Re: Midwives and Drugs (long)
From: franka@VAX.CS.HSCSYR.EDU
Sun Sep 29 13:12:46 1996
I just wanted to make a brief comment. The issue of correct
interpretation of an adverse drug reaction is crucial. Many times what
my patients call an "allergy" is really and adverse reaction and vice
versa. Also, I hold to the first do no harm tenet. If you give Pitocin,
it is necessary to provide something for possible tetany, if
metoclopramide, benadryl is relatively benign. The key it seems, is the
appropriate screening of the patients first. My wife and I as well as
those I will deliver know that I am a big propronent of non-invasive OB.
But I do think that trouble shooting is important for primary prevention
of the bad outcome. I would say that it would be worthwhile to have some
brief, intensive pharmacology sessions for those who would want to
prescribe. The emphasis being on adverse drug reactions, trouble
shooting, etc.
The less drugs available, the less likely someone would be to
push the limits of their expertise.
Thanks for listening. Hope it was useful in your thought process.
The use of Pit for PPH, or also for the augmentation or induction?
Benadryl on hand is not so bad, it's OTC here anyway.
Phenergan as well, for nausea.
AlexFrank MD, Syracuse NY.
On Sat, 28 Sep 1996, Michael Rice wrote:
> BACKGROUND
> ==========
>
> In Queensland, Australia, the State Health people are rewriting the Drugs
> and Poisnons Regulations to allow nurses in certain circumstances to
> possess, supply, dispense and administer certain restricted or controlled
> drugs without reference to any medical practitioner. (Note that they have
> studiously avoided giving nurses the ability to "prescribe").
>
> The areas in which this may be possible include remote areas, immunisation
> clinics, sexual health clinics, aboriginal and islander clinics, and
> midwives in independent/private practice.
>
> The motivation for the changes may include a well-meant desire to legitimise
> existing practices (eg remote area nurses have been dispensing to their own
> prescriptions for years) or cost savings (less doctors employed in sexual
> health clinics perhaps) or ...
>
> MIDWIVES and DRUGS
> ==================
>
> The present practice
> --------------------
>
> --------------------
> Presently women who wish to be attended by a midwife for a homebirth may be
> --------------------
> sent to their doctor with a "shopping list" of drugs which the doctor is
> asked to prescribe for them, and may include metoclopramide, oxytocin,
> pethidine, lignocaine, paracetamol/codeine and so on.
>
> Presumably the midwife follows the doctor's prescription in administering
> these drugs if they are used. Where the liability for adverse outcomes lies
> is anybody's guess.
>
> Of course, many doctors are reluctant to prescribe in these circumstances,
> and the patient may have to shop around to find someone other than her
> regular doctor to do so.
>
> The Colleges' positions
> ----------------------
>
> ----------------------
> Not surprisingly, the Royal Australian College of Obstetricians and
> ----------------------
> Gynaecologists is unsupportive of the process and has withdrawn from
> assisting the State Health Department. The Royal Australian College of
> General Practitioners has agreed to support the creation of protocols
> directed at safety issues, realising that whatever the College position,
> planned homebirths will continue to occur.
>
> I have been asked by the RAGP to be on a subcommittee to formulate protocols
> suitable for midwives in independent/private practice.
>
> The Drugs
> ---------
>
> The committee has so far approved the following:
> oxytocin 10u IMI for prevention of PPH, active management of 3rd stage
>
> oxytocin 10u IMI for treatment of excessive postpartum bleeding, to a
> maximum of 20units
>
> The drugs still to be considered are:
> lignocaine, for perineal repair
> metoclopramide, for nausea and vomiting in labour
> nitrous oxide, for analgesia in labour
> paracetamol 500mg with codeine 30mg for postpartum pain
>
> Other possibilities include:
> diazepam or midazolam for seizures due to lignocaine, or other causes
> benztropine or diphenhydramine for dystonic reactions to metoclopramide
> prochlorperazine for nausea if metoclopramide is contraindicated by previous
> adverse reaction.
>
> REQUEST FOR COMMENTS
> ====================
>
> I'd be grateful for any comments directed at specific drugs from the "still
> to be considered" list, including the need for inclusion at all, appropriate
> maximum dose (remember this may be a homebirth setting) and whether other
> drugs ought to be carried for adverse reactions.
>
> For example, for lignocaine, is a maximum dose of 3mg/kg appropriate at home
> or should it be less; should anticonvulsants also be carried to deal with a
> rare adverse reaction?
>
> For metoclopramide, should anticholinergics be required to be carried? Is it
> effective enough to be carried at all?
>
> The position of my College (the RACGP) is likely to be that no drugs other
> than oxytocin will be supported. I may still have to have some input into
> protocols for the others, particularly if it seems that drugs to deal with
> adverse reactions ought to be included.
>
> Thanks for your patience and comments.
>
> Michael
>
> --
>
> ------------------------------------------------------------------------------
> Dr Michael Rice M.B.,B.S.,Dip R.A.C.O.G.,F.R.A.C.G.P.
> ------------------------------------------------------------------------------
> mcrice@gil.com.au General Practitioner
> ------------------------------------------------------------------------------
> ------------------------------------------------------------------------------
> Lot 10, Samantha Road ph 07 5543 1873
> ------------------------------------------------------------------------------
> Cedar Vale via Beaudesert, 4285 fx 07 5543 2537
> ------------------------------------------------------------------------------
> or international +61 7 5543 xxxx as above
> ------------------------------------------------------------------------------
>
>
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