Principles of drug administration: administration of medicines per vaginam
between the ingers, guiding it into the fornix as above, or insert the examining hand into the vagina, slide the pessary in using the non-examining hand, and guide it into place using the examining hand. Lubricant may be applied to the pessary to aid insertion.
•
Remove ingers, wipe the vulva with the wipes. Ensure that the retrieval string is accessible (if used);maintain the woman’s dignity.
•
Remove gloves, use handrub, auscultate the fetal heart and then assist the woman to resume a comfortable semi-recumbent position.•
Dispose of equipment correctly and wash and dry hands.•
Document administration and indings and act accordingly.Other preparations
The procedure is the same for any administration of a medication P.V. except that a vaginal examination is gener-ally not needed when positioning of the medication is not crucial. Under these circumstances the medication often has its own applicator. This is slid along the posterior vaginal wall until the medication is high in the vagina. It is removed after the medication has been ejected.
length and frequency; assessment of fetal wellbeing;
blood pressure; temperature, pulse and respiration;
and assessment for levels of pain.
•
Adherence to national and local protocols with regard to infection control, personal protection, the administration of medicines and care in labour.•
Contemporaneous record keeping of the care given before, during and after the administration.PROCEDURE: administration of medicines P.V.
•
Gain informed consent, conirm the prescription, ensure privacy and establish fetal wellbeing.•
Wash and dry hands, put on apron.•
Gather equipment:■ sterile gloves and handrub
■ sterile vaginal examination pack (according to local protocol)
■ disposable sheet
■ sterile single-use water-based lubricant
■ disposable wipes
■ the drug.
•
Conirm the woman’s identity. Ask the woman to adopt an almost recumbent position (use a wedge to avoid aortocaval occlusion if necessary), with her knees bent, ankles together and knees parted, placing a disposable sheet beneath her buttocks.•
Remove any sanitary towels or underwear, keeping the genital area covered.•
Open the gloves, open the drug, place it and a blob of the lubricant onto the sterile side of the paper (or use the vaginal examination pack).•
Apply handrub and then gloves.•
Ask the woman to lift the covers exposing the genital area.•
For PGE2 administration, part the labia with the thumb and foreinger of the non-examining hand:■ lubricate the two ingers of the examining hand and gently insert into the vagina, in a downwards and backwards direction along the posterior vaginal wall to locate the cervix, ensuring the thumb does not come into contact with the woman’s clitoris or anus. Slide the gel applicator between the vaginal wall and the examining hand, until it has been guided into the posterior vaginal fornix by the examining hand. The plunger is then depressed by the other hand and the gel
administered. Lubricant may be applied to the tip to aid insertion
■ for the application of a tablet or pessary, either insert the examining hand with the pessary secured
ROLE AND RESPONSIBILITIES OF THE MIDWIFE These can be summarized as:
• practising within evidence-based protocols
• education and support of the woman
• observation of normality for mother and fetus, referral if necessary
• contemporaneous documentation.
SUMMARY
•
There are both advantages and disadvantages to using the vaginal route for medication.•
For the induction of labour prostaglandin works locally to ripen the cervix. It should be used with caution, serious as well as less serious side effects are possible.•
The midwife has a number of responsibilities including all those associated with the administration of medicines and with safe and effective woman-centred care.REFERENCES
SELF-ASSESSMENT EXERCISES
The answers to the following questions may be found in the text:
1. Describe how the midwife prepares the woman for administration of a P.V. medication.
2. List the possible side effects of PGE2. 3. Describe how PGE2 is administered P.V.
4. Discuss the role and responsibilities of the midwife after the administration of PGE2 P.V.
BNF (British National Formulary), 2014.
BNF66. BMJ Group & Pharmaceutical Press, London.
Gulmezoglu, A.M., Crowther, C.A., Middleton, P., Heatley, E., 2012.
Induction of labour for improving birth outcomes for women at or beyond term. Cochrane Database Syst. Rev. (6), Art. No.: CD004945,
doi:10.1002/14651858.CD004945 .pub3.
Jordan, S., 2010. Drugs increasing uterine contractility: uterotonics (Oxytocics).
In: Jordan, S. (Ed.), Pharmacology for Midwives, second ed. Palgrave Macmillan, Basingstoke. (Chapter 6).
NICE (National Institute for Health and Clinical Excellence), 2008. Induction
of Labour. NICE, London. Available online: <www.nice.org.uk> (accessed 5 March 2015).
NICE (National Institute for Health and Care Excellence), 2014. NICE Quality Standards (QS60) Induction of Labour April 2014. NICE, London.
Available online: <www.nice.org.uk>
(accessed 5 March 2015).
Principles of drug administration: administration of medicines per rectum
Chapter
The rectum can be a useful route for the administration of some medicines if the woman is nil by mouth, uncon-scious, or vomiting. This chapter reviews the correct proce-dure and discusses the role and responsibilities of the midwife.
The rectal route
This is a commonly used route for the administration of some medicines, but it is not always the most popular route for patients. The superior rectal vein drains the upper part of the rectum, while the inferior rectal veins drain the lower part. The lining of the rectum is delicate. Medicines can be well absorbed but there are potential dangers: rupturing the mucosa, infection and haemorrhage. The nearness of some of the branches of the vagus nerve in the rectum means that a bradycardia can be induced; extreme care is taken with any women needing a suppository who have an existing cardiac condition. There may also be inconsistencies in the amount of drug absorbed via the rectal route: the inferior rectal veins enter the circulation directly (lower rectum), facilitating faster drug absorption. From the upper rectum the superior rectal vein transports medication via the liver;
the absorption systemically is slower. The presence of faeces in the rectum can also reduce drug absorption. The midwife should observe the woman for any signs of under- or over-dose following P.R. drug administration (Jordan 2010).
Bradshaw et al (2009) suggest that any administration of suppositories or enema should be preceded by a digital rectal examination. This includes a risk assessment: particu-larly in understanding the client’s medical history, examin-ing the perianal area, assessexamin-ing anal sphincter tone, and noting the presence/absence of faeces in the rectum. A digital rectal examination should be carried out by an appropriately trained and competent practitioner. The author would suggest that the majority of maternity clients are unlikely to need this level of ongoing intervention, those that do should be cared for jointly by obstetric
22
CHAPTER CONTENTS
Learning outcomes 171
The rectal route 171
Suppositories 172
Which way are they inserted? 172 Where should they be placed? 172
Enemas 172
Informed consent 172
Positioning of the woman 172
PROCEDURE: administration of
medicines per rectum 173
Role and responsibilities of the midwife 173
Summary 174
Self-assessment exercises 174
References 174
LEARNING OUTCOMES
Having read this chapter, the reader should be able to:
•
describe the safe administration of suppositories and enemas, making differentiations accordingly•
discuss the issues highlighted in the literature regarding suppository use, identifying that which is researched evidence and that which is not•
discuss the role and responsibilities of the midwife in relation to per rectum (P.R.) administration.Medicines inserted into the rectum have two predominant actions:
•
for laxative purposes•
systemic treatment, e.g. analgesia (paracetamol, diclofenac), uterotonics (misoprostol), anti-emetics (systemic suppositories are sometimes called retention suppositories).suggested by Abd-el-Maeboud et al (1991) implies that the suppository is retained, even if only inserted a small way into the rectum. It is generally accepted, however, that for laxative purposes suppositories should be inserted 2–4 cm in, beyond the anal canal into the rectum. While the dif-ferences in blood supply to different parts of the rectum were noted earlier, trying to place the suppository correctly in relation to this is almost impossible.
Laxative suppositories should be placed between the faeces and the rectal wall. Suppositories for systemic use work better if the rectum is empty; they too should be in contact with the rectal wall.