Toradol use in L&D

[foreverLaur]

let me just preface this by saying i am a nursing student doing my ob rotation right now.

toradol is apparently a very common medication used in l&d. the hospital i am at for clinical uses it all the time and i have heard other classmates say their hospitals use it too. yesterday i had a patient in the recovery room after a c-section. she was breast feeding and had some break through pain (she had duramorph in her spinal). the patient had a standing order for toradol and the nurse gave her 30mg. i researched the medication and found that it has a lot of black box warnings. it is contraindicated in l&d because it can inhibit uterine contractions and it is contraindicated in nursing mothers because potential adverse affects can be passed on to the babies less than 1 month old. it is also contraindicated if the patient is at a high bleeding risk because it inhibits platelet function. so it sounds to me like this is the worst possible drug to be using in these situations and hospitals are using it as their go-to drug! can someone please explain to me why? with just this knowledge, i don't feel comfortable giving it.[color=#663366]

[lynzsey11]

Im a new nurse on L&D, and toradol is a mainstay on my floor. I dont know why it is given so much with all the side effects, but I can tell you it is given all the time.

[WolfpackRed]

toradol is an NSAID and better for breastfeeding mothers than opioids, as the opioid metabolites can pass through the milk to the child to cause respiratory depression.

the platelet dysfunction is transient and only lasts~1-3 days.

the uterine contraction are not a major concern as the mother can get oxytocin, methergine, uterine massage, etc.

Finally, black box warnings should be taken with a grain of salt. Yes, they do represent an extreme outcome, but often it is a small population of patients. look into why and how the black box warning came about.

An example for anesthesia related drugs is droperidol. it is an excellent drug for the prevention of post op nausea and vomiting, but due to a black box warning, which was initiated ~30 years ago due to a handful of deaths, the drug is hardly used. the drug is now in generic formulation and there is no money in fighting the FDA to remove the black box despite research showing its safe use since that time.

[Elvish, BSN, DNP, RN, NP]

First, no one will give Toradol to a pregnant woman in L&D, as it can close the fetal PDA, which we want after the baby is born, but not before. So don't even worry about that black box warning. (ETA - not meaning you should ignore it, just know that it's not prescribed for women about to deliver.)

Second, NSAIDs are generally considered safe in the breastfeeding community, even stronger ones like Toradol. The amount excreted in breastmilk is small enough that the benefit the baby gets from receiving mom's milk is far greater than any risk from Toradol. (Opioids too, for that matter, but that's beside the point.) Next time you are on the unit for clinical, ask if they have a copy of Dr. Hale's Medications and Mother's Milk (link below). It is a great resource beyond medication package inserts. It's our gold standard for what can and can't be given while breastfeeding. There's very very little that's actually truly contraindicated....and Toradol doesn't make the list. (Even some contrast dyes are compatible w/ breastfeeding, it just depends which one!)

http://www.ibreastfeeding.com/catalog/Drugs-and-Breastfeeding/c29/p237/2010-Medications-and-Mothers&%2339-Milk/product_info.html

[klone, MSN, RN]

The only time we do not use Toradol in OB (after delivery, of course - it's never used in L&D) is if urine output is scant, or if she has a clotting disorder and cannot have any NSAIDs.

IMO, Toradol works better than narcotics for post surgical pain. And it's not contraindicated with breastfeeding.

[JeneraterRN]

Darn, I jumped on this one because I thought I could give a good answer, but the previous three responders nailed it. Kudos to all!

[AprilAZRN]

We use if often post c/s. I've also seen an increase in use for PTL pts that present in triage less than 28 weeks. It works very well.

[MKS8806]

This is all very interesting! We hardley EVER give Toradol! In fact, its not even a standing order on our unit. I think in the past year, I've had 1 MAYBE 2 patients that have been prescribed Toradol post partum (usually c-section patients), but end up getting it DC'd due to low urine output or something along that line. I'm wondering if we shouldn't be using it more?

[foreverLaur]

So how, as nursers, do we know when it is OK to "ignore" black box warnings and when it is something we should really be concerned about? The drug guides just list all the information!!

[JeneraterRN]

So how, as nursers, do we know when it is OK to "ignore" black box warnings and when it is something we should really be concerned about? The drug guides just list all the information!!

Your MD has the training and knowledge base (hopefully) to make a risk vs. benefit decision. If you feel like you should question it, then do. Hopefully, the MD's you are around are approachable and are willing to explain.

[rn/writer, RN]

As Elvish said, Dr. Hale's Medications and Mother's Milk, is an excellent resource.Black box warnings in the regular drug books are like the disclaimers on television drug ads. You know, the ones that list problems that sound far worse than the problem you're taking the drug for in the first place. This is legalese and cya at it's finest. If they mention all of the worst case scenarios and you end up with one of them, they can say, "Hey, we warned you."

Besides trusting the docs' experience, talk to your co-workers. There are some things in L&D that make a number of nurses squeamish. But Toradol is probably pretty low on the list of worries.

The only reason we would withhold Toradol is low platelets, clotting problem, or allergy. It's one of our most effective meds and has among the fewest side effects. The babies don't seem to be affected in any adverse way. On the unit where I work, it is definitely one of the best meds in our bag of tricks.

[suezan59]

We use Toradol for post-op C/S all the time; however, they max out at 4 doses because it's rough on the kidneys (or so I was told). The breast milk transfer issue is not taken into consideration because mom is just not making that much milk yet. Same with the Dilaudid and morphine PCAs we use all the time - OK for newborns who are just getting colostrum, but not if mom's milk is in.