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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 THOKCHOM
TUTOR
R.C.O.N
SUBMITTED BY:-
VARSHA SHARMA
MSC NURSING FIRST YEAR
RUFAIDA COLLEGE OF NURSING
INDEX
SNO CONTENT PAGE NO TEACHERS
SIGNATURE
1 INTRODUCTION 2
2 STANDING ORDERS 2
 DEFINITION 3
 OBJECTIVES 3
 USES 3
 STANDING ORDER FOR A MIDWIFE
DURING:- 4
ANTEPARTUM 6
INTRAPARTUM 8
3 POSTPARTUM 11
4 LIST OF LIFE SAVING DRUGS AND ITS 15
5 RECOMMENDATION 15
6 CONCLUSION 18
RESEARCH ABSTRACTS
BIBILOGRAPHY
STANDING ORDERS, USE OF SELECTED LIFE SAVING DRUGS AND
INTERVENTIONS OF OBSTETRICS EMERGENCIES APPROVED BY THE
MOHFW
INTRODUCTION
A 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.

OBJECTIVES
1. 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.
USES
1. Providing treatment during emergency
2. 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
PRISCRIPTION
All 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
or
Peptac 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 night


MENDELSON’S SYNDROME before theatre, repeated two hours before
IN 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 only


PREPARATION

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 policy


OF 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.

PAEDIATRICS
The 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

ANALGESIA
NSAID 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 twice


daily

Lacunose 10ml orally twice daily

Glycerine suppository 1 or 2 per rectum as


required
HAEMORRHOID Anusol cream apply twice daily and after
each
PREPARATIONS 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


th
the meeting held on the 19 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 Recommendations of the Expert


saving drugs and Advisory Group
interventions in
obstetric emergencies
1 Administration of Inj. It was decided that Tab. Misoprostol
Oxytocin and would be used as prophylaxis against
Misoprostol: 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. Magsulf is the drug of choice for


inj.Magnesium controlling eclamptic fits.
sulphate for prevention The first does should be given by the
and management of ANM/staff nurse/Medical Officer at
Eclampsia 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 It was universally felt that the
infusion to treat shock. 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 The indications for which antibiotic


antibiotics 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 There was a universal consensus


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

6. Removal of retained For incomplete abortion. If bleeding


products of conception. continues, the ANM and staff nurses
can perform only digital evacuation
of products of conception.

7. Manual removal of MRP Should be carried out only by


placenta (MRP) 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 Conduction of an assisted vaginal


assisted vaginal delivery was not possible at the
delivery (forceps community level due to obvious
&vacuum extraction) 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 Scientific evidence proven that
perineal tears. 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.
Abstract
Intravenous 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