standing orders in obg

1. CODE OF ETHICS AND
STANDARDS OF MIDWIFERY
PRACTICE AND STANDING
ORDERS IN OBSTETRICS
PRESENTED BY:-
MS LISA CHADHA
F. Y MSC NURSING
BVCON, PUNE

2. CODE OF ETHICS
A written set of guidelines issued by an
organization to its workers and
management to help them conduct their
actions in accordance with its primary
values and ethical standards.

3. International Code of Ethics for
Midwives
• The aim of the International Confederation of
Midwives (ICM) is to improve the standard of
care provided to women, babies and families
throughout the world through the
development, education and appropriate
utilization of the professional midwife

4. • Such care may encompass the
reproductive life cycle of the woman
from the pre-pregnancy stage right
through to the menopause and to the
end of life.

5. International Code of ethics

6. The Code of ethics
• I. Midwifery Relationships
• a. Midwives develop a partnership with individual women in
which they share relevant information that leads to informed
decision-making, consent to an evolving plan of care, and
acceptance of responsibility for the outcomes of their
choices.
• b. Midwives support the right of women/families to participate
actively in decisions about their care.
• c. Midwives empower women/families to speak for
themselves on issues affecting the health of women and
families within their culture/society.
• .

7. • d. Midwives, together with women, work with policy and funding
agencies to define women’s needs for health services and to
ensure that resources are fairly allocated considering priorities
and availability
• f. Midwives respectfully work with other health professionals,
consulting and referring as necessary when the woman’s need
for care exceeds the competencies of the midwife.
• g. Midwives recognize the human interdependence within their
field of practice and actively seek to resolve inherent conflicts.
• h. Midwives have responsibilities to themselves as persons of
moral worth, including duties of moral self-respect and the
preservation of integrity

8. • II. Practice of Midwifery
• a. Midwives provide care for women and childbearing families
with respect for cultural diversity while also working to eliminate
harmful practices within those same cultures.
• b. Midwives encourage the minimum expectation that no woman
or girl should be harmed by conception or childbearing.
• c. Midwives use up-to-date, evidence-based professional
knowledge to maintain competence in safe midwifery practices
in all environments and cultures.

9. • d. Midwives respond to the psychological, physical,
emotional and spiritual needs of women seeking
health care, whatever their circumstances (non-
discrimination).
• e. Midwives act as effective role models of health
promotion for women throughout their life cycle, for
families and for other health professionals.
• f. Midwives actively seek personal, intellectual and
professional growth throughout their midwifery
career, integrating this growth into their practice.

10. • III. The Professional Responsibilities of Midwives
• a. Midwives hold in confidence client information in order to
protect the right to privacy, and use judgment in sharing this
information except when mandated by law.
• b. Midwives are responsible for their decisions and actions,
and are accountable for the related outcomes in their care of
women.
• c. Midwives may decide not to participate in activities for which
they hold deep moral opposition; however, the emphasis on
individual conscience should not deprive women of essential
health services.

11. • d. Midwives with conscientious objection to a given
service request will refer the woman to another
provider where such a service can be provided.
• e. Midwives understand the adverse consequences
that ethical and human rights violations have on the
health of women and infants, and will work to
eliminate these violations.
• f. Midwives participate in the development and
implementation of health policies that promote the
health of all women and childbearing families.

12. • IV. Advancement of Midwifery Knowledge and
Practice
• a. Midwives ensure that the advancement of
midwifery knowledge is based on activities that
protect the rights of women as persons.
• b. Midwives develop and share midwifery knowledge
through a variety of processes, such as peer review
and research.
• c. Midwives contribute to the formal education of
midwifery students and ongoing education of
midwives.

13. International Standards for
Midwife

14. International Standards for
Midwife
• The International Confederation of
Midwives (ICM) has developed the ICM
Global Standards for Midwifery
Regulation (2011) in response to
requests from midwives, midwifery
associations, governments, UN
Agencies and other stakeholders.

15. • GOAL
• The goal of these standards is to promote regulatory
mechanisms that protect the public (women and
families) by ensuring that safe and competent
midwives provide high standards of midwifery care to
every woman and baby.
• AIM
• The aim of regulation is to support midwives to work
autonomously within their full scope of practice. By
raising the status of midwives through regulation the
standard of maternity care and the health of mothers
and babies will be improved.

16. ICM Global Standards for Midwifery
Regulation
• 1. Model of regulation
• 1.1 Regulation is midwifery specific
• Midwifery requires legislation that establishes a
midwifery-specific regulatory authority with adequate
statutory powers to effectively regulate midwives,
• support autonomous midwifery practice and enable
the midwifery profession to be recognized as an
autonomous profession.
• Midwifery-specific legislation protects the health of
mothers and babies by ensuring safe and competent
midwifery practice

17. • 1.2 Regulation should be at a national level
• Where possible regulation should be at a national
level. However, if this is not possible there must be a
mechanism for collaboration and communication
between the midwifery regulatory authorities.
• National regulation enables uniformity of practice
standards and facilitates freedom of movement of
midwives between jurisdictions

18. • 2. Protection of title
• 2.1 Only those authorised under relevant legislation
may use the title ‘midwife’ endowed by that legislation
• Mothers and their families receiving care from a midwife
have a right to know that they are being cared for by a
legally qualified practitioner.
• A legally qualified practitioner is individually
responsible and accountable for her actions and is
required to adhere to professional codes and standards.
• Reserving the title ‘midwife’ for legally qualified
midwives identifies legally qualified midwives from
others who provide aspects of maternity care.

19. • 3. Governance
• 3.1 The legislation sets a transparent process for nomination,
selection and appointment of members to the regulatory authority
and identifies roles and terms of appointment.
• Because there is no evidence for any specific model of selection of
members for regulatory authorities
• The ICM recommends a combination of appointment and election
for all members of the midwifery regulatory authority. The choice
will depend on feasibility and local acceptance.
• All members of the regulatory authority should demonstrate
experience and expertise against predetermined selection criteria
such as broad experience in the midwifery profession; business
and finance expertise; education expertise and legal expertise.

20. • 3.2 The majority of members of the midwifery
regulatory authority are midwives who reflect the
diversity of midwifery practice in the country.
• Midwife members should be appointed or elected
from nominees put forward by the midwifery
profession.
• The midwife members need to reflect the diversity of
midwives and of midwifery practice in the country,
have credibility within the profession and be
authorized to practice in the jurisdiction

21. • 3.3 There must be provision for lay
members
• Lay members of the midwifery
regulatory authority should reflect the
diversity of the country including
ethnicity. Ideally lay members will
provide perspectives that reflect those
of childbearing women.

22. • 3.4 The governance structures of the midwifery
regulatory authority should be set out by the
legislation.
• The midwifery regulatory authority has systems and
processes in place to specify roles and
responsibilities of board or council members;
powers of the council; process of appointment of
chairperson.
• Such processes must be transparent to the public
through publication of an annual report and other
mechanisms for publicly reporting on activities and
decisions.

23. • 3.5 The chairperson of the midwifery
regulatory authority must be a midwife.
• The members of the midwifery
regulatory authority should select the
chairperson from amongst the midwife
members.

24. • 3.6 The midwifery regulatory authority is funded by members of
the profession
• Payment of fees is a professional responsibility that entitles
midwives to obtain registration or a license to practice if that
midwife meets the required standards.
• Ideally the midwifery regulatory authority is entirely funded by
the profession. However, in countries where the midwifery
workforce is small or poorly paid some government support may
be required.
• Government funding has the potential to limit the autonomy of
the midwifery regulatory authority and therefore needs to be
provided through a mechanism that minimizes such a
consequence.

25. • 3.7 The midwifery regulatory authority works in
collaboration with the midwifery
• Professional associations.
• The midwifery regulatory authority’s processes
should be based on principles of collaboration and
consultation.
• The midwifery regulatory authority needs to work in
partnership with other midwifery organizations that
also have a role in public safety and standard setting
such as the midwifery association.
•

26. • 3.8 The midwifery regulatory authority works
in collaboration with other regulatory
authorities both nationally and internationally.
• Collaboration with other regulatory authorities, both
nationally and internationally, promotes
understanding of the role of regulation and more
consistent standards globally.
• Collaboration can provide economies of scale for
developing shared systems and processes that
improve quality.

27. • 4. Functions
• 4.1. Scope of practice
• 4.1.1 The midwifery regulatory authority defines the
scope of practice of the midwife that is consistent
with the ICM definition and scope of practice of a
midwife.
• The midwifery profession determines its own scope of
practice rather than employers, government, other
health professions, the private health sector or other
commercial interests.
• The scope of practice provides the legal definition of
what a midwife may do on her own professional
responsibility.
• The primary focus of the midwifery profession is the
provision of normal childbirth and maternity care.

28. • The scope of practice must support and enable
autonomous midwifery practice and should therefore
include prescribing rights, access to
laboratory/screening services and admitting and
discharge rights.
• As autonomous primary health practitioners midwives
must be able to consult with and refer to specialists
and have access to back up emergency services in all
maternity settings.
• Associated non-midwifery legislation may need to be
amended to give midwives the necessary authorities
to practice in their full scope. For example, other
legislation that controls the prescription of
narcotics/medicines or access to lab/diagnostic

29. • 4.2. Preregistration midwifery education
• 4.2.1. The midwifery regulatory authority sets the
minimum standards for preregistration midwifery
education and accreditation of midwifery education
institutions that are consistent with the ICM education
standards.
• The midwifery profession defines the minimum standards
for education and competence required for midwifery
registration.
• The ICM definition and scope of practice of a midwife,
essential competencies for basic midwifery practice and
standards for midwifery registration should provide the
framework for pre-registration midwifery education
programmes

30. • 4.2.2. The midwifery regulatory authority
approves preregistration midwifery education
programmes leading to the qualification
prescribed for midwifery registration.
• The midwifery regulatory authority
establishes the processes to approve
midwifery education programmes and
accredit midwifery education organisations in
order to ensure that the programmes and
graduates meet the approved education and
registration standards and the ICM Global
Standards for Midwifery Education.

31. • 4.2.3. The midwifery regulatory authority accredits the
midwifery education institutions providing the
approved preregistration midwifery education
programme.
• In countries where national accreditation
organizations exist the midwifery regulatory authority
collaborates in the processes of approval and
accreditation.
• In these situations each organization may focus on its
own specific standards and area of expertise and
accept the assessment of the other.

32. • 4.2.4. The midwifery regulatory authority audits
preregistration midwifery education programmes and
midwifery education institutions.
• The midwifery regulatory authority establishes the
processes for ongoing monitoring and audit
mechanisms of pre-registration midwifery education
programmes and the midwifery education institutions
providing the programmes in order to ensure that
appropriate standards are maintained
• While it establishes the processes the midwifery
regulatory authority may employ external auditors to
carry out this work.

33. 4.3. Registration
• 4.3.1. The legislation sets the criteria for
midwifery registration and/or licensure.
•4.3.2. The midwifery regulatory authority
develops standards and processes for
•registration and/or licensure meet specific
standards set by profession (via the
•midwifery regulatory authority).

34. • 4.3.3. The midwifery regulatory authority develops
processes for assessing equivalence of applicants
from other countries for entry to the midwifery
register/or licensure.
• Midwifery registrants from other countries must meet the same
registration standards as local midwifery registrants.
• The assessment process should be comprehensive and may
include:
 Sighting and assessing original qualifications and post-
registration midwifery experience of applicants and comparing
these with the educational preparation of local new graduate
midwives.
 Assessing the competence of applicants against the
competencies for entry to the register;

35.  Assessment methods may include examinations and
clinical assessment of competence.
 Midwives from other countries who meet registration
standards should be required to complete an
adaptation programme to orientate to local society and
culture, health system, maternity system and
midwifery profession.
 Midwives can hold provisional registration until these
requirements are met within the designated timeframe.

36. • 4.3.4. Mechanisms exist for a range of registration
and/or licensure status.
• From time to time midwifery regulatory authorities
need flexibility to temporarily limit the practice of a
midwife, for example, while a midwife is having her
competence reviewed or is undertaking a
competence programme or has a serious health issue
that may compromise safe practice.
• Legislation should include categories of registration
to provide for particular circumstances. For example
provisional, temporary, conditional, suspended and
full midwifery registration/licensure.

37. • 4.3.5. The midwifery regulatory authority maintains a
register of midwives and makes it publicly available.
• The midwifery regulatory authority demonstrates
public accountability and transparency of its
registration processes by making the register of
midwives available to the public. This may be
electronically through a website or by allowing
members of the public to examine the register.
• Women and their families have a right to know that
their midwife is registered/licensed and has no
conditions on her practice. Therefore this information
needs to be accessible to the public.

38. 4.3.6. The midwifery regulatory authority establishes
criteria, pathways and processes leading to
registration/licensure for midwives from other countries
who do not meet registration requirements.
•Where midwives from other countries do not meet the
registration standards a range of options can be
considered including examination, education
programmes, clinical assessment.
•Some midwives may not be able to meet the registration
standards without first completing another pre-
registration midwifery education programme.

39. • 4.3.7. The midwifery regulatory authority
collects information about midwives and
• their practice to contribute to workforce
planning and research.
• The midwifery regulatory authority has a role
in supporting workforce planning. Information
collected can inform planning for pre-
registration and post registration midwifery
education and inform governments about
workforce needs and strategies

40. • 4.4. Continuing competence
• 4.4.1. The midwifery regulatory authority implements a
mechanism through which midwives regularly demonstrate
their continuing competence to practice.
• Midwifery competence involves lifelong learning and the
demonstration of continuing competence for
registration/licensure.
• Eligibility to continue to hold a licence to practice midwifery is
dependent upon the individual midwife’s ability to demonstrate
continuing competence.
• Assessment and demonstration of continuing competence is
facilitated by a recertification or relicensing policy and process
that includes such things as continuing education, minimum
practice requirements, competence review (assessment) and
professional activities.

41. • 4.4.2. The legislation sets out separate requirements
for entry to the midwifery register and/or first license
and relicensing on a regular basis.
• A requirement for regular relicensing separates the
registration/first licensing process from the
subsequent application to practice process.
• Historically in many countries relicensing required
only the payment of a fee. Internationally there is an
increasing requirement for demonstration of ongoing
competence (including updating knowledge) as a
requirement for relicensure of health professionals.

42. • 4.4.3. A mechanism exists for regular relicensing of
the midwife’s practice.
Midwives may be on the midwifery register for life
(unless removed through disciplinary means or by
death). However, the establishment of separate
processes to approve the ongoing practice of midwives
will enable the midwifery regulatory authority to
monitor the continuing competence of each midwife.
.

43. • 4.4.4. Mechanisms exist for return to practice
programmes for midwives who have
• been out of practice for a defined period.
• The midwifery regulatory authority is responsible for
ensuring that all midwives are competent.
• As part of a continuing competence framework the
midwifery regulatory authority ensures that standards
and guidelines are set that identify the timeframes and
pathways for midwives returning to practice after a
period out of practice.

44. • 4.5. Complaints and discipline
• 4.5.1. The legislation authorises the midwifery
regulatory authority to define expected standards of
conduct and to define what constitutes
unprofessional conduct or professional misconduct.
• The midwifery regulatory authority has a public
protection role and increasingly there is a public
expectation that all professions are transparent and
effective in setting standards for practice that protect
the public.
• The midwifery regulatory authority sets the standards
of professional conduct and ethics and judges when
midwives fall below expected standards.

45. • 4.5.2. The legislation authorises the midwifery
regulatory authority to impose, review and
remove penalties, sanctions and conditions on
practice
• The midwifery regulatory authority requires a
range of penalties, sanctions and conditions
including censure; suspension; midwifery
supervision; requirement to undertake an
education programme; requirement to undergo
medical assessment; restricted practice;
conditional practice; and removal from the
register

46. • 4.5.3. The legislation sets out the powers and
processes for receipt, investigation, determination and
resolution of complaints.
• Appropriate mechanisms must be in place to
effectively manage issues of competence, health and
conduct. The mechanisms must ensure natural justice.
• The detail in the legislation will depend on the judicial
system and cultural context in place in any country.
Very prescriptive legislation may restrict the
development of a flexible and responsive midwifery
workforce.
•

47. •
• 4.5.4. The midwifery regulatory body has
policy and processes to manage complaints
in relation to competence, conduct or health
impairment in a timely manner.
• Complaint processes enable anyone to make
a complaint about a midwife
(consumer/service user, other health
professional, employer, another midwife, or
regulator can initiate a complaint).

48. • 4.5.5. The legislation should provide for the
separation of powers between the investigation of
complaints and the hearing and determining of
charges of professional misconduct.
• Separation of investigation and hearing and
determination allows for fairness to the midwife and
transparency to the public.
• Separation of powers prevents a conflict for the
midwifery regulatory authority between protecting
the interests of the midwifery profession and
ensuring public safety.
•
• The decision is made in the public interest, rather
than that of the profession

49. • 4.5.6. Complaints management processes are
transparent and afford natural justice to all parties.
• A freely available and accessible appeal process
should be in place.
•
• 4.6. Code of conduct and ethics
• 4.6.1. The midwifery regulatory authority sets the
standards of conduct and ethics.
• The codes of conduct and ethics are a baseline for the
practice and professional behaviour expected from a
midwife and the midwifery profession. The profession
sets these standards via the midwifery regulatory
authority.

50. STANDING ORDERS IN
OBSTETRICS

51. Definition
• Standing Orders are orders in which
the nurse may act to carry out specific
orders for a patient who presents with
symptoms or needs addressed in the
standing orders. They must be in
written form and signed and dated by
the Licensed Independent Practitioner

52. • Standing orders are approved and signed by the
physician in charge of care before their
implementation.
• They are commonly found in critical care setting and
other specialized practice setting where client’s needs
can change rapidly and require immediate attention.
• Standing orders are also common in the community
health setting, in which the nurse encounters
situations that do not permit immediate contact with a
physician.

53. • Examples of situations in which standing orders may
be utilized can include,
• Administration of immunizations (e.g. influenza,
pneumococcal, and other vaccines)
• Nursing treatment of common health problems
• Health screening activities
• Occupational health services
• Public health clinical services
• Telephone triage and advice services
• Orders for lab tests.
• School health
• During labor

54. • Objectives
• To maintain the continuity of the treatment of the
patient.
• To protect the life of the patient.
• To create feeling of responsibility In the members of
health team.

55. • Uses
• Providing treatment during emergency
• Enhance the quality and activity of health
service.
• Developing the feeling of confidence and
responsibility in nurses and other health
workers.
• Protecting the general public from troubles.
• Enhancing the faith of general public in
medical institution.

56. List of standing orders
• The Expert Advisory Group Meeting held on
140.10.2004 as a follow up the meeting held
on the 19th
of July 2004 was to suggest
recommendations on various issues which
needed policy decisions related to the use of
selected life saving drugs and interventions
in obstetric emergencies by Staff Nurses
LHVs and ANMS.

57. • 1. Administration of Inj. Oxytocin and
Misoprostol
• It was decided that Tab. Misoprostol would be used as
prophylaxis against PPH, in all deliveries, as a part of
active management of the third stage of labour.
• Tab. Misoprostol should be given, sublingually or
orally, 600mg (3 tablets of 200 mg each), immediately
after the delivery of the baby.
• If a woman bleeds for more than 10 minutes after
deliver, she should be given 10U Inj. Oxytocin
preferably by the IV route (when the ANM is trained to
give the same)

58. • 2 . Administration of Inj. Magnesium sulphate for
prevention and management of Eclampsia
• Inj. MGSO4 is the drug of choice for controlling eclamptic fits.
• The first does should be given by the ANM/staff nurse/Medical
Officer at the PHC.
• The woman should immediately be referred to a CHC/FRU and not
a PHC. This is because in these cases termination of pregnancy
will be required, and a PHC may not be equipped for the same.
• This first dose should be given as a 50% solution (this preparation
is available in the market). 8cc need to be given to make a total
dose of 4 gms.

59. • 3 Administration of IV infusions to treat shock
• It was universally felt that the administration of IV
infusions was a life saving procedure. As
haemorrhage was the commonest cause of maternal
mortality, the administration of 3ml of fluid for every
ml of blood lost could keep the woman alive during
the time it took to transport her to the nearest
CHC/FRU where blood transfusion facility was
available.
• As of now, the ANMs are neither trained nor allowed
by the regulatory authorities to establish an IV line.
After the discussion, it was decided that:

60. – If the ANM is trained to give IV infusion, she should
administer wherever feasible, even at home.
– The ANM should start infusion with Ringer Lactate or
Dextrose Saline.
– If an IV infusion was being started incases of PPH, it was
recommended the IV fluid should be augmented with 20U of
Oxytocin for every 500 ml bottle of fluid. This could be
continued throughout transportation.
– However, the logistics and feasibility of the ANM being able to
carry IV infusion sets and IV fluids to homes need to be
explored, and ensured.

61. • 4 Administration of antibiotics:
• The indications for which antibiotic therapy is
recommended are:
– Premature rupture of membranes
– Prolonged labour
– Anything requiring manual intervention
– UTI
• Puerperal sepsis There should be instructions
for the ANM that after starting the woman on
antibiotics, she should inform the PHC
Medical Officer

62. • 5 Administration of antihypertensive:
• There was a universal consensus that
only the Medical Officer should be
allowed to administer anti-
hypertensives to a woman with
hypertension in pregnancy.

63. • 6 Removal of retained products of
conception:
• For incomplete abortion, if bleeding
continues, the ANM and staff nurse can
perform only digital evacuation of products of
conception. However the staff nurse can use
MVA under the supervision of the Medical
Officer.

64. • 7 Manual removal of placenta (MRP):
•
• MRP should be carried out only by the Medical Officer
in a health facility (PHC/CHC) setting.
• If the placenta was partially separated (as could be
diagnosed by the presence of vaginal bleeding), the
ANM should try and see if a part of the placenta could
be seen coming out from the os. Then she could
assist the removal of the placenta .
• The ANM should be trained in the active management
of the third stage of labour.

65. • 8 Conduction of an Assisted Vaginal Delivery (forceps
& vacuum extraction):
• Conduction of an assisted vaginal delivery was not
possible at the community level due to obvious
reasons. Hence it was universally felt that:
• Assisted vaginal deliveries (i.e. the use of obstetric
forceps or vacuum extraction) should be carried out
by the Medical Officer only.
• The ANMs and the staff nurse need to be trained in
the use of a partograph, for diagnostic purpose only.
This will help her in taking a decision for referral in a
case of prolonged labour.

66. • 9 Repair of vaginal and perineal tears:
• Scientific evidence proved that superficial tears do
not require any repair, because the outcome was the
same whether or not such a tear was sutured. The
ANM should be able to recognize a superficial tear,
and should be able to distinguish it from deeper
tears. She should simply apply pad and pressure on
the tear.
• For second and third degree tears which require
repair, the ANM should refer the woman to a higher
facility.

67. • The Staff Nurse should be allowed to repair a second
degree tear at the PHC setting, under the supervision
of the Medical Officer. But she too should refer third
degree tears after vaginal packing.
• It was decided that the medical officer and the staff
nurse require to be trained in repairing tears, and the
ANM requires training in recognizing the degree of
tear.
• No additional material/items thus need to be added to
the ANM kit for the repair of vaginal/perineal tears.

68. RECENT STUDY
• Facilitators and barriers to the use of
standing orders for vaccination in
obstetrics and gynecology settings
• JANUARY 2017
• American Journal of Obstetrics &
Gynecology

69. STUDY DESIGN: At 6 safety-net and private obstetrician gynecology
practices, 51 semi structured interviews were completed by trained
qualitative researchers over 2 years with clinical staff and vaccination
program personnel. Standardized qualitative research methods were
used during data collection and team-based data analysis to identify
major themes and subthemes within the
interview data.
RESULTS: All study practices achieved partial to full implementation of
vaccine standing orders for human papillomavirus, tetanus diphtheria
pertussis, and influenza vaccines. Facilitating factors for vaccine
standing order adoption included process standardization, acceptance
of a continual modification process, and staff training. Barriers to vaccine
standing order adoption included practice- and staff-level competing
demands, pregnant women’s preference for medical providers to
discuss vaccine information with them, and staff hesitation in
determining HPV vaccine eligibility.

70. CONCLUSIONS:
With guidance and commitment to integration of new
processes, obstetrician-gynecology practices are able to
establish vaccine standing orders for pregnant and non
pregnant women. Attention to certain process barriers can
aid the adoption of processes to support the delivery
of vaccinations in obstetrician-gynecology practice setting,
and provide access to preventive health care for many
women.

72. BIBLIOGRAPHY
• Kamini Rao, textbook of midwifery and obstetrics for
nurses, Elsevier publication, 1st
edition .
• Annamma Jacob, text book of midwifery, 1st
edition,
jaypee publication 2005.
• Adele pillitteri, child health nursing care of the child and
family, 1st
edition Lippincott publication.
• Potter & perry , fundamentals of nursing,5 th edition,
Elsevier publication.
• www.drugs2004rn.com.
• www.pubmed.com