CAPITULO III: PAPEL DE LA ATPDEA EN EL SECTOR DEL BRÓCOL
3.5 ACCESO AL MERCADO DE LOS ESTADOS UNIDOS
3.5.2 Barreras no arancelarias
High level evidence indicates prophylactic Carbetocin is no more effective then Oxytocin in preventing PPH greater than 500 mL or 1000 mL.10 Carbetocin has not been compared with bolus dose intramuscular or intravenous Oxytocin in vaginal birth.76 A summary of evidence and
recommendations regarding use of Carbetocin is provided in Table 27.
Table 27. Carbetocin in comparison with other uterotonics Carbetocin* compared with selective oxytocics76 Compared to
Oxytocin infusion
• In women with at least 1 risk factor for PPH – decreases the need for uterine massage as a uterotonic intervention
• In elective CS – decreases the need for uterine massage and therapeutic oxytocics but does not decrease incidence of PPH
Compared to Syntometrine
In vaginal births:
• Decreases blood loss
• Fewer adverse effects including postpartum hypertension • Does not decrease incidence of PPH
Cost effectiveness • Limited data on cost-effectiveness of Carbetocin
• One study only – Carbetocin more cost effective than Oxytocin
Recommendations:
• In elective CS consider substituting Oxytocin infusion with Carbetocin10,76
IV 100 microgram in 1 mL, given slowly over 1 minute after birth of the baby77
• Carbetocin (Duratocin®
) is currently not indicated in emergency CS or after vaginal birth48,77 • Lam restriction48
: For use in women at high risk of post partum haemorrhage following delivery of the infant by elective caesarean section under epidural or spinal anaesthesia
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Appendix A: Bimanual compression
Bimanual compression
If conscious, inform woman of procedure and provide analgesia, then:
• Using non-dominant hand:
o Keeping fingers straight and thumb tucked in palmar side of index finger insert hand into vagina with palm facing the woman’s thigh
o Once fingers meet resistance roll the hand so that palm is upward and curl fingers into a fist placing thumb on top of index finger o Place the fist into the anterior
fornix of the vagina and apply upward pressure
• Using other (dominant) hand: o Identify the uterine fundus o Deeply palpate to situate fingers
behind the fundus
o Cupping the fundus compress it firmly around the intravaginal fist o Maintain compression and
evaluate effect
Administering PF2α
If conscious, inform woman of procedure and provide analgesia, then:
• Situate non-dominant hand using same techniques as above
• The dominant hand is used to
administer intramyometrial PGF2α via an injection in multiple sites of the uterine fundus
• Stabilisation of the fundus can be achieved by having an assistant situate their fingers behind the fundus
Images reproduced with permission from Advance Life Support Obstetrics (ALSO) Asia Pacific. (Modified content from same source)
Appendix B: Uterine atonia interventions
Balloon Tamponade
© 2007 Lisa Clark courtesy of Cook Medical Inc Permission for use granted by Cook Medical Incorporated,
Bloomington, Indiana The process for using the intra-uterine balloon is as follows49:
• Empty uterine cavity of clots
• Insert the end of the balloon through the cervix into the uterine cavity, ensuring the balloon is completely inside the uterus
• Inflate the balloon with sufficient volume of warm sterile saline (approx 250-500 mL); the uterus should now be firm with minimal blood loss
• Assess blood loss through drainage portal for tamponade effect. If bleeding continues tamponade ineffective and surgical intervention required
• Commence broad spectrum antibiotic cover • Continue or commence oxytocic infusion
B-Lynch compression suture
The technique is performed at laparotomy or CS:
• (Re) open the abdomen and (re) open the uterus
• Check the uterine cavity for bleeding sites that might be oversewn
• Test for haemostasis before using the B- Lynch suture using bimanual compression and swabbing the vagina – if bleeding is controlled temporarily in this fashion the B- Lynch suture is likely to be effective • Placement of the suture, as demonstrated,
requires surgical expertise
Images reproduced with permission from Wiley. Reference: B-Lynch C, Coker A, Lawal A, et al. The B-Lynch surgical technique for the control of massive postpartum haemorrhage: an alternative to hysterectomy? Five cases reported. BJOG 1997; 104:372–375
Uterine artery ligations17
This technique is performed at laparotomy or CS: • The goal of arterial ligation is to decrease
uterine profusion and subsequent bleeding • It is considered less technically challenging
and time consuming than ligation of other arteries e.g. internal iliac
Image: © 2012 Saunders, An Imprint of Elsevier
Reference: Francois K, Foley M. Chapter 19: Antepartum and postpartum hemorrhage. In: Gabbe S, Niebyl J, Simpson J, Landon M, Galan H, Jauniaux E, et al., editors. Obstetrics: normal and problem pregnancies. 6th ed. Philadelphia: Saunders, Elseiver; 2012
Appendix C: Sample PPH proforma
This example form requires approval for use by the local health service
PPH identified: hrs Date: …../…../..… By: Help called @ hrs
Initial management
Assess for cause – 4 T’s
Arrival of team members
Estimated
Blood
Loss
Start
mL
*Tone
Tissue
Trauma
Thrombin
Person/designation
Time
End
mL ▪ Fundus
contracted?
▪ Oxytocic
given?
▪ Placenta
delivered?
▪ Products
complete?
▪ Cervix
▪ Vagina
▪ Perineum
intact?
▪ Blood
clotting?
▪ Absence of
oozing?
Action
Check
Address woman
Adjust position – lie
flat/trendelenburg
*Drug and route
Dose
Time
Airway / 02 @15 L/min
IV cannula (1) sited
IV cannula (2) sited
Bloods labelled/sent: ▪FBC
▪ X-match ▪ ELFTs ▪ Coags
IDC sited
Fluids – avoid excessive crystalloids
Time T
P
BP
Sp0
2 Ready for OT and consent obtainedTime
Type and volume
Rate
Transfer OT (O2 on, flat, left lateral)ID LABEL
Adapted from Royal College of Obstetricians and Gynaecologists (RCOG) – PPH Chart (Reference: RCOG, Prevention and management of postpartum haemorrhage. Green-top Guideline No.52. 2009)
NB: Recommended for use in tracking events when sufficient clinical staff available. Proforma does not replace need to complete standard medication or fluid forms
Appendix D: Blood administration: transfusion
Clinical aspects Good practice points*
Informed consent • Refer to Queensland Government procedural consent form: Blood and blood products transfusion consent
Explain • Likely cause of bleeding or low blood count – include any uncertainty
• Nature of the transfusion – what is involved • Benefits expected
• Risks common and rare but serious • Alternatives – include risk of doing nothing
Ask • Do you have any questions or is there anything you didn’t understand?
Provide • Interpreter as required
• Written information – refer to Queensland Government: Consent information – Patient copy, Blood and Blood Products Transfusion consent
Document • Consent or refusal or, if required, Advanced health directive
Commencing the transfusion
• Two clinicians to cross check:
o Details on crossmatch label on blood bag with the UR, name and date of birth on woman’s ID bracelet and prescription order
o Unit number information matches the crossmatch label and crossmatch report
o Blood type on bag with blood group results filed in the woman’s chart (will not match if O Negative blood in an emergency transfusion is used) o Blood has not expired
o Integrity of the blood product (e.g. leaks, large clots, haemolysis) • Transport in esky to keep blood cool – units are not to be placed directly on ice-
bricks
• Do not leave the bag out of blood fridge for more than 30 minutes
• Equipment – ensure giving sets, filters, infusion pumps and blood warmers are appropriate for use in blood transfusion
o Prime with 0.9% Sodium Chloride or blood component
• Do not mix blood with intravenous drugs or infusions or colloids with calcium added (e.g. Haemocel)
• Proceed with the transfusion no faster than 5 mL/minute for the first 15 minutes, unless otherwise indicated by the patient’s clinical condition
Monitoring the transfusion
• Document pulse rate, respiration rate, BP and temperature – for each blood component pack:
o Immediately prior to commencing or at transfusion start o 15 minutes after commencing administration
o At transfusion end
• Increase frequency of observations as clinically indicated • Closely observe for the first 15 minutes for reactions • Regular visual observation is essential
• If applicable, refer to local health service policy for any additional observations • Adverse reactions:
o Discontinue if a significant adverse reaction and initiate appropriate therapy
o Do not take down blood component o Maintain IV access via a sideline
o Do not resume transfusion without a clinical review o Report:
§ Via local clinical incident reporting systems (e.g. PRIME)
§ To the supplying laboratory or blood bank
o Return the remainder of any implicated blood units (and other empty bags