Management of uterotonic drugs used for AMTSL Name of presenter Prevention of Postpartum Hemorrhage Initiative (POPPHI)

1. Management of uterotonic drugs used for AMTSL Name of presenterPrevention of Postpartum Hemorrhage Initiative (POPPHI) ProjectPATH

2. Objectives 3b - 1 • By the end of this topic, learners will be able to: • Describe recommendations for storing uterotonic drugs used for AMTSL. • Describe the importance of documenting uterotonic drug use and movement. • Identify problems related to poor documentation of uterotonic drugs. • Estimate the quantity of uterotonic drugs to order for your facility

3. We don’t have any more oxytocin. Hm….maybe that’s because she doesn’t want to be bothered with managing our drugs. Consequences of poor drug management 3b - 2

4. Estimating uterotonic drug needs 3b - 3 • The estimate of the drug and dosage forms required for a given period is undertaken • To avoid shortages (out of stock) and ensure credible health care service, • To prevent excess stock and avoid waste (loss or mismanagement of financial resources).

5. Estimating uterotonic drug needs 3b - 4 • Factors that influence choice and quantity of drugs include: • Population which the health institution serves. • Volume of birth. • Seasonal variation in number of births to be expected. • Monthly (rate of) drug consumption. • Delivery (lead) time. • Time lag between placing orders and receiving the orders. • Request indicator (re-order level): Quantity of drug product that serves as a signal for re-ordering.

6. Terms used for drug management 3b - 5 Maybe I ordered too much…. • Request indicator (RI) • Average monthly consumption • Delivery (lead) time • Quantity to be requested • Stock in balance

7. Review of calculations 3b - 6 • Average monthly consumption • Divide the total consumption over the period by the number of months the drug was consumed. • Request indicator (time for re-ordering) = May also be known as “Minimum stock level” • Average monthly consumption×delivery time • Quantity to order • (Average monthly consumption × Lead time) + (1 month consumption for unforeseen events) +/- (difference between RI and Stock in balance)

8. Case study – Work with a learning partner 3b - 7 Refer to Learning Activity 3.4, question 1 (page 17 in the Learner’s Notebook): The pharmacy manager is preparing her monthly order request and would like to calculate how many ampoules of oxytocin 10 IU to order. When she carried out an inventory, she counted 50 ampoules of oxytocin 10 UI, of which 4 ampoules were expired. The average monthly consumption is 30 ampoules of oxytocin (10 UI). How many ampoules should the pharmacy manager order?

9. Case study – Answer 3b - 8 • Quantity to order = (Average monthly consumption × Lead time + 1 month consumption for unforeseen events) – (Stock in balance over RI) • Delay (lead) time : 1 month • Stock in balance : (50 ampoules – 4 expired ampoules) = 46 ampoules in balance • Average monthly consumption : 30 ampoules • RI : (30 ampoules x 1 month) = 30 ampoules • Stock over RI = 30 – 46 = 16 ampoules over RI • Quantity to order : [(30 x 1) + (30)] – (16) = 44 ampoules

10. Dirt Temperature Humidity Light Quality assurance 3b - 9 • In areas where medications are stored … …what can affect the quality of medications you use ?

15. Quality assurance : Temperature 3b -14 • In the pharmacy: • Make sure that there is a system in place to monitor the temperature of the refrigerator / cold box • Make sure that there is a back-up system in place in case of frequent electricity cuts - for example, gas or solar refrigerators, placing ice packs in the refrigerator to keep it cool, etc. • Store misoprostol at room temperature and away from excess heat and moisture • To ensure the longest life possible of injectable uterotonics, keep them refrigerated at 2–8°C • Protect ergometrine and Syntometrine from freezing and light. .

16. Quality assurance : Temperature 3b -15 • In the delivery room : • Check the manufacturer’s label for recommendations on how to store injectable uterotonic drugs outside the refrigerator. In general: • Oxytocin may be kept outside the refrigerator at a maximum of 30°C (warm, ambient climate) for up to three months and then discarded • Ergometrine and Syntometrine vials may be kept outside the refrigerator in closed boxes and protected from the light for up to one month at 30°C and then discarded • Misoprostol should be stored at room temperature away from excess heat and moisture

17. Quality assurance : Temperature (2) 3b -16 • In the delivery room : • Record the temperature in the delivery room on a regular basis, preferably at the hottest times of the day • Periodically remove ampoules from the refrigerator for use in the delivery room – carefully calculate the number removed from the refrigerator based anticipated need • Only remove ampoules or vials from their box just before using them • Make sure that there are adequate stocks of syringes and injection safety materials • Avoid keeping injectable uterotonics in open kidney dishes, trays, or coat pockets

18. Rotation and stocking 3b -18 These expire later than the tins behind them. Which should I use first? • Use the system of: FIRST IN FIRST OUT (FIFO) • Keep track of expiration datesRecord all drugs that have been used or sold • Regularly conduct a physical inventory of the stock in balance • FIRST TO EXPIRE FIRST OUT (FEFO)

19. Disposal of expired/broken stocks 3b -19 • Clearly identify and document any ampoules that are expired or have been broken • If an ampoule has expired or broken: • Do not keep it with stock to be distributed/used. • Put all broken or expired ampoules in a closed safety box that is clearly labeled“Expired, do not use.” • Store the safety box at a safe distance from stock to be distributed/used. • Subtract any expired or broken ampoules from the balance in stock as soon as they are taken out of the stock to be distributed/used. • Apply national protocols for destruction or return of expired or broken ampoules.

20. Case studyFind the error 3b -20 • Find one partner to work with. • Refer to learning activity 3.4, question 4 (pages 17-18 in the Learner’s Notebook).

22. Recording use of uterotonic drugs 3b -21 Tools for keeping track of uterotonic drugs include: • Order book • Stock cards • Daily log of uterotonic drug use • Delivery register • Oxytocin logbook in the delivery room

23. Recording movement of medications (2) 3b -22 Document movement of uterotonic drugs in at least two different management tools to guarantee accurate information and accountability

24. Summary 3b -23 • It is advisable to request drugs on a regular basis to prevent shortages. • If drugs are not always available, patients may lose confidence in the health centre and will be discouraged from visiting it. • It is important to make requests on a regular basis, as drugs will only be delivered when requested. • The delivery time should be taken into consideration in ensuring that drugs are not in short supply. • If drugs are available but not stored in a way that keeps them effective, money will be wasted and quality of care affected negatively.

25. Learning activities 3b -24 • Please complete learning activities found in the Learner’s Notebook for Session 3b. • You may work individually or in groups on the learning activities during breaks, in the evening, or in the clinical area when there are no clients. • You may correct your answers individually or with another participant or the facilitator. • See a facilitator if you have questions.