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Standard: Prescribing and Administering PRESCRIBING AND ADMINISTERING DRUGS

Purpose

The purpose of this standard is to describe CMO expectations regarding the prescribing
and administering of drugs.
Midwifery standards of practice refer to the minimum standard of professional
behaviour and clinical practice expected of midwives in Ontario.
Definition

Midwives have the requisite knowledge, skills, and judgment to prescribe drugs from
the list of Designated Drugs. Any drug that can be administered by a midwife according
to the Ontario Regulation 884/93 Designated Drugs can be prescribed by the midwife.
Standard

The authority of midwives, according to the Ontario Regulation 884/93 Designated
Drugs, to initiate a prescription for a drug, is limited to treating conditions that they can
diagnose and for which they can provide the necessary counseling, informed choice
decision making and ongoing management of care.
In the course of engaging in the practice of midwifery, midwives may use any drug and
may administer any substance by injection or inhalation on the order of a member of
the College of Physicians and Surgeons of Ontario. Midwives may also administer,
prescribe or order any drug or substance that may lawfully be purchased or acquired
without a prescription.
TO ENSURE SAFETY
Midwives must:

• Assess the client, conducting laboratory and diagnostic investigations as • Comply with relevant federal and provincial legislation Page 1 of 16
Standard: Prescribing and Administering • Adhere to all relevant standards, guidelines or policies established by agencies or organizations (e.g., public health unit or blood banks) involved in the provision or control of any of the authorized drugs or substances • Provide either a written, or when necessary, a telephone prescription or verbal • Consider whether the drug is a safe and effective treatment for the specific • Provide the client and/or client representative with the necessary information about the drug prescribed including expected therapeutic effect, potential side effects, contraindications and precautions • Consider drug resistance, medication errors, infection control and safety, when they prescribe and/or administer any substance from the regulation • Ensure there are adequate systems in place to prevent prescription fraud • Ensure proper reporting of drug reactions and medication errors (Appendix 2, Reporting Adverse Drug Reactions and Medication Errors) • Monitor the client’s response to the drug therapy after prescribing, and continue, adjust dosage or discontinue the drug therapy as appropriate.
RECORD KEEPING
Midwives must:

• Conduct a medical history and document the symptoms and/or conditions being • Obtain a ful understanding of the drugs the client is taking using the “Best Possible Medication History” (see Appendix 3 for an example of what can be included) • Document in the client’s record, in a timely manner, al telephone prescriptions • Provide a follow-up care plan as appropriate and document in the client’s record • Document the client’s response to the drug therapy • Ensure proper recognition and management of medication errors including documentation and reporting as outlined by Association of Ontario Midwives (Appendix 2, Reporting Adverse Drug Reactions and Medication Errors) • Ensure proper risk management reporting when drug reactions or medication errors occur in a hospital (Appendix 2) Page 2 of 16
Standard: Prescribing and Administering

LEGAL PRESCRIPTION:
• Midwives may only prescribe drugs for the intended purpose as described in the Guideline to Prescribing and Administering Designated Drugs (below) and the amended Ontario Regulation 884/93 Designated Drugs. • Midwives may not self-prescribe a drug, or prescribe a drug for a family member outside the provision of midwifery care, or when there is a conflict of interest. • Midwives will document the drug prescribed and the prescription number in the
A legal prescription prepared by a midwife must include:
• A prescription number • Ful date (day, month and year) • Client’s name • Client’s address (if available) • Name of drug, drug strength (where applicable), dose and the quantity of the • Full instructions/directions for use of the prescribed drug • Refill instructions, if any • Printed name of the midwife prescriber with telephone number and address • College registration number and the professional designation • Midwife’s signature
MIDWIVES OBTAINING CONSULTS AND PROVIDING INTER-PROFESSIONAL
CARE, RELATING TO PRESCRIPTIONS:

• May not delegate the act of prescribing a drug • Notify any relevant health care provider involved in the client’s care when clinically appropriate and document that this notification has been given • Consult with appropriate health care professional if the client’s response to the 1 CMO Standard Caring for Related Persons Page 3 of 16
Standard: Prescribing and Administering When midwives continue drug therapy initiated by another health care professional they must: • Provide and document ongoing assessments • Monitor and document the client’s response to the drug therapy • Communicate the client’s response and change to or discontinuation of drug therapy to the initiating health care provider as appropriate • Consult with appropriate health care professional at any point in the continuing
ENSURING APPROPRIATE STORAGE
Midwives must:

• Ensure recommendations for storage and handling issued by the medication/ • Dispose unused and expired medications/vaccines/blood products in accordance to the guidelines set forth by public health and blood bank Guideline to Prescribing and Administering amended Ontario Regulation 884/93
Designated Drugs

The following guideline applies to the substances that have been added to the Ontario
Regulation 884/93 Designated Drugs (as of February 2010), which midwives are able to
independently prescribe and administer for their clients in the community, hospital or
other sites of midwifery practice.
ANTIBIOTICS

When prescribing and administering antibiotics midwives are expected to adhere to
recommendations to minimize the risk of developing antibiotic resistance. The safest
effective available agent should be prescribed or administered.
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Standard: Prescribing and Administering
Antibiotics, intravenous:
1. Group B Streptococcus

Ampicillin, Cefazolin, Clindamycin, Erythromycin, Penicillin G
Intravenous (IV) antibiotics may only be prescribed and administered on the member’s
own responsibility to the expectant mother for the prophylaxis of neonatal Group B
streptococcus during the intrapartum period.
When a pregnant woman requires treatment for or prophylaxis for Group B
streptococcus and she is al ergic to penicil in G, laboratory confirmation of drug
sensitivities to the culture should be obtained to ensure that the most appropriate
antibiotic is selected. Ampicillin is an alternative choice to penicillin, and cefazolin is
recommended in penicillin allergic patients. In patients at high risk for anaphylaxis to
penicillin, intravenous clindamycin or erythromycin is recommended.
Intravenous antibiotics cannot be prescribed on the member’s own responsibility in
any other situation.
Antibiotics, oral:

Oral antibiotics may only be prescribed by the member in the course of routine
provision of midwifery care.
This includes treatment for:
1. Urinary tract infections (UTI)
Ciprofloxacin, Sulfamethoxazole-trimethoprim, Nitrofurantoin, Trimethoprim

2 Centre for Infectious Disease Preventions and Control, Canadian Task Force on Preventive Health Care’s Prevention of Early-onset Group B Streptococcal Infection in the Newborn) (updated 2002). Available online aSOGC clinical practice guidelines no. 149, September 2004. “The prevention of early-onset neonatal group B streptococcal disease.” JOGC, Sept 2004: 826-32 3 Urinary tract infections in pregnancy, M Lee RPh, P Bozzo, A Einarson RN, G Koren MD Page 5 of 16
Standard: Prescribing and Administering
Oral (PO) antibiotics should be prescribed after culture and sensitivities have been
identified. Sulfamethoxazole-trimethoprim and trimethoprim should be avoided in first
trimester of pregnancy due to increased risk of neural tube defects (NTDs). If clinical y
required during first month of pregnancy, a high dose of folic acid (4mg/day) should be
given to prevent NTDs.
Sulfamethoxazole-trimethoprim should be avoided in the last 2 to 6 weeks of
pregnancy since sulfonamides may displace bilirubin from albumin binding sites and
cause kernicterus in infants, especial y at preterm.
Fluoroquinolones (e.g., ciprofloxacin) should not be prescribed during pregnancy unless
the benefit outweighs the risk and all other antibiotic options have been eliminated.
If symptoms persist after the prescribed course of treatment, a consultation with a
physician is required
2. Mastitis
Amoxicillin-clavulanic acid, Cephalexin, Ciprofloxacin, Clindamycin, Cloxacillin

Antibiotics are prescribed only for fever and signs and symptoms of blocked duct that
do not resolve within 24 hours or are worsening quickly after non-pharmacological
treatment.
If symptoms persist after the prescribed course of treatment, a consultation with a
physician is required.

3. Bacterial Vaginosis
Clindamycin, Metronidazole

Women with a past history of premature labour and who have Bacterial Vaginosis (BV),
whether or not it is symptomatic, may benefit from treatment with antibiotics.
Bacterial vaginosis during pregnancy is associated with premature rupture of the
4 Medication Safety in Pregnancy and Breastfeeding, by Gideon Koren MD, Motherisk Page 6 of 16
Standard: Prescribing and Administering
membranes, chorioamnionitis, preterm labour, preterm birth and post-cesarean
delivery endometritis. During pregnancy, treatment is recommended for symptomatic
patients and asymptomatic women with BV who have had a previous preterm birth.
The goal is to reduce the risk of preterm prelabour rupture of the membranes and low
birth weight.
If symptoms persist after the prescribed course of treatment, a consultation with a
physician is required.
Antibiotics, topical:
1. Breast and Nipple Pain

Mupirocin-betamethasone valerate-miconazole (All Purpose Nipple Ointment)

Topical antibiotics may be used as part of a therapeutic regime for breast and nipple
pain. All Purpose Nipple Ointment is a combination antibiotic, antifungal and low dose
steroid cream that may be used to treat persistent nipple pain. It is used as a topical
treatment for candidiasis of the nipple in the breastfeeding woman, with or without
secondary bacterial infection. The cream should be applied sparingly to the nipples
after each feeding and not washed or wiped off, even prior to the next feed. Al Purpose
Nipple Ointment is not recommended for use in pregnancy. While general y well
tolerated, Al Purpose Nipple Ointment should not be used over large areas of the skin,
and is not intended for prolonged use. If the condition has not improved within a
week, a consultation with a physician is required.

NON-STEROIDAL ANTI-INFLAMMATORY DRUGS (ORAL)
1. Postpartum Pain
Diclofenac, Naproxen

Oral non-steroidal anti-inflammatory drugs (NSAIDS) may be used to treat postpartum
pain. The general approach to the use of NSAIDs in any population is to use the lowest
dose for the shortest period of time to reduce the risk of any adverse events including
GI bleeding. NSAIDs should not be given to clients who are asthmatic or allergic to
ASA. Ibuprofen is the least potent of the NSAID group and at formulations up to 400
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Standard: Prescribing and Administering
mg is available as an OTC. Naproxen and acetaminophen have been proven to have the
same effect on postpartum pain.

ANTI-HEMORRHAGICS AND OXYTOCICS

1. Management of postpartum bleeding

Carbetocin, Misoprostol

Oxytocics and anti-hemorrhagics are to be administered for the management of
postpartum bleeding on the member’s own responsibility. The choice of agent and
method of administration will be dependant upon the clinical scenario and availability
of these medications.
Carbetocin - off label

Carbetocin (e.g., Duratocin®) is approved for use in Canada for the prevention of
uterine atony and postpartum hemorrhage fol owing elective cesarean section under
epidural or spinal anesthesia. It was shown to be effective for the off-label treatment of
postpartum hemorrhage following vaginal birth, and is used as a second-or-third line
agent in Ontario hospitals, used only after oxytocin and ergonovine maleate, where
available, have been attempted.
Midwives are not authorized to use Carbetocin to treat anything other than
postpartum hemorrhage.

Misoprostol – off label
Misoprostol is a synthetic prostaglandin Eanalog that is approved for use as an
antisecretory agent with protective effects on the GI mucosa. It was shown to be
effective for the off-label treatment of postpartum uterine atony or postpartum
hemorrhage uncontrol ed by the use of oxytocin. Misoprostol is a second-or-third line
agent, used only after oxytocin and ergonovine maleate, where available, have been
attempted. Misoprostol should not be taken by anyone with a history of al ergy to
5 Skovlund et al, European Journal of Clinical Pharmacology, 1991, Volume 40, Number 6, pg. 539-542. Page 8 of 16
Standard: Prescribing and Administering
prostaglandins. If misoprostol is administered as a third line agent in response to a
postpartum hemorrhage occurring out-of-hospital, transport to hospital and
consultation with a physician is indicated. The use of misoprostol for prevention of PPH
or for the induction of labour is currently under evaluation. Its use for induction of
labour in the presence of a living fetus is restricted to clinical trials. Midwives CANNOT
prescribe or order misoprostol for this application. However, where a physician has
ordered misoprostol for induction of labour in a non-viable pregnancy, the midwife may
continue to be involved in the woman’s care.
Midwives are not authorized to use Misoprostol to treat anything other than
postpartum hemorrhage.


LOCAL ANESTHETICS

1. Perineal Repairs in Immediate Postpartum

Bupivacaine, Chloroprocaine

Local anesthetics are to be administered on the member’s own responsibility for the
management of pain during the repair of the perineum in the immediate postpartum
period. The choice of agent and method of administration wil be dependent upon the
clinical scenario, the local community standard and availability of these
medications.
Bupivacaine (MARCAINE)

Amide local anesthetic for infiltration block anesthesia for use during perineal repair
that is slightly slower acting (5-10 minutes) but has a longer duration of effect (2-4
hours). Lidocaine (Xylocaine) is an amide local anesthetic and remains available to
midwives.

Chloroprocaine (NESACAINE)

Ester local anesthetic for infiltration block anesthesia for use during perineal repair, that
is rapid acting and has a shorter duration of effect (less than 30 minutes). This local
anesthetic is more likely to cause hypersensitivity.
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Standard: Prescribing and Administering

All local anesthetics are approved for use by midwives only on perineal repairs in
the immediate postpartum.
OTHER DRUGS
1. Domperidone – off label

Domperidone is an antidopaminergic drug approved for the treatment of nausea and
vomiting. It has been used off-label to enhance breastmilk production in women where
non-pharmacologic methods have proven ineffective and/or in women with a previous
history of inadequate milk supply. Domperidone must not be given intravenously.
Caution should be used in patients with hepatic disease and with those taking
anticholinergics, since they may antagonize the effect of the domperidone in the GI
tract. It should not be co-administered with ketoconazole due to the increased risk of
QTc prolongation and associated heart arrhythmias.
Midwives are not approved to use Domperidone to treat anything other than
inadequate milk supply.

2. Measles / Mumps / Rubella (MMR) Vaccine

(E.g., M-M-R® II, Priorix®) Women found to be rubella-susceptible during the antenatal
period should be offered MMR vaccine in the immediate postpartum period. Women
without detectable antibodies or no prior vaccination for rubella should be immunized
only if they are not pregnant at vaccination time and if pregnancy is avoided for 1
month following vaccination. MMR vaccine should not be administered to individuals
who are pregnant (the possible effect on the fetus is not known), have acute febrile
respiratory or other infections, or any acute illness, have a history of sensitivity to
neomycin or gelatin; have blood dyscrasias, lymphomas or other generalized
malignancies; have untreated active tuberculosis; or are undergoing treatment with
immunosuppressive agents of any kind. Breastfeeding is not a contraindication to
receiving this vaccination. Whenever vaccines are administered the midwife must send
a record of immunization to the physician to whom care is transferred at 6 weeks
postpartum. A record of immunization should also be sent to the local public health unit
in communities where this is required.
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Standard: Prescribing and Administering
3. Varicella Zoster immune globulin

(E.g., VariZIGTM) Varicel a zoster immune globulin is recommended for susceptible
people, including pregnant women, provided that significant exposure has occurred.
Administration of varicella zoster immune globulin is recommended for prevention or
reduction of severity of maternal infections within 4 days of exposure to the varicella
zoster virus. Greatest effectiveness of treatment is expected when it is begun within 4
days of exposure; treatment after 4 days is of uncertain value. Pregnant women may be
at a higher risk of complications from chickenpox than healthy adults. The decision to
administer varicella zoster immune globulin to a pregnant woman should be evaluated
on an individual basis. The clinician should consider the patient's health status, type of
exposure, and likelihood of previous unrecognized varicella infections before deciding
whether to administer varicella zoster immune globulin. If after careful evaluation of al
available information, which may include the use of reliable and sensitivity tests for
varicella antibody, a normal pregnant woman with significant exposure to varicella is
believed susceptible, varicella zoster immune globulin may be administered. It is not
known whether it is excreted in human milk. Because many drugs are excreted in
human milk, caution should be exercised when varicella zoster immune globulin is
administered to a nursing mother.

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Standard: Prescribing and Administering APPENDIX 1

Alphabetic List of Drugs in Midwives’ Authority

Any drugs that can be administered by a midwife according to the Ontario Regulation
884/93 Designated Drugs can be prescribed by the midwife
The following drugs are designated in regulation as substances or drugs that midwives
may administer by injection on their own responsibility:

Ampicillin — for the purpose of preventing neonatal group B streptococcal disease
Bupivacaine — for the purpose of local anaesthesia for episiotomy or the repair of tears
Carbetocin
Carboprost tromethamine
Cefazolin — for the purpose of preventing neonatal group B streptococcal disease
Chloroprocaine — for the purpose of local anaesthesia for episiotomy or the repair of
tears
Clindamycin — for the purpose of preventing neonatal group B streptococcal disease
Dimenhydrinate
Diphenhydramine hydrochloride
Epinephrine hydrochloride
Ergonovine maleate
Erythromycin — for the purpose of preventing neonatal group B streptococcal disease
Hepatitis B immune globulin
Hepatitis B vaccine
Intravenous fluids
Lidocaine hydrochloride with or without epinephrine —for the purpose of local
anaesthesia for episiotomy or the repair of tears
Measles-mumps-rubella virus vaccine
Oxytocin - for the purpose of treating postpartum hemorrhage
Penicillin G — for the purpose of preventing neonatal group B streptococcal disease
Phytonadione
RhD immune globulin
Varicella Zoster immune globulin


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Standard: Prescribing and Administering

The following drugs are designated as drugs that midwives may administer by inhalation
on their own responsibility:

Nitrous oxide Therapeutic oxygen

The following drugs are designated as drugs that midwives may prescribe on their own
responsibility:

Amoxicillin-clavulanic acid —for the purpose of treating mastitis Cephalexin — for the
purpose of treating mastitis
Ciprofloxacin (oral)
Clotrimazole
Clindamycin (oral)
Cloxacillin (oral)
Diclofenac (oral)
Domperidone — for the purpose of promoting lactation
Doxylamine succinate-pyridoxine hydrochloride
Ergonovine maleate (oral)
Erythromycin ophthalmic ointment
Folic acid (oral; greater than 1mg/dose)
Hepatitis B immune globulin
Hepatitis B vaccine
Hydrocortisone anorectal therapy compound
Metronidazole (oral)
Miconazole
Misoprostol — for the purpose of preventing postpartum hemorrhage
Mupirocin-betamethasone valerate-miconazole (topical)
Naproxen (oral)
Nitrofurantoin — for the purpose of treating urinary tract infections
Nystatin
Phytonadione
RhD immune globulin
Sulfamethoxazole-trimethoprim (oral)
Trimethoprim — for the purpose of treating urinary tract infections
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Standard: Prescribing and Administering APPENDIX 2

Reporting Adverse Drug Reactions and Medication Errors

Reporting Adverse Drug Reactions
You can report any suspected adverse drug reactions to drugs and other health
products to the Canada Vigilance Program by visiting the Reporting Adverse Reactions
to Drugs and Other Health Products page a
The site offers the Canada Vigilance Reporting Form for use in the reporting by health
care professionals and clients via fax, mail, online or phone.
Canada Vigilance Regional Office phone 1 866- 234-2345 and fax 1 866-234-678-6789
Reporting Medication Errors
Consider reporting any medication errors confidential y to The Institute for Safe
Medication Practices Canada, an independent national non-profit agency. Contributing
to this database provides information for the purpose of developing policies to prevent
future adverse events. For information about this non-profit organization, go to their
home page a or their page with information about
reporting medication incidents at Canadian Medication Incident Reporting and
Prevention System (CMIRP
For further information about incident reporting, refer to the AOMand HIROC websites.



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Standard: Prescribing and Administering APPENDIX 3

Best Possible Medication History (BPMH)

Best Possible Medication History (BPMH) is a medication history obtained by a
healthcare provider which includes a thorough history of all regular medication use
(prescribed and non-prescribed), using a number of different sources of information.
The BPMH is different and more comprehensive than a routine primary medication
history (which is often a quick patient medication history).
The BPMH involves a:
1. Patient medication interview where possible. 2. Verification of medication information with more than one source as appropriate including: o family or caregiver o community pharmacists and physicians o inspection of medication vials o patient medication lists o medication profile from other facilities o prescription drug claim histories of Ontario Drug Benefit (ODB) recipients (Drug Profile Viewer) o previous patient health records
The BPMH includes drug name, dose, frequency and route of medications a patient is
currently taking, even though it may be different from what was actual y prescribed.
Using tools such as a guide to gather the BPMH may be helpful for accuracy and
efficiency. (A BPMH Interview Guide i.
If a patient is unable to participate in a medication interview, other sources may be
utilized to obtain medication histories or clarify conflicting information. Other sources
should never be a substitute for a thorough patient and/or family medication interview.
For patients who present prescription bottles and/or a medication list, each individual
medication and corresponding dosing instruction should be verified, if possible.
Frequently, patients take medications differently than what is reflected on the
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Standard: Prescribing and Administering prescription label. Also, patients may not have updated their personal list with newly prescribed medications. 2 Midwives should ensure that client’s reporting drug al ergies are asked the extent and type of allergy, sensitivity or reaction they have had and this should be documented in the client’s record. 21 St. Clair Avenue East | Suite 303 | Toronto, Ontario | M4T 1L9 T: (416) 640-2252 | F: (416) 640-2257 | www.cmo.on.ca 6 Queen’s University, Office of Interprofessional Education and Practice. Medication Reconciliation: A Learning Guide. Web page retrieved August 19, 2010 on the World Wide Web at: http://meds.queensu.ca/courses/assets/modules/mr/4.html Page 16 of 16

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