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

SN
O

CONTENT

1
2

INTRODUCTION
2
STANDING ORDERS
2
3
DEFINITION
3
OBJECTIVES
3
USES
STANDING ORDER FOR A
4
MIDWIFE DURING:ANTEPARTUM
6
INTRAPARTUM
8
POSTPARTUM
11
LIST OF LIFE SAVING DRUGS AND ITS 15
RECOMMENDATION
15
CONCLUSION
18
RESEARCH ABSTRACTS
BIBILOGRAPHY

3
4
5
6

PAGE
NO

TEACHER
S
SIGNATU
RE

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 clients 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
DOCTORS 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
MENDELSONS 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
PREPARATION

Simple linctus 5ml once only

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
OF LABOUR

Oxytocin 10 i.u.as per unit policy

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
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
one

Only one PARACETAMOL BASED ANALGESIC

should be prescribed at any
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

HAEMORRHOID
PREPARATIONS

Glycerine suppository 1 or 2 per rectum as

required
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 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
PREPARATION

Simple linctus 5ml 3-4 times a day.

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

2.

Use of selected life

saving
drugs
and
interventions
in
obstetric emergencies
Administration of Inj.
Oxytocin
and
Misoprostol:

Recommendations of the Expert

Advisory Group
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
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

3.

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.
Administration of i.v It was universally felt that
infusion to treat shock. 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.

4.

Administration
antibiotics

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.
of 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.

6.

was
a
universal
of There
consensus that only the
Medical Officer should be
allowed to administer antihypertensive to a woman
with
hypertension
in
pregnancy.
Removal of retained For incomplete abortion. If
products of conception. bleeding continues, the ANM
and staff nurses can perform
only digital evacuation of
products of conception.
Administration
antihypertensives

7.

8.

9.

of 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
Conduction
of
an Conduction of an assisted
assisted
vaginal vaginal delivery was not
delivery
(forceps possible at the community
&vacuum extraction)
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.
Repair of vaginal and Scientific evidence proven
perineal tears.
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,
Manual removal
placenta (MRP)

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 womens 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 g 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, 1 st
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