Response to Letter to Editor ‘Additional procedures for pelvic gauze packing for obstetric haemorrhage’

Abstract

We would like to thank Drs Matsubara, Usui and Sakuma for sharing their practice of using a single long Iodoform gauze containing an antibacterial agent (triiodomethane) for pelvic packing as this may reduce the risk of sepsis as well as of miscounting swabs. 1 The authors state that iodine has a broad antimicrobial spectrum with no tendency to produce bacterial resistance.Although they speculate that the iodine-impregnated gauze may reduce infection, this is not proven and most clinicians will still cover these women with broad-spectrum antibiotics. However, we are concerned about the risk of iodine toxicity, which may not be as rare as suggested by the authors. Our literature search [2][3][4][5] indicates that iodine toxicity is related to the amount of iodine absorbed, which in turn is dependent on the concentration of the solution, duration of contact and the route of administration: the longer sheet of Iodoform gauze in contact with a large surface of peritoneum and bowel may allow significant uptake as iodine is more easily absorbed through mucosa compared to skin.Furthermore, the temporary acute renal failure which often follows significant obstetric haemorrhage can impair iodine excretion through the kidneys and plasma levels should be monitored in these patients.Our preference is to use 30 × 30 cm swabs because these are freely accessible in most labour ward theatres. All our cases had received routine intravenous antibiotic cover at induction prior to the caesarean sections, and our practice is to continue this until the packs are retrieved. We are aware of the risk of miscounting, and our theatre team maintains a strict surgical checklist, handover and counting disciplines which mitigate against retained swabs. In the stressful environment that accompanies massive haemorrhage scenarios, we are conscious of the importance of distractions 6 and will especially create a 'sterile cockpit' environment 7 during which the critical phase of swab and instrument counting are not disturbed.We acknowledge that one of the advantages to Drs Matsubara, Usui and Sakuma's suggestion of using a long single swab is that in cases of packing following obstetric hysterectomy, the tail of the gauze strip can be introduced through a partially closed vault into the vagina (as per the Logothetopulos technique 8 ) and the pack subsequently removed by traction via this route, thus obviating a econd laparotomy.Abdomino-pelvic packing should no longer be laughingly dismissed as a 'bail-out' technique for the less skilled obstetric surgeon. Rather, this remains a crucial skill, which complements the other surgical skills essential when managing massive peripartum bleeding as is evidenced by the fact that one in 14 cases in a recent series of 718 peripartum hysterectomies required further packing for intractable bleeding. 9Lastly, we agree with the authors' comment that accoucheur experience is important when making the decision whether or not to initiate packing; what is equally important is that the clinician resists the temptation...