STANDING ORDERS AND

PROTOCOLS AND USE OF

SELECTED LIFE SAVING DRUGS

PRESENTED BY: JYOTI DHANGAL

M.Sc. NURSING 1st YEAR
 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.
• 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.
 DEFININTION
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.
• Health screening activities
• Occupational health services
• Public health clinical services
• Telephone triage and advice services
• Orders for lab tests.
• School health
• During labor.
 OBJECTIVES

• To maintain the continuity of the treatment of

the patient
• To protect the life of the patient.
• To create feeling of responsibility in the
members of health team.
 USES
Providing treatment during emergency.
Enhance the quality and activity of health service.
Developing the feeling of confidence and
responsibility in nurses and other health workers.
Protecting the general public from troubles.
Enhancing the faith of general public in medical
institution.
Therapeutic termination of pregnancy-medical and
surgical.
Following sensitizing events such as
amniocentesis.
THE DRUGS WHICH CAN BE AMINISTERED DURING
ANTEPARTUM, INTRAPARTUM, POSTPARTUM
PERIOD BY A MIDWIFE WITHOUT DOCTOR’S
PRISCRIPTION

• All intravenous and Controlled Drugs must be

checked by two midwives.
NB: Any prescriptions for diamorphine and
temazepam must be countersigned by the duty
doctor within 24 hours
Management of preterm labor :
The incidence of preterm birth is approximately 6-
7% of all births.
Treatment :
Inhibition of uterine contractions : Nefidipine (10
mg)
Improvement of fetal lung maturity:
Dexamethasone: Injection 4 mg dexamethasone
phosphate
Betamethasone: Injection 6 mg
 CONT…
Postpartum hemorrhage: PPH is the most common
cause of maternal mortality. It is estimated that 127000
maternal deaths occur annually due to PPH.
Prevention:
Inj. Oxytocin 10 IU IM
Tablet Misoprostol 200 micrograms (when oxytocin is not
available or cannot safely be used).
Treatment:
Inj Oxytocin 10 IU IM
Sodium Chloride 0.9%
Sodium lactate compound solution (RL)
Severe Pre-eclampsia and eclampsia:
Pre-eclampsia and eclampsia are major health problems in
India. Every year, eclampsia is associated with an
estimated 50000 maternal deaths worldwide.
Treatment:
Magnesium sulfate
Calcium gluconate injection 100 mg/ml is given in case of
magnesium toxicity
Management of severe hypertension:
Hydralazine inj 20 mg or tablet 25 mg or 50 mg.
Methyldopa tablet 250 mg.
Maternal sepsis:
Infection can follow an abortion or childbirth
and is a major cause of death.
Treatment:
Ampicillin injection 500 mg
Gentamicin injection 40 mg
Metronidazole injection 500 mg
Provision of safe abortion services and/or the
management of incomplete abortion and miscarriage
Unsafe abortion complications can lead to death
associated with hemorrhage and sepsis. The majority of
unsafe abortions take place in developing countries. In
2008, it was estimated that 21.6 million unsafe abortions
were performed worldwide. Each year, 47 000 women die
due to complications of unsafe abortion
Treatment:
Misoprostol: tablet 200 micrograms
Mifepristone + misoprostol: tablet 200 mg + tablet 200
micrograms.
 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 500 i.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 500 i.u. by i.m. injection at
28 and 34 weeks gestation
 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.
 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 delivery, she should be given 10U Inj.
Oxytocin preferably by the IV route
 ADMINISTRATION OF INJ.
MAGNESIUMSULPHATE FOR PREVENTION
AND MANAGEMENT OF ECLAMPSIA
 Inj. Magsulf is the drug of choice for controlling eclamptic fits. The
first does should be given by the ANM/staff nurse/Medical Officer
at the PHC. The woman should immediately refer to a CHC/FRU.
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.
 CONT…
 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 centre 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
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 loss 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 20 U 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.
 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
 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.
 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
CONDUCTION OF AN ASSISTED VAGINAL
DELIVERY (FORCEPS &VACUUM
EXTRACTION)

Conduction of an assisted vaginal delivery

was not possible at the community level
due to obvious reasons. Hence it was
universally felt that: Assisted vaginal deliveries
(i.e. The use of obstetric forceps or vacuum
extraction) should be carried out by the medical
officer only. The ANM and staff nurse need to be
trained in the use of partograph purpose
only. This will help her in talking a decision for
referral in case of prolonged labour.
 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 the
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 postpartum haemorrhage and shock.
3. Injection magnesium sulphate for management of
Eclampsia.
4.Use of Gentamycin IM, Ampicillin and metronidazole
orally for prevention of infection (puerperal sepsis,
premature rupture of membranes, prolong labour, any
manual intervention)
 CONCLUSION

Nurses must have a solid knowledge based on

the factors affecting maternal, new-born 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.
 REFERENCES

• Annamma Jacob, text book of midwifery, 1st edition, jaypee

publication
• Standing order and protocols and use of life saving drugs in
obstetrics [accessed on 2-3-2019] available on
https://docslide.net/documents/seminar-on-standing-orders-
and-protocols-and-use-of-selected-life-saving.html.
• Priority life saving drugs for women [accessed on 2-3-2019]
available at
https://www.who.int/medicines/publications/EN_A4_WHO
EMPMAR20121 .
• www.drugs2004rn.com.
• www.pubmed.com
• www.scribd.com