Under the Human Medicines Regulations (2012),17 medicines can only be supplied and administered under the directions of a doctor.
Student midwives can administer any medicine prescribed by a doctor under the direct supervision of a registered midwife.
These regulations permit exemptions which allow other professionals to supply and administer medicines in specific circumstances. Midwives are exempt under Section seventeen, Part three from this requirement in relation to certain specified medicines, provided they have notified their intention to practice and the drugs are for use only within their sphere of practice. This allows midwives to supply and administer these drugs without the direction of a doctor.
This is known as the midwives exemptions list (see below) updated in these regulations. This ensures appropriate and responsive care can be given to women safely as part of a midwife’s normal sphere of practice and especially during emergencies. The regulation exemption allows student midwives to administer medicines from this list under the direct supervision of a registered midwife, with the exception of diamorphine, morphine, or pethidine.
The medicines to which this exemption applies are as follows:
• Adrenaline
• Anti- D immunoglobulin
• Carboprost
• Cyclizine lactate
• Diamorphine
• ergometrine maleate
• Hepatitis B vaccine
• Hepatitis B immunoglobulin
• Lidocaine hydrochloride
• Morphine
• Naloxone hydrochloride
• Oxytocins, natural and synthetic
• Pethidine hydrochloride
• Phytomenadione
• Prochlorperazine
• Sodium chloride 0.9%
• Gelofusine®
• Haemaccel®
• Hartmann’s solution.
Midwives can also supply and administer all non- prescription medicines, including all pharmacy and general sales list medicines, without a prescrip-tion. These medicines do not have to be in a patient group direction (PGD) for a midwife to be able to supply them.
Patient group directions
PGDs are detailed documents compiled by a multidisciplinary group of a local trust or hospital. They allow certain drugs to be given to particular groups of clients without a prescription to a named individual.
DRUG ADMINISTRATION IN MIDwIfeRY 15
This arrangement is very useful, as it allows the midwife to give a drug listed in the PGD to a woman, without having to wait for a doctor to come and prescribe it individually. The midwife is responsible for following the instructions related to dosage and contraindications provided in the PGD.
examples of drugs included in a PGD are:
• Dinoprostone (Prostin e2® gel) for induction of labour; 1mg or 2mg gel can be repeated after 6h. Give a lower dose if the cervix is favourable
• Ranitidine 150mg tablets.
It is recommended that, if a drug is on the midwives exemption list, it does not need to appear in a PGD. Under medicines legislation, there is no provi-sion for ‘standing orders’; therefore, these have no legal basis.
The NMC (2015)18 has published Standards for Medicines Management which includes dispensing, storage and transportation, administration, dele-gation, disposal, and management of adverse events and controlled drugs.
Registered midwives must only supply and administer medicines for which they have received appropriate training.
There is clear instruction on the role of the midwife in directly supervising student midwives during drug administration and that only a registered mid-wife may administer a drug which is part of PGD arrangements.
References
17 Statutory Instruments 2012 No. 1916 (2012). The Human Medicines Regulations 2012. Available at: M www.legislation.gov.uk/ uksi/ 2012/ 1916/ made.
18 Nursing and Midwifery Council (2015). Standards for Medicines Management. London: Nursing and Midwifery Council.
Independent midwife prescribing
Current legislation gives independent prescribing rights, including for some controlled drugs, to midwives, nurses, and other health- care professionals within the individual practitioner’s sphere of competence. whilst the midwife has a wide range of drugs which can be administered within the Midwives exemptions (UK), there are situations where to be able to independently prescribe has a real advantage for prompt and appropriate action and con-tinuity of care for mothers by experienced, suitably qualified midwives. for example, prescription of antibiotics for mastitis, infected perineum, or uri-nary tract infection. The drugs to be prescribed will be agreed within the NHS trust, as the employer, for the individual midwife’s sphere of practice, e.g. the labour ward or the community. In this way, the midwife’s personal practice can be enhanced by making effective use of prescribing.
If the midwife is going to prescribe for the newborn baby, the same prin-ciples apply, but the midwife must also demonstrate prescribing compe-tency for this special group as overseen and assessed by an experienced paediatrician.
In the UK, the midwife must undertake an NMC- approved programme at a university approved to run the course at degree or normally Masters degree level. for midwives, the lead midwife for education will oversee the mentoring and assessment process to ensure the principles and practice of prescribing are applied to midwifery practice. Once achieved, the qualifica-tion is recordable on the NMC professional register. As with other aspects of professional practice, evidence of continuing professional development in prescribing must be kept in the midwife’s professional portfolio.
A designated medical practitioner (DMP) will mentor and assess the required competencies, supported by an experienced midwife prescriber/
SoM to support the midwifery perspective.
The programme and assessment are based on:
• An in- depth knowledge of pharmacology, modes of action, side effects, contraindications, and drug interactions of individual drugs
• An in- depth knowledge and ability to accurately diagnose the conditions being prescribed for
• Safe, effective, and cost- effective prescribing
• Legal and ethical aspects of prescribing
• evidence- based practice
• Record- keeping
• The seven steps to safe prescribing
• The single competency framework for all prescribers.
Supplementary prescribing
In some circumstances the midwife may be a supplementary midwife pre-scriber to an independent medical prepre-scriber, working within the terms of an agreed clinical management plan (CMP). This allows the midwife to make changes to the prescribed dose or drug without the need to see the doctor, providing the criteria of the CMP are met.
INDePeNDeNT MIDwIfe PReSCRIBING 17
Further reading
Beckwith S, franklin P (2011). what is a non-medical prescriber? In: Beckwith S, franklin P. Oxford Handbook of Prescribing for Nurses and Allied Health Professionals, 2nd edn. Oxford: Oxford University Press, pp. 3–17.
National Prescribing Centre (1999). Signposts for prescribing nurses— general principles of good prescribing. Nurse Prescribing Bulletin 1: 1– 4.
National Prescribing Centre (2012). A Single Competency Framework for All Prescribers.
London: National Institute for Health and Care excellence. Available at: M med.mahidol.ac.th/
nursing/ sites/ default/ files/ public/ knowledge/ doc/ 3.pdf.
Nursing and Midwifery Council (2006). Standards of Proficiency for Nurse and Midwife Prescribers.
London: Nursing and Midwifery Council. Available at: M www.nmc.org.uk/ standards/ additional- standards/ standards- of- proficiency- for- nurse- and- midwife- prescribers/ .
Nursing and Midwifery Council (2010). Nurse and Midwife Independent Prescribing of Unlicensed Medicines. London: Nursing and Midwifery Council. Available at: M www.nmc.org.uk/ globalassets/
sitedocuments/ circulars/ 2010circulars/ nmccircular04_ 2010.pdf.