In the UK, regulations for the prescription and administration of drugs by midwives fall under the responsibility of the Nursing and Midwifery Council (NMC), which issues codes and standards relating to the practical application of Acts such as the Medicines Act 1968 (now broadly repealed by the Human Medicines Regulation 2012), the Misuse of Drugs Act 1971, and the Medicinal Products: Prescription by Nurses Act 1992, and their subsequent amendments. From 2019, the Royal Pharmaceutical Society’s Competency Framework for all Prescribers will be adopted as the NMC’s standards of competency for prescribing practice.
Many of the NMC’s publications on the matter are not legally binding but would be taken into account if there were to be medicolegal or regulatory action concerning administration of drugs. Against this background of central control, the setting up of, and adherence to, local policies is strongly encouraged, in recognition of the differing requirements from unit to unit.
A compromise must exist between: (1) supporting the midwife’s role as an independent practitioner, (2) reducing the workload on medical staff by not requiring them to treat common and relatively minor conditions, (3) permitting the rapid administration of drugs that may have real benefits to mothers and reduce morbidity or mortality, and (4) restricting the use of potentially harmful drugs or reducing the incidence of adverse effects. Whether a particular drug should be allowed to be given thus depends on the incidence, importance and potential severity of the condition for which it is indicated and the efficacy, method of administration and safety profile of the drug concerned. In recent years, many NHS trusts have developed strategies for improving safety in administering drugs, along with improved methods of assessing competency for nursing and midwifery staff.
Drugs that midwives can administer without medical prescription
Registered midwives may prescribe and administer any of the drugs that are specified under midwives’ exemptions; this includes drugs such as lidocaine, oxytocin and pethidine (Table 17.1). As of 2011, midwifery students may also administer drugs on the midwives’ exemption list (apart from controlled drugs), under the direct supervision of a midwife. Exemptions are distinct from prescribing, which requires the involvement of a pharmacist and the completion of an accredited prescribing course. The NMC attributes professional accountability for any prescribing decisions to the prescribing midwife.
There is regional variation according to local policies, and individual trusts bear ultimate responsibility for approving drug policies within their maternity services. Local regulations are usually decided by a panel including representatives of midwives, pharmacists and obstetricians; anaesthetic staff may also be involved, for example in helping with analgesic or local anaesthetic drug policies.
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Table 17.1 Sample standing orders for drugs that may be prescribed and administered by midwives without medicalprescription |
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Analgesics |
Opioids (usually pethidine, up to two intramuscular doses) Paracetamol; codydramol; cocodamol Entonox Diclofenac |
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Local anaesthetics |
Lidocaine for infiltration/local application |
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Gastrointestinal |
Liquid antacids Laxatives Cyclizine; prochlorperazine |
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Oxytocics |
Oxytocin; ergometrine; carboprost |
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Haematological |
Iron/folate oral preparations Anti-D immunoglobulin Hepatitis B vaccine/immunoglobulin Vitamin K (neonatal) |
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Other |
Adrenaline 1:1000 intramuscular (for anaphylaxis) Gelofusine; Hartmann’s solution; 0.9% saline Naloxone (adult and neonatal) Topical clotrimazole/nystatin; hydrocortisone Transcutaneous electrical nerve stimulation (TENS) |
Midwives in different units may interpret the NMC’s guidelines differently, especially with regard to epidural top-ups; for example, midwives in certain units may be prepared to administer epidural drugs prescribed by a doctor (i.e. an anaesthetist) whereas those in others may not. This is rarely a problem with local anaesthetic drugs alone but may be problematic with mixtures of local anaesthetics and opioids, e.g. fentanyl, which are both controlled drugs and unlicensed for epidural use. In all cases, midwives’ willingness to give epidural drugs is only on the understanding that ultimate responsibility for administering the drug is with the anaesthetist.
The regulations are regularly reviewed, with recent attention being paid to administration of intravenous fluids to reflect (1) the widespread competence of midwives in venous cannulation and (2) the number of women choosing to deliver at home and therefore the potential for severe haemorrhage away from hospitals.
Key points
• The Nursing and Midwifery Council (NMC) issues professional guidelines and codes for administration of drugs by midwives.
• Midwives are able to administer several drugs without a doctor’s prescription, according to the NMC’s recommendations and local policies.
• Midwives may administer certain drugs unlicensed for use in labour, e.g. epidural fentanyl, if covered by local policies and on the written prescription of a doctor.
Further reading
Nursing and Midwifery Council. Standards for Medicines Management. London: NMC, 2007 (updated 2015). www.nmc.org.uk/standards/standards-for-post-registration/standards-for-medicines-management (accessed December 2018).
Royal Pharmaceutical Society. Safe and Secure Handling of Medicines: a Team Approach.
London: RPS, 2005 (updated 2018). www.rpharms.com/resources/professional-standards/safe -and-secure-handling-of-medicines (accessed December 2018).