Prescribing in pregnancy: the role of independent and supplementary nurse prescribersAs nursing practice advances to encompass prescribing, it is important to have clarity around roles and responsibilities for different groups of patients and clients. This section focuses on the role of nurses who hold the nurse independent prescriber qualification (NIP) in relation to prescribing medicines to pregnant and postnatal women. This section does not apply to midwives who hold a NIP qualification.
Principles of good practiceAll NIPs must follow the NMC Code and other NMC standards that support best practice, using legislation as a baseline for practice decisions.
All nurses are encouraged to work collaboratively to support best practice and care for all women who are pregnant, using their professional judgement based on best available evidence from contemporary sources such as National Institute for Health and Care Excellence (NICE) pathways.It is good practice to have pre-agreed guidelines/standards around areas of practice that involve someone who is pregnant, including the process for escalation to the most appropriate professional.
If in doubt about roles/competence, advice should be sought from an appropriate professional colleague.
NIPs must be able to recognise when the complexity of clinical decisions requires specialist knowledge and expertise, and consult or refer accordingly.
A useful distinction may be whether the ‘condition’ is related to the pregnancy or not; even then we would recommend consideration of the possible impact on pregnancy, and consult appropriately.
A member of the midwifery or obstetric team is available 24 hours a day by contacting local maternity units, should you need to consult or refer.
Remember that all pregnant women should have a named midwife throughout their pregnancy, labour and postnatal period and women should commence their midwifery care at the earliest opportunity.
Early Pregnancy ClinicsNurses working in early pregnancy clinics may see women with threatened miscarriages. There should be pre-agreed guidelines and standards, which include midwifery and/or obstetric input, on managing this. These documents must state that NIPs should not prescribe medicinal products for pregnant women who need medication to manage their threatened miscarriage.
The RCN would also recommend that nurses advise all pregnant women to book their pregnancy with their midwife, if they have not already done so.
Minor injury or illness (for example sprains, lacerations, fractures, coughs colds and rashes)NIPs can work in environments where they see patients independently, including women who are pregnant. In such circumstances it will be necessary to take a full history to establish the nature of the complaint that has brought the women to your practice, explaining that further referral may be necessary. If the condition relates to the woman’s pregnancy, then she should be seen by a midwife or doctor.
Other non-pregnancy related conditions may be treated, however, the RCN would recommend that you advise all pregnant women to seek advice from their named midwife at the earliest convenience, even if the condition appears to be unrelated to the pregnancy.
Pre-agreed guidance, which has included midwifery and/or obstetric engagement, will enable clarity around local practice.
Long term conditionsMany long term conditions can impact on pregnancy and pregnancy can influence the status and/or progression of a disease/condition.
Collaborative working with the multi professional team to establish appropriate care pathways will be critical to enhance the quality of the woman’s care experience, as well as ensuring continuity of care after birth.
Many maternity units have midwives who specialise in looking after women with diabetes and other long term conditions.
Provided the women is under the care of a midwife, obstetrician and/or specialist team, a baseline assessment would be required in order to determine the best care pathway for her. This should include how best to maintain continuity of care through the pregnancy and birth with her own health centre or GP practice.
In respect to her long term condition, and provided there is collaborative working with the midwifery team or GP, an NIP may prescribe for a women who is pregnant, in relation to her long term condition, if that nurse has the competence to do so.
Working in general practice: folic acidThe RCN believes that NIPs working in general practice should not prescribe folic acid to a woman who is pregnant. They should be seen by a GP or midwife as this is prescribing in relation to a women's pregnancy.
Sexually Transmitted Infections (STIs) and prescribingSometimes pregnant women who have an STI state that they do not wish to disclose their diagnosis to other health professionals.
Patient confidentiality is a key principle of good nursing practice, as is professional judgement. Any treatment and care the woman is receiving outside her midwifery and/or obstetric care has the potential to impact on the progress of her pregnancy and labour, therefore women should always be encouraged to share their treatment plan.
However, it may be necessary to treat women diagnosed with a sexually transmitted infection who choose not to inform their GP, midwife or obstetrician. Whilst every effort should be made to encourage the woman to seek midwifery care immediately, and share her condition and diagnosis with the midwife /obstetrician, her confidentiality has to be respected in line with the NMC Code.
It is assumed that if working in an area requiring specialist knowledge that all nurses will be competent in understanding the potential impact of many sexually transmitted infections on a pregnancy and during labour.
Postpartum careThe postnatal period or puerperium normally last for six weeks and is the time after birth when the woman’s body, including hormone levels and uterus size, returns to a non-pregnant state.
The midwife is responsible for the woman's care during this time. All women will have regular contact with their midwife for at least the first 10 days after the birth and receive ongoing care from the health visiting team.
Minor injuries or illnesses may be treated by an NIP; a suspected post-pregnancy sepsis should be referred to the GP or appropriate medical care.
Usual concerns about prescribing for women who are breastfeeding should be observed. Refer to the British National Formulary (BNF) for advice.
For further information: RCN Competences: Advanced Nurse Practitioners" (2012).