SUBMITTED BY SUBMITTED TO

MS DIMSEY .R.MARAK MS SUBHASHINI.G

1ST YEAR MSC NURSING HOD OBG NURSING

P.I.O.N. P.I.O.N.

MASTER PLAN

TOPIC : PHARMOCO DYNAMICS IN OBSTETRICS

UNIT : VII

COURSE AND YEAR : MSC NURSING 1ST YEAR

DATE AND TIME :

NAME OF THE STUDENT : MS DIMSEY.R.MARAK

NAME OF THE SUPERVISOR : MS SUBHASHINI. G.

SUBJECT : OBSTETRICS AND GYNAECOLOGY NURSING

SL .NO CONTENT

1. INTRODUCTION2. OBJECTIVES3. TERMINOLOGIES

Teratogenic Orgenogenesis Hypotonea Substance

4. CONTENT Definition Drug used in pregnancy, labour, and post natal mothers Drug used in new born Definition of analgesics and types Definition of anaesthesia and types Role and responsibilities of midwifery Standing orders.

5. CONCLUSION

6. BIBLIOGRAPHY

7. ABSTRACT JOURNAL

INTRODUCTION

Most women are exposed to drugs of one type or another during pregnancy. These may be prescribed drugs or those bought over the counter. They may be given as part of the management of the pregnancy itself or that of coincidental medical problem. However, when considering the use of any drugs in a pregnant or breastfeeding woman, it is important to consider the effects of drug not only on the women itself, but also on the foetus or neonate. Many drugs have undesirable effects of the foetus and should therefore be avoided during pregnancy. On the other hand, some drugs are given to the women because of their therapeutic effects on the foetus.

DEFINITION: Drogue means a dry herb in French is a substance used in the diagnosis and present or treatment of a disease

DEFINITION BY WHO:

Drug is any substance or product that is used or intended to be used to modify or explore physiological systems or pathological status for the benefit of the recipient.

DRUGS USED IN PREGNANCY

Folic acid:

It is recommended that all women planning a pregnancy should take folic acid in a dose acid of 400mg daily and that this should continue throughout the first trimester. Folic acid is a vitamin that is involved in the process of cell growth and division. There are no risks associated with folic at this dose.

Iron preparation:

Iron is one nutrient requesed for production of hune compounds; especially haemoglobin in the red blood cells.Both mother and foetus produce red blood cells, during the last trimester, the foetus absorbs more iron to produce blood. Supplements may cause nausea and constipation.

Antacid drugs: antacids are alkalis that act by reducing the acidity of stomach acid. Modern antacid drugs are mostly based on calcium, magnesium and aluminium salts, which are relatively non-absorbable. They

are often combined with alginates, which coat the lining of the oesophagus and stomach and therefore reduce contact with stomach acid. Because they are relatively non-absorbable, they are safe for use in pregnancy.

ANTIHYPERTENSIVE DRUGS:

Antihypertensive drugs are used in hypertensive disorders of pregnancy. The commonly used drugs. They are as follows

Methyldopa: It stimulates central a-adrenergic receptors or acts as false transmitter, resulting in reduction of arterial pressure.

Dose and administration: 250mg BID to 1gm TID orally and IV infusion 250-500mg

Side effects: Nausea vomiting, diarrhoea, constipation, bradycardia angina weight gain, drowsiness, dizziness headache and depression

Labetalolis:It is a nonselective b blocker

Dose and administration: 100mg tid upon 800mg daily AC HS and IV infusion

1-2mg/min until desired effect.

Side effects: Orthostatic hypotension, bradycardia, chest, pain, drowsiness

, headache, nightmares, lethargy, sore throat, dry burning eyes.

Propranolol: It is b adrenergic blocker-decreases preload, after load, which is responsible for decreasing left ventricular end diastolic pressure and systemic vascular resistance.

Dose and administration: 80mg-240mg in divided doses orally.

Side effects:

Maternal: Severe hypotension, sodium retention, bradycardia, bronchospasm, cardiac failure.

Fetal: Bradycardia and impaired foetal responses to hypoxia, IUGR with prolonged therapy, neonatal hypoglycemia.

Nifedipine: It is calcium channel blocker and produces direct arteriolar vasodilatation by inhibition of inward calcium channels in vascular smooth muscles.

Dose and administer: 5-10mg TID AC HS

Side effects: Flushing, hypotension, palpitations, bradycardia, inhibition of labour headache, fatigue, drowsiness, nausea, vomiting

Sodium nitroprusside It is peripheral vasodilator, directly relaxes arteriolar, venous smooth muscle, resulting in reduction of cardiac preload and after load.

Dose and administration: IV infusion 0.5mg-10mg/kg/minute.

Side effects:

Maternal

Nausea, vomiting, severe hypotension. Restlessness decreased reflexes, loss of consciousness.

Fetal: Toxicity, due to metabolites-cyanide and thiocyanate.

DIURETICS: Diuretics are used in the following conditions during pregnancy

Pregnancy induced hypertension with massive oedema.

Eclampsia with pulmonary edema.

Severe anaemia in pregnancy with heart failure.

Prior to blood transfusion in severe anaemia

Frusemide:A loop diuretic acts on loop of Henle by increasing excretion of sodium and chloride.

Dosage and administration:

Tab 40mg daily following breakfast for 5 days a week .In acute conditions, the drug is administered parenterally in doses of 40mg-120mg daily.

Side effects:

Maternal: Weakness, fatigue, muscle cramps, hypokalaemia, hypocalaemia hyponatraemia and postural hypotension.

Fetal: May occur due to decreased placental perfusion leading to foetal comprise. Thrombocytopenia and hyponatraemia are other hazards.

Hydrochlorothiazide: It is sulphonamide derivative and acts on distal tubule by increasing excretion of water, sodium, chloride and potassium.

Dose and administration: Orally 25-100mg/day

Side effects: Polyuria, glycosuria, frequency, nausea, vomiting, anorexia, rash urticaria, fever.

TOCOLYTIC AGENTS:

These drugs can inhibit uterine contractions and used to prolong the pregnancy. In women who develop premature uterine contractions, in addition to putting them to absolute bed rest and sedating, tocolytic drugs are administered in an attempt to inhibit uterine contractions.

Isoxsuprine (duadilan): It acts directly on vascular smooth muscle, causes cardiac stimulation and uterine relaxation.

Dose and administration:

Initial: I V drip 100mg in 5 percent dextrose. Rate 0.2mg per minute to continue for at least two hours after the contractions cease.

Maintenance: IM 10 mg six hourly for 24 hours, tab 10 mg 6-8 hourly.

Side effects: Hypotension, tachycardia, nausea, vomiting, pulmonary edema, cardiac arrhythmias, adult respiratory distress syndrome.

RITODRINE hydrochloride (yutopar): Uterine relaxant-acts directly on vascular smooth muscle. Causes cardiac stimulation and uterine relaxation.

Dose and administration:

Initial: IV drip 100mg in 5% dextrose. Rate, 0.1mg per minute gradually increased by 0.05mg per minute q10 min until desired response. To continue for at least 2 hours after the contractions cease.

Maintenance: Tab 10 mg 6-8 hourly

P.O 10 mg given half hour before termination of IV per minute

Side effects: Hyperglycaemia, headache, restlessness, sweating, chills and drowsiness, nausea, vomiting, anorexia and malaise.Alterd maternal and foetal heart tone and palpitations.

ANTICONVULSANTS:

The commonly used anticonvulsant is magnesium sulphate.Diazepam; phenytoin and phenobarbitone are also used.

MAGNESIUM SULPHATE: It decreases acetylcholine in motor nerve terminals, which is responsible for anticonvulsant properties, thereby reduces neuro muscular irritablitity.It also decreases intracranial edema and helps in dieresis and depressant action on the uterine muscle and CNS.

Dose and administration For control of seizures,20ml of 20% solution IV in 3-4 minutes; to be followed immediately by 10ml of 50% solution IM< and continued 4hourly till 24 hours postpartum. Repeat injections are given only if the knee jerks are present, urine output exceeds 100ml in previous 4 hours and the respirations are more than 10/minute. The therapeutic level of serum magnesium is 4-7 mEq/L.

4gm IV slowly over 10min, followed by 2gm/hr, and then 1gm/hr in drip of 5% dextrose for tocolytic.

Side effects

Maternal:Severe CNS depression evidence of muscular paresis(diminished knee jerks)

Fetal: Tachycardia,hypoglycaemia

Depresses subcortical levels of CNS, anticonvulsant and antianxiety.

Dosage and administration:PO, 2 -10 mg tid-qid with milk or food to avoid G.I symptoms

IV, 5-10 mg(bolus),2 mg/min may repeat q5-10 min, not to exceed 60 mg,may repeat in 30 min if seizures reappear.

Side effects

Mother:Hypotension,dizziness,drowsiness,headache.

Fetus:Respiratory depressant effect, which may last for even three weeks after birth.Hypotonea and thermoregulatory problems in newborn.

PHENYTOIN(Dilantin):

It inhibits spread of seizure activity in motor cortex.

Dosage and administration

Eclampsia-10 mg/kg IV at the rate not more than 50mg/minute, followed 2

Hours later by 5mg/kg.

Epilepsy-300-400mg daily orally in divided doses.

Side effects

Maternal:Hypotension, cardiac arrhythmias and phlebitis at injection site.

Fetal :Prolonged use by epileptic patients may cause craniofocal abnormalities; MR, microcephalcy and growth deficiency.

Dose and administration :

120-240mg/day in divided doses

Maternal :Sedation, drowsiness,hangover headache, hallucination.

Fetal: Withdrawal syndrome.

ANTICOAGULANTS:

HEPARIN:It prevents conversion of fibrinogen to fibrin.

Dose and administration

Administered parenterally; only 5,000-7,000 IU to be administered initially as

IV push followed by 2,500 units subcutaneously every 24 hours.

Side effects

Leukopenia, thrombocytopenia, osteoporosis, haemorrhage alopecia.

ANALGESICS

PETHIDINE: It is synthetic narcotic analgesic agent, well absorbed by all routes of administration. It actions to inhibits ascending pain pathways in central nervous system, increases pain threshold and alters pain perception.

Dose and administration

Injectable preparation contains 50mg/ml, can be administered SC, IM, and IV. Its dose is 50-100mg IM combined with promethazine 25mg.

Side effects

Mother: Drowsiness, dizziness confusion, headache, sedation, euphoria, nausea and vomiting

Fetal: Respiratory, depression, asphyxia.

NALBUPHINE (Nubain): It is classified as a narcotic agonist-antagonist analgesic that works by interacting with opiate receptors in the central nervous system.

Dose and administration: It is given10-20mg subcutaneous or intravenous every 3 to 6 hour.

Side effects: respiratory depression, headache, sedation, dizziness, nervousness, restlessness confusion, nausea and vomiting.

Foetal: Respiratory depression.

160mg in 24hour intramuscular or intravenous

Fentanyl: It is a synthetic narcotic analgesic agent.

DOSE AND ADMINISTRATION: 0.05-0.1mg IM q 1 to 2 hours prn. Available in injectable form, 0.05mg/ml.

SIDE EFFECTS: Dizziness, delirium, euphoria,nausea,vomiting, muscle rigidity, blurred vision.

PROMETHAZINE(Phenergan): It is an antihistamine,H1 - receptor antagonist belonging to the phenothiazine group.It is used in 1st stage of labour

DOSAGE AND ADMINISTRATION:Available for oral use as 12.5,24 and 50mg tablets and for parenteral use as 25 and 50 mg/ml solutions.The dose is 25mg, 8 hourly orally and 25 mg intramuscularly, to be repeated as necessary.

SIDE EFFECTS: Drowsiness, dizziness,poor coordination, fatigue, anxiety, confusion neuritis, parasthesia.

DRUG USED IN LABOUR

OXYTOCIN: It is a hormone normally produced by the posterior pituitary;it stimulates uterine contractions.It may be used either to induce labour or to augment a labour that is progressing slowly because of inadequate uterine contractions.

Indications for pregnancy

To induce abortion To expedite expulsion of hydatidiform moleTo stop bleeding following evacuationTo induce labour

Labour

To augment labourTo prevent and treat PPH.

Postpartum

To initiate milk let-down in breast engorgement

DOSAGE AND ADMINISTRATION

Controlled and intravenous infusion begin induction at 0.5 milliunits/min and increase dose 1 to 2 milliunits/min intervals of no less than 30 to 60 min until adequate progress is achieved.

SIDE EFFECTS

Hypertonic uterine activityFoetal distress and fetal deathUterine ruptureHytopensionNeonatal jaundice

ERGOT DERIVATIONS :It acts directly on the myometrium.It stimulates uterine bleeding. It is used in the treatment and prevention of PPH.As the drug produces titanic uterine contractions,it should only be used after delivery of the anterior shoulder or following delivery of the baby.

DOSAGE AND ADMINISTRATION: 0.2mg IM every 2-4 hour and 0.5-1mg tablets.

SIDE EFFECT

Hypertension, nausea ,vomiting headache. Prolonged use in puerperium may interfere with lactation by decreasing

the concentration of prolactin. Prolonged use may lead to gangrene of the toes due to its

vasoconstrictive effect.

PROSTAGLANDINS(PGS): Prostaglandins are synthesized from one of the essential fatty acids, arachidonic acid, which is widely distributed throughout the body.It is induction of abortion during second trimester and as well as for induction of labour in intra- uterine death of fetus.

DOSE AND ADMINISTRATION:

Tablets- containing 0.5 mg prostin E2

Vaginal suppository-containing 20mg PGE2 or 50 mg PGE2α

Injectable ampoules or vials of prostin E2 1mg/ml Prostin F2α 5mg/ml.

SIDE EFFECTS

Headache, dizziness, hypotension leg cramps, joint swelling blurred vision.

DRUG USED IN NEWBORN

BRONCHODILATORS:

Adrenaline (Epinephrine) 1mg / ml (1:1000 concentrations) it used as a part of newborn resuscitation cardio-pulmonary resuscitation

Dose 0.1-0.3ml/kg/dose of 1:10,000 dilutions, repeat every 3-5 minute, if necessary.

Route intravenous or endotracheal route .direction: Take 0.1 ml in syringe.Dilute it with 0.9ml to make with water for injection (10 times dilution)

Aminophylline injection 250 mg in 10 ml ampoules. It used for apnoea of prematurity.

Dosage loading does:5.0-8.0mg/kg intravenous.Maintenance:1-2mg/kg/dose q 8 hourly intravenous.

Directions for use: 250mg/10ml vial. Take 0.1ml of solution in 1ml syringe. Dilute with 0.9ml to make 1ml with water for injection. Resultant concentration is 2.5mg/ml.Administer required dose IV over 2 minutes.

Compatible: With 5% dextrose, normal saline, ringers lactate.

Calcium gluconate

Presentation: 9mg/ml

Uses: Treatment of low blood calcium level.Dosage:1-2ml/kg/dose every 6-8 hourly intravenous (infusion or bolus)

Direction for use

1. To be diluted in equal amount of distilled water.

2. Inject very slowly while monitoring heart rate. If there is bradycardia discontinue the injection.

3.Take care to avoid extravasations, if being given as infusion-as it may cause sloughing of skin.

ANTIBIOTICS

Ampicillin

Presentation: injection 100, 250,&500 mg vials

Dosage: 50-100 mg/kg/day divided q 8-12 hourly,IV IM

Meningitis: 100-200 mg/kg/day divide q 6-8 hourly IV

Directions: 250mg vial. Add 2.5ml water for injection. Resultant concentration 50mg/ml.

Compatible: Normal saline, ringer lactate.

Amikacin:

Neonates

Single daily dosing IV, IM.Under 30 week gestation 7.5 mg/kg/dose 24hourly.

30-35 week gestation: 10mg/kg/dose 24hourly

Term: Week 1 of life: 15mg/kg/dose 24 hourly

Week 2 to 4 of life: 22.5mg/kg/dose 24 hourly

Infants and children to 10 years. Single daily dosing

22.5mg/kg/dose 24 hourly.

ANTICONVULSANTS

Phenobarbitone

Presentation: Injection 200mg/ml 1ml ampoules. It used in neonatal seizures.

Dosage: Loading dose: 15-20mg/kg IV

Maintenance: 3-5mg/kg/day PO in 1-2 divided doses.

Direction for use 200mg/1ml.give required amount slowly over 15-20 minutes.

Phenytoin100mg /2ml

Dosage: Loading dose: 15-20mg/kg IV

Direction for use Dilute in normal saline and give slowly at a rate 1mg/min infusion.

Compatible Normal saline only

ANALGESICS AND ANTIPYRETICS

Acetaminophen: 40 to 65 mg /kg/24hour orally in 4 divided doses.

Paracetomal: 40 to 65 mg /kg/24hour orally in 4 divided doses.

ANTIEMETICS:

Promethazine: 0.25mg to 0.5mg/kg/dose-repeat 6 hour later.

Domperidone: 0.3 to 0.6mg/kg/24 hour in divided doses.

ANALGESICS AND ANAESTHESIA

Pain is a highly subjective experience. Pain is whatever the client says it is. The amount and type of pain experienced during labour vary widely from person to person. During labour different types of pain arise from different sources. As the uterus contracts and the cervix dilate, the client feels visceral pain as described persistent, aching, or spreading. The pain may be localised to the abdominal region or felt in the lower back, hips or thighs. Some women describe generalised aching throughout the body. This type of pain is intensified by fatigue. Another type of pain sensation is caused by pressure of the descending foetus as it stretches the birth canal. This type of generalised body pain is called somatic pain described as intense pressure or need to bear down, is typically most intense during the transition phase of the first stage of labour and during the second stage of labour.

Analgesia is the use of medication to reduce the sensation of pain.

PARENTERAL AND INHALATIONAL ANALGESIA

Parenteral narcotics: Pethidine is the most frequently used narcotic given intramuscularly. It is administered in a dosage of 50mg to 100mg intramuscularly with 2 to 4 hours interval. Alternatively it can titrated intravenously to effect in the presence of severe pain for a rapid response. Morphine can also be administered but it is not frequently used as the neonatal respiratory depression and maternal nausea and vomiting associated with morphine are more severe.

Inhalational analgesia: Nitrous oxide is the main inhalational anaesthetic that is used for obstetric analgesia. It is used mainly in a 50:50 combination with oxygen. It is delivered with a demand valve and there will not be any flow from the system unless an inspiratory effort is made with the mask properly sealed on the face. It may produce light headedness and nausea. It is suitable for use when the mother is in severe pain especially during late whilst waiting for the effects of other methods to take their effects.

REGIONAL ANALGESIARegional analgesia is the most effective method of providing labour analgesia for the mother currently available and is more costly and need the services of an anaesthetist in their administration and maintenance.

Epidural analgesia: This involves the administration of a dilute amount of local anaesthetic either in the form bupivacaine combined with a low concentration of short acting narcotic like fantasy through a catheter placed in the epidural space and administered either in the form of bolus doses by a doctor or nurse.

Combined spinal epidural (CSE) analgesia: This technique is fairly similar to an epidural except that after the epidural needle is an in the epidural space, a long spinal needle is placed through this needle to the intrathecal space. The CSE set is more expensive compared to an epidural set.

Spinal analgesia: This method which involves the administration of a small amount a local anaesthetics and narcotic into the intrathecal space as a bolus dose is not frequently used for labour analgesia. The local

anaesthetic provides only 1 to 3 hours of pain relief which may not be adequate to cover pain toward the end of the first stage or second stage.

Complications: Complication can arise from these methods in the form of hypotension, spinal headaches, and convulsions, peripheral or central neurological damage.

ANAESTHESIA

Anaesthesia is the use of medication to partially or totally block all sensation to an area of body. It may loss of normal sensation, and sometimes in loss of consciousness.

Local infiltration: It is the least extensive form of anaesthesia and presents the lowest risk to the mother and fetus.It is administered by direct injection of the anaesthetic agent, such as lidocaine, into the perineal tissue surrounding the area where the episiotomy will be made. Local anaesthesia is performed immediately before the delivery and blocks sensation long enough for the delivery and for repair of the episiotomy. The most side effects are hypotension, dizziness, palpitations and headache, tachycardia or tremors.

REGIONAL ANAESTHESIA

Regional anaesthetics block a nerve or group of nerves without causing loss of consciousness. This form of anaesthesia allows the women to remain alert and able to participate in the delivery. Regional forms of anaesthesia are most commonly recommended by health care providers and chosen by expectant. It includes paracervical,pudendal, epidural and spinal blocks.

Paracervical Block :Paracervical Block prevents impulse transmission from the lower segment of the uterus surrounding the cervix.It is accomplished by injecting a local anaesthetic transvaginally,adjacent to the outer rim of the cervix.It may be administered during the active phase of labour, achieving rapid and complete relief of uterine pain during cervical dilation. It does not

block pain impulses from the vagina or perineum and also not interfere with the bearing down reflux. It is used infrequently.

Pudendal Block: Pudenda Block prevents impulse transmission through the pudendal nerves, which transmit impulses from the perineum. The pudendal nerve is located near the lower margin of the ischial spines. Injection of the pudendal nerves is accomplished by the transvaginal route. A long needle, with or without a protective guide (sometimes called a trumpet),is used to instill medication around the nerves on each side of the body. The pudendal block is given within a few minutes of delivery and gives result in relaxation of the muscles of the perineum hastening the delivery. It also blocks pain transmission when episiotomy is performed and repaired.

Epidural Block: Epidural anaesthesia results in loss of sensation from the lumbosacral region of the spinal cord by blocking impulse transmission from major nerve roots located outside the dura mater.While the pain impulses are blocked by epidural anaesthesia, sensation of manipulation or pressure can still be detected by the women. It administered by the epidural route affects the lower trunk and legs; therefore it can be used during labour and during either vaginal or caesarean delivery. Epidural anaesthesia is accomplished by insertion of a needle or catheter into the epidural space and medication is inserted through the needle or catheter so that it can flow around the dura mater and may be administered as a single dose shortly before delivery. The site of insertion will vary based on the type of epidural selected. In the lumbar epidural the needle or catheter is inserted into the space between vertebrae L4 and L5 using surgical aseptic technique.

Spinal Block: Spinal anaesthesia causes loss of sensation to the lower trunk and lower extremities by blocking transmission of nerve impulses from major nerve roots located within the subarachnoid space of the spinal column. It is not typically used for vaginal delivery but is reserved for caesarean delivery. It is administered using a procedure similar to that used in a spinal tap.

GENERAL ANAESTHESIA

General anaesthesia is administered intravenously or by inhalation. Medications used for general anaesthesia given by inhalation include the gases nitrous oxide, halothane, enflurane, and isoflurane.Intravenous medications

used for include ketamine and thiopental sodium. General anaesthesia using is not common because of the risks it presents to both the mother and fetus.It may be used for routine caesarean sections but is less desirable than spiral anaesthesia. It may be required in emergency situations when rapid administration of anaesthesia is essential or in cases where a regional anaesthesia is contraindicated because of other medical conditions such as infection, malformation of the spinal column.

When general anaesthesia is anticipated, the woman is given supplemental oxygen before surgery in order to increase the oxygen saturation level. An intravenous line is established so that there is direct access to the vasculature. The intravenous line is used to administer anaesthetics for induction and to provide immediate access for any other medications that may be needed.

All parturient for caesarean section, more so those who have undergone a period a labour and given narcotic parenterally are considered to have “full stomach” as they have delays in gastric emptying. These when aspirated whilst they are rendered unconscious during the administration of a general anaesthesia can give rise to consequences that can threaten the mother’s life. Hence, general anaesthesia for caesarean section whether in an elective or emergency situation involves a “crash induction” which is the administration of an induction agent together with a very rapid- acting muscle relaxant whilst cricoids pressure is applied before the endotracheal tube is inserted and its cluff inflated.

TYPES OF GENERAL ANAESTHESIA

Nitrous oxide: The anaesthetic, which is 40 percent nitrous oxide and 60 percent oxygen, is administered by facemask or inhaler. Its induction is fast and pleasant and it is non-irritating, on-explosive and less disruptive of physiological functions than any other general anaesthetic. Its main use is in the second stage of labour, as an induction agent or as a supplement to more potent general anaesthesia.Halothane (Fluothane): Not used as frequently as nitrous oxide, halothane nevertheless bears mention for obstetrical anaesthesia. Its induction is rapid, predictable and safe, since it causes little or no nausea or vomiting. It provides moderate to good uterine relaxation, although it may cause

respiratory depression as well as irritability of cardiac tissue, which can result in arrhythmia. It may also cause increased uterine contraction along with the risk of postpartum haemorrhage.Methoxyflurane (Penthrane): Administered by inhaler for analgesia, or in combination with other agents for anaesthesia, methoxyflurane induction is pleasant but slower than with gas agents. Uterine contraction may result from its use, and administration is restricted to low doses for short periods because of the risk of postpartum bleeding.Thiopental sodium (Pentothal): This ultra short-acting barbiturate is given intravenously and it produces narcosis within 30 seconds. Induction and emergence are smooth and pleasant, with little nausea or vomiting. It is most frequently used for induction or as an adjuvant to more potent anaesthetics.

ROLES AND RESPONSIBILITIES OF MIDWIFERY NURSE PRACTIONER.

Midwives must

Know and comply with the state laws and regulations regarding prescribing of medications.

Know and comply with the state nurse practice act related to medication prescribing authority.

Limit access to prescription pads and notify local Pharmacies and the drug enforcement agency if blank prescriptions are stolen.

Limit telephone refills to one prescription and require the patient to come in and be seen before providing additional telephone refills,

Avoid refilling narcotics and pain medication by telephone and outside of regular office hours

Perform peer review of the prescribing practices of licensed independent practitioners and obtain additional education and expertise as needed

Maintain drugs in a safe area with limited access and if appropriate or required by law, under lock and key

Store drugs at manufacturer’s recommended temperature Store drugs in a separate location away from food or other materials or

supplies Avoid storing similar looking drugs near one another

Avoid keeping drugs with similar sounding names o the formulary, but if such similarities do occur, provide adequate additional warnings on packaging

Regularly check drug expiration dates and properly discard/destroy expired drugs prescribing medications

Know the appropriate indications, dosage range,route(s) of administration, contraindications, side effects, and warnings related to the drugs prescribed and/or administered

Maintain readily available, current drug reference materials and refer to them whenever there are questions regarding a drug or when prescribing a drug that is not frequently prescribed.

Maintain access to resources that provide clinical information on drug interactions.

Consult with physicians and pharmacists when appropriate to confirm appropriate drug selection, prescription and ordering, and to check for potential drug interaction or contraindication with patient’s existing drug therapy.

STANDING ORDERS

The objectives of the public health policy in health care by MOHFW are:

1) To further develop health care services with improved access and quality to respond to the needs of disadvantaged groups.

2) To ensure that no one is denied services due to inability to pay.

3) To ensure better and equitable utilization of services.1. Increased health spending2. Promotion of the third sector (not-for- profit voluntary sector)3. Restructuring the public health systems to increase accountability 40i) Upgradation of health facilities will be linked with reform in hospital management, financing and accountability systems. This is covered in greater detail in other sections.ii) Systems for collection, compilation, analysis and feedback of relevant data will be developed for evidence based policy formulation and programmatic interventions with disaggregated data, focussing on the disadvantaged.

Economic, gender, social and geographical factors will be used in the disaggregation.iii) Need based planning and budget allocations will be made in accordance with the extent of disease burden, economic backwardness and poverty levels of regions, districts and blocks.4. Promoting Social Health Insurance5. Improving public sector efficiency and utilization through a mix of inputs6. Management Information System for data on health indicators for the poor and disadvantaged7. Differential Planning and Budgeting 41

i) Where required regulatory mechanisms will be established to ensure optimum utilization of facilities by the poor and disadvantaged. Medical audit and innovative mechanisms to check exploitation and malpractices will be instituted.ii) To ensure health care in tribal and remote / hilly areas, mapping of health facilities will be done and deficiencies made good through mobile health units. Local bodies (PRIs) will be encouraged to establish and run mobile health units in tribal areas.iii) Appointment of Community Health Workers in tribal areas, selected from the habitation by the community, trained and paid by the state (as done in Andhra Pradesh) will be done with necessary modifications made to gain community support, participation and self-reliance. Involvement of traditional healers and dais will be encouraged, with training and linkages with support systems.iv) The existing shortage of PHCs in tribal areas will be made good by establishing approximately 39 new PHCs. This will however be done on the basis of a detailed facility mapping exercise, and in consideration of other factors influencing access of tribal people to adequate primary health carev) Facilities in all block PHCs will be upgraded in a phased manner, and in Blocks where no CHCs exist the remaining Block PHCs will be converted into CHCs.

vi) Cost effective interventions will be made through the infrastructure and manpower available in the established private sector, local bodies and NGO establishments (as in West Bengal, Karnataka and Andhra Pradesh on public.

8. Strengthening incentives, regulation and redress mechanisms9. Outreach services in inaccessible areas10. Establishing more PHCs in tribal areas and converting all block PHCs into CHCs 42

Private partnership basis to address health needs of the urban poor. Services of doctors and allied health professionals for basic and specialist care may be contracted from the private sector.ii) Donations and sponsorship will be sought from the private sector and philanthropists to support particular interventions e.g., for street children’s health care and health promotion in government and municipal schools.11. Primary health care in urban slums

CONCLUSION: Medication taken in pregnancy can harm the unborn child through teratogenic effects. Teratogenic effects may take the form of malformations that occur during the period of organogenesis or subsequently by causing alterations in the structure or function of organ systems formed during orgenogenesis.It is important to remember for the safety and well being of the women, all prescriptions for medication are legible and clear in their instruction.It is equally important that prescribed medicines are given at the appropriate time.

JOURNAL ABSTRACT:

“Drugs which have been taken by only a limited number of pregnant women and women of childbearing age, without an increase in the frequency of malformation or other direct or indirect harmful effects on the human foetus having been observed.”

“Every child comes with the message that God is not yet discouraged of man”

Rabindranath Tagore

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4. Gloria Hoffmann Wold “Contemporary maternity nursing”Chapter 11,1997 Mosby, P225-235.

5. D.C.Dutta ,Hiralal Konar. “Text book of obstetrics: in pregnancy” Chapter33 6th edition 2004,New Central Book Agency (P) LTD.P498-519.

6. Nightingale nursing times Vol 4, Issue 5, August 2008.7. Health action October 2009

TERMINOLOGIES Substance: material constituting an organ or body

Dose: the quantity to be administered at one time as a specified amount of medicine.

Teratogenic: an agent that causes physical defects in the developing embryo.

Organogenesis: the origin and development of organs

Thiocyanate: a salt analogous in composition to a cyanate, but containing sulphur instead of oxygen.

Hyponatraemia :deficiency of sodium in the blood.

Hypotonia: diminished thymus activity.

Microcephaly:having an abnormally small head.

Vasoconstrictive:decrease in the calibre of blood vessels.

Inspiratory:the drawing of air into the lungs

Alginates: a salt of alginic acid .