ALL INDIA INSTITUTE OF MEDICAL SCIENCES

JODHPUR
COLLEGE OF NURSING

Practice Teaching ON
TOPIC- STANDING ORDERS, USE OF SELECTED LIFE
SAVING DRUGSAND INTERVENTIONS OF OBSTETRICS
EMERGENCIESAPPROVED BY THE MOHFW
SUBJECT- Obstetrics and Gynaecology Nursing

Submitted to: Submitted by:

Dr. Deviga Farheen khan
Nursing Tutor M.Sc. Nursing 1st year
College of nursing College of nursing
AIIMS Jodhpur AIIMS Jodhpur
DATE OF SUBMISSION:25/05/2021
 STANDING ORDERS, USE OF SELECTED LIFE SAVING DRUGSAND
INTERVENTIONS OF OBSTETRICS EMERGENCIESAPPROVED 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.

Any prescriptions for diamorphine and temazepam must be countersigned by the duty doctor
within 24 hours.

ANTEPARTUM

ANALGESIA -Paracetamol- 1gram as a single dose, once only

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

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

PROPHYLAXIS FOR MENDELSON’S SYNDROME IN ELECTIVE LSCS- Ranitidine tablet

150mg at 22.00 on night before theatre, repeated two hours before 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

CANNULA- Heparin 10IU/ml 5ml instilled into i.v. 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 SEDATIONT- emazepam 10mg as a single dose up to 2.00amin 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

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

ANTI –D IMMUNOGLOBULIN- Anti-D immunoglobulin may be given to all non-sensitized

Rh D negative women within 72 hours of a sensitizing event in the following circumstances

Prior to 20 weeks gestation Anti-D 250 IU by I.M. injection.

The following conditions are:

Threatened miscarriage after 12 weeks gestation

Spontaneous miscarriage after 12 weeks gestation

Ectopic pregnancy

Therapeutic termination of pregnancy – medical and surgical

Following sensitizing events such as amniocentesis

After 20 weeks gestatation Anti- D 500i.u. by i.m. injection

Ante partum hemorrhage

External cephalic version

Intrauterine death

Invasive prenatal diagnostic and intrauterine procedures

Blunt abdominal trauma

Routine Ante-natal Anti-D prophylaxis

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

INTRAPARTUM

ANALGESIA- Entonox inhalation as required

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

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

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

ACTIVE MANAGEMENT- Oxytocin 10 i.u.as per unit policyOF LABOURSyntometrine 1ml

i.m. with anterior shoulder at delivery

I.V. THERAPY- Compound Sodium Lactate 1 litre i.v. over 8-12hours 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 threetimes 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 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 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 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.

1 Administration of Inj.Oxytocin and Misoprostol:

It was decided that Tab. Misoprostol would be used as prophylaxis against PPH, in all
deliveries, as a part of active management of the third stage of labour.

• Tab. Misoprostol should be given, sublingually or orally, 600mg (3 tablets of 200 mg each),
immediately after the delivery of the baby. If a woman bleeds for more than 10minutes after
deliver, she should be given 10IU Inj.Oxytocin preferably by the IV route

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

Inj. Mag sulf is the drug of choice for controlling eclamptic fits. The first does should be given
by the ANM/staff nurse/Medical Officer at the PHC The woman should immediately be
referred to a CHC/FRU and not a PHC. This is because in these cases termination of
pregnancy will be required, and a PHC may not be equipped for the same. This first
dose should be given as a 50% solution (this preparation is available in the market). 8cc need
to be given to make a total dose of 4gms. 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
2hours. This is because a second dose of magnesium sulphate may be required after
2 hours. Hence early and immediate referral is essential.

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

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

It was universally felt that the administration of IV infusions was a life saving
procedure. As haemorrhage was the commonest cause of maternal mortality, the
administration of 3ml of fluid for every ml of blood lost could keep the woman alive. As
of now, the ANMs are neither trained nor allowed by the regulatory authorities to
establish an IV line. After the discussion, it was decided that:

• If the ANM is trained to give IV infusion, she should administer wherever

feasible ,even at home.

• The ANM should start infusion with Ringer Lactate or Dextrose Saline.

• If an IV infusion was being started in cases of PPH, it was recommended the IV fluid
should be augmented with 20U of Oxytocin for every 500 ml bottle of fluid. This
could be continued throughout transportation. However, the logistics and feasibility of
the ANM being able to carry IV infusion sets and IV fluids to homes need to be
explored, and ensured.

4.Administration of antibiotics

The indications for which antibiotic therapy is recommended are:

• Premature rupture of membranes

• Prolonged labour

•Anything requiring manual intervention

• UTI

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

5.Administration of antihypertensives

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

6.Removal of retained products of conception.

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

7.Manual removal of placenta (MRP)

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

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

an assisted vaginal delivery was not possible at the community level due to obvious
reasons. Hence it was universally felt that :Assisted vaginal deliveries (i.e. The use of
obstetric forceps or vacuum extraction) should be carried out by the medical officer only. The
ANM and staff nurse need to be trained in the use of partograph purpose only. This will
help her in talking a decision for referral in case of prolonged labour.

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

REFERENCE
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,
1stedition Lippincott publication.
4. Potter & perry , fundamentals of nursing,5 th edition, Elsevier
publication.
5. www.drugs2004rn.com.6.www.pubmed.com