INDEX

SINO CONTENT PAGE NO

1 INTRODUCTION 2
2 STANDING ORDERS 2
 DEFINITION 3
 OBJECTIVES 3
 USES 3
 STANDING ORDER FOR A MIDWIFE
DURING: - 4
ANTEPARTUM 6
INTRAPARTUM 8
3 POSTPARTUM 11
4 LIST OF LIFE SAVING DRUGS AND ITS 15
5 RECOMMENDATION 15
6 PROTOCALS 16
CONCLUSION
7 RESEARCH ABSTRACTS 29
8 BIBILOGRAPHY 30

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STANDING ORDERS, USE OF SELECTED LIFE SAVING DRUGS AND
INTERVENTIONS OF OBSTETRICS EMERGENCIES APPROVED BY
THE “MOHFW” (MINISTERY OF HEALTH AND FAMILY WELFARE)

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.

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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.

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 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.

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

MENDELSON’S 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

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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 Simple linctus 5ml once only

PREPARATION

ANTISPASMODIC Peppermint water 10ml in plenty of water,

once only.

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 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 250iu 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

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 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 policy

OF LABOUR
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

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 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:

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 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 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

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 Lacunose 10ml orally twice daily

Glycerine suppository 1 or 2 per rectum as

required
HAEMORRHOID Anusol cream apply twice daily and after each
PREPARATIONS 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 Simple linctus 5ml 3-4 times a day.

PREPARATION
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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.

SI NO Use of selected life Recommendations of the Expert

saving drugs and Advisory Group
interventions in
obstetric emergencies
1 Administration of Inj. It was decided that Tab. Misoprostol
Oxytocin and would be used as prophylaxis against
Misoprostol: 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
2 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

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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
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

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 early and immediate referral is
essential.

• 22G needles and 10cc syringes also

needed to be included in the ANM
kit.

It was universally felt that the

administration of IV infusions was a
3. Administration of i.v life saving procedure. As
infusion to treat shock. 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

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 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.

The indications for which antibiotic

therapy is recommended are:

• Premature rupture of membranes

4. Administration of
• Prolonged labour
antibiotics
•Anything requiring manual
intervention

• UTI

• Puerperal sepsis

There should be instructions for the

ANM that after starting the woman
5. Administration of on antibiotics, she should inform the
antihypertensives PHC Medical Officer

There was a universal consensus that

only the Medical Officer should be
allowed to administer anti-
hypertensives to a woman with
hypertension in pregnancy.

PROTOCALS

Practices and Protocols

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 Triaging Pregnant Women

Obstetric History and examination

Normal delivery can be done

Needs cesarean section

No identifiable risk of
complication: Nurse led
intervention
Cesarean facility
Specialist care
avilable
Risk assesssment
Risk of complication: Review resources
Specialist led
intervention Cesarean facility
not available
Review resources
Specialist care not
avilable

Conduct normal
delivery
Refer client to
higher center
Conduct cesarean
section

Signs/symptoms of Pre-eclampsia/Eclampsia/Toxemia: Elevated

BP>30mmHg, edema hands/feet Marked hypertension (ex: 160/110),
headache, blurred vision, pulmonary edema.

Coma and convulsive seizure or systolic BP > 140 or diastolic > 90, occurring
between the 20th week of pregnancy and the end of the first week postpartum.

FR-AED

1. Routine Medical Care

2. Assure minimal stimulation (handle gently, DO NOT check pupils for

reaction to light – this may precipitate seizure)

3. If patient is having seizure, follow seizure protocol

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 4. Place patient on left side

BLS

1. F.R. Care

2. Obtain 12 lead ECG if indicated by chief complaint or patient presentation

and transmit to:

OSF Saint Elizabeth Medical Center Emergency Department (It is beyond the
scope of the EMTBasic to interpret 12-leads and/or cardiac rhythms)

ILS/ALS

1. BLS Care

2. Initiate IV of Normal Saline @ KVO (20mL/hr)

3. Valium 5 mgm IV for seizure activity that is greater than 5 minutes and
with Medical witnessed by EMS after contact
Control

Transport agencies:

Rapid transport – avoid sirens if possible (may precipitate seizure)

COMPLICATIONS DURING PREGNANCY

Placentae Previa

Occurs as a result of abnormal implantation of the placenta on the lower half of

the uterine wall. Bleeding occurs when the lower uterus begins to contract and
dilate in preparation for labor and pulls the placenta away from the uterine wall.
The hallmark of placenta previa is the onset of painless bright red vaginal bleeding,
usually in the 3rd trimester of pregnancy.

Abruptio Placentae

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The premature separation of a normally implanted placenta from the uterine wall.
Signs and symptoms can vary depending on the extent and character of the
abruption.

• sudden onset of sharp, tearing pain and the development of a stiff,

board like abdomen but no vaginal bleeding (bleeding is trapped between the
placenta and the uterine wall.

• f the abruption is complete (totally separated from the uterine wall)

massive vaginal bleeding and profound maternal hypotension occur

FR-AED/BLS

1. Note the amount of bleeding

2. Place patient on her left side

3. Load and Go ASAP

4. Consider ILS/ALS intercept

Contact Medical Control early

ILS/ALS

1. Initiate IV of 500 mL Normal Saline give 200 cc bolus to maintain BP of > 90

mmHg 2. If able, start a second IV

3. May repeat IV bolus as needed to maintain BP at or > 90mmHg

Care of the Pregnant Patient

FR-AED

1. Routine Medical Care

2. Obtain a pregnancy history

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> length of gestation (# of months pregnant)

 previous pregnancies (gravida)

 # of children from previous pregnancies (para)

 due date

 history of complications of pregnancy

 any current pain

 contractions

 frequency of contractions

 membranes intact or ruptured

 expecting multiple births

 estimate amount of bleeding if any (# of pads saturated)

 any risk factors (see note below)

3. Position patient on left side if in 2nd or 3rd trimester. Elevate feet 10-12
inches if hypotensive

4. Take and record vital signs every 5 minutes

BLS

1. FR-AED care

2. Obtain 12 lead ECG if indicated by chief complaint or patient presentation

and transmit to: OSF Saint Elizabeth Medical Center Emergency Department

(It is beyond the scope of the EMT-Basic to interpret 12-leads and/or cardiac
rhythms)

3. Determine if there is time to transport based on the following:

 assess nature, extent and time of contractions

 assess patient for high-risk factors

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  assess the status of the membranes and any discharge

 assess for pushing with contractions

 consider length of previous labor

ILS/ALS

1. BLS Care

2. Initiate IV of Normal Saline @ KVO (20mL/hr)

3. If hypotensive, (B/P < 90 systolic) give 200mL IV bolus and reassess

**factors which may cause a high-risk of complications for the pregnant

patient**

 lack of prenatal care

 drug abuse

 teenage pregnancy (mid-or-early teens)

 history of diabetes

 hypertension

 cardiac disease

 previous breech or c-section deliveries

 pre-eclampsia, eclampsia or toxemia

 twins or multiple births

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

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high-risk groups. Nurse can help women to increase control over the factors that
affecting health, thereby improving their health status

Childbirth: Field Delivery

FR/AED/BLS

If remaining on scene due to imminent delivery:

a. Contact Medical Control with decision to remain on scene

b. Place patient in position of comfort

c. Place patient on a firm surface

d. Prepare OB kit

e. Allow delivery to progress spontaneously

f. Support baby’s head so that it does not emerge too quickly

g. Tear amniotic membrane, if it is still intact and visible outside

the vagina

h. Check for cord around neck (if cord is around neck, try to slip it
over the shoulder and head)

i. If unable to remove the cord from around the neck, place

umbilical clamps 2 inches apart and cut cord between clamps

j. Carefully support head throughout delivery.

k. Suction baby’s mouth and nose with bulb syringe as soon as

head emerges

l. Tell mother to resume pushing. Support the head as it rotates.

A slight lowering of the baby to allow delivery of the anterior (top )
shoulder, and then gentle lifting to allow

delivery of the posterior (bottom) shoulder may be helpful. DO NOT

PULL on infant. The baby should delivery completely.

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 m. Baby will be wet and slippery. Be prepared to support baby
during birth process with towel or blanket.

ILS/ALS

1. FR/AED/BLS care

2. IV of 500 mL Normal Saline give one bolus of 200 cc then TKA (20 mL/hr)

Care of the Newburn

FR-AED/BLS/ILS/ALS

1. Hold infant at level of mother

2. Suction mouth then nose with bulb syringe

3. Determine APGAR score at 1 minute and record - If less than 8 refer to

Newborn Resuscitation Guideline and APGAR scoring sheet (pgs 57, 58, 59).

4. After the umbilical cord stops pulsating, clamp it 6 and 8 inches from the
newborn’s abdominal wall and cut the cord between the clamps with a sterile
scalpel or scissors. (If no sterile cutting instrument is available, do not cut the
cord. Lie the infant, with cord clamped, on the mother’s abdomen)

5. Check the cord ends for bleeding. If there is any bleeding from the cord, re-
clamp in another place close to the original clamp.

6. Place infant on a flat surface in sniffing, Trendelenberg position – use jaw

thrust maneuver to open airway. If no respiration in 15 seconds, use BVM with
100% oxygen to ventilate

7. If no brachial pulse or pulse is <100 BPM begin CPR

8. Dry, warm, and vigorously stimulate infant for several minutes if necessary

9. Determine APGAR score at 5 minutes.

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 10.Do not separate mother and baby until both have ID bands on with date,
name of mother, sex of child.

Post Delivery

Care of the Mother

FR-AED

1. Routine Medical Care

2. Placenta should deliver in 5-30 minutes.

3. Place sanitary pad over vaginal opening

4. Massage fundus

5. Observe for excessive bleeding. Refer to Vaginal Hemorrhage Protocol

BLS

1. FR-AED Care

2. Do not delay transport while waiting for placenta to deliver

ILS/ALS

1. BLS care

2. Initiate IV of Normal Saline @ KVO if systolic BP is above 100. If systolic

BP is below 100 run IV @ rate to maintain systolic B/P at 90 – 100.

To massage the uterus post delivery, place one hand with fingers fully extended
just above the mother’s pubic bone and use the other hand to press down into the
abdomen and gently massage the uterus approximately 3 – 5 minutes until it
becomes firm. This procedure will help to stop any vaginal bleeding.

Severe Vaginal Haemorrhage

Postpartum or Miscarriage
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FR-AED/BLS

1. Routine Medical Care

2. Place a sanitary napkin (use large bandage if needed) over the vaginal
opening. Make note of time placed.

Remove any pads as they become soaked, but save all pads to use in evaluating
blood loss.

3. Save all tissue that is passed.

4. Massage fundus of uterus to keep firm and contracted.

5. If patient becomes hypotensive, position patient on left side with legs

elevated.

6. Promptly transport patient.

7. Consider ILS intercept.

8. Apply pulse oximeter and record value

ILS/ALS

1. BLS Care

2. Initiate IV of Normal Saline @ KVO if systolic BP > 90 mmHg 3. Run IV

@ rate to maintain B/P @ 90 if systolic BP < 90 mmHg.

Abnormal Deliveries

Prolapsed Cord

FR-AED

1. Routine Medical Care

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 2. Oxygen at 15 L per NRB

3. Place mother in knee-chest position with hips elevated on pillows

4. Protect cord from being compressed by placing a sterile gloved hand in

vagina between pubic bone and presenting part with cord between fingers.
Exert counter pressure against presenting part.

Keep hand in position until relieved by hospital personnel.

5. Palpate cord for pulsations.

6. DO NOT ATTEMPT TO PUSH CORD BACK. OR PULL ON THE CORD

7. Keep exposed cord moist and warm.

8. Apply pulse oximeter and record value

BLS/ILS/ALS

1. FR-AED care

2. Initiate transport immediately.

Abnormal Presentation (breech or limb)

FR-AED

1. Routine Medical Care

2. Oxygen at 15 L per NRB

3. Notify Medical Control asap of situation

4. DO NO ATTEMPT TO PULL BABY FROM VAGINA BY LEGS OR

TRUNK or EXTREMITIES

5. Elevate mothers hips

6. If breech presentation : As soon as legs are delivered, support baby’s body

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 7. After shoulders are delivered, gently elevate trunk and legs to aid in delivery
of head (if face down)

8. Head should deliver in 30 seconds. IF NOT – place 2 fingers into vagina to

locate the infant’s mouth. Press vaginal wall away from baby’s mouth to force
an airway. Apply gentle pressure to the mother’s fundus.

9. If limbs are presenting part Patient needs rapid transport by transport agency

10.Avoid touching the presenting limb as that stimulation may cause baby to
take a breath.

BLS/ILS/ALS

1. FR-AED care

2. Initiate transport immediately

NEWBORN ASSESSMENT

FR-AED/BLS/ILS/ALS

Evaluate APGAR score at 1 minute and 5 minutes

APGAR SCORING

SIGN 0 1 3
Heart Rate Absent < 100 > 100
Respirations Absent Slow >40
Muscle Tone Limp Some flexion Vigorous
Reflex irritability None Grimace Grimace
Colour Diffusely pale/blue Centrally pink Completely pink

Neonatal Resuscitation
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FR/BLS

 Deliver head

 Suction mouth and nose and posterior pharynx with #10 Fr

catheter or bulb syringe  Deliver body

 Clamp/cut cord If meconium absent:

 Dry/stimulate/cover head

 Keep warm

 Evaluate respiratory rate

 Evaluate heart rate

If meconium present (thick/particulate)

 Visualize and suction back of oral cavity as deep as possible

without trauma

 Ventilate between suctioning attempts with BVM

 Dry/stimulate/cover head after thorough suctioning complete

 Evaluate respiratory rate

 Evaluate heart rate Respiratory rate slow/gasping, absent:

 Position airway

 Support ventilation with BVM @ 100% oxygen

 Ventilate at 12-20 per minute (every 3-5 seconds)

 Re-evaluate frequently

Respiratory rate spontaneous with good effort:

 Evaluate heart rate

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  Keep warm

Heart Rate < 60:

 Continue ventilations @ 12-20/min

 Begin chest compressions @ 30-2 if single EMT, 15-2 if two

EMT

 Compression: ventilation ratio @ 3:1

 Evaluate APGAR at 1 min and repeat at 5 minutes Heart Rate

80 – 100:

 Support ventilations with BVM

 Re-evaluate frequently Heart Rate > 100:

 Continue to warm and re-evaluate frequently  Evaluate color

 APGAR at 1 min and repeat at 5 minutes  PINK:

Contact Medical Control

 Transport ASAP
 Keep warm
 Re-evaluate frequently

 BLUE:

Administer 100% oxygen by mask or BVM

Contact Medical Control

Keep warm, re-evaluate frequently

Neonatal Resuscitation Continued

ILS/ALS

1. BLS/FR care

2. IF heart rate < 80/min:

27
 Secure advanced airway – intubate as indicated

 Epinephrine 0.01-0.03mg/kg ET (0.1-0.3mL/kg) of 1:10,000 May repeat

every 3-5 minutes as indicated

 Initiate IV of Normal Saline @ KVO

 Cardiac monitor

 Pulse oximeter

 Re-evaluate frequently  Contact Medical Control 3. If heart

rate 80 – 100/min:

 Support ventilations with BVM and 100% oxygen  Advanced

airway as indicated – intubate orally  Evaluate color:

 PINK:

Transport ASAP

Observe Keep warm  BLUE:

Contact medical control

Consider: NARCAN 0.1mg/kg ET/IV Dextrose 12.5% 1-2 mL/kg IV

Fluid bolus 10 mL/kg

Special Considerations

Small amounts of meconium may merely discolor the amniotic fluid with no
particles of meconium visible. Special management of these infants is not
necessary. Meconium management is indicated for amniotic fluid that is “pea
soup” in appearance, or contains particles of meconium.

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.

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Abstract

OBJECTIVES:
The purpose of the study was to compare the efficacy of misoprostol 400 μg 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:

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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.

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.

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

MANIBA BHULA NURSING COLLEGE

BARDOLI

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SUB : OBSTETRIC AND GYNAECOLOGY NURSING
TOPIC : DEVELOPING NURSING STANDARDS AND
PROTOCOL IN SPECIALTY UNIT (LABOUR ROOM)

SUBMITED TO SUBMITED BY
MS HIRAL MISTRY MS TANDELKINJAL
HOD OF O.B.G. SYMSC (OBG)
MBNC MBNC
DATE:

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