Core Section of Patient Group Directions 1.

Introduction
Patient group direction supersedes Midwives Standing Orders. This patient group direction states which medicines may be supplied and administered by midwives within the Borders General Hospital NHS Trust. Midwives may, under the Medicines Act 1968, supply all medical products on the General Sale List and Pharmacy List and administer a small range of Prescription Only Medicines. The formulary contains monographs for all products within the patient group directions and should be used in conjunction with the information in the core section of the patient group direction.

2.

Clinical Decision Making

Patients who may receive midwives formulary medicines This patient group direction should be used for the supply and/or administration of the agreed medicines to ante-partum, intra-partum or post partum mothers within the Borders General Hospital NHS Trust. The medicines may only be used within individual product monograph recommendations and contra-indications. 2.1 Consent If the patient does not wish to receive treatment with a formulary item, and no alternative is listed, medical help should be sought to find a suitable therapy. Patient Information Leaflets may be supplied if available. 2.2 Contra-indications No product in this formulary should be used without consideration of the possible consequences to the patient. Formulary products should not be used if the patient has previously had or suspected an adverse reaction to the product, or if a contra-indication for that patient occurs in the monograph. In these cases the patient should be referred to a doctor. 2.3 Precautions The products listed in this formulary should be used only for the specific condition specified in the monograph. Formulary items should not be used for the treatment of patients who have known, or suspected hypersensitivity to any product or any of its ingredients. In the event that an adverse reaction occurs, use of the product should be stopped and medical help sought immediately. Facilities for treating anaphylaxis should always be available.

3.

Designated staff authorised to administer midwives formulary products

Authorised Staff The following staff who are employed by the Borders General Hospital NHS Trust are authorised to administer Midwives Formulary products without individual medical prescription for conditions specified in the product monograph. 3.1 Registered Midwife In addition the following requirements are necessary: 3.2 To be professionally accountable To have received adequate training and be competent To be familiar with contra-indications to the product To have access to the current group protocols for the administration of Medicines in the Midwives Formulary To be trained to identify anaphylaxis To have immediate access to appropriate equipment and drugs to treat anaphylaxis and have access to the current protocol and guidelines for its management To maintain their own professional level of competence and knowledge.

Head of Midwifery/Midwife Managers will be responsible for: Ensuring that there are patient group directions for the administration of medicines in the midwifery formulary Ensuring that midwives administering products have received adequate training and follow the patient group directions for the administration of products in the midwifery formulary.

3.3

The midwife will be given a copy of the patient group directions which she/he will sign along with the line manager and Pharmacist.

4.

Treatment Available
4.1 Product, Dose, Route and Frequency See individual product monograph and summary table 4.2 Adverse Reactions See individual product monographs 4.3 Follow-up Treatment Patients should be observed for any sign of adverse drug reaction
2

5.

Documentation
5.1 Out-patient settings The supply of medicines must be documented in the womans case notes, eg an immediate discharge letter should be completed and filed (B77). 5.2 In-patients All medicines must be prescribed on the Obstetric Medicine Chart for Self Medication/Borders General Hospital NHS Medicine Chart and documented in the case notes, according to policies and procedures relating to the department. The name of the prescribing midwife must be printed legibly and signed.

6.

Further Points
Manufacturer and patient information leaflets for any product in the formulary should be read and advice taken from them. The recommendations for storage and handling of any product in the formulary must be followed.

7.

Concurrent Medication
See individual product monograph

8.

Management and monitoring of Group Protocols

8.1 Consultative Group Vince Summers: Brian Magowan: Hazel Gueldner: Margaret Davison: Chief Trust Pharmacist Consultant Obstetrician Obs & Gynae Pharmacist Midwife

The following can be administered without reference to medical staff, provided that all are entered correctly in the drug prescription sheet as per BGH prescribing guidelines and signed by the initiating midwife. All intravenous and Controlled Drugs must be checked by two midwives. NB: Any prescriptions for diamorphine and temazepam must be countersigned by the duty SHO within 24 hours. Please refer to the appended monograph for the individual drug before administering. ANTEPARTUM ANALGESIA ANTACID Paracetamol 1gram as a single dose, once only Maalox suspension 10ml as a single dose, once only or Peptac liquid 10-20ml as a single dose, once only Ispaghula Husk 3.5g one sachet in water, once only Ranitidine tablet 150mg at 22.00 on night before theatre, repeated two hours before theatre. Sodium Citrate 0.3M 30ml orally once only immediately prior to transfer to Theatre Compound Sodium Lactate 1 litre i.v. over 8-12 hours, to a maximum of two litres 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 under occlusive dressing 45 minutes prior to venous cannulation once only NIGHT SEDATION Temazepam 10mg as a single dose up to 2.00am in the morning.

APERIENT PROPHYLAXIS FOR MENDELSONS SYNDROME IN ELECTIVE LSCS I.V. THERAPY

DINOPROSTONE VAGINAL GEL As per induction of labour guidelines. FOLIC ACID DEMULCENT COUGH PREPARATION ANTISPASMODIC Folic acid 400microgram tablet once daily, until 12-14 weeks gestation. Simple linctus 5ml once only Peppermint water 10ml in plenty of water, once only.

ANTI D IMMUNOGLOBULIN Anti-D immunoglobulin may be given to all non-sensitised Rh D negative women within 72 hours of a sensitising event in the following circumstances Prior to 20 weeks gestation Anti-D 250iu by i.m. injection Threatened miscarriage after 12 weeks gestation Spontaneous miscarriage after 12 weeks gestation Ectopic pregnancy Therapeutic termination of pregnancy medical and surgical Following sensitising events such as amniocentesis Incomplete miscarriage requiring E.R.P.O.C. After 20 weeks gestatation Anti- D 500i.u. by i.m. injection Antepartum haemorrhage 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

The above should be used in conjunction with the guidelines Obstetric/Antenatal screening/Rhesus Programme from the Borders General Hospital Laboratory Handbook 3rd Edition 1999

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 PROPHYLAXSIS FOR MENDELSONS SYNDROME ACTIVE MANAGEMENT OF LABOUR Ranitidine tablet 150mg every 6 hours Sodium Citrate 0.3M 30ml prior to Theatre as a single dose Oxytocin 10i.u.as per unit policy Syntometrine 1ml i.m. with anterior shoulder at delivery Compound Sodium Lactate 1 litre i.v. every 812 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 under occlusive dressing 45 minutes prior to venous cannulation once only LAXATIVES Glycerine Suppository 1 or 2 per rectum or Docusate sodium 90mg microenema as required Lignocaine 1% 10ml by perineal infiltration

I.V. THERAPY

EPISIOTOMY

PAEDIATRICS

The following may be administered to babies after delivery without reference to Paediatric staff: Oxygen by facemask Phytomenadione 1mg by i.m. injection

ANAESTHETICS RESTRICTIONS New anaesthetic guidelines in relation to post-operative pain management have been recently issued (March 1999). Midwives should, therefore, be aware it is no longer appropriate to use obstetric patient group directions for post-operative analgesia during the first 24 hours. The anaesthetic department has assumed responsibility for post-operative pain management in this period. If the patent requires an adjustment to their prescription the on-call anaesthetist should be contacted.

POSTPARTUM EPISIOTOMY REPAIR ANALGESIA NSAID ANALGESIC Lignocaine 1% by perineal infiltration to a maximum of 20ml 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 ANALGESIC 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 Lactulose 10ml orally twice daily Glycerine suppository 1 or 2 per rectum as required

HAEMORRHOID PREPARATIONS

Anusol cream apply twice daily and after each 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 812 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 under occlusive dressing 45 minutes 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. Rubella vaccine (live) 0.5ml by deep subcutaneous or intramuscular injection if mother not immune. Ferrous sulphate tablet 200mg three times a day if haemoglobin below 10g/dl. If symptomatic refer to SHO. Simple linctus 5ml 3-4 times a day. Peppermint water 10ml in plenty of water, once only.

VACCINES

IRON SUPPLEMENT

DEMULCENT COUGH PREPARATION ANTISPASMODIC

10

EMERGENCY PRESCRIPTIONS The following can be administered FOLLOWING AND ONLY WITH reference to medical staff, provided that all are entered correctly in the casenotes/drug or i.v. prescription sheet, signed by the initiating midwife and countersigned by the duty SHO as soon as practicable OXYGEN TREATMENT OF SEVERE HYPOGLYCAEMIA ANTEPARTUM HAEMORRHAGE POSTPARTUM HAEMORRHAGE Oxygen 6 litres/minute by face mask Glucagon 1mg i.m. or i.v. Hypostop gel orally as required Compound Sodium Lactate 500-1000ml stat IV Gelofusine 500ml stat IV Syntometrine 1ml i.m. Oxytocin 10i.u by i.m. or i.v. injection Oxytocin 40i.u. in 1 litre Compound Sodium Lactate at a rate of up to 250ml/hour Gelofusine 500ml stat IV The following can be prepared and administered if there is an existing prescription written by Medical staff. It must be checked by two midwives. TO CONTINUE TREATMENT OF PREMATURE LABOUR Ritodrine 150mg in Glucose 5% 500ml, rate as per guidelines. Atosiban concentrate for intravenous infusion 75mg (10ml) in 90ml Sodium Chloride 0.9% as per obstetric unit guidelines.

11

FORMULARY A Monograph for the following drugs allowed to be administered under the patient group directions are appended. If you are at all unsure about the suitability of a particular drug for a particular patient please refer to the duty SHO or a pharmacist before prescribing or administering.

(i) (ii) (iii) (iv) (v) (vi) (vii) (viii) (ix) (x) (xi) (xii) (xiii) (xiv) (xv) (xvi) (xvii) (xviii) (xix)

Amethocaine Gel Anti-D Immunoglobulin Anusol Cream Atosiban Injection Co-dydramol Tablets Compound Sodium Lactate Infusion BP Cyclizine Injection 50mg Diamorphine Injection 5mg or 10mg Diclofenac Tablets and Suppositories Dinoprostone Vaginal Gel 1mg or 2mg (Prostin) Docusate Sodium Microenema 90mg Entonox Ferrous Sulphate Tablet 200mg Folic Acid Tablets 400micrograms Gelofusine (Gelatin) Intravenous Infusion Glucagon Injection 1mg (GlucaGen) Glycerin Suppository 4g Heparin Injection 10iu/ml Hypostop Gel
12

(xx) (xxi) (xxii) (xxiii) (xxiv) (xxv) (xxvi) (xxvii) (xxviii) (xxix) (xxx) (xxxi) (xxxii) (xxxiii) (xxxiv) (xxxv) (xxxvi) (xxxvii) (xxxviii) (xxxix)

Ibuprofen Tablet 400mg or 600mg or Suspension 100mg/5ml Ispaghula Husk Sachet 3.5g (orange) Lactulose Solution Lignocaine (Lidocaine) 1% Injection Maalox Suspension Metoclopramide Injection 10mg Oxygen Oxytocin Injection Paracetamol Tablet 500mg or Suppositories 500mg Peppermint Water Peptac Liquid Phytomenadione Injection 1mg Ranitidine Tablets 150mg Ritodrine Injection Rubella Vaccine 0.5ml Scheriproct Ointment Simple Linctus Sodium Citrate 0.3M Solution Syntometrine Injection Temazepam Tablet 10mg

13

(i)

AMETHOCAINE GEL Pharmaceutical Presentation White gel containing amethocaine 4% w/w. Each tube contains 1.5g of gel which disperses 1g equivalent to 40mg amethocaine. Indication Local anaesthetic for application to a skin site prior to insertion of a needle or cannula. Contra-indication Allergy to any of the ingredients or other local anaesthetic. Premature infants or infants less than 1 month old. Dose 1g of gel to be applied to the affected area. (Do not rub the gel into the skin). Apply a plastic film dressing for 30-45 minutes, then remove the dressing and wipe off the gel. Maximum duration of gel application to the skin must not exceed 1 hour. Side effects Redness, itching and swelling of the site of application.12 Rarely blistering of the skin may occur. Patient Information The site will remain numb for about 4-6 hours. The gel should only be applied to the intended site and should not be placed on any wounds or broken skin, the eyes, ears, mouth, genitals or anus.

References: August 2001

BNF No 41; Ametop Package Information leaflet

14

(ii)

ANTI-D IMMUNOGLOBULIN 250IU or 500IU Pharmaceutical Presentation Clear liquid containing either 250IU or 500IU per vial. Indication Protection of non-immune Rh(D) negative individual exposed to Rh(D) positive cells. Contra-indication Must not be given to Rh(D) positive individuals, or those with known sensitivity to any of the ingredients or those who are known to have immune Anti-D antibodies. The product must not be given intravenously. Dose As per guidelines within 72 hours of a sensitising event, by deep intramuscular injection, preferably into the deltoid muscle. NB: The product should be stored at between 2C and 8C in a fridge. However, it can be kept for 1 week at ambient temperature (25C) without detrimental effect on one occasion during the shelf life. Side effects This product is generally well tolerated. Rare anaphylactoid reactions may occur if individual has antibodies against immunoglobulin A (IgA) or has atypical reactions after blood transfusion or administration of blood derivatives. Large doses may cause fever and chills. Patient Information Administration of live vaccines should not be carried out until 3 months after you have had this product. If you have had a live vaccine in the last 2-4 weeks, the efficacy of that vaccine may be impaired. There may also be interference with some laboratory tests so tell your GP if you have to attend for any blood tests.

References: August 2001

Technical Information leaflet

15

(iii)

ANUSOL CREAM Pharmaceutical Presentation A buff coloured cream containing zinc oxide 10.75%, bismuth oxide 2.14% and balsam peru 1.8%. Indication Relief of pain, swelling, itch and irritation of external and internal haemorrhoids (piles). Contra-indication Sensitivity to any of the ingredients. Care should be taken if there is any rectal bleeding. Dose Apply to the affected area after washing and drying, morning and night and after each bowel movement. For internal haemorrhoids the nozzle provided should be used. Side effects Mild irritation or burning on application of cream. Sensitivity reactions including rash. Patient Information The tube is for your own personal use. If the nozzle is used to apply the cream to internal haemorrhoids, it should be cleaned after each use. To aid recovery and help prevent recurrence of haemorrhoids, you should eat a diet with plenty of fibre, drink plenty of water and take regular exercise.

References: August 2001

BNF No 41, Anusol Package Information leaflet

16

(iv)

ATOSIBAN INJECTION Pharmaceutical Presentation Solution for IV injection: Solution containing Atosiban 6.75 as Atosiban acetate in 0.9ml. Solution for IV infusion: Solution containing Atosiban 37.5mg as Atosiban acetate in 5ml for intravenous infusion after dilution.

Indication To delay imminent pre-term birth in 24 to 33 weeks of pregnancy. Contra-indication Known hypersensitivity to any of the ingredients. Gestational age below 24 or above 33 weeks, Premature membrane rupture after 30 weeks gestation, Intrauterine growth retardation, abnormal fetal heart rate, uterine haemorrhage, eclampsia or severe pre-eclampsia, intrauterine fetal death, placenta praevia, abruptio placenta, suspected intrauterine infection. Caution in hepatic or renal disease or diabetic patients. Dose As per unit policy. Bolus dose of 0.9ml should be the solution for IV injection and need to be given by a doctor; the infusion should be prepared using the solution for IV infusion. Side effects Nausea, vomiting, headache, dizziness, flushing, tachycardia, hypotension, hyperglycaemia, fever, insomnia, pruritis, rash, rarely uterine haemorrhage or atony. Hypersensitivity reactions including injection site inflammation has been noted. Patient Information This is to suppress the contractions of the uterus. This infusion may be continued for up to 45 hours to try and prevent progression of labour. If you feel unwell, tell your midwife.

Reference: August 2001

BNF 41, Tractocile Data Sheet

17

(v)

CO-DYDRAMOL TABLETS 10/500 Pharmaceutical Presentation Round white tablet containing Paracetamol 500mg and dihydrocodeine 10mg. Indication Relief of mild to moderate pain Contra-Indication Current prescription for any other paracetamol-containing analgesic. Known hypersensitivity to paracetamol or dihydrocodeine or medicines containing these drugs. Caution in patients with breathing difficulties, hypothyroidism, alcoholic liver disease, liver or kidney problems. May affect warfarin treatment. Metoclopramide may enhance absorption of paracetamol. Dose Two tablets every 4-6 hours, to a maximum of 8 tablets in any 24 hours. Side Effects Constipation, nausea, headache and dizziness. Hypersensitivity reactions or blood disorders may occur. Patient Information This product contains paracetamol. Maximum of 2 tablets at any one time and maximum of 8 tablets in any 24 hour period. Also contains dihydrocodeine. May cause drowsiness. If you feel drowsy you should not drive or operate machinery. If you take an overdose, seek medical advice immediately.

References: August 2001

BNF No 41 Package Information leaflet

18

(vi)

COMPOUND SODIUM LACTATE INFUSION BP Pharmaceutical Presentation Solution for infusion containing sodium chloride, sodium lactate, potassium chloride, calcium chloride, sodium hydroxide and lactic acid in water for injection. Indication Intravenous fluid. Contra-indication Caution in heart failure, oedema, hypertension, eclampsia, aldosteranism or renal failure. Dose 1000ml to be given over 8-12 hours as required in the management of the patient. Side effects Excess administration may lead to hypokalaemia and metabolic alkatosis, especially with impaired renal function. Symptoms include tiredness, shortness of breath, muscle weakness, mood changes and irregular heart beat. Patient Information

References: August 2001

Martindale 32nd edition

19

(vii)

CYCLIZINE INJECTION 50mg Pharmaceutical Presentation Ampoule containing cyclizine lactate 50mg in 1ml solution. Indication Antihistamine type antiemetic. Contra-indication Know sensitivity to cyclizine. Caution in glaucoma, severe heart failure, obstructive bowel disease, and patients taking other sedating drugs or alcohol. Dose 50mg by intramuscular injection three times daily as required to maximum 150mg/day. Side effects Urticaria, rash, drowsiness, blurred vision, dry mouth, tachycardia, urine retention, constipation, nervousness, insomnia, restlessness, hallucinations (auditory and visual), cholestatic jaundice, chorea, hypersensitivity hepatitis, agranulocytosis and fixed drug eruptions have been reported. Patient Information There may be side effects such as drowsiness, dry mouth, palpitations, difficulty in passing urine, constipation and vision problems. Tell your midwife if you experience any of these problems.

References: August 2001

BNF No 41, Valoid data sheet

20

(viii)

DIAMORPHINE INJECTION 5mg or 10mg Pharmaceutical Presentation Each vial contains a white sterile freeze-dried powder of diamorphine hydrochloride BP 5 or 10mg for reconstitution for injection. Indication Treatment of severe pain during labour. Contra-indication Known hypersensitivity to diamorphine. Respiratory depression, obstructive airways disease, raised intracranial pressure (head injury requires caution), phaeochromaocytoma or within 2 weeks of taking a monoamine oxidase inhibitor. Great caution should be used if known or suspected history of drug abuse. Caution in toxic psychosis, acute alcoholism, adrenal insufficiency, CNS depression, myoedema, severe inflammatory obstructive bowel disorders, hepatic or renal impairment. Dose Reconstitute the powder with water for injection prior to use. 5-10mg (pre-pregnancy weight <50kg 5mg only) by intramuscular injection every 3-4 hours to a maximum of two injections before reference to a registrar. This must not be given if delivery is imminent. Monitor respiration for 30 minutes after administration. Side effects Respiratory depression, possible circulatory depression, sedation, nausea, vomiting, constipation, sweating, dizziness, confusion, urinary retention, biliary spasm, miosis, vertigo, palpitations, orthostatic hypotension, dry mouth, mood changes, urticarial, pruritis, facial flushing and raised intracranial pressure. Patient Information The analgesic will usually be given with something to make you feel less sick. The effect should last for 3 or 4 hours. If you feel unwell tell your midwife.

References: August 2001

BNF No 41, Data Sheet

21

(ix)

DICLOFENAC TABLETS 50mg or SUPPOSITORY 50-100mg Pharmaceutical Presentation Tablets: Round brown tablets each containing diclofenac sodium 50mg Suppositories: Suppository containing diclofenac 50mg or 100mg in a wax base. Indication Non-steroidal anti-inflammatory drug for the relief of pain. Contra-indication Known hypersensitivity to diclofenace, aspirin, any other NSAID, or any of the ingredients. Any other NSAID prescription, Asthma unless previous NSAID or aspirin administration was tolerated. Active gastro-intestinal disease. Contraindicated within 8-12 days of mifepristone administration. Caution in patients on lithium diuretics, cyclosporin, warfarin and other drugs (see BNF), or those with renal, hepatic or cardiac impairment. Dose Caesarean section: 100mg by suppository in theatre, followed by either 50mg diclofenac or another NSAID by mouth 14-16 hours later. Vaginal delivery: 50mg every 8 hours by mouth or rectum. Side effects Gastro-intestinal upset, nausea, vomiting, diarrhoea, occasional bleeding or ulceration, bronchospasm, dizziness, headache, blurred vision, haematuria, fluid retention. Patient Information These tablets should be taken regularly, with or just after food or a drink of milk to minimise the effects on the stomach (NB: suppositories can also cause stomach irritation.) If you have indigestion or stomach pain, tell your midwife. Also if you experience being short of breath (especially if you have asthma or other chest problems) tell your midwife. You can safely take paracetamol-based painkillers with this medication. Suppositories should be removed from their packaging and inserted into the rectum as directed.

References: August 2001

BNF No 41, Voltarol data sheet

22

(x)

DINOPROSTONE VAGINAL GEL 1mg or 2mg (Prostin) Pharmaceutical Presentation Translucent gel containing either 1mg or 2mg dinoprostone per 3gram. Indication Induction of labour as per guidelines when there are no maternal or fetal contraindications. Contra-indication Known sensitivity to prostaglandins. Active cardiac, renal, hepatic or pulmonary disease. Suspected or confirmed placenta praevia or unexplained vaginal bleeding during the pregnancy, fetal distress or malpresentation. In patients where prolonged contractions are inappropriate, eg previous surgery, difficult labour or grand multipare, ruptured membranes or active pelvic inflammatory disease. Caution in asthma, epilepsy, glaucoma, hypertension or compromised hepatic renal or cardiovascular function. Dose As per guidelines for induction of labour. Side effects Nausea, vomiting, diarrhoea, most common. Rarely, hypersensitivity to dinoprostone, uterine rupture, cardiac arrest, abruptio placenta, uterine hypercontractility or hypertonus, fetal distress, maternal hypertension, stillbirth, neonatal death, rapid cervical dilation, fever, bronchospasm or asthma, pulmonary or amniotic fluid embolism, backache, rash, pain, irritation and warmth of vagina, uterine hypercontractility with or without fetal bradycardia and low Apgar scores in the newborn. Patient Information You will be examined by the midwife prior to administration of the gel into the vagina. You will be asked to lie down for 30 minutes after this. After 6 hours you may need a second dose. Tell you midwife if anything occurs after the gel is inserted, for example contractions.

References: August 2001

BNF No 41 Prostin data sheet

23

(xi)

DOCUSATE SODIUM ENEMA 90mg Microenema (Fletchers enemette) Pharmaceutical Presentation Enema containing Docusate sodium 90mg and glycerol 3.78g. Also contains polyethylene glycol and sorbic acid. Indication Evacuation of bowel before medical procedures. Relief of constipation Contra-indication Intestinal obstruction. Dose The enema should be inserted into the rectum and the contents squeezed out before the tube is withdrawn. Side effects May cause transient discomfort. Prolonged use may lead to rectal irritation, atonic non-functioning colon and hypokalaemia. Patient Information This preparation is for rectal use. The enema will produce a response within one hour. If you experience any discomfort or there is no response within 1 hour let a member of staff know.

References: August 2001

BNF No 41, Package Information leaflet

24

(xii)

ENTONOX Pharmaceutical Presentation Gas which is odourless, tasteless and colourless containing oxygen 50% and nitrous oxide 50%. Indication Inhalational analgesia during labour. Contra-indication Spontaneous or traumatic pneumothorax. Severe bullous emphysema. Caution: Cylinder should be stored horizontally for at least 24 hours at room temperature to ensure gases are mixed if the temperature is below 10C in the storage area. Above 10C, the cylinders can be kept upright and gases will remain mixed. Dose To be inhaled on demand. Side effects Bone marrow depression or megaloblastic anaemia may occur with prolonged use of 24 hours or greater. If the mask or cylinder head becomes frosted, the cylinder should be replaced with a new one (to prevent gas separation). Patient Information If this is not suiting you, please discuss other analgesia options with your midwife.

References: August 2001

Martindale 32nd edition, Grampian PGD

25

(xiii)

FERROUS SULPHATE TABLET 200mg Pharmaceutical Presentation Round, white sugar coated tablet containing ferrous sulphate 200mg Indication Treatment of iron deficiency anaemia. Contra-indication Hypersensitivity to any iron preparations Patients who cannot tolerate iron preparations or have disorders of iron metabolism. Haemoglobin levels above 11.5g/dl. Caution with other medications (See BNF). Dose One tablet three times a day. The tablet should be swallowed whole. Side effects Nausea, epigastric pain, gastrointestinal irritation, altered bowel habit (diarrhoea or constipation). Patient Information Tablets should preferably be taken on an empty stomach. However if this causes gastro-intestinal irritation they may be taken with or after food to minimise this effect. The stools may be discoloured (black). The tablet may cause either diarrhoea or constipation. If this becomes a problem, please let a member of staff know. May interfere with other medication ask if you are taking other medication especially antibiotics, methyldopa, penicillamine or cholestyramine.

References: August 2001

Martindale 32nd edition

26

(xiv)

FOLIC ACID TABLET 400micrograms Pharmaceutical Presentation White tablets containing folic acid 400micrograms. Indication Prevention of neural tube defects in early pregnancy. Contra-indication Know sensitivity to folic acid. Dose One tablet daily with food until the 12th-14th week of pregnancy. Ideally this should be started before conception but can be started at any time if pregnancy is suspected. Side effects Nil known. Patient Information This preparation will help to prevent any problems with the developing baby such as spina bifida. If you have epilepsy you should discuss taking this preparation with your doctor before you start taking it.

References: August 2001

Preconcieve package information leaflet

27

(xv)

GELOFUSINE (Gelatin) INTRAVENOUS INFUSION Pharmaceutical Presentation Intravenous infusion solution containing succinylated gelatin 4%. Indication Correction of low blood volume during haemorrhage as a short term measure. Contra-indication Known hypersensitivity to any of the ingredients. Use with caution in cardiac disease or renal impairment. Dose 500ml to be infused as required. Side effects Hypersensitivity reactions, but rarely severe anaphylactoid reactions. A transient increase in bleeding time may occur. Patient Information This is used to keep the volume of blood in the body at a similar level as you are losing blood.

References: August 2001

Gelofusine package information leaflet

28

(xvi)

GLUCAGON INJECTION 1mg (GlucaGen) Pharmaceutical Presentation Kit containing one vial containing 1mg glucagon (rys) as a white powder along with one syringe containing 1ml water for injection. Indication Treatment of severe hypoglycaemia when patient cannot take anything by mouth. Contra-indication Sensitivity to any of the ingredients, phaeochromocytoma. Caution in patients on indomethacin or warfarin. Dose 1mg by subcutaneous, intramuscular or intravenous injection immediately after reconstitution, followed by carbohydrate by mouth when recovery is sufficient to allow this. NB: If the solution is not clear, do not inject. If this does not have an effect within 10 minutes, a doctor must be called. Side effects Nausea and vomiting common if dose given too rapidly or more than 1mg given. Diarrhoea, hypokalaemia and rapid heart beat may occur. Hypersensitivity reactions rare. Patient Information The pack should be stored in the fridge and used by the expiry date. If this is not possible, it may be stored at room temperature up to 25oC for a maximum of 18 months or until the expiry date, whichever is shorter.

References: August 2001

BNF No 41, GlucaGen package information leaflet

29

(xvii)

GLYCERIN SUPPOSITORY 4g Pharmaceutical Presentation Pale amber suppository containing glycerin BP 70% w/w gelatin and water. Indication Treatment of constipation by the rectal route. Contra-indication Sensitivity to any of the ingredients. First 3 months of pregnancy. Intestinal blockage. Dose One or two suppositories to be inserted rectally after being moistened with water. Side effects Stomach cramps may be experienced. May irritate the rectum. Patient Information This preparation will produce a response within 15 to 30 minutes. The suppositories are for rectal use, it should not be swallowed. If any discomfort occurs, let a member of staff know. This product should only be used for a short time. If you need to use it for more than a few days, consult your doctor.

References: August 2001

Package Information leaflet

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(xviii)

HEPARIN INJECTION 10iu/ml Pharmaceutical Presentation Solution containing Heparin Sodium 10 international units per ml. Indication Anticoagulant to flush in-dwelling cannulae to maintain patency. Contra-indication Known hypersensitivity to heparin or any of the ingredients. Haemorrhagic disorders or haemophilia or bleeding including thrombocytopenia. Dose 5ml to be instilled into cannula as required every 4-8 hours as required. NB: ensure compatibility with drugs injected before and after the heparin to avoid precipitation. Side effects As this is a low dose preparation, it is unlikely that any side effects will be experienced. Higher doses of heparin may cause haemorrhage, skin necrosis, thrombocytopenia, hyperkalaemia. Patient Information This is a substance produced naturally in the body so you should have no problems after it is injected to help keep the cannula working while it is in your vein.

References: August 2001

BNF No 41, Hepsal information leaflet

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HYPOSTOP GEL Pharmaceutical Presentation Clear lemon flavoured gel for oral use containing dextrose 40%. Indication Treatment of hypoglycaemia by the oral route. Contra-indication Sensitivity to any of the ingredients. Dose 23g by the oral route as required. May be repeated if necessary after 10-15 minutes. Side effects Nausea. Patient Information The 23gram dose contains 9.2grams glucose.

References: August 2001

Package Information leaflet

32

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IBUPROFEN TABLET 400mg or 600mg or SUSPENSION 100mg/5ml Pharmaceutical Presentation 400mg: Round pink sugar coated tablet containing ibuprofen 400mg 600mg: Lozenge shaped pink tablet containing ibuprofen 600mg Suspension: Orange flavoured liquid containing ibuprofen 100mg per 5ml Indication Non-steroidal anti-inflammatory drug for treatment of mild to moderate pain. Contra-indication Hypersensitivity to aspirin or any other NSAID or any ingredient of the tablet. Asthma unless NSAID tolerated with previous use. Active gastro-intestinal disease. Current prescription for another NSAID. Warfarin therapy. Contra-indicated within 8-12 days after use of mifepristone. Caution in patients on diuretics, cyclosporin, lithium and other drugs (see BNF). Caution in renal, hepatic or cardiac impairment. Dose One tablet or 20-30ml suspension, can be given up to three times a day with food. Maximum 1.8grams per day. Doses above 1.8g per day need to be prescribed by a doctor may prescribe up to 2.4g per day individual doses. Side effects Gastro-intestinal upset, nausea, diarrhoea, occasional bleeding or ulceration, bronchospasm headache, dizziness, blurred vision, haematuria, fluid retention. Rarely renal or hepatic problems. Patient Information These tablets or suspension should be taken regularly with or just after food or a drink of milk to minimise effects on the stomach. If any indigestion or stomach problems occur, tell your midwife. Also if shortness of breath occurs (especially if you have asthma or other chest problems), contact your midwife. Also let someone know if you have a skin rash or any unexplained bruising or swelling. You can safely take paracetamol-based painkillers with this medicine.

References: August 2001

BNF No 41, Brufen data sheet

33

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ISPAGHULA HUSK SACHET 3.5g (Orange) Pharmaceutical Presentation Sachet containing ispaghula husk 3.5g. Also contains orange flavour and betacarotene (colour), aspartame (sweetener), citric acid, potassium bicarbonate, sodium bicarbonate and povidone. Indication Treatment of constipation (bulk-forming type). Contra-indication Intestinal obstruction, faecal impaction, colonic atony. Phenylketonuria. Hypersensitivity to any of the ingredients. Dose One sachet in a glass of cold water (approx 150ml or pint) twice daily after meals. Side effects Flatulence, bloating may be experienced. Patient Information The sachets should be taken regularly and should work within 3 days. Fluid intake must be adequate to help the preparation work effectively. If flatulence and/or bloating occur, this should diminish after a few days.

References: August 2001

BNF No 41, Fybogel information leaflet

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LACTULOSE SOLUTION Pharmaceutical Presentation Clear or pale yellow coloured solution containing Lactulose 3.35g per 5ml. Indication Treatment of constipation by osmotic action. Contra-indication Galactosemia, intestinal obstruction, allergy to any of the ingredients. Caution in lactose intolerance. Dose 10mls of solution orally twice daily. This may be taken with water or fruit juice. Side effects Abdominal discomfort, flatulence and cramps. Patient Information Needs to be taken regularly to be effective. May take up to 2-3 days to have an effect. Any bloating should disappear within a few days. If diarrhoea starts, stop taking this preparation.

References: August 2001

BNF No 41, Package Information leaflet

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LIGNOCAINE (LIDOCAINE) 1% INJECTION Pharmaceutical Presentation Ampoules containing clear solution of lignocaine 1% w/v. Indication Local anaesthesia for use prior to cannulation or episiotomy or during repair of the perineum. Contra-indication Known hypersensitivity to lignocaine. Complete heart block, hypovolaemia or supraventricular tachycardia. Avoid in porphyria. Caution in epilepsy, bradycardia, impaired respiratory or hepatic function. Dose NB: Care must be taken to ensure solution is not injected into a vein or artery. Local anaesthesia prior to cannulation: 0.1ml by local infiltration. Local anaesthesia prior to episiotomy: 10ml by local infiltration. Repair of perineum: up to 20ml by local infiltration (only if at least 1 hour has passed after episiotomy. If not, total volume administered should not exceed 20ml for episiotomy and repair). Side effects Transient drowsiness and amnesia may occur, followed by confusion, convulsions, bradycardia, hypotension and respiratory depression which may lead to cardiac arrest. Patient Information There will be a loss of sensation at the site of injection which will slowly be reversed.

References: August 2001

BNF No 41, Package Information leaflet

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MAALOX SUSPENSION Pharmaceutical Presentation White suspension, flavoured with peppermint, containing magnesium hydroxide 195mg and dried aluminium hydroxide 220mg per 5ml. Indication Antacid suspension. Contra-indication Kidney failure, bowel obstruction or severe abdominal pain of unknown cause. Dose 10ml may be given 20-60 minutes after meals and at bedtime as required. Side effects Magnesium hydroxide has laxative effects and aluminium hydroxide may cause constipation. Alteration of bowel habit may occur with prolonged excessive use. Patient Information The antacid may interfere with the absorption of other medicines such as antibiotics or epilepsy medicines. If possible do not take this at the same time as other medication (if possible leave at least 2 hours after taking this medicine).

References: August 2001

BNF No 41, Maalox Data Sheet

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METOCLOPRAMIDE INJECTION 10mg Pharmaceutical Presentation Ampoule containing solution of metoclopramide hydrochloride BP 10mg in 2ml. Indication Prevention and treatment of nausea and vomiting. Contra-indication Known hypersensitivity to any of the ingredients. Phaeochromocytoma, gastrointestinal obstruction, performation or haemorrhage. Caution in patients with epilepsy or drugs that have extrapyramidal side effects, hepatic or renal impairment. Dose Women over 60kg at start of pregnancy : 10mg every 8 hours as required to a maximum of 30mg/day. Women under 20 years old or under 60kg: 5-10mg every 8 hours as required by intramuscular injection to a maximum of 500mcg/kg in 24 hours. Side effects Extrapyramidal effects, especially dystonia, hyperprolactinaemia, drowsiness, restlessness, rash, pruritis, depression, diarrhoea, neuroleptic malignant syndrome, oedema. Patient Information This will help prevent or treat nausea and vomiting.

References: August 2001

BNF No 41, Maxolon Data Sheet

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OXYGEN Pharmaceutical Presentation Colourless, tasteless, odourless gas. Indication To correct hypoxia. To correct hypoxia in neonates after delivery. Contra-indication Areas where there is fire or danger of spark. No oil or grease must be put onto the valves or an explosion may result. Dose As required. Administration can be by face mask, nasal cannula, endotracheal tube, head box or oxygen tent. Side effects Pulmonary toxicity (as cough, substernal distress and decrease in vital capacity) and CNS toxicity (nausea, vertigo, twitching, convulsions, mood changes and loss of consciousness). Patient Information

References: August 2001

Grampian PGD, BNF No 41

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OXYTOCIN INJECTION 10iu/ml Pharmaceutical Presentation Each ampoule contains oxytocin Ph Eur 10units in 1ml solution. Indication Oxytocic to aid induction of labour or prevent uterine bleeding after delivery by intravenous infusion or injection. Contra-indication Sensitivity to any of the ingredients. Hypertonic uterine contractions, obstructed delivery or where vaginal delivery is inadvisable, fetal distress. Use with care in patients who have had a previous caesarean section, over 35 years of age, mild or moderate cardiac disease or hypertension or have a small pelvis. Do not use for prolonged periods in severe pre-eclamptic toxaemia, severe cardiovascular disease or in oxytocin-resistant uterine inertia. Dose Augmentation of labour: see unit policy. Management of 3rd stage of labour in patients with cardiac disease or moderate to severe hypertension: 10 units IM instead of syntometrine - as per unit policy. Management of major obstetric haemorrhage: see unit policy. Side effects Nausea, vomiting, uterine spasm at low dose, uterine hyperstimulation at high doses with fetal distress, soft-tissue damage. High doses in large volume of fluid may cause water intoxication (headache, anorexia, nausea, vomiting, drowsiness, abdominal pain, unconsciousness and convulsions). Patient Information This is to help the labour or to control bleeding after the baby is born. If you feel unwell or uncomfortable, tell your midwife.

References: August 2001

BNF No 41, Syntocinon Data Sheet

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PARACETAMOL TABLET 500mg or SUPPOSITORY 500mg Pharmaceutical Presentation Round white tablet containing paracetamol 500mg. White suppository containing paracetamol 500mg Indication Relief of mild to moderate pain or pyrexia. Contra-indication Hypersensitivity to paracetamol or paracetamol-containing preparations. Prescription for another paracetamol-containing preparation. Caution in patients taking metoclopramide, domperidone, cholestyramine or warfarin. Dose Two tablets every 4-6 hours, to a maximum of 8 tablets in any 24 hours. Two suppositories every 4-6 hours by rectum to a maximum of 8 in 24 hours. Side effects Rare, but may cause skin rashes or blood disorders. Patient Information Do not take any other medicines containing paracetamol whilst taking these tablets. Maximum 2 tablets or suppositories at any one time and no more than 8 tablets or suppositories in any 24 hour period. If you take an overdose, see medical advice immediately.

References: August 2001

BNF No 41

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PEPPERMINT WATER Pharmaceutical Presentation Clear liquid containing peppermint oil 0.05% v/v with a distinctive aroma of peppermint. Indication Relief of flatulence. Contra-indication Allergy to any of the constituents. Dose 10ml to be taken in plenty of water up to four times a day when required. Side effects Rare, but do include hypersensitivity, skin rash, headache, muscle tremor, ataxia and bradycardia. Patient Information Solution should be taken with plenty of water. Once opened, the bottle should be discarded after 1 month.

References: August 2001

Package Information Sheet

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PEPTAC LIQUID Pharmaceutical Presentation Aniseed-flavoured suspension containing sodium bicarbonate 133.5g, sodium alginate 250g and calcium 80mg in 5ml. The preparation is sugar and gluten free. Indication Dyspepsia. Contra-indication Sensitivity to any of the ingredients. Caution if on a low sodium diet contains 3.1mmol per 5ml. Caution with other medication including phenytoin, gabapentin, azithromycin, sodium valproate and others see BNF for details. Dose 10mls after meals and at bedtime when required. Side effects Constipation, flatulence, stomach cramps or belching. Patient Information Shake the bottle well before use. Do not take this within one to two hours of taking any other medicines by mouth. This medicine is safe to take during pregnancy and while breastfeeding.

References: August 2001

BNF No 41, Peptac Information leaflet, Pepatc data sheet

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PHYTOMENADIONE INJECTION 1mg (Konakion Neonatal) Pharmaceutical Presentation Ampoule containing a green/yellow solution of phytomenadione 1mg in 0.5ml for intramuscular injection. Indication Prevention of haemorrhagic disease of the new-born. Contra-indication Know hypersensitivity to any of the constituents. Caution if mother/baby has been given anticoagulant medication or has liver disease or has artificial heart valves. Dose 0.5ml by intramuscular injection. Side effects Flushing of face, bluish stain colour, sweating, feeling of chest tightness or cold extremeties (hands, feet, nose and ears). Patient Information This is the injection form of phytomenadione (vitamin K). If you wish the baby to be given the oral preparation, please discuss it with the midwife who will contact a paediatrician.

References: August 2001

BNF No 41, Konakion data sheet

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RANITIDINE TABLETS 150mg Pharmaceutical Presentation Round white tablet containing ranitidine 150mg. Indication To reduce the amount of acid in the stomach prior to theatre to prevent Mendelsons syndrome. Contra-indication Known sensitivity to ranitidine. Porphyria. Caution in renal or hepatic disease (reduce dose). The tablets are unsuitable for people with lactose intolerance or galactosaemia. Dose Antepartum: Intrapartum: One tablet at 22.00 the night before and 2 hours prior to theatre along with sodium citrate 0.3M. One tablet every 6 hours during labour, with sodium citrate 0.3M immediately prior to theatre.

Side effects Headache, dizziness, rash, confusion, unexplained fever, gastro-intestinal upset, diarrhoea, jaundice, wheeze, feeling faint. Rarely tachycardia, agitation, visual disturbances, erythema multiforme, alopecia, depression, muscle or joint pain, gynaecomastia in men. Patient Information These tablets affect the acid in the stomach. If you feel unwell whilst taking these tablets, tell your midwife. References: August 2001 BNF No 41, Ranitic information leaflet

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RITODRINE INJECTION Pharmaceutical Presentation Each 5ml ampoule contains ritodrine hydrochlorde 10mg per ml in an aqueous buffered vehicle. Indication Management of uncomplicated pre-term labour between 24 and 33 weeks gestation. Contra-indication Known hypersensitivity to any of the ingredients. Antepartum haemorrhage, intra-uterine fetal death, intra-uterine infection, eclampsia and severe preeclampsia, cord compression, placenta praevia. Caution in cardiac disease, hypertension, diabetes mellitus, hypothyroidism, mild to moderate preeclampsia, beta-blocker therapy and other drug therapy (see BNF). Dose As per unit policy, the solution should be added to dextrose 5% infusion. Monitor heart rate during administration. Side effects Nausea, vomiting, tachycardia, palpitations, hypotension, sweating, tremor, hypokalaemia, uterine bleeding, pulmonary oedema. chest pain, arrhythmias, liver function abnormalities. Rarely enlargement of salivary gland. Leucopenia and agranulocytosis reported on prolonged administration. Patient Information This infusion will relax the uterus and will slow down or stop the labour. Tell your midwife if you feel unwell during the infusion.

References: August 2001

Yutopar data sheet, BNF No 41

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RUBELLA VACCINE 0.5ml Pharmaceutical Presentation Solution containing live rubella vaccine in 0.5ml solution. Indication Active immunisation against rubella in women of child-bearing age. Contra-indication Sensitivity to any of the ingredients. Pregnancy (early pregnancy consult product literature/BNF). Dose 0.5ml by deep subcutaneous or intramuscular injection. Side effects Mild dose of rubella may occur. Patient Information This will protect you against the risks of German measles. You are advised not to become pregnant within one month of having this injection. If you do, consult your doctor at the earliest opportunity.

References: August 2001

BNF No 41, Ervevax information leaflet

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SHERIPROCT OINTMENT Pharmaceutical Presentation Ointment containing cinchocaine hydrochloride 5mg and prednisolone 1.5mg per gram. Indication Short term use (up to 7 days) for the relief of haemorrhoids (piles) and anal itching. Contra-indication Sensitivity to any of the ingredients or local anaesthetics. Viral infection (eg chicken pox, herpes etc). Bacterial or fungal skin infection which is not being treated. Caution in first 3 months of pregnancy. Dose Apply to the affected area twice daily after washing and drying. If severe symptoms, it can be applied up to four times on the first day of treatment only. Once the condition is controlled, application may be done once daily, up to a maximum treatment course of 7 days. Side effects Allergic skin reactions may occur. Thinning of skin may occur on prolonged use. Patient Information The tube is for your own personal use. If the nozzle is used to apply the ointment to internal haemorrhoids it should be cleaned after each use. To aid recovery and help prevent recurrence of haemorrhoids you should eat a diet with plenty of fibre, drink plenty of water and take regular exercise.

References: August 2001

BNF No 41, Scheriproct information leaflet

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SIMPLE LINCTUS Pharmaceutical Presentation Sugar free solution containing Citric Acid BP 114.29mg in 5ml. Also contains glycerol, sodium carboxymethylcellulose, sodium benzoate, saccharin sodium, lycasin, ethanol, anise oil, chloroform, natural red colour. Indication Symptomatic relief of dry irritating cough. Contra-indication Known allergy to citric acid or any of the ingredients. May affect the absorption of oral steroids including the contraceptive pill. Dose 5ml up to 3-4 times a day. Side effects Rare, allergic reactions have been recorded for saccharin and sodium benzoate. Excessive quantities may cause irritation or a deterioration of tooth enamel. Patient Information This should soothe your cough. If symptoms persist or do not resolve, let your midwife know.

References: August 2001

Simple Linctus information sheet

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SODIUM CITRATE 0.3M SOLUTION Pharmaceutical Presentation Solution for oral use containing sodium citrate 441.15mg per 5ml. Bottle should be used within 14 days of first opening. Indication Prophylaxis of Mendelsons Syndrome during cesarean section in conjunction with ranitidine tablets. Contra-indication Known hypersensitivity to sodium citrate. Caution in cardiac disease, hypertension, renal impairment, people on a sodiumrestricted diet, oedema, eclampsia and aldosteronism. Dose 30ml orally prior to transfer to theatre. Side effects May have a laxative effect. Patient Information This along with ranitidine tablets, alters the acidity of the stomach contents to reduce problems associated with anaesthesia.

References: August 2001

Martindale 32nd edition, Sodium Citrate 0.3M information sheet

50

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SYNTOMETRINE INJECTION Pharmaceutical Presentation Solution containing ergometrine 500micrograms and oxytocin 5units in 1ml solution. Indication Management of third stage of labour or to control bleeding after delivery. Contra-indication Sensitivity to any of the contents, pregnancy and early labour, severe cardiovascular, pulmonary, hepatic or renal disease, eclampsia and pre-eclampsia, sepsis. Caution in mild/moderate hypertension, hepatic, cardiovascular or renal problems. Dose Management of third stage of labour 1ml intramuscularly after shoulder delivered. Control of bleeding 1ml intramuscularly. Side effects Nausea, vomiting, abdominal pain, headache, dizziness or skin rashes may occur. Patient Information This will help reduce the blood loss after the delivery of the baby.

References: August 2001

BNF No 41, Syntrometrine data sheet

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TEMAZEPAM TABLET 10mg Pharmaceutical Presentation Round white tablet containing temazepam 10mg. Indication Short term use in insomnia. Contra-indication Known hypersensitivity to temazepam or any other ingredients, respiratory depression, severe hepatic impairment, myasthenia gravis, pulmonary insufficiency. Dose One 10mg tablet may be given each night, up until 02.00 in the morning. Side effects Drowsiness which may continue the next day, light headedness, confusion, ataxia, amnesia. Patient Information This should help you sleep better, although the effects may persist during the next day. You should not drive whilst taking these tablets if you feel sleepy. They are for short term use only so will only be prescribed in hospital for you.

References: August 2001

BNF No 41, Package Information leaflet

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