Neonatal drug administration
Drug administration is a complex system involving a number of essential phases and steps that midwives must follow to prevent mistakes (NMC 2010). A simple way to avoid error is to follow the ‘seven rights’ of medicine administration (Pape 2003) (Figure 76.1).
- Right patient: Check that the name, date of birth and hospital number of the baby match the prescription chart. Check for any known allergies.
- Right drug: Does the drug fit with the medical management plan for the baby? Is the drug correctly prescribed? Never administer a drug without an understanding of its usage and dosage, therapeutic action and potential side effects.
- Right reason: Question the reason for administration and assess if the drug is necessary. Midwives must perform an assessment of the baby’s current condition and question if the baby is fit to have the required dose.
- Right dose: Does the dose take into account the baby’s current weight? Underdosing can result in the medicine proving ineffective and overdosing can lead to adverse or fatal responses.
- Right time: Check the last dose (if relevant) and ensure that it is appropriate to administer the drug at the prescribed time.
- Right route: Check that the prescribed route of administration is appropriate for the baby. Routes of administration include oral, intramuscular, subcuticular, intradermal or topical. Although medicines are sometimes administered intravenously (IV) or via an umbilical venous catheter (UVC) these routes of administration are generally reserved for sick neonates. Additional training is required for midwives to gain this skill.
- Right documentation: Following drug administration the midwife needs to immediately document and sign on the appropriate drug administration chart.
The need to administer medications in neonates can generate significant anxiety for parents and carers. Time must be taken to explain the rationale and the potential adverse effects of treatment prior to administration. Effective communication skills are essential to not only prepare the parents but also to obtain consent for the drug to be given to the baby. Allow time for parents to ask questions. It is important to follow local infection control policies to minimise the risk of harm to the baby and others. This will require drugs to be checked and prepared in the designated drug preparation area where you are working. This should be a quiet and clean environment with no distractions; distractions can lead to significant errors.
Midwives will sometimes be required to administer oral medication to neonates and also, educate parents to give oral medication with safety and confidence.
- Equipment: prescription chart, neonatal oral drug administration syringe and prescribed medication. Oral drugs are administered using a 1 or 2-mL drug administration syringe dependent on total volume to be given.
- Follow the ‘seven rights’ of drug administration and obtain consent from parents. Wash your hands.
- Draw up the required volume of medication and take to bedside/cot side.
- Have the parent/colleague hold the baby wrapped in a blanket, in an upright position.
- Insert the hub of the syringe gently into the corner of the baby’s mouth and direct towards the cheek (Figure 76.2). Up to 0.5 mL should be administered at a time to allow the baby time to swallow the medication slowly, and also prevent choking. If time is not allowed for swallowing the baby is likely to expel the drug out of his/her mouth. In this situation the doctor must be informed to advise appropriately.
- Following administration comfort and settle the baby. Dispose of equipment according to local policy and wash hands. Observe baby for effect/adverse reactions.
The intramuscular (IM) route should only be used where no acceptable alternative exists for administration, due to the procedure causing pain for the baby. A maximum volume of 1 mL should be administered via this route. Reduction of pain is possible by using the vastus lateralis site (outer thigh; Figure 76.3). It may be useful to adopt distraction strategies such as breastfeeding, non-nutritive sucking and oral sucrose administration (Shah et al. 2009).
- Equipment: prescription chart, IM medication ampoule, filter needle, 1-mL syringe, 25 gauge needle (term baby), cotton wool swab, gloves, sharps box.
- Follow the ‘seven rights’ of drug administration and obtain consent from parents.
- Wash hands. Draw up the required medication into the syringe using a filter needle. Discard filter needle appropriately and change the needle to a 25 gauge needle to reduce unnecessary trauma and pain.
- Take medication to the bed/cot side.
- With parental help position the baby appropriately and prepare baby with chosen distraction strategy. Expose and locate the vastus lateralis (Figure 76.3).
- Clean the injection site with cotton wool and tepid water. Allow to dry.
- Position the leg to relax the muscle and pierce the skin at a 90 degree angle into the vastus lateralis.
- Slowly inject the medication to minimise discomfort.
- Remove the needle and check the injection site for bleeding. Apply gentle pressure with cotton wool if necessary.
- Dispose of needle into sharps bin immediately.
- Comfort and settle the baby. Wash hands and observe baby for any reaction or adverse response to administration. Complete documentation.