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(NAR) VOL. 26 NO. 2/ APRIL - JUNE 2015
[ DOH Administrative Order No. 2015-0020, May 11,
2015 ]
GUIDELINES IN THE ADMINISTRATION OF LIFE-SAVING
DRUGS DURING MATERNAL CARE EMERGENCIES BY
NURSES AND MIDWIVES IN BIRTHING CENTERS
Adopted: 11 May 2015
Date Filed: 14 May 2015
I. Background
The Philippines is signatory to the United Nations Millennium Declaration that defined
8 development goals 3 of which relates directly to health. The Millennium
Development Goals (MDGs) are for countries of the world to accomplish in a span of
15 years to ensure the attainment of better quality of life for its people. In health,
emphasis has been heavily placed on accelerating improvements in the attainment of
MDGs 4 and 5 that aim to reduce under-five child and maternal mortality by 2015.
Beyond 2015, the global target is an MMR of less than 70 by 2030; for the country the
aim is to reduce maternal mortality ratio to 39.
To guide program implementers and service providers, the Department of Health,
issued 2 administrative orders aimed at making pregnancy and delivery safer for both
the mother and child: 1) AO 79, s. 2000 also known as the Safe Motherhood Policy
issued in July 2000 and 2) AO 2008-0029 on Implementing Health Reforms to Rapidly
Reduce Maternal and Neonatal Mortality in 9 September 2008. This is known as the
MNCHN Policy. Both issuances target a reduction in maternal and newborn mortality.
Studies and experiences of other countries that have drastically reduced their maternal
mortalities have shown that although women and the unborn need care, attention during
delivery is most important to guarantee better survival of the mother and her newborn.
In the Philippines 73% of births are attended by skilled health professionals and 61%
occur at a health facility (NDHS 2013). But while there are improvements in maternal
health outcomes, maternal mortality ratio remain high at 221/100,000 live births (FHS
2011) and 130/100,000 live births (UN Estimate, 2013). There is thus a need to further
the delivery of basic emergency obstetrics and newborn care at the periphery. These
services shall include among others the administration of life saving drugs by nurses
and midwives in circumstances where a referral doctor or facility is not available.
II. Objective
This Guideline mandates the health sector to strengthen the capacity of nurses and
midwives in maternal and newborn care to adequately and appropriately respond to
pregnancy-related complications by ensuring that they are trained on Basic Emergency
Obstetric and Newborn Care (BEmONC) and other related training courses and
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allowing them to perform all the BEmONC signal functions as defined by the
Department of Health including the administration of life saving drugs as mandated by
Republic Act 10354 (RPRH Act of 2012).
This AO likewise mandates every nurse and midwife practitioner to administer life-
saving drugs such as but not limited to oxytocin, anticonvulsants, corticosteroids, and
antibiotics in emergency situations and where there are no available doctor and health
facility.
III. Scope and Coverage
This Order shall apply to all heads of health facilities providing birthing services as
well as registered nurses and midwives that provide skilled health professional
maternal and newborn care services in both the public and private health sector.
IV. General Principles
To ensure safer pregnancy and delivery, the following principles shall guide every
policy maker, program manager, local chief executive, health officer and health care
provider in maternal and newborn health:
1. For better health outcomes, every pregnancy shall be planned and supported.
2. Health care providers shall perform the highest quality of care possible to ensure
safety in every delivery.
3. Gender and culture sensitivity shall be the norm in health service provision.
4. A three-pronged approach that comprise the following shall be adopted:
a. Birthing Centers upgraded to perform emergency obstetric and newborn
care;
b. Health Professionals trained to proficiency in the performance of basic
emergency obstetric and newborn care; and
c. Reproductive health services made universally accessible to persons of
reproductive age.
5. Every woman shall be encouraged to give birth in a health facility.
6. System-wide approach shall be implemented to ensure a wide reach.
7. Every client shall be accorded the right to make free and informed decisions in
matters related to one’s health.
V. Definition of Terms
1. Basic Emergency Obstetric and Newborn Care (BEmONC) refers to lifesaving
services for emergency maternal and newborn conditions/ complications being
provided by a health facility or professional to include the following services:
administration of parenteral oxytocic drugs, administration of loading dose of
parenteral anticonvulsants, administration of loading dose of parenteral
antibiotics, antenatal administration of loading dose of steroids in threatened
premature delivery, performance of assisted vaginal deliveries, removal of
retained placental products, and manual removal of retained placenta. It also
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includes neonatal interventions which include at the minimum: newborn
resuscitation, provision of warmth, referral and blood transfusion where possible.
2. Skilled Health Professional refers to a doctor, nurse and midwife who has been
educated and trained in the skills needed to manage normal and complicated
pregnancies, childbirth and the immediate postnatal period, and in the
identification, management and referral of complications in women and
newborns.
Midwife is a professional trained to provide services that require an
understanding of the principles and application of procedures and
techniques in the supervision and care of women during pregnancy, labor
and puerperium, management of normal deliveries, including performance
of internal examination during labor except when patient is with antenatal
bleeding, carry out written order of the physician with regard to antenatal,
intra-natal and postnatal care of the normal pregnant including giving of
immunization, oral and parenteral dispensing of oxytocic drug, suturing
perineal laceration, give intravenous fluid during obstetrical emergencies
provided she has been trained for that purpose and may inject vitamin K to
newborns.
Nurse is a duly registered professional who has successfully completed
training in a formal nursing education program and has acquired knowledge
and skills in health promotion and maintenance, disease prevention,
physical and psychosocial assessment and management of health and illness
for women throughout their life cycle. As a member of the BEmONC Team,
the nurse provides independent and collaborative functions under the direct
and indirect supervision of a physician in the provision of preventive care,
episodic care, collaborative care and surgical care.
3. Life Saving Drugs are drugs such as oxytocin, magnesium sulfate, antenatal
steroids, and antibiotics, among other medicines used to prevent and manage
pregnancy-related complications.
4. For purposes of this Administrative Order, Emergency shall be defined as a
condition or state of a patient wherein based on the objective findings of a
prudent medical officer, nurse or midwife on duty for the day there is immediate
danger and where delay in initial support and treatment may cause loss of life or
cause permanent disability to the patient.
VI. Implementing Guidelines
RA 10354 otherwise known as the Responsible Parenthood and Reproductive Health
Act of 2012 mandates nurses and midwives who are tasked to provide maternal and
newborn care services to administer life-saving drugs such as but not limited to
oxytocin, steroids, antibiotics and magnesium sulfate in accordance with the following
conditions:
1. The patient is suffering from a complication evaluated to be an emergency as
defined in this Order and no physician and health facility is available to manage
such condition.
2. Nurses shall have completed the 11-day basic emergency obstetric and newborn
care (BEmONC) skills training course and certified to perform the BEmONC
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signal functions required of nurses by a Training Center recognized by the
Department of Health.
3. Midwives shall have completed the 11-day basic emergency obstetric and
newborn care (BEmONC) skills training course or the 7-day BEmONC training
for midwives and certified to perform the BEmONC signal functions required of
midwives by a Training Center recognized by the Department of Health.
4. The BEmONC Skills Training Course shall include the administration of life
saving drugs. Thus a nurse or midwife certified to perform the BEmONC signal
functions as defined by the Department of Health is automatically certified to
administer life saving drugs.
5. All emergency drugs to be administered by nurses and midwives shall be covered
by a physician’s order.
In cases where a written order is impossible to obtain such as when the
physician is not physically available, a verbal order shall be acquired
through a call and appropriately recorded by the nurse or midwife. The
verbal order shall be read to the physician before ending the call for
confirmation. As soon as the physician is physically available in the health
facility, he or she shall be made to sign the verbal order made.
In areas where geographic isolation brought about by calamities or armed
conflict are likely to occur any time and a written or verbal order is
impossible to obtain, a clinical protocol duly signed by the physician shall
be made available at the Birthing Center. Said protocol shall specify the
following:
> Signs and symptoms of an emergency condition
> Drug to administer for such manifestations
> Timing and dosage of drug administration
> Route of drug administration
> Frequency of administration
> Signs and symptoms of an improving condition
6. The nurse or midwife shall inform the physician by all means about the
administration of an emergency drug and apprise him or her of the patient’s
condition when or where possible. These actions shall be recorded in the
Individual Treatment Chart/Patient’s Chart.
7. All patients administered with an emergency drug shall be REFERRED
IMMEDIATELY after the administration of the loading dose or as soon as the
situation warrants, to the nearest facility providing comprehensive emergency
obstetric and newborn care (CEmONC).
8. In the interest of saving patients’ lives, nurses and midwives shall strictly observe
the protocol for referral.
Emergency transport shall be available to the patient either for free or for a
fee.
A health worker shall be available to accompany the patient to the referral
hospital.
Relevant Patient’s record should be with the patient at the time of referral
for endorsement to the referral hospital.
Referral note that specifies reason for referral and specific actions and
medical management received at the referring facility.
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While the patient is in transit, a call to the referral facility shall be made by
the referring health worker to inform the receiving officer at the referral
facility of such referral.
VII. Roles and Responsibilities
A. Training Centers offering BEmONC Skills course shall:
1. Manage the Training Program and conduct BEmONC Skills Training to service
providers: doctors, nurses and midwives from the public and private sector as
well as members of the academe, such as but not limited to the faculty members
of schools of midwifery and colleges of nursing.
2. Conduct a Post Training Evaluation (PTE) as required by the BEmONC Skills
Training design and certify the trainee’s ability to perform the BEmONC signal
functions required according to the definition of the Department of Health.
3. Issue a Certificate of Training to each trainee upon completion of the course
requirements that include but are not limited to the following: pretest, passing the
post test and return – demonstrations other related learning experiences (RLEs)
and Certificate of Competency upon passing the Post Training Evaluation.
4. Ensure that the course is in compliance with the Standards of Nursing and
Midwifery in the Philippines, certify that the Training Course is accredited by the
Professional Regulation Commission (PRC) Board of Nursing and Board of
Midwifery.
B. Local Government Units through the Provincial, City and Municipal Health Offices
shall:
1. Ensure that the operation of their Birthing Centers in both the public and private
sector comply with the DOH licensing requirements and the accreditation
requirements of PhilHealth.
2. Ensure that life-saving drugs are available in all Birthing Centers including
private birthing centers at all times in adequate number based on case load and
experience.
3. Allow their staff to attend training programs such as but not limited to the
BEmONC skills training course by providing paid time, cost of travel and the
allowable per diem.
4. Sponsor or source out sponsors for their staff training.
5. Implement this Order by translating into local policy for optimal compliance by
critical stakeholders.
6. Engage local chapters of professional groups such as: The Philippine Obstetrical
and Gynecological Society (POGS), The Philippine Pediatric Society (PPS), The
Philippine Society for Newborn Medicine (PSNbM), Philippine Nurses
Association (PNA), The Philippine League of Government Nurses and the
various Midwives Association to assist the Local Health Board in ensuring the
effective implementation of this Order.
7. Ensure the setting-up of an operational public-private service delivery network
that defines an efficient referral system within and outside geographical
boundaries.
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8. Ensure that each Birthing Center, including private birthing centers, has a stand
by emergency transport, which is either a properly maintained government
ambulance or privately owned public conveyance.
9. Conduct periodic monitoring and supervision of birthing centers to ensure health
workers’ compliance to the standards of BEmONC including the provision of life
saving drugs and assess quality of care.
C. Department of Health through the Disease Prevention and Control Bureau, Women
and Men’s Health Development Division shall:
1. Provide over-all supervision of the BEmONC Skills Training Program being
implemented in recognized Training Centers in the country.
2. Ensure that related training protocols including its technical contents are updated.
3. The National Safe Motherhood Program shall collaborate with the DOH Regional
Offices on the conduct of periodic monitoring of the implementation of this order
through such activities as monitoring of Program indicators that reflect client and
provider behavior change as well as quality of care.
4. Cause the expansion of Training Centers for BEmONC skills as necessary.
5. Allot funds for the sponsorship of trainees to the BEmONC skills course.
VIII. Monitoring and Evaluation
Monitoring and supervision of BEmONC teams as well as individually practicing
professionals including nurses and midwives in the public and private health sector
shall be conducted through a cooperative effort of the Provincial and City Health
Offices and the DOH Regional Offices.
IX. Repealing Clause
The provision of previous Orders and other related Issuances that are inconsistent with
this Administrative Order are hereby rescinded. All other provisions of existing
issuances which are not affected by this Order shall remain valid and in effect.
X. Effectivity
This Order shall take effect immediately.
(SGD) JANETTE LORETO-GARIN, MD, MBA-H
Acting Secretary of Health
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