SEMINAR ON STANDING ORDERS AND PROTOCOLS AND USE OF

SELECTED LIFE SAVING

DRUGS AND INTERVENTIONS OF OBSTETRIC EMERGENCIES

APPROVED BY

THE MOHFW

SUBMITTED TO:-Mrs. SOMIBALA THOKCHOMTUTORR.C.O.N

SUBMITTED BY:-VARSHA SHARMA

MSC NURSING FIRST YEAR

RUFAIDA COLLEGE OF NURSING

INDEX

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INTRODUCTIONSTANDING ORDERS

DEFINITION OBJECTIVES USES STANDING ORDER FOR A MIDWIFE

DURING:- ANTEPARTUM

INTRAPARTUM POSTPARTUMLIST OF LIFE SAVING DRUGS AND ITS RECOMMENDATIONCONCLUSIONRESEARCH ABSTRACTSBIBILOGRAPHY

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STANDING ORDERS, USE OF SELECTED LIFE SAVING DRUGS AND INTERVENTIONS OF OBSTETRICS EMERGENCIES APPROVED BY THE

MOHFW

INTRODUCTIONA sound understanding of the principle of safe medication management

is essential for all nurses, midwifes and health agencies involved in the care of patient, residents and clients.STANDING ORDERS

A standing order is a document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedure for specific client with identified clinical problem. Standing orders are approved and signed by the physician in charge of care before their implementation. They are commonly found in critical care setting and other specialized practice setting where client’s needs can change rapidly and require immediate attention. Standing orders are also common in the community health setting, in which the nurse encounters situations that do not permit immediate contact with a physician.

Before implementing any therapy, including those includes in standing orders, must use sound judgment in determining whether the interventions are correct and appropriate. Second, before implementing any intervention it is the responsibility of a nurse to obtain the theoretical knowledge and develop the clinical competencies necessary to perform the intervention.

Standing orders are the instructions and orders of specific nature. On the basis of these, in the non availability of doctor, the nurse and health workers can provide treatment to patient at home, hospital or health instructions and community. Generally this instruction/order is in written form, still in some medical instruction and health enterprises standing orders are followed as tradition. It is appropriate to follow standing instruction only on temporary basis, or in case of emergency or when doctor is absent.

BACKGROUND

Historically, standing orders have been used in many practice settings. These documents provide guidance and direction for licensed nurses when carrying out orders in the absence of a Licensed Independent Practitioner

DEFINITION

Standing Orders are orders in which the nurse may act to carry out specific orders for a patient who presents with symptoms or needs addressed in the standing orders. They must be in written form and signed and dated by the Licensed Independent Practitioner.

Examples of situations in which standing orders may be utilized can include,

Administration of immunizations (e.g. influenza, pneumococcal, and other vaccines)

Nursing treatment of common health problems Health screening activities Occupational health services Public health clinical services Telephone triage and advice services Orders for lab tests. School health During labor.

OBJECTIVES1. To maintain the continuity of the treatment of the patient.2. To protect the life of the patient.3. To create feeling of responsibility in the members of health team.

USES1. Providing treatment during emergency2. Enhance the quality and activity of health service.3. Developing the feeling of confidence and responsibility in nurses and

other health workers.4. Protecting the general public from troubles.5. Enhancing the faith of general public in medical institution.

THE DRUGS WHICH CAN BE AMINISTERED DURING ANTEPARTUM, INTRAPARTUM, POSTPARTUM PERIOD BY A MIDWIFE WITHOUT DOCTOR’S PRISCRIPTIONAll intravenous and Controlled Drugs must be checked by two midwives.NB: Any prescriptions for diamorphine and temazepam must be

countersigned by the duty doctor within 24 hours.

ANTEPARTUM

ANALGESIA Paracetamol 1gram as a single dose, once only

ANTACID Maalox suspension 10ml as a single dose, once only

orPeptac liquid 10-20ml as a single dose, once only

LAXATIVE Ispaghula Husk 3.5g one sachet in water, once only

PROPHYLAXIS FOR Ranitidine tablet 150mg at 22.00 on nightMENDELSON’S SYNDROME before theatre, repeated two hours beforeIN ELECTIVE LSCS theatre. Sodium Citrate 0.3mg 30ml orally

once only immediately prior to transfer to Theatre

I.V. THERAPY Compound Sodium Lactate 1 litre i.v. over 8-12 hours, to a maximum of two liters

Heparin 10IU/ml 5ml instilled into i.v. CANNULA

When required every 4-8 hours

LOCAL ANAESTHETIC Lignocaine 1% 0.1ml intradermally prior to cannulation once only

Amethocaine gel 4% 1g 45 minutes prior to venous cannulation once only

NIGHT SEDATION Temazepam 10mg as a single dose up to 2.00am in the morning.

DINOPROSTONE VAGINAL GEL As per induction of labor guidelines.

FOLIC ACID Folic acid 400microgram tablet once daily, until 12-14 weeks gestation.

DEMULCENT COUGH Simple linctus 5ml once onlyPREPARATION

ANTISPASMODIC Peppermint water 10ml in plenty of water, once only.

ANTI –D IMMUNOGLOBULIN

Anti-D immunoglobulin may be given to all non-sensitized Rh D negative women within 72 hours of a sensitizing event in the following circumstances

Prior to 20 weeks gestation Anti-D 250 IU by I.M. injection. The following conditions are:`

Threatened miscarriage after 12 weeks gestation Spontaneous miscarriage after 12 weeks gestation Ectopic pregnancy Therapeutic termination of pregnancy – medical and surgical Following sensitizing events such as amniocentesis

After 20 weeks gestatation Anti- D 500i.u. by i.m. injection Ante partum hemorrhage External cephalic version Intrauterine death Invasive prenatal diagnostic and intrauterine procedures Blunt abdominal trauma

Routine Ante-natal Anti-D prophylaxis

Anti-D 500i.u. by i.m. injection at 28 and 34 weeks gestation

INTRAPARTUM

ANALGESIA Entonox inhalation as required

Diamorphine i.m. 5-10mg every 3-4 hours (women <50kg before pregnancy 5mg only) providing delivery is not imminent, up to a maximum of 2 doses without reference to a Registrar. Monitor respirations for 30 minutes after administration)

ANTI-EMETICS Cyclizine 50mg i.m. every 8 hours as required to a maximum of 150mg/24 hours

Metoclopramide 10mg i.m. every 8 hours as required to a maximum of 30mg in 24 hours or 500 micrograms per Kg in 24 hours for women<60kg

ACTIVE MANAGEMENT Oxytocin 10 i.u.as per unit policyOF LABOUR

Syntometrine 1ml i.m. with anterior shoulder at delivery

I.V. THERAPY Compound Sodium Lactate 1 litre i.v. over 8-12 hours as required to a maximum of 2 litres

Heparin 10u/ml 5ml instilled into i.v. cannula every 4-8 hours when required

LOCAL ANAESTHETIC Lignocaine 1% 0.1ml intradermally prior to cannulation, once only

Amethocaine gel 4% 1g prior to cannulation once only

LAXATIVES Glycerine Suppository 1 or 2 per rectum or

Docusate sodium 90mg microenema as required

EPISIOTOMY Lignocaine 1% 10ml by perineal infiltration.

PAEDIATRICSThe following may be administered to babies after delivery without reference to Paediatric staff:

Oxygen by facemask Phytomenadione 1mg by i.m. injection

POSTPARTUM

EPISIOTOMY REPAIR Lignocaine 1% by perineal infiltration to a maximum of 20ml

ANALGESIANSAID ANALGESIC Only one NSAID should be prescribed at any one time

Cesarean Section for first 24 hours: Anaesthetist will be responsible for analgesia. Unless contra-indicated diclofenac suppository 100mg will be given rectally in Theatre. One dose of an NSAID can be given 14-16 hours after the suppository. If Diclofenac is given, the total dose must not exceed 150mg by all routes in any 24 hours period.

Vaginal delivery or Cesarean Section after first 24 hours:

Ibuprofen tablet or syrup 400mg or 600mg three times a day.

Diclofenac tablet or suppository 50mg three times a day (to a maximum of 150mg in 24 hours by any route).

PARACETAMOL BASED Only one PARACETAMOL BASED ANALGESIC should be prescribed at any one time.

Paracetamol 1gram every 4-6 hours to a maximum of 4grams in any 24 hours as plain or effervescent tablets or rectally as suppository.

Co-dydramol 2 tablets every 4-6 hours to a maximum of 8 tablets in any 24 hours.

ANTIEMETIC Cyclizine 50mg i.m. every 8 hours as required to a maximum of 150mg/24 hours.

Metoclopramide 10mg i.m. every 8 hours as required to a maximum of 30mg in 24 hours or 500 micrograms per Kg in 24 hours for women<60kg

LAXATIVES Ispaghula Husk 3.5g, 1 sachet in water twicedaily

Lacunose 10ml orally twice daily

Glycerine suppository 1 or 2 per rectum as required

HAEMORRHOID Anusol cream apply twice daily and after eachPREPARATIONS bowel movement

Scheriproct ointment apply twice daily for 5-7 days then once daily until symptoms cleared

I.V. THERAPY Compound Sodium Lactate 1 litre i.v. every 8-12 hours as required to a maximum of 2 litres

Heparin 10u/ml 5ml instilled into i.v. cannula every 4-8 hours when required

LOCAL ANAESTHETIC Lignocaine 1% 0.1ml intradermally prior to cannulation, once only

Amethocaine gel 4% 1g prior to venous cannulation once only

ANTI –D Anti-D Immunoglobulin 500i.u or more. by i.m. injection to Rh D negative women with a Rh D positive baby within 72 hours of delivery as per obstetric unit guidelines.

VACCINES Rubella vaccine (live) 0.5ml by deep subcutaneous or intramuscular injection if mother not immune.

IRON SUPPLEMENT Ferrous sulphate tablet 200mg three times a day if haemoglobin below 10g/dl.

DEMULCENT COUGH Simple linctus 5ml 3-4 times a day.PREPARATION

ANTISPASMODIC Peppermint water 10ml in plenty of water, once only.

LIFE SAVING DRUGS AND ITS RECOMMENDATION

The Expert Advisory Group Meeting held on 140.10.2004 as a follow up

the meeting held on the 19th of July 2004 was to suggest recommendations on various issues which needed policy decisions related to the use of selected life saving drugs and interventions in obstetric emergencies by Staff Nurses.

S NO Use of selected life saving drugs and interventions in obstetric emergencies

Recommendations of the Expert Advisory Group

1 Administration of Inj. Oxytocin and Misoprostol:

It was decided that Tab. Misoprostol would be used as prophylaxis against PPH, in all deliveries, as a part of active management of the third stage of labour. • Tab. Misoprostol should be given, sublingually or orally, 600mg (3 tablets of 200 mg each), immediately after the delivery of the baby.

If a woman bleeds for more than 10 minutes after deliver, she should be given 10U Inj. Oxytocin preferably by the IV route

2. Administration of inj.Magnesium sulphate for prevention and management of Eclampsia

Inj. Magsulf is the drug of choice for controlling eclamptic fits. The first does should be given by the ANM/staff nurse/Medical Officer at the PHC The woman should immediately be referred to a CHC/FRU and not a PHC. This is because in these cases termination of pregnancy will be required, and a PHC may not be equipped for the same. This first dose should be given as a 50% solution (this preparation is available in the market). 8cc need to be given to make a total dose of 4 gms. It should be given deep intramuscular in the gluteal region. If this precaution is not taken, it will lead to the development of abscess at the injection site. Before and during transportation for referral, certain supportive treatment needs to be included in the protocol for management of case of eclampsia. • Ensure that the woman does not fall down or injuries herself in any manner. • Ensure that her air passages are clear. • If transportation is going to take a long time, catheterization of the woman may be considered. • A soft mouth gag should be put to prevent tongue bite. • It should be ensured that the woman reaches the referral center within 2 hours. This is because a second dose of magnesium sulphate may be required after 2 hours. Hence early and immediate referral

is essential. • 22G needles and 10cc syringes also needed to be included in the ANM kit.

3. Administration of i.v infusion to treat shock.

It was universally felt that the administration of IV infusions was a life saving procedure. As haemorrhage was the commonest cause of maternal mortality, the administration of 3ml of fluid for every ml of blood lost could keep the woman alive.As of now, the ANMs are neither trained nor allowed by the regulatory authorities to establish an IV line. After the discussion, it was decided that: • If the ANM is trained to give IV infusion, she should administer wherever feasible, even at home. • The ANM should start infusion with Ringer Lactate or Dextrose Saline. • If an IV infusion was being started in cases of PPH, it was recommended the IV fluid should be augmented with 20U of Oxytocin for every 500 ml bottle of fluid. This could be continued throughout transportation.

However, the logistics and feasibility of the ANM being able to carry IV infusion sets and IV fluids to homes need to be explored, and ensured.

4. Administration of antibiotics

The indications for which antibiotic therapy is recommended are: • Premature rupture of membranes • Prolonged labour •Anything requiring manual

intervention • UTI • Puerperal sepsis

There should be instructions for the ANM that after starting the woman on antibiotics, she should inform the PHC Medical Officer

5. Administration of antihypertensives

There was a universal consensus that only the Medical Officer should be allowed to administer anti- hypertensive to a woman with hypertension in pregnancy.

6. Removal of retained products of conception.

For incomplete abortion. If bleeding continues, the ANM and staff nurses can perform only digital evacuation of products of conception.

7. Manual removal of placenta (MRP)

MRP Should be carried out only by the medical officer in health facility(PHC or CHC)settings.If the placenta was partially separated (as could be diagnosed by the presence of vaginal bleeding ) the ANM should try and see if a part of the placenta seen coming out from the OS. Then she could exist the removal of the placenta.The ANM should be trained in the active management of the 3rd stage of the labour

8. Conduction of an assisted vaginal delivery (forceps &vacuum extraction)

Conduction of an assisted vaginal delivery was not possible at the community level due to obvious reasons. Hence it was universally felt that :Assisted vaginal deliveries(i.e.

The use of obstetric forceps or vacuum extraction) should be carried out by the medical officer only.The ANM and staff nurse need to be trained in the use of partograph purpose only. This will help her in talking a decision for referral in case of prolonged labour.

9. Repair of vaginal and perineal tears.

Scientific evidence proven that superficial tears do not require any repair, because the outcome was the same whether or not such a tear was sutured.The ANM should be able to recognise a superficial, and should be distinguish it from deeper tears. She should simply apply pad and pressure on the tear.For second and third degree tears which require repair, the ANM should refer the women to a higher facility.The staff nurses should be allowed to repair a second degree tear at the PHC setting, under the supervision of the medical officer. But she too should refer third degree tears after vaginal packing.It was decided that the medical officer and the staff nurses required to be trained in recognizing the degree of tear.No additional material /iteams thus need to be added to the ANM kit for the repair of vaginal/perineal tears.

According to that the nurses are approved for use of thee drugs by nurses and ANM as mentioned below:-

1. Tab misoprostol for prevention of post partum haemorrhage.

2. IV Infusion and injection Oxytocin for management of post partum hemorrhage and shock.

3. Injection magnesium sulphate for management of Eclampsia.4. Use of Gentamycin IM,Ampicillin and metonidazole orally for prevention

of infection (pureperial sepsis,premature rupture of membranes,prolong labour,any manual intervention )

CONCLUSION

Nurses must have a solid knowledge based on the factors affecting maternal, newborn and women’s health and barriers to health care. It is useful for identifying high-risk groups. Nurse can help women to increase control over the factors that affecting health, thereby improving their health status

RESEARCH ABSTRACT

A Study to Compare the Efficacy of Misoprostol, Oxytocin, Methyl-ergometrine and Ergometrine-Oxytocin in Reducing Blood Loss in Active Management of 3rd Stage of Labor.Abstract

OBJECTIVES:The purpose of the study was to compare the efficacy of misoprostol 400 μg per rectally, injection oxytocin 10 IU intramuscular, injection methylergometrine 0.2 mg intravenously and injection (0.5 mg ergometrine + 5 IU oxytocin) intramuscular on reducing blood loss in third stage of labor, duration of third stage of labor, effect on haemoglobin of the patient, need of additional oxytocics or blood transfusion and associated side effects and complications.

STUDY DESIGN:A prospective non-randomized uncontrolled study was carried out in the Department of Obstetrics and Gynecology, SSG Hospital and Medical College, Baroda enrolling 200 women and dividing them into four groups. Active management of 3rd stage of labor was done using one of the 4 uterotonics as per the group of the patient. The main outcome measures were the amount of blood loss, the incidence of postpartum

hemorrhage and a drop in hemoglobin concentration from before delivery to 24 h after delivery.

RESULTS:Methylergometrine was found to be superior to rest of the drugs in the study with lowest duration of third stage of labor (P = 0.000096), lowest amount of blood loss (P = 0.000017) and lowest incidence of PPH (P = 0.03). There was no significant difference in the pre-delivery and the post-delivery hemoglobin concentration amongst the four groups with P = 0.061. The need of additional oxytocics and blood transfusion was highest with misoprostol as compared to all other drugs used in the study with P = 0.037 and 0.009, respectively. As regards side effects, misoprostol was associated with shivering and pyrexia in significantly high number of patients as compared to the other drugs used in the study while nausea, vomiting and headache were more associated with methylergometrine and ergometrine-oxytocin. However all the side effects were acceptable and preferable to the excessive blood loss.

CONCLUSION:Methylergometrine has the best uterotonic drug profile amongst the drugs used, strongly favouring its routine use as oxytocic for active management of third stage of labor. Misoprostol was found to cause a higher blood loss compared to other drugs and hence should be used only in low resource setting where other drugs are not available. The role of misoprostol in third stage of labor needs larger studies to be proved.

ABSTRACT:-2

Comparison of the efficacy of nifedipine and hydralazine in hypertension.

Source

Department of Obstetrics & Gynecology, Women Hospital, Tehran University of Medical Sciences, Iran.AbstractIntravenous hydralazine is a commonly administered arteriolar vasodilator that is effective for hypertensive emergencies associated

with pregnancy. Oral nifedipine is an alternative in management of these patients. In this study the efficacy of nifedipine and hydralazine in pregnancy was compared in a group of Iranian patients. Fifty hypertensive pregnant women were enrolled in the study. A randomized clinical trial was performed, in which patients in two groups received intravenus hydralazine or oral nifedipine to achieve target blood pressure reduction. The primary outcomes measured were the time and doses required for desired blood pressure achievement. Secondary measures included urinary output and maternal and neonatal side effects. The time required for reduction in systolic and diastolic blood pressure was shorter for oral nifedipine group (24.0 ± 10.0 min) than intravenus Hydralazine group (34.8 ± 18.8 min) (P ≤ 0.016). Less frequent doses were required with oral nifedipine (1.2 ± 0.5) compared to intravenus hydralazine (2.1 ± 1.0) (P ≤ 0.0005). There were no episodes of hypotension after hydralazine and one after nifedipine. Nifedipine and hydralazine are safe and effective antihypertensive drugs, showing a controlled and comparable blood pressure reduction in women with hypertensive emergencies in pregnancy. Both drugs reduce episodes of persistent severe hypertension. Considering pharmacokinetic properties of nifedipine such as rapid onset and long duration of action, the good oral bioavailability and less frequent side effects, it looks more preferable in hypertension emergencies of pregnancy than hydralazine.

BIBILOGRAPHY

1. Kamini Rao, textbook of midwifery and obstetrics for nurses, Elsevier publication, 1st edition .

2. Annamma Jacob, text book of midwifery, 1st edition, jaypee publication 2005.

3. Adele pillitteri, child health nursing care of the child and family, 1st edition Lippincott publication.

4. Potter & perry , fundamentals of nursing,5 th edition, Elsevier publication.

5. www.drugs2004rn.com .6. www.pubmed.com 7. www.scribda,com