Midwives Exemptions

Under the Acts of Parliament that govern midwifery practice, midwives are given exemption to supply medicines, in the course of their professional practice, that are on the P and GSL lists, and some items that are POM. Midwives exemptions were previously called standing orders, but this term is no longer applicable. Midwives should be clear that they can only administer medication if they are familiar with its use, dosage, side effects, precautions, contraindications and method of administration (NMC 2007, Anon 2010). This administration does not need a prescription, a patient-specific direction (PSD) or a patient group direction (PGD) (see below). If, however, the medicine is not on the exemptions list then one of these will be required.

Which medicines may be given under ‘Midwives Exemption’?

The full Midwives Exemptions POM list can be viewed on the NMC website (NMC 2011). Examples include diclofenac, hydrocortisone acetate, miconazole, nystatin, phytomenadione, sodium chloride 0.9%, cyclizine lactate, anti-D immunoglobulin, pethidine hydrochloride, oxytocin, and lidocaine. Student midwives were, from 2011, permitted, when under the supervision of a sign-off mentor, to administer the medications on the Midwives Exemption list, except for controlled drugs (NMC 2011). Being supervised by a sign-off mentor means in this context that the student must be physically watched administering the medicines. Student midwives may participate in the preparation and checking of controlled drugs if they are again being directly supervised by a sign-off mentor.

The administration of any medicine

Medicines, prescribed and given correctly, can make a significantly positive difference to patients. However, given incorrectly, the harm caused can have far-reaching consequences both in human and monetary terms. Matthew (2007) suggested that up to 10,000 preventable deaths occur each year due to medication errors. In promoting safer administration of medicines, Elliott & Liu (2010) describe the nine ‘rights’ that should be considered with each medicine administration:

It is clear that all systems need to be robust; there is the possibility for error to occur within research and development, manufacture, packaging and prescribing as well as administration. Elliott & Liu (2010) cite studies that show that the largest and most consistent errors in drug administration are human errors, ‘at the bedside’. These may result from inexperience, lack of care and attention or the pressures of the daily workload. The midwife does not blindly comply with instructions but has to be knowledgeable and fully aware of what they are complicit in. For drug administration the midwife should be familiar with the drug to be administered, knowing why it is to be given, normal dosage, precautions, contraindications and side effects (NMC 2007). If this knowledge is not known, the British National Formulary (BNF)/BNF for Children (BNFc), other colleagues, the prescriber or the pharmacist could all be consulted. The electronic BNF/BNFc is updated monthly and should be the initial checking reference.

Prescriptions

Medicines that are on the POM list require a prescription. Midwives Exemptions (NMC 2011), as discussed earlier, allow midwives in the UK to administer some medicines from this list under their own autonomous practice. For all other POM, a PSD or prescription is required. This means that the prescriber (medical or approved non-medical) has reviewed the patient and assessed their need. For inpatients a PSD is often recorded on a medicine administration record; in the community, anti-forgery prescription forms are used.

Given that a PSD is specific to an individual, it should be written clearly as to identify that named client. Three identifiers constitute good practice; name and address, date of birth and NHS number are the best three. The presence of allergies should be established and documented. If appropriate, an alert identity band should be on the client’s wrist when hospitalized. Any prescription should be written in black ink and should be legible. It should also contain details of:

E-prescribing (electronically) has been shown to reduce some of the errors; all of the above information still has to be included.

Patient group direction

A PGD is a specific written instruction covering the supply and administration of a named (prescription only) medicine or vaccine. It allows specific health care professionals to supply/administer a medicine directly to a patient with an identified clinical condition, without the need for a prescription, e.g. for labour care. The midwife is responsible in these circumstances for establishing that the client they are working with meets the criteria laid out as part of the PGD before the medicine is administered (Bussey 2011). PGDs are determined locally in consultation with medical staff, pharmacists and relevant healthcare professionals. They have a set of specific legal requirements (Griffith 2010) and can include controlled and ‘off licence’ medicines. A midwife must know and understand the PGD in order to practice under it; in many NHS Trusts midwives sign annually to confirm their understanding and compliance.

PROCEDURE: administration of a non-controlled drug