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What Kinds of Applications Are Described Here? What Business Functions Do They Support? How Do They Improve Operational Efficiency and Decision Making?

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Submitted By mackhenzie24
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Ninety percent of all postpartum hemorrhages are caused by uterine atony-that is, failure of the uterine muscles to contract normally after the baby and placenta are delivered. The blood vessels supplying the placenta during pregnancy are severed when the placenta separates from the wall of the uterus. The bleeding that results from these severed vessels normally stops when the uterus contracts, compressing the vessels. However, if the uterus doesn't contract enough, the bleeding can continue. Significant blood loss can result from a floppy, uncontracted uterus.
Factors that may prevent the muscles of the uterus from contracting include the following: * prolonged labor; * the use of oxytocin (Pitocin) during labor; * general anesthesia; * twin or multiple births; * increased amounts of amniotic fluid (polyhydramnios); * delivery of a large baby; * history of more than five pregnancies; * abnormal labor (dystocia); and * infection (chorioamnionitis).
In addition, fragments of placenta remaining in the uterus after delivery or benign growths within the walls of the uterus (known as fibroids) can also prevent the uterus from contracting normally.
Active Management
Many practitioners actively manage the third stage of labor, gently pulling the umbilical cord and administering oxytocin to help the uterus contract and promote delivery of the placenta. The uterus can also be massaged to help it contract firmly. Many studies show this technique reduces postpartum hemorrhage and the need for blood transfusions. For this reason, use of oxytocin after delivery, sometimes right after the baby is delivered and sometimes after the placenta has been delivered, is now commonplace. Oxytocin is given intravenously or injected into a muscle.
If heavy bleeding from atony occurs despite the use of oxytocin after delivery, then other drugs such as Prostaglandin F-2-alpha (Hemabate) and methylergonovine (Methergine) may be used to help control hemorrhage. In rare cases, other more drastic procedures may be required. Occasionally, surgery may be required to tie off large blood vessels that supply the uterus or to perform a hysterectomy for life-threatening circumstances. Newer techniques are also becoming available, including radiological procedures called uterine artery embolization. In this procedure, a radiologist injects small particles into the uterine artery to block blood flow to the uterus which may be able to control uterine hemorrhage. Pharmacological Treatment of Uterine Atony
At present, oxytocin is the initial agent universally administered for the prevention and treatment of uterine atony. However, dosing and delivery regimes vary widely and there are no consistent guidelines regarding the correct and most effective delivery method. Bolus IV doses of 5 to 10 units have been frequently used in clinical practice. However, the side effects are dose related and virtually nonexistent with dilute intravenous solutions. Most formularies suggest that bolus doses should not exceed 5 units although there is little research regarding the most effective method of delivering oxytocin. Recently, Carvalho et al found that a bolus dose of 0.35 units followed by 40mU/min was effective in maintaining uterine contraction in elective CS patients. In contrast, in patients undergoing CS for failure to progress who had received oxytocin for labor augmentation, the minimum effective bolus dose was found to be 2.99 units. The increase in bolus required is likely secondary to oxytocin receptor desensitization (see below). Commonly, 20 units diluted in 1 liter of IV solution are given prophylactically. In the event of uterine atony, the author’s preference is to add an additional 20 units to the liter of fluid and to give small 0.5 to 1 unit bolus doses as required.
An important aspect regarding oxytocin administration is that in vitro studies have shown that continuous exposure to oxytocin decreases the myometrial cells response to oxytocin. That is, there is a desensitization or down regulation of oxytocin receptors. This in turn suggests that in long augmented labors, additional oxytocin may not be beneficial. Therefore, early in these cases, one should consider switching to alternative uterotonic agents in the presence of excessive bleeding. The most common side effects of large bolus doses of oxytocin include nausea, vomiting and hypotension. The decrease in BP is transient, is accompanied by a reflex tachycardia and, in turn, an increase in cardiac output. Because of the transient nature of the hypotension, it is well tolerated in the healthy obstetrical population. However, caution is advised in patients with pre-existing cardiac disease in whom an increase in heart rate or cardiac output might be detrimental or in patients suffering from hypovolemic shock.
2. Ergonovine Maleate
Ergot is usually the second line drug for the treatment of uterine atony. It increases uterine tone through direct alpa-adrenergic stimulation. It is frequently administered intramuscularly in a dose of 0.25 mg but can be given by a slow intravenous injection of 0.125 mg. Too rapid administration can result in severe nausea, vomiting and retching as well as severe hypertension. The onset of action is 3-5 minutes. In contrast to oxytocin which is sometimes administered with the anterior shoulder, Ergot should not be administered before the placenta is delivered as this has been shown to cause an increase in the incidence of retained placenta.
Ergot alkaloids are well known to cause both arterial and venous constriction. This can result in significant cardiovascular effects, specifically hypertension and coronary artery spasm. The pressor effects can be particularly marked in patients with PIH, chronic hypertension and in combination with other vasopressors. Should an acute rise in blood pressure occur, it can be treated with vasodilators such as nitroglycerine, nitroprusside or hydralazine.
3. Carboprost (Hemabate)
Carboprost (15-Methyl Prostaglandin F2 alpha) is generally administered as an intramyometrial injection but can also be given intramuscularly. The initial dose is 0.25 mg and can be repeated every 15 minutes to a maximum of 2.0mg/24hours. Adverse effects include acute peripheral vasoconstriction, hypertension, particularly in patients with PIH, bronchoconstriction, and ventilation and perfusion mismatch leading to hypoxemia. Carboprost should probably be avoided in patients with decreased respiratory function, especially severe asthma and chronic bronchitis.
4. Misoprostol
Misoprostol is a synthetic prostaglandin E2 analogue that is given in a dose of 1000 mcq per rectum. In the event of a PPH, both misoprostol and carboprost can be given simultaneously as they act at different receptor sites. In contrast to carboprost, misoprostol tends to cause vaodilation and can therefore result in hypotension. A decrease in SVR is accompanied by an increase in heart rate and cardiac output.

Replacement Therapy
In the majority of cases of PPH, volume replacement and transfusion therapy are frequently required. Initial replacement with crystalloids and colloids are obviously the first line of treatment. 10%Pentaspan, a synthetic colloid, is the most commonly used colloid. It effectively expands the intravascular volume by a factor of 1.6. Essentially, administration of 500ml of pentaspan increases the volume of the vascular compartment by approximately 750ml.
10% Pentaspan and 6% Voluven, synthetic colloids, are the two colloids presently available in Canada.
Pentaspan effectively expands the intravascular volume by a factor of 1.6. Essentially, administration of 500 ml of pentaspan increases the volume of the vascular compartment by approximately 750ml. The total daily doseage is 28ml/kg with the hemodynamic effects lasting approximately 12-24 hours. Repeated administration beyond 72 hours has not been studied.
Plasma volume expansion by Voluven is 100% of the infused volume, that is, 500 ml of Voluven increases the intravascular volume by 500 ml which lasts for approximately 4-6 hours. This results in less tissue and plasma accumulation which theoretically should lessen potential side effects. The most common dosage regime is 33ml/kg/day which can be repeated over several days with no significant accumulation over a 10 day period. There has been some limited experience with doses up to 50ml/kg/day.
Both colloids are contraindicated in patients with known hypersensitivity to hydroxyethyl starch, with anuria or oliguria not related to hypovolemia, or with congestive heart failure when volume overload is a potential problem. At high dosages both products may cause a dilution of plasma proteins, including the coagulation factors.

RBC Transfusions
Obviously, ongoing bleeding requires blood transfusions. In more recent years a restrictive transfusion policy has become a more common practice. In 2005, Health Canada suggests maintaining the hemoglobin greater than 70g/l during active bleeding. “… except for patients with unstable coronary artery syndromes, a restrictive transfusion policy (trigger Hg 70g/l) has proved at least as effective as, and possibly superior to a liberal transfusion policy in critically ill patients”. These guidelines are useful as an end point but may need to be adjusted depending on the presence of an ongoing coagulopathy. Recent evidence suggests that under these circumstances (ie, a coagulopathy) a higher hemoglobin is necessary for platelet activation. It is also important to ensure prompt blood availability in any patient with a hemoglobin less than 80g/l. As a Filipino, you must know your rights. This is to protect you from government officials abuses . It is clearly stated in our constitution our rights as a Filipino citizen.

It is in Article IV of the Philippines Constitution called the Bill of Rights. So what are the Bill of Rights?

1. Right to due process of law and equal protection of the law.
2. Right from arbitrary arrest and unreasonable search and seizures.
3. Privacy of communication of correspondence.
4. Freedom of speech and freedom of the press.
5. Right to peaceful assembly and petition.
6. Freedom of religion.
7. Liberty of abode and travel.
8. Right to secure information from government records.
9. Right to form associations.
10. Right to own property.
11. Inviolability of contracts.
12. Right to a speedy and public trial.
13. Right against self-incrimination and right to counsel.
14. Freedom from torture, threat, or secret detention.
15. Compensation for torture and rehabilitation of victims and their families.
16. Right to bail.
17. Presumption of innocence
18. Writ of habeas corpus.
19. Freedom of innocence.
20. Prohibition against the death penalty and excessive fines.
21. Right to humane and adequate facilities.
22. No imprisonment for failure of debts or poll tax.
23. Right against double jeopardy.
24. Right to vote and to hold office.
25. Prohibition of ex post facto law and bill of attainder.

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