Having read this chapter, the reader should be able to:
This chapter considers the safe management of medication for the oral route, the preparations available and the role and responsibilities of the midwife. The procedures are described for adult and neonatal administration. It should be read in conjunction with Chapter 18.
The majority of medication taken via the mouth (orally) is absorbed by the gastrointestinal tract, often in the stomach. However, the distinction is made between medication that is swallowed and that which is held in the mouth.
• Buccal refers to medication that is absorbed through the vessels in the mouth; in this case the medication is lodged in the cheek. On a medicine administration record (see Chapter 18) ‘buccal’ is often written in full and not abbreviated.
• Sublingual preparations sit under the tongue. They are often abbreviated as ‘s.l.’. Both these and buccal preparations avoid the gastrointestinal tract, enter the circulation directly via the superior vena cava, and therefore have a rapid response. Jordan (2010) suggests that if there has not been a response within 5 minutes of receiving the medication, then there is not likely to be one.
• Lozenges are often sucked (systemic effect) or used for local effect, e.g. anaesthetic relief of sore throats, antifungal coating of the tongue. Some medications are chewed, this should be clear in the prescription.
Ansell & Dougherty (2011) suggest there are distinct advantages in using the oral route for medication. It is often an easy and convenient route without too much disruption or embarrassment, and often the medications are the least expensive. However, for some situations alternative routes or preparations may be needed:
These questions and the answers to them constitute a risk assessment. If the oral route is not safe or inappropriate at that time, an alternative route/medication should be prescribed. Oral medication is given via nasogastric or other enteral feeding tubes in particular circumstances.
Oral preparations may be affected by other constituents in the stomach, and so the manufacturer’s directions should be followed (e.g. before, during or after a meal) for maximum effectiveness. In the same way, the medication should be administered in the form that it comes in; crushing, dissolving, cutting or opening a tablet/capsule when this is not indicated can cause under- or overdose and also constitutes using a medication ‘off licence’ – the midwife becomes fully liable for its effects (Chapter 18). Medication that is modified in its release is designed to pass through the stomach and be absorbed in the small intestine. Altering this medication in any way can cause inactivity or immediate activity, both of which can be dangerous. Some medications have an enteric coating to prevent damage to the lining of the stomach. Oral medications are:
• Tablets, caplets, capsules: these are generally swallowed whole, sitting up if possible and with a glass of water (Jordan 2010). If possible the woman should remain sat upright for a further 30 minutes. This prevents irritation to the oesophagus and other tissues. If scored, tablets/caplets may be divided in half using a tablet cutter, according to the required dosage. The cutter is washed and dried after use. Examples of tablets include analgesics, antibiotics, iron supplementation.
• Granules, powders and soluble tablets: these need to be thoroughly dissolved before administration. This is generally in water, but the manufacturer’s guidelines should be followed. Examples include analgesics, e.g. paracetamol.
• Elixir: this may be supplied prepared, or require careful dilution according to the instructions. Some solutions require refrigeration. The bottle needs inverting several times to ensure thorough mixing before administration. Examples include antacids and antibiotics.
• Sprays: these should be used according to the manufacturer’s instructions but are often sprayed into the cheek or under the tongue. Examples include glyceryl trinitrate, nicotine replacement therapy.
• Gels: some gels are used for their local action, e.g. pain relief for teething or antifungal treatment, others such as dextrose (hypoglycaemia) or midazolam (epilepsy) are used when a rapid effect is needed.