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MODULE I
INTRODUCTION TO PHARMACOLOGY

Lesson 1 Principles of Pharmacology

Lesson 2 Pharmacological
Considerations in IVT

Lesson 3 Law, Medicine and the

Midwife

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MODULE I

INTRODUCTION TO PHARMACOLOGY

 INTRODUCTION

This module sets the scene by describing the state of the evidence based in midwifery
pharmacology; it continues with an account of pharmacological principles, terms and definitions
as they relate to midwifery practice. It also outlines the extra considerations involved when
intravenous (IV) drug administration is undertaken outside specialist intensive care facilities.
Lastly, it describes the statutory framework for the control of medicines and discusses the
implications for midwives.

LEARNING OUTCOMES

After studying the module, you should be able to:

1. Discuss the foundations of pharmacology.
2. Explain the interactions between the drug and its recipient.
3. Explain the rights and route of drug administration.
4. Apply properly the steps of IV cannulation following the healthcare process.
5. Determine the possible complications of IV therapy and its management.
6. Explain the legal regulations of pharmacology in the Philippines.

 DIRECTIONS/ MODULE ORGANIZER

There are three (3) lessons in Module 1. Read the lesson carefully then answer the given
exercise after each lesson. This is to assess your understanding and/or to augment your
learnings. Work on these exercises carefully and submit your output as advised by your
instructor.

In case you encounter difficulty, discuss this with me anytime via messenger or email.
If not, set an appointment with me to talk your concerns at the CCHAMS faculty office.

Good luck and enjoy while learning.

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Lesson 1

 PRINCIPLES OF PHARMACOLOGY

Pharmacology
The study of the actions of drugs, incorporating knowledge from other interrelated
sciences, such as pharmacokinetics (how the body absorbs, distributes, metabolizes, and
excretes a drug) and pharmacodynamics (a drug’s mechanism of action and effect on an
organism).

The three basic concepts of pharmacology:

1. Pharmacokinetics—the absorption, distribution, metabolism, and excretion of drugs
by the body
2. Pharmacodynamics—the biochemical and physical effects of drugs and the
mechanisms of drug actions
3. Pharmacotherapeutics—the use of drugs to prevent and treat diseases.

The other important aspects of pharmacology, include:

• How drugs are named and classified
• How drugs are derived
• How drugs are administered

Drug Classifications
Drugs are classified by how they affect certain body systems, such as the use of
bronchodilators for respiratory conditions; by their therapeutic use, such as anti-nausea; or
based on their chemical characteristics, such as beta-blockers.

Drug Names
Midwives must know both the trade name of a drug, which is assigned by the
pharmaceutical company that manufactures the drug, and the generic name, which is the
official drug name and is not protected by trademark.

Drug Nomenclature
Every drug has (at least) three names:
1. Chemical Name – a scientific name that precisely describes the drug’s atomic
and molecular structure.
2. Generic Name or nonproprietary name or official name - an abbreviation of the
chemical name and it refers to a common established name regardless of its
manufacturer. There is only one generic name for a drug.
3. Brand Name (there can be one or more proprietary or trade names) – it is selected
by the drug company selling the product. Trade names are protected by
copyright. The symbol ® after a trade name indicates that the name is registered
by and restricted to the drug manufacturer.

Drugs Derivation
Drugs and biologic products are derived from 4 main sources:
1. Plants: examples of which are digitalis
2. Animals and human: from which drugs such as insulin, epinephrine are obtained
3. Minerals or mineral products: examples such as iodine and iron
4. Chemicals: made in laboratories

Route of Drug Administration

The various routes of administrations are classified into local route and systemic route.
The local route is the simplest mode of administration of a drug at the site where the desired
action is required. When the systemic absorption of a drug is desired, medications are usually
administered by two main routes: the enteral route and the parenteral route.

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Figure 1. Routes of Drug Administration

I. Local Route: applied to a localized area of the body or to the surface of a body part
regardless of the location of the effect.

Table 1. Local Route

Route Description
Topical • Drugs are applied into the skin or mucous membrane of the eye, ear,
nose, mouth, vagina etc., mainly for local action.
• It provides a high local concentration of the drug without affecting the
general circulation.
• Drugs that are absorbed into the circulation after local administration
may then have systemic effects.
• Drugs for topical applications are usually available as creams, ointment,
liniment and drops.

II. Enteral Routes: any administration that makes use of the GIT to administer the drug

Figure 1. Enteral Routes of Drug Administration

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Table 2. Enteral Routes

Route Description
Oral • The most frequently used route and the first choice for drug
administration as much as possible.
• Drugs administered orally are placed in the mouth and swallowed.
Rectal • The rectal mucosa is capable of absorbing many soluble drugs into the
circulation.
• Rectal medication may be in suppository form or in liquid form to be
administered as a retention enema.
Sublingual/Buccal • The drug is placed under the tongue (sublingual route) or between gums
and inner lining of the cheek (buccal route).
• In both cases, the drug is allowed to dissolve, avoiding swallowing as far
as possible.
• The drug is rapidly absorbed through the mucosa into circulation,
thereby bypassing the portal circulation and, thus, the first-pass
metabolism in the liver.

II. Parenteral Routes: any administration that avoids the used of the GIT to administer
the drug

Figure 2. Parenteral Routes of Drug Administration

Table 3. Parenteral Routes

Route Description
Subcutaneous (SC) • Administration beneath the skin; hypodermic.
• Synonymous with the term subdermal or hypodermal.
Intramuscular (IM) • Administration within a muscle.
Intradermal (ID) • Administration within the dermis.
Intravenous (IV) • Administration within or into a vein or veins.
Intra-arterial (IA) • Administration within an artery or arteries.
Intrathecal (IT) • Administration within the cerebrospinal fluid at any level of the
cerebrospinal axis, including injection into the cerebral ventricles
Intraperitoneal (IP) • Administration within the peritoneal cavity.
Intravitreal • Administration within the vitreous body of the eye.

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Transdermal • Commonly referred to as “the patch”.

• Drugs administered must be highly lipophilic.
Inhalation • Also known as pulmonary route.
• A common route, both for local and for systemic actions.
• Drugs may be inhaled as gases (e.g., nitrous oxide) and enter the
bloodstream by diffusing across the alveolar membrane.

Figure 3. Injection Sites (Ruiz and Montoto. 2018)

The Evidence-Based for Pharmacologic Intervention

All treatments and their effects are multidimensional. When assessing the contribution
made by drugs to health care, we could consider the available evidence under the headings:
• magical/placebo and nocebo effects
• empirical evidence
• rational/scientific evidence

Drug Therapy
The interactions between the drug and the person receiving it can be divided into four
stages:
• Getting the drug into the body – pharmaceuticals
• Getting the drug around, about and out of the body – pharmacokinetics
• Actions of the drug on the body – pharmacodynamics
• Effects of the drug on the person – therapeutics

Figure 3. Drug Therapy

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Pharmaceuticals: getting the drug into the body

Two issues are considered here:
a) Compliance
Compliance or concordance with medication is the extent to which clients
adhere to prescribed regimens and the associated professional advice.
Factors associated with non-compliance include:
✓ Women in pregnancy who consider themselves to be healthy
✓ Fear of harming the unborn child
✓ Living alone
✓ Taking more than three drugs
✓ More than two drug administrations per day
✓ Reduced esophageal motility, for example dehydration

b) Drug Formulation
The storage requirements of each preparation depend on the
formulation. Therefore, the data sheet for each product and brand should be
consulted for instructions on storage.

Pharmacokinetics: how the body handles the drug

This section addresses the questions:
• Is the drug getting to the desired site of action? (absorption and distribution)
• Is the drug getting out of the body? (elimination)
• Is there a risk of accumulation and toxicity?

The LADME scheme (Figure 4) describes the pharmacokinetic processes which follow a
given dosage regimen. LADME processes can be divided into two classes, drug input (liberation
and absorption) and drug output (distribution, metabolism and excretion)
(http://www.rxkinetics.com/).

The LADME Scheme:

• Liberation – the process of release of
a drug from the pharmaceutical
formulation.
• Absorption – the process of a
substance entering the blood
circulation.
• Distribution – the dispersion or
dissemination of substances
throughout the fluids and tissues of
the body.
• Metabolism (or biotransformation, or
inactivation) – the recognition by the
organism that a foreign substance is
present and the irreversible
transformation of parent compounds
into daughter metabolites.
• Excretion – the removal of the
substances from the body. In rare
cases, some drugs irreversibly
accumulate in body tissue.

Figure 4. The LADME Scheme (wikipedia.org)

Therapeutic Range
Every drug has a therapeutic range or a desirable range for the concentration of drug in
plasma. Above the therapeutic range, toxic effects may appear. Below the therapeutic range,
the drug does not have the desired effect. For some drugs this range is very narrow, and the
therapeutic concentration is very close to the concentration at which adverse effects appear.

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The body handles all drugs in three stages and are affected to some extent by pregnancy.
1. Absorption
The process by which a drug is made available to the body fluids for
distribution. The absorption of a drug will depend on the route of administration,
formulation, and the way the drug molecules move across cell membranes
throughout the body. Important barriers to drug absorption and distribution
include: the gut wall, capillary walls, cell membranes, the blood/brain barrier,
the placenta, the blood/milk barrier.

2. Distribution
Distribution is the movement of the drug around the body. It is affected
by: a) plasma protein binding; b) the lipid solubility of the drug (that is whether
it dissolves in fatty tissues); c) the binding properties of the drug; d) blood flow
to the organs and the state of the circulation; e) stage of life cycle, for example
pregnancy, infancy; f) disease state, for example pre-eclampsia or heart failure

3. Elimination or Clearance
The route of elimination varies with individual drugs. Some drugs are
eliminated unchanged whereas others are extensively metabolized. Most drugs
are excreted via the kidneys, although the bile is also an important route of
excretion. Many drugs are passed into breast milk. Alcohol is unusual in that 5–
10 percent is eliminated unchanged via the lungs, sweat and urine. For most
drugs, elimination involves metabolism in the liver plus excretion by the kidneys.

Pharmacodynamics: actions of the drug on the body

This section addresses the question: what are the effects of the drug on the tissues?
Drugs work as a result of the physiochemical interactions between drug molecules and the
patient’s/recipient’s molecules. These chemical reactions may alter the way the cells are
functioning which in turn may lead to changes in the behavior of tissues, organs, and systems.
Drugs modify the existing functions of the body; they cannot introduce new functions. Most
drugs act on more than one type of cell and therefore have multiple effects on the body.

Figure 5. Pharmacokinetics vs. Pharmacodynamics

Most drug molecules work via:

• Protein receptors in cell membranes or within cells
Many drugs work by acting on specific receptor proteins. These are
components of the cell membrane which normally respond to the body’s
hormones and neurotransmitters – the endogenous ligands. Examples include
insulin receptors, opioid receptors, dopamine receptors, histamine receptors.
Many drugs imitate the actions of the body’s own ligands. Some drugs are direct
replacements, for example insulin and epinephrine (adrenaline). Others provide
an artificial boost to certain receptors, for example opioids.

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Figure 6. Drug-Plasma Protein Binding (Sparreboom et al., 2001)

• Ion channels in cell membranes

Ion channels are similar to receptors in the way they bind to certain
drugs. Examples include calcium antagonists (nifedipine) and local anesthetics
such as lignocaine. However, because ion channels are present in a wide variety
of cells and tissues, the side effects of these drugs can affect several body
systems. For example, local anesthetics affect both nerves and muscles.

• Enzymes in cells or extracellular fluid

Enzymes are present in all cells, catalyzing their vital biochemical
reactions. Some drugs bind to enzymes and inhibit their actions. Examples
include, NSAIDs (non-steroidal anti-inflammatory drugs, such as aspirin,
ibuprofen), MAOIs (mono amino oxidase inhibitors for depressive illness). It is
likely that these drugs are able to interact with certain enzymes by virtue of
their shape and structure in a similar manner to the drug–receptor interaction.

• Non-specific actions
Some drugs are presumed to act by virtue of their physiochemical
properties, rather than as a result of the specific shape of their molecules. For
example, antacids such as sodium bicarbonate or aluminum hydroxide neutralize
gastric secretions without acting on the cells of the body.

Therapeutics: the effects of the drug on the person

This section addresses the questions: has the drug produced any effect on the recipient?
If so, is the result therapeutic or toxic?
Changes in Physiology of Cells, Tissues and Organs
Even if a drug is working on the body’s cells, there may be no noticeable
response. For example, due to individual differences, an oxytocic or a tocolytic may be
ineffective.

Clinical Effects
Clinical response shows considerable individual variation. This is not always
entirely predictable, and idiosyncratic reactions can occur. For example, some women
are unduly sensitive to oxytocin, and therefore infusions are commenced using a very
low dose (BNF, 2000). Clinical effects also depend upon age, gender, pregnancy, disease

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state, drug interactions, weight, height, and genetic make-up. For example, women
generally require lower doses of drugs than men, even when body weight is taken into
consideration.

Side Effects
Side effects are adverse drug reactions that occur within the normal range of
therapeutic doses. Most drugs have potential side effects. These can be grouped under
the headings:
• Related to the Drug’s Main Actions
These are often the drug’s main side effects. Severity is usually related
to the dose administered. Since such side effects are often highly significant
and entirely predictable, appropriate monitoring systems must be in place.
For example, unless adequate checks are undertaken anti-coagulants can
cause bleeding, and insulin can cause hypoglycemia. With other drugs, the
link between drug actions and side effects is less obvious and requires rather
more understanding of physiology.

• Unrelated to the Drug’s Main Actions:

✓ Related to Subsidiary Actions
Many drugs act on more than one type of cell receptor; this
consequence gives the potential for diverse side effects. Again, these
side effects are predictable, and the midwife should monitor or
caution the woman appropriately.
For example, oxytocin acts on the oxytocic receptors of the
uterus, but it also acts on the anti-diuretic (ADH) receptors in the
nephrons. This property gives it the potential to trigger water
retention and fluid overload. Therefore, the midwife must monitor
fluid balance.
In pregnancy, the subsidiary actions of drugs on the uterus assume
great importance. Any drugs which stimulate uterine contractility
should be avoided, including stimulant laxatives, misoprostol and all
drugs chemically related to ergotamine.

✓ Hypersensitivity Responses
A hypersensitivity response is possible with almost all drugs,
although antimicrobials are particular offenders. Individuals with a
history of atopic disorders, such as asthma or eczema, are particularly
vulnerable.
Most drugs or their metabolites can combine with carrier proteins
in the circulation to form immunogens, substances which produce an
immune response. This may affect any one of several organs such as
skin, liver or bone marrow. The severity of the hypersensitivity
response is also variable, ranging from a temporary skin rash to life-
threatening aplastic anemia.

✓ Cell Damage
Some drugs can cause direct damage to cells. For example, in
large doses, paracetamol (acetaminophen) can damage the liver and
kidneys. Other drugs, such as components of tobacco, damage cells by
altering the DNA regulating oncogenes which control cell division.
Drug-induced teratogenesis is a result of cell damage. The risks of
fetal damage depend on several factors as well as the chemical
composition of the drug (Lipkin, 1993):
• The stage of pregnancy
• The amount of drug ingested
• The number of doses – a single dose may be less damaging than
repeated exposure
• Other agents to which mother and fetus are exposed
• The mother’s nutritional status
• The genetic makeup of mother and fetus.

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EXERCISE
Instruction: In a separate sheet, answer the following questions briefly.

1. In your own words, explain the following statements in 3-5 sentences:

a. Relevance of your course (Mid 201) in your profession.
b. Pharmacokinetics, Pharmacodynamics and Pharmacotherapeutics.
c. Side Effects and Adverse Reactions
2. Discuss the following:
a. Rights of drug administration
b. Advantages and disadvantages of each route of drug administration.
c. Different drug preparations

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