th ed., pp. 585-599). St. Louis: Elsevier.
8. Infusion Nurses Society (INS). (2021). Infusion therapy standards of practice. Standard 36: Needleless connectors. Journal of Infusion Nursing, 44(Suppl. 1), S104-S107. (Level I)
9. Infusion Nurses Society (INS). (2021). Infusion therapy standards of practice. Standard 41: Flushing and locking. Journal of Infusion Nursing, 44(Suppl. 1), S113-S118. (Level I)
10. Infusion Nurses Society (INS). (2021). Infusion therapy standards of practice. Standard 43: Administration set management. Journal of Infusion Nursing, 44(Suppl. 1), S123-S125. (Level I)
11. Infusion Nurses Society (INS). (2021). Infusion therapy standards of practice. Standard 59: Infusion medication and solution administration. Journal of Infusion Nursing, 44(Suppl. 1), S180-S183. (Level I)
12. 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 November 30, 2023, from https://www.ismp.org/sites/default/files/attachments/2017-11/ISMP97-Guidelines-071415-3.%20FINAL.pdf (Level VII)
13. Institute for Safe Medication Practices (ISMP). (2018). ISMP list of high-alert medications in acute care settings. Retrieved November 30, 2023, from https://www.ismp.org/sites/default/files/attachments/2018-08/highAlert2018-Acute-Final.pdf (Level VII)
14. Institute for Safe Medication Practices (ISMP). (2022). 2022-2023 Targeted medication safety best practices for hospitals. Retrieved November 30, 2023, from https://www.ismp.org/guidelines/best-practices-hospitals (Level VII)
15. Spain, R.O. (2024). Chapter 19: Nursing care of the family during labor and birth. In D.L. Lowdermilk and others (Eds.), Maternity & women’s health care (13th ed., pp. 375-416). St. Louis: Elsevier.

ADDITIONAL READINGS

Druzin, M. and others. (2021). Improving health care response to hypertensive disorders of pregnancy: A California Maternal Quality Care Collaborative (CMQCC) quality improvement toolkit. Retrieved November 30, 2023, from https://www.cmqcc.org

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

Clinical Review: Aimee Hardt, MN, APRN, CNS, ACCNS-N

Published: January 2024