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M1 & T1.1 Prescribing & Legislation in Midwifery – Comprehensive Study Notes

Resources & Core Readings

  • Midwifery Preparation for Practice ➔ focus on Chapter 33.
    • Only comprehensive New Zealand (NZ) midwifery text; NZ Midwifery Council reportedly draws on it for the national examination.
    • Perceived inaccuracies = raise via professional body rather than discard the resource.
  • Companion digital resources:
    • New Zealand Formulary (NZF) for Medicines.
    • BPAC, Pharmac schedules, Medsafe, Christchurch Drug Information site.

Lecture / PowerPoint House-Keeping

  • Original slides updated to reflect new Midwifery Council 2024 Competence Statement & Scope.
    • If you downloaded the deck before Monday, re-download.
  • Hyperlinks inside slide-show mode are clickable.

Historical Context of Midwifery Prescribing in NZ

  • Nurses Amendment Act (early 1990s) → legal basis for midwifery-led maternity care.
  • Midwifery prescribing originally excluded antibiotics & oral contraceptives; CEO Karen Gillan successfully challenged MOH.
    • MOH letter 1996 → pharmacists advised midwives could prescribe with equal subsidy.
  • Take-home: legislative change can lag (≈ 6 years in this case).

Key Legislation & Sections To Recognise (no need to memorise years)

  • Medicines Act 1981 – esp. s.105P: pre-requisites to prescribe (qualification, additional training, test of knowledge, ongoing CPD).
  • Medicines Regulations 1984 – conditions under which authorised prescribers can issue Rx.
  • Misuse of Drugs Act/Regulations – governs controlled drugs (opioids, etc.).
  • Health Practitioners Competence Assurance (HPCA) Act 2003 – umbrella act; defines “authorised prescriber”.

Midwifery Council Scope & Competence 2024

  • Previous Competency 2 now redistributed:
    • New clause m18: “Demonstrates ability to prescribe, supply, administer therapeutic products & monitor effect within legal/ regulatory parameters & with informed consent.”
  • Link provided on slides for full competency list.

Professional Guidance & Consensus Statements

  • NZ College of Midwives Consensus Statement: Prescribing for conditions commonly associated with uncomplicated pregnancy.
  • Midwives must demonstrate knowledge of:
    1. Effects
    2. Side-effects
    3. Interactions
    4. Contra-indications
      before obtaining informed consent.

Condition & Medication Groups Generally Appropriate for Midwife Prescription

  • Minerals & vitamins: folic acid, iodine, vitamin D, vitamin K (neonate), iron.
  • Anti-pruritics & simple analgesia.
  • Local anaesthetics (e.g.
    lignocaine for IV cannulation, suturing).
  • Contraceptives (combined, POP, LARCs if trained).
  • Antibiotics / antibacterials (e.g. GBS, UTI, mastitis).
  • Vaccines: influenza, Tdap, Hep B (maternal & neonatal), Rh Ig.
  • Immunoglobulins.
  • Antifungals (e.g.
    clotrimazole).
  • Uterotonics (oxytocin, misoprostol, prostaglandin gel).
  • Antacids & reflux agents.
  • Controlled drugs for intrapartum analgesia: pethidine, morphine, fentanyl, nitrous oxide.
  • Diagnostic/monitoring agents & IV fluids.

Marion Hunter’s Practical List (illustrative, not exhaustive)

  • Antenatal: folic acid, iodine, iron, vitamin D, thrush creams, UTI abs, anti-emetics, nitrous oxide cylinders.
  • Intrapartum: IV fluids, opioids, prostaglandin gel.
  • Neonatal: vitamin K, hepatitis B vaccine & immunoglobulin, topical eye agents.
  • Postpartum: same analgesics/antibiotics spectrum, lactation-related treatments.

Controlled Drugs – Special Caveats

  • Midwives may prescribe/administer controlled drugs only for intrapartum use.
  • Historic option to supply codeine tablets has been removed; Council statement explicitly prohibits routine antenatal codeine.
  • Community pharmacists now tightly monitor OTC codeine sales; confirm with whānau.

Role of the Pharmacist

  • Dispensing & increasingly administering (e.g.
    maternal Tdap, Rh Ig).
  • May refuse / query prescriptions they consider outside scope or clinically unsafe.
  • Escalation path: prescriber → regulatory body / professional college.
  • Some pharmacies use CCTV & auditing software to detect diversion of controlled meds.

Cultural Safety & Partnership

  • Begin medication discussions at first contact; build trust so women feel safe to disclose all substances used.
  • Research 2013: (37\%) of pregnant wāhine used meds other than multivitamins.
  • Incorporate whānau preferences, alternative therapies & financial considerations (e.g.
    Floradix vs.
    subsidised iron).

Medication Safety in Pregnancy

  • Thalidomide history → heightened caution.
  • Organogenesis window ≈ first 11 weeks; minimise exposure unless benefit > risk.
  • Low-dose aspirin for pre-eclampsia prophylaxis commences ≥ 12 weeks.
  • Vitamin B6 often used for NVP; confirm evidence & dosage.
  • Herbal products not regulated; evaluate case-by-case.
  • Discard old FDA A/B/C/D/X categories; rely on NZF narrative risk statements.

Physiological Changes Affecting Pharmacokinetics

  • ↑ plasma volume & GFR.
  • ↓ gastric motility, altered absorption.
  • ↑ hepatic metabolism of some drugs.
  • Placental transfer dependent on lipid solubility, MW < 500 Da, protein binding.

Key Agencies & Databases

  • Pharmac → subsidy status, Pharmaceutical Schedule.
  • Medsafe → safety data sheets, ADR reporting.
  • BPAC → clinical audits & bulletins (note rising vitamin D scripts: now 4^{th} most dispensed med, formerly 12^{th}).
  • Christchurch Drug Info Service / Universal List of Medicines → in-depth monographs.

Practical / Exam Pointers

  • Be able to match a scenario to the relevant Act & outline your obligations.
  • Know where midwifery prescriber authority starts & stops (e.g.
    cannot initiate neonatal IV antibiotics).
  • Always document: indication, counselling given, consent obtained, monitoring plan.
  • Maintain CPD & peer review (requirement under HPCA).