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Midwife Requests for Diamorphine "Just in Case"

We took advice from NHS Hampshire's Accountable Officer for CD prescribing whose advice is below

Key message

Midwives are able to possess and administer opioids so that should be the mechanism used for clinical governance and drug safety and accountability reasons

As I am neither clinician nor pharmacist, I sought advice from those who are. A precis of responses is below, followed by extracts from updated versions of the relevant legislation:

Pethidine is a pretty hopeless analgesic so I'm not surprised that the evidence bears that out.
Midwives are able to possess and administer opioids so that should be the mechanism used.  I have had a few run ins with midwives over the years because GPs have been asked to prescribe an ampoule for just in case when the GP has no involvement in this part of the patient's care - I think Midwives find it more convenient not to hold opioids but rather get an ampoule prescribed for each patient!
We mustn't confuse this with anticipatory prescribing for end of life

Midwives can prescribe Pethidine and Diamorphine. They should do so and provide the medication in the "just in case" box. However, as several other drugs are required "just in case" in the same box eg naloxone, which will be prescribed by the midwife via her Trust, perhaps an alternative would be for an Obstetrician to prescribe the drugs, rather than a GP.. This could be better monitored if it always came from the same source.  I presume this will need agreement at each local maternity unit that they have adopted this recommendation to change opiate prescribing.

1968 Medicines Act

11. Exemption for nurses and midwives.  (1) The restrictions imposed by section 8 of this Act do not apply to the assembly of any medicinal products by a person in the course of that person's profession as  a registered and qualified nurse or a registered midwife ...
1997 Precription Only Medicines Order

58(2) OF THE ACT

4. Registered midwives.
Prescription only medicines containing any of the following substances-

Chloral hydrate
Ergometrine maleate
Pentazocine hydrochloride
Triclofos sodium.

The sale or supply shall be only in the course of their professional practice and in the case of Ergometrine maleate only when contained in a medicinal product which is not for parenteral administration.

Article 11(2)

2. Registered midwives.
Prescription only medicines for parenteral administration containing any of the following substances but no other substance specified in column 1 of Schedule 1 to this Order-

Ergometrine maleate
Lignocaine hydrochloride
Naloxone hydrochloride
Oxytocins, natural and synthetic
Pentazocine lactate
Pethidine hydrochloride
Promazine hydrochloride.

The administration shall be only in the course of their professional practice and in the case of Promazine hydrochloride, Lignocaine and Lignocaine hydrochloride shall be only while attending on a woman in childbirth.
2001 Controlled Drug Regulations

Exemption for midwives
11. - (1) Notwithstanding the provisions of sections 4(1)(b) and 5(1) of the Act, a registered midwife who has, in accordance with the provisions of rules made under section 14(1)(b) of the Act of 1997 article 42 of the Order, notified to the local supervising authority her intention to practise may, subject to the provisions of this regulation -
(a) so far as necessary to her professional practice, have in her possession;
(b) so far as necessary as aforesaid, administer; and
(c) surrender to the appropriate medical officer such stocks in her possession as are no longer required by her of, any controlled drug which she may, under and in accordance with the provisions of the Medicines Act 1968 and of any instrument which is in force thereunder, lawfully administer.

(2) Nothing in paragraph (1) authorises a midwife to have in her possession any drug which has been obtained otherwise than on a midwife's supply order signed by the appropriate medical officer.

Record-keeping requirements in respect of drugs in Schedule 2 in particular cases 21. - (3) A midwife authorised by regulation 11(1) to have any drug specified in Schedule 2 in her possession shall -
(a) on each occasion on which she obtains a supply of such a drug, enter in a book kept by her and used solely for the purposes of this paragraph the date, the name and address of the person from whom the drug was obtained, the amount obtained and the form in which it was obtained; and

(b) on administering such a drug to a patient, enter in the said book as soon as practicable the name and address of the patient, the amount administered and the form in which it was administered.

SCHEDULE 8 Regulations 8(8) and 9(8)

1. Any of the following persons may supply or administer a specified controlled drug under a patient group direction, namely-
(c) a registered midwife;

Matthew Thomas

Accountable Officer - NHS Hampshire and Hampshire Community Health Care

Controlled Drugs Support Manager - NHS Portsmouth

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Updated on Wednesday, 21 May 2014 2910 views