Mich. Admin. Code R. 338.17137 - Administration of prescription drugs or medications

Rule 137.

(1) Pursuant to section 17111 of the code, MCL 333.17111, a licensed midwife who has appropriate pharmacology training and holds a standing prescription from an appropriate health professional with prescriptive authority, is permitted to administer the following prescription drugs and medications:

(a) Prophylactic vitamin K to an infant, either orally or through intramuscular injection.

(b) Antihemorrhagic agents to a postpartum mother after the birth of the infant.

(c) Local anesthetic for the repair of lacerations to a mother.

(d) Oxygen to a mother or infant.

(e) Prophylactic eye agent to an infant.

(f) Prophylactic Rho(D) immunoglobulin to a mother.

(g) Agents for group B streptococcus prophylaxis, recommended by the federal Centers for Disease Control and Prevention, to a mother.

(h) Intravenous fluids, excluding blood products, to a mother.

(i) Antiemetics to the mother.

(j) Epinephrine.

(2) Administration of any of the drugs included in subrule (1) of this rule must comply with this rule. The indications, dose, route of administration, duration of treatment, and contraindications relating to the administration of drugs or medications identified under subrule (1) of this rule are shown in Table 1 and Table 2:

Table 1

Maternal - Administration of Prescription Drugs and Medications

Medication	Indication	Dose	Route of Administration	Duration of Treatment	Contraindications	Comments
Oxygen	Maternal distress or fetal distress.	10-12 L/minute.	Free-flow, nasal cannula, mask.	Until stabilized or transfer of care.	None, with indications present.
Pitocin 10 units/ml	Prevention and treatment of postpartum hemorrhage.	10 units/ml.	Intramuscular.	1-2 doses, PRN.
Pitocin 10 units/ml	Prevention and treatment of postpartum hemorrhage.	20 units in 1000 ml IV fluids, initial bolus rate 1000 ml/hour bolus for 30 minutes (equals 10 units) followed by a maintenance rate 125 ml/hour over 3.5 hours (equals remaining 10 units).	Intravenous.	4 hours.
Methyl-ergonovine (Methergine) 0.2 mg/ml	Prevention and treatment of postpartum hemorrhage.	0.2 mg/ml.	Intramuscular.	0.2 mg IM q2-4hr PRN; not to exceed 5 doses.	Contraindicated for patient with hypertension or Reynaud's disease. Can be used in conjunction with Pitocin after delivery of the placenta.	IM preferred for acute postpartum use. Oral methergine can help to lessen continued bleeding after hemorrhage.
Methyl-ergonovine (Methergine) 0.2 mg	0.2 mg tab.	Oral.	0.2-0.4 mg PO q6-8hr PRN for 2-7 days.	Contraindicated for patient with hypertension or Reynaud's disease.	IM preferred for acute postpartum use. Oral methergine can help to lessen continued bleeding after hemorrhage.
Misoprostol (Cytotec)	Treatment of postpartum hemorrhage.	600 mcg oral or 800 mcg buccal or rectal.	Oral, buccal, rectal.	1 dose.
Hemabate (Carboprost)	Treatment of postpartum hemorrhage.	0.25mg IM.	Every 15-90 minutes; not to exceed 8 doses.	Asthma.	Relative counterindications: hypertension.
Tranexamic Acid (TXA or Lystdea)	Treatment of postpartum hemorrhage.	1g in 10 ml IV at 1 ml/min, administered over 10 minutes.	Intravenous.	Use within 3 hours and as early as possible after onset of postpartum hemorrhage.	Contraindicated for patient with deep vein thrombosis, history of coagulopathy, or active hypersensitivity to TXA.	TXA should be administered slowly as an IV injection over 10 minutes because bolus injection carries a potential risk of hypotension. Should not be mixed with blood or solutions containing penicillin or mannitol.
RHo (D) Immune Globulin (Rhogam)	Prophylactic dose: RH-patient at 28-30 weeks gestation; RH- patient after a miscarriage; postpartum RH- patient with an RH+ baby. A prenatal dose can also be given after an injury under advisement of a physician.	300 mcg pre-filled syringe.	Intramuscular.	Administer within 72 hours of birth or antenatal event.	RH positive; IgA deficiency.
Penicillin G	Group Beta Strep (GBS) prophylaxis in labor.	Initial loading dose: 5 million units IV. Subsequent doses: 2.5-3.0 million units IV every 4 hours.	Administer via IV with prepared minibag.	Until delivery.	Allergy to penicillin.	No saline limitation when administering antibiotics.
Ampicillin	Group Beta Strep prophylaxis in labor.	Initial loading dose: 2 g IV. Subsequent doses: 1 g IV every 4 hours.	Administer via IV with prepared minibag.	Until delivery.	Allergy to penicillin.	No saline limitation when administering antibiotics.
Cefazolin	Group Beta Strep prophylaxis in labor.	Initial loading dose: 2g IV. Subsequent doses: 1g IV every 8 hours.	Administer via IV with prepared minibag.	Until delivery.	Allergy to cefazolin.	Cefazolin is the first choice for patients who have a history of allergy to penicillin but no history of anaphylactic reaction to penicillin. Use clindamycin or vancomycin for patients who have a history of anaphylactic penicillin allergy. No saline limitation when administering antibiotics.
Clindamycin	Group Beta Strep prophylaxis in labor.	900 mg IV every 8 hours until delivery.	Administer via IV with prepared minibag.	Until delivery.	Allergy to clindamycin.	Use only with patient with history of anaphylactic reaction to penicillin and the GBS isolate is laboratory proven to be susceptible to Clindamycin. No saline limitation when administering antibiotics.
Vancomycin	Group Beta Strep prophylaxis in labor.	1 g IV every 12 hours.	Administer via IV with prepared minibag.	Until delivery.	Allergy to vancomycin.	Use only with patient with history of anaphylactic reaction to penicillin and the GBS isolate is laboratory proven to be resistant to Clindamycin. No saline limitation when administering antibiotics.
Epinephrine	Severe allergic reaction.	Single dose of 0.3 mg, USP, 1:1000 (0.3 ml) in a sterile solution.	5-15 minutes. Transport to hospital should be initiated.	Discontinue medication that is causing reaction; place patient supine and elevate lower extremities. Protect the airway. Transport to hospital should follow.
Lactated Ringers solution	Dehydration during labor.	Up to 2L.	Intravenous.	Over the course of 3-5 hours.	Most patients respond to intravenous hydration and a short period of gut rest, followed by reintroduction of oral intake. Preferred over normal saline.
0.9% Normal Saline solution	Dehydration during labor, when LR not available. Postpartum hemorrhage. Allergic reactions.	1L- 2L bolus.	Intravenous.	During course of infusion.	Intrapartum: the addition of 5% Dextrose to solution can increase success rate with nausea or vomiting.
Lidocaine	Postpartum repair of vulvo-vaginal lacerations.	Injectable: up to 20 ml 2%, up to 30 ml 1%, or up to 60 ml 0.5%.	Injection.	2 hours.	Known allergy or signs or symptoms of allergic reaction.	Do not use lidocaine with epinephrine, max dose 4.5 mg/kg infiltration.
Lidocaine	Postpartum repair of vulvo-vaginal lacerations.	Topical cream, spray, or gel.	Known allergy or signs or symptoms of allergic reaction.
Diphenhydra mine (Benadryl)	To reduce vomiting during labor.	25 to 50 mg every 4 to 6 hours / 10-50 mg every 4-6 hours.	Oral; intravenous.
Ondansetron (Zofran)	To reduce vomiting during labor.	4-8 mg IVP / 4 mg (up to twice PRN).	Oral; intravenous.	May produce headache as side effect.

Table 2

Neonatal - Administration of Prescription Drugs and Medications

Medication	Indication	Dose	Route of Administration	Duration of Treatment	Contraindications	Comments
Oxygen	Neonatal resuscitation, if indicated; abnormal pulse oximetry readings.	10L/minute, or as indicated.	Bag and mask, free-flow.	Until pulse-oximetry readings are within target range of infant age, or transfer of care.	None, with indications present.	Administration of oxygen to a neonate should be in accordance with NRP standards. When an oxygen blender is not accessible, free-flow oxygen may be used combined with pulse oximetry. Current research cautions that inappropriate use of oxygen can cause free radical and oxidative stress damage in the neonate.
0.5%Erythromycin Ophthalmic ointment	Prophylaxis of neonatal ophthalmia neonatorum due to N. gonorrhoeae or chlamydia trachomatis.	1 cm ribbon of 0.5% ointment in each eye within 24 hours of birth.	Ocular, in lower eyelid.	1 dose.	Hypersensitivity to drug class or component.	May cause ocular irritation or blurred vision.
Vitamin K 1.0 mg/0.5 ml	Prophylaxis and therapy of hemorrhagic disease of the newborn.	0.5-1.0 mg.	Intramuscular.	1 dose.	Family history of hypoprothrombine mia; hypersensitivity to drug class or component.	Vitamin K 1.0 mg/0.5 ml
Epinephrine	Neonatal resuscitation.	0.1 - 0.3ml/kg (0.01 - 0.03 mg/kg) of body weight in a 1:10,000 concentration.	Administered in the umbilical venous catheter followed by 1 " 3 ml flush of sterile normal saline.	Repeat every 3-5 min if HR <60 bpm with chest compressions.	EMS services should be en route.
Epinephrine	Neonatal resuscitation.	1 ml/kg 1:10,000 concentration.	Endotracheal.	Repeat every 3-5 min if HR <60 bpm with chest compressions.	Max 3 ml/dose, EMS services should be en route.

Administration of Prescription Drugs and Medications

Maternal
Cefazolin	Group Beta Strep prophylaxis in labor.	Initial loading dose: 2g IV. Subsequent doses: 1g IV every 8 hours.	Administer via IVPB with prepared minibag.	Until delivery.	Allergy to cefazolin.	Cefazolin is the first choice for patients who have a history of allergy to penicillin but no history of anaphylactic reaction to penicillin. Use clindamycin or vancomycin for patients who have a history of anaphylactic penicillin allergy.
Clindamycin	Group Beta Strep prophylaxis in labor.	900 mg IV every 8 hours until delivery.	Administer via IVPB with prepared minibag.	Until delivery.	Allergy to clindamycin.	Use only with history of anaphylactic reaction to penicillin. Clindamycin and Vancomycin are the drugs of choice for GBS prophylaxis for patients who have a history of anaphylactic reactions to penicillin.
Vancomycin	Group Beta Strep prophylaxis in labor.	1 g IV every 12 hours.	Administer via IVPB with prepared minibag.	Until delivery.	Allergy to vancomycin.	Use only with history of anaphylactic reaction to penicillin. Clindamycin and Vancomycin are the drugs of choice for GBS prophylaxis for patients who have a history of anaphylactic reactions to penicillin.
Epinephrine	Severe allergic reaction.	Single dose of 0.3 mg, USP, 1:1000 (0.3 mL) in a sterile solution.	5-15 minutes. Transport to hospital should be initiated.	Discontinue medication that is causing reaction; place patient supine and elevate lower extremities. Protect the airway. Transport to hospital should follow.
Lactated Ringers Solution	Dehydration during labor.	Up to 2L.	Intravenous.	Over the course of 3-5 hours.	Most patients respond to intravenous hydration and a short period of gut rest, followed by reintroduction of oral intake. Preferred over normal saline.
0.9% Normal Saline solution	Dehydration during labor, when LR not available. Postpartum hemorrhage. Allergic reactions.	1L- 2L bolus.	Intravenous.	During course of infusion.	Intrapartum: the addition of 5% Dextrose to solution can increase success rate with nausea or vomiting.
Lidocaine	Postpartum repair of vulvo-vaginal lacerations.	Injectable: up to 5 ml 2%, 10 ml 1%, or 20 ml 0.5%. Topical cream, spray, or gel.	Injection.	2 hours.	Known allergy or signs or symptoms of allergic reaction.	Do not use lidocaine with, epinephrine, max dose 3 mg/kg.
Antiemetic ranitidine zantac	To reduce vomiting during labor.	150 mg every 6 hours.	Oral.	Treat until symptoms subside.
Diphenhydra mine	To reduce vomiting during labor.	25 to 50 mg every 4 to 6 hours / 10-50 mg every 4-6 hours.	Oral; intravenous.
Ondansetron	To reduce vomiting during labor.	4-8 mg IVP / 4 mg (up to twice PRN).	Oral; intravenous.	May produce headache as side effect.
Neonatal
Oxygen	Neonatal: neonatal resuscitation, if indicated; abnormal pulse oximetry readings.	Neonatal: 10L/minute, or as indicated.	Neonatal: bag and mask, free-flow.	Neonatal: until pulse- oximetry readings are within target range of infant age, or transfer of care.	None, with indications present.	Administration of oxygen to a neonate should be in accordance with NRP standards. When an oxygen blender is not accessible, free-flow oxygen may be used combined with pulse oximetry. Current research cautions that inappropriate use of oxygen can cause free radical and oxidative stress damage in the neonate.
0.5% Erythromycin Ophthalmic ointment	Prophylaxis of neonatal ophthalmia neonatorum due to N. gonorrhoeae or chlamydia trachomatis.	1 cm ribbon of 0.5% ointment in each eye within 24 hours of birth.	Ocular, in lower eyelid.	1 dose.	Hypersensitivit y to drug class or component.	May cause ocular irritation or blurred vision.
Vitamin K 1.0 mg/0.5 ml	Prophylaxis and therapy of hemorrhagic disease of the newborn.	0.5-1.0 mg.	Intramuscular.	Single dose.	Family history of hypoprothrombi nemia; hypersensitivity to drug class or component.	Vitamin K 1.0 mg/0.5 ml
Epinephrine	Neonatal resuscitation.	0.1 - 0.3 mL/kg (0.01 - 0.03 mg/kg) of body weight in a 1:10,000 concentration.	Administered in the umbilical venous catheter followed by 1 - 3 mL flush of sterile normal saline.	Repeat every 3-5 min if HR <60 bpm with chest compressions.	EMS services should be en route.
Epinephrine	Neonatal resuscitation.	1 ml/kg 1:10,000 concentration.	Endotracheal.	Repeat every 3-5 min if HR <60 bpm with chest compressions.	Max 3 ml/dose, EMS services should be en route.

Notes

Mich. Admin. Code R. 338.17137

2019 AACS; 2023 MR 6, Eff. 3/21/2023