 this several times before but we'll just quickly do a couple of polls because we would like to know who we are managing to reach so could I ask you all please to type in the box where you reside and we'll quickly see whether the demographics are changing. Is that the first Canadian one that we've seen? I don't know. Guatemala. Particularly if you're from interesting places. I'm probably the first Guatemalan we've seen. But I think that's our speaker. I know, I know, but that still counts. Yes of course it does, of course it does. Anymore that's only 11 left, you have us in the room. No? Okay don't want to labour the point. Okay that's grand I shall end that poll then and another quick one if you don't mind. So the next question is what is your main occupation or role? So I'll just clear those answers and we open the poll. Could you please click on that was quick. These students have a very quick reaction that they did you see that? Oh gracious. And there's a goodly number of students here by the looks of it. Are you going to go to the Student Cafe later on? We had a very good one earlier on. Anybody else wanting to click? Gosh we are outnumbered with students. Maybe we should change what we're doing. Chris, very good. Maybe so. I'm anticipating my question now. Okay obviously so everybody's getting a bit bored with these things. Okay so I will just close that just now and do a quick final poll please if you'll just bear with me for two seconds and we want to know where you are joining us from for the poll. Clearly answers. We open it. Where are you all from? Oh we have people back from a clinical facility. I'm starting to watch the percentages going down. Ah now I want to know what is other. So whoever put other could they please pop it into the chat box out of interest? I'm a nosy person really. Okay anybody else going to put anything? No? Okadoki. Thank you very much then. Right I am getting rid of all of that and over to you Chris. Thanks very much Linda. Okay it's my great pleasure to introduce our next speaker Annaly Reed. Annaly is a medical laboratory scientist but has decided that having done that for a few years she wants to become a midwife rather than go to medical school and she's currently in her second year in midwifery school. She's currently in Guatemala although she comes from New York. Annaly's presentation proctolosis or rectal fluid infusion is a low resort and effective method for use in out of hospital environments should fluid replacement therapy become necessary. Use of proctoclysis I'm sure I'm pronouncing that wrong. During wartimes was ineffective for certain casualties but when administered in a timely fashion it served to rehabilitate the subject until other therapies could begin like blood transfusion or surgery or intravenous therapy and so on. The examination of several studies provides an understanding that the rectal colon readily absorbs fluids, electrolytes and even drugs across its mucosa. Validating its use for fluid replacement therapy in emergent situations where IV access is unavailable or difficult. Midwives are often in out of hospital environments and or working in certain state jurisdictions that prevent them from using IV fluid replacement when postpartum hemorrhage, hyperemesis or dehydration warrant the use of fluid replacement therapy. This presentation explains why rectal fluid infusion is an easy and effective method to accomplish fluid replacement therapy. So now I'd like to hand over to Annali Reed. Annali. Yes hi good morning good afternoon good night to all of you present here and of course happy International Day of Midwifery. As Chris said my name is Annali Reed and I am a current medical laboratory scientist but most importantly a student midwife and this presentation is based on research and analysis that I've recently done and will explain the use of proctoclysis or rectal fluid infusion and how it can be used in medicine and most importantly midwifery today. So what is proctoclysis? Well if we break down the Latin according to Miriam Webster's medical dictionary proct means rectum and we have crisis which means the introduction of large amounts of fluid into the body and so when we put those terms together we have proctoclysis which is the introduction of large amounts of fluid into the rectum to replace that lost i.e. hemorrhage or hyper-emesis to provide nutrients i.e. a woman has been dehydrated or a woman that might be intrapartum and unable or unwilling to eat or to maintain blood pressure which could technically be all of the above. So a little history of proctoclysis in 1909 Dr. John Benjamin Murphy created the Murphy drip and this was his method to infuse needed fluids into the body via the rectum and as you can see here on the picture the top portion which has the number seven and one is the fluid reservoir where you know various solutions were put and then there's kind of a little dripper that is at point six and 23 where that fluid reservoir would slowly or quickly drip down into the tube that was connected to the insertion point where they would enter into the rectum. Proctoclysis was also used in World War I it was used in the Vietnam War and then around the 21st century it kind of got booted out of the way by IVs, intraasia therapy, intraparitoneal, parenteral, and hypodermaclysis and those are other methods of fluid replacement therapy that are out there now. So what would we need proctoclysis for if we have all of these wonderful other methods to use? Well one set of researchers decided to state that the rectal route is one of the least efficient routes of fluid administration and in patients with peripheral vasoconstriction intraosseous route would probably offer the patient the best chance of survival. So my question then is well okay intraosseous is definitely very effective and it's fast and in cases of vasoconstriction because that is you know one of the things that we can't use IV axis if there's vasoconstriction. What happens when there's no option to use intraosseous therapy as this is a difficult and it's painful procedure it requires special sterile conditions and it needs specialized equipment. What happens when IV axis is unobtainable due to the vasoconstriction that results from fluid loss or dehydration or in the cases of some midwives that you know practiced in the States I know sometimes IV therapy is not legal like we're not able to have IVs on hand to use during a birth or should we need them. So that goes out of the picture. Hypodermiclysis also has its limits such as needing special equipment and special training and parenteral fluid therapy also needs special training and it will very likely induce nausea and vomiting in a woman that's probably already nauseous and might be vomiting already so that leaves us with one effective option and that is proctoclysis. Proctoclysis is or also recto fluid infusion therapy is a low maintenance procedure it requires no complex training it is low cost and uses minimal equipment it requires only a couple of syringes in the catheter or a basic enema kit which should probably be the easiest for us to get access to. It does not require a sterile field because as we all know the rectum is not a sterile site and most importantly it is effective in restoring an effective circulatory volume and it's effective in providing adequate tissue perfusion to correct type of bulimia it's effective in preventing death and it's effective in preventing death and it is effective in preventing death that's it those are great reasons to use proctoclysis in my book. In conventional medicine a i.e. emergency medicine or wilderness rural practitioners they can benefit by using recto fluid infusion to rehabilitate a subject until other therapy is available such as a blood transfusion or surgery or to at least bring up the blood volume a little bit so that they can put an IV if that's their preferred method of fluid therapy. In midwifery practitioners that are in as I said low resource environments where you know in a country where they might not have access to IVs or the hospital might be two three days away you want to have something in your back pocket so that you can you know sustain the blood volume of your patient until you can transport if that's even an option and then again first certain state jurisdictions they can benefit from using recto fluid therapy because they just aren't able to do IV and if you don't want to you know end up going to the hospital if you're able to stay home longer then it's a great option to use for clients that are experiencing hyperemesis dehydration postpartum hemorrhage et cetera. Is this evidence-based where's the science behind it because you know as midwives we want to make sure that we're practicing evidence based practices right. My examination of several different studies have provided an understanding that the recto colon does readily absorb fluid electrolytes and even drugs across the mucosa. In a study using the rabbit as an animal model they induced type of lemak shock and the rabbit's response to the fluid replacement therapy which was done via the rectum was measured using the mean arterial pressure and as you can see here in the control group the mean arterial pressure was from 21.4 and it only rose up to over 22.1 that's not using proctoclysis the subject group the mean arterial pressure went from 21.7 to an average of 38.1 using proctoclysis as a therapy fluid replacement therapy method so that's a pretty significant increase in the blood volume and the arterial pressure. There was a meta-analysis that was done comparing traditional Chinese medicine and they administered their therapies included drugs it included herbs via a rectal infusion route and they compared that therapy versus conventional western medical therapy so IV boluses or oral medicines and it was found that the response to the proctoclysis actually matched and or surpassed the western therapies in the majority of the cases so there's some that was a big study that was done. There was also a case study that I found describing a group of doctors that journeyed through some the mountains in Nepal and they were checking along and happened upon a 21 year old Nepalese young man who was with some friends but they obviously didn't know how to treat the symptoms that he was displaying he had hyper amethyst and he was actually vomiting while in or sorry he was vomiting blood so hemat amethyst and he was also passing black stool for three days when by the time they found him he was barely conscious his respiratory rate was at 32 breaths per minute so that's double the normal respiratory rate. He had severe peripheral vasoconstriction so the IV oxys is obviously out of the picture and non-pulpable radial pulses. After their initial resuscitation using rectal fluid infusion the subject's carotid pulse reduced from 127 beats per minute to 95 beats per minute and his radial pulse improved from thredian indistinct to palpable. They were able to sustain this man's life for two days which was the length of time that they had to travel on foot to the nearest hospital and even when they got to that first hospital the only thing that they could offer this man was a blood transfusion and he had to be flown out by helicopter I believe to receive surgery because he was having a GI bleed so they were able to save this man's life using rectal fluid infusion because there was no other option I mean they were high in the mountains and the nearest place was two days on foot so as you can see there is evidence to support proctoclysis so at this point we are probably all wondering how do we do this fluid replacement therapy there's three ways there's the use of a basic enema kit you can use a catheter and a syringe or you can use the Murphy drip apparatus and obviously since the Murphy drip was 100 plus years old I wasn't able to find enough literature to give me a good enough understanding of how to set that up so I'm going to just go over the first two methods and that should probably cover your bases pretty well so in either method you can use a solution of a variety of substances depending on what the purpose of your fluid replacement therapy is or you know some people also actually also call this a nutritive enema so you're providing nutrients via the rectum for purposes like hyperemesis or dehydration for those scenarios you can use raspberry tea an infusion of raspberry tea you can use chicken broth you can use garlic water anything that you think will be able to provide nutrients to your client and for the postpartum hemorrhage you do want to have a crystalline solution that's kind of specific so a palm full of sugar and a pinch of salt can be added to the normal volume of an enema bag or if you happen to have IV solutions on hand normal saline that is you can go ahead and use that as well but you know for those of us that are working from you know a home birth situation a palm full of sugar and a pinch of salt you add that to the normal volume of an enema bag which is 1.5 liters and there you have your solution all right um in both methods I also want to say be sure to boil and filter the water if you're taking it from a lake or a river if time permits because you know although the rectum is not a sterile environment we do want to you know stay away from introducing giardia or some other parasite into the subject because that won't end well um all right so I'm going to explain the catheter syringe method first and then the enema method just because I feel that the letter is a bit easier to understand and that's probably what most midwives would go for um okay so in the catheter syringe method you'll be administering about 10 to 30 milliliters of the salt solution at a time and then you're going to give water orally so basically the idea is you're administering this chrysoid solution and you're giving water if able to to kind of travel down the gradient you know so water instead of the water escaping via urine or feces it will go into the blood volume um if you're getting water from the lake or river again please do filter or boil that water um and then make sure you cool it to the temperature of or close to the temperature of your patient's body because you don't want to burn them you don't want it to be too cold either um you'll dissolve your prepared solution into the water whether it be saline uh tea infusion chicken broth etc and then you'll of course get informed consent from your patient as you would with any procedure that's to be done um if you know the situation allows that and assist or allow the patient to lower their clothing um and you can have them lie in a lateral position so on their side with one the the top leg kind of you know to the closer to the lateral area of the body um or you can do a knee chest position which probably might be more comfortable for a pregnant woman um you'll wash your hand glove up and then draw up sterile water with a 10 milliliters syringe so that you'll be able to inflate the catheter balloon once you've done that you'll just set it to the side and be sure to lube the end of the foley with a lubricant of some sort it could be olive oil it could be coconut oil almond oil whatever you have that you know more natural probably better um and then you'll insert the foley about four to seven inches into the rectum and inflate the balloon using that 10 mil syringe probably no more than about five centimeters you want to go so once your foley's in you will gently tug on it to make sure that until you feel you know the resistance from the balloon and you then have the green light to go ahead and start um infusing your solution um for this method the reservoir as you saw in the murphy drip there was a reservoir at the top holding all of the fluid depending on where you are what kind of situation you're in um a syringe that's a 50 mil syringe will work you'll just pull the plunger out and you'll pour your solution in there or if you don't have a 50 mil later syringe you can use a glove that you remove the fingertip of the glove and you'll tape it or attach it in some way or form to the catheter tube um so you have your reservoir set up your tubes in and now holding the reservoir with your dominant hand you'll slowly pour the solution into the reservoir using the other hand and we want to keep in mind that the reservoir needs to be held or you can suspend it from a post if you have one in a position higher than the patient um about hip level is a good spot for this kind of therapy because you don't want it up too high because the higher you hold it the faster it will um drip into the patient and with rectal fluid infusion or a nutritive enema if you want to call it that um you want to do it as slowly as possible and yes gene you want to be sure if the patient is on the left side if you're using a side position for insertion yes all right so then once you've got the fluid running into the rectum you will of course monitor the patient and adjust the infusion to maintain heart rate respiratory rate comfort and all of that in your patients okay so the enema method for this method you'll be using a basic enema kit and you'll prepare solution again if water is coming from a river or a lake please do boil it first and let it cool to the patient's body temperature um wash your hands glove up and once you're all set with that have the patient lie laterally be very careful not to damage the rectum fainter as leila has said and um yeah you can use the lateral position lying lateral position or the knee chest position whichever she'll be more comfortable with or whichever you feel more comfortable um administering the therapy as well as important um so you want to let air out of the tube by allowing some of the solution to kind of flow down into the tube and then pinch it closed before you even put it anywhere near the patient um and then you will lube the tube again using olive oil or coconut oil and insert it about three to four inches into the rectum the enema tube is going to be a little bit larger in diameter than a oily so you'll put it uh less farther into the rectum and you'll very slowly begin to administer your solution at a rate of about 0.5 liters per minute if you have time um try to do a little bit slower than that um but if not 0.5 liters per minute is a good good marker and again remember to hold the bag at just about the height of the woman's hip that's lower you slow down the rate which is also good but if time does not permit that then you work with what you can do um allow about 20 minutes for the entire solution to enter the rectum if the if you cannot wait that long ask the woman to then hold the solution inside of her for as long as she can and that way it will absorb more of the nutrients the electrolytes into the rectum before she kind of lets that um pass back out so with this method again you want to keep in mind you're doing a super super slow enema we don't want to create an enema effect like a wash out we want it to be slow we want it to be absorbed into the body um and we want to give that rectal portion of the elementary canal the chance to absorb everything that we are trying to put into the body um not sure if there's any athletes out there but it's kind of like the same thing when you're coming off of the soccer field or the basketball court during halftime and you're really thirsty but you know that you can't gobble down a half a bottle of water because at least for me like my side would hurt me if I drank a lot of water before you know running again so I would kind of just like put a little bit of water like a mouthful in my mouth and kind of swish around and let my mouth absorb the water and like swell just down a little bit down my throat it's kind of the same idea you know you're still getting some kind of hydration in your mouth when you put just a little bit of water in there and it's being soaked into the elementary canal and that's the same thing that the rectum is doing you're really slowly allowing it to absorb and go into the body so once you've administered your solution again make sure to check up on the woman check her vitals and you know monitor her heart rate and if it is an emergency situation and you're able to do transport to a hospital as soon as possible of course to treat the underlying problem okay so those are the two methods that we can use to do proctoclysis and just as a recap proctoclysis does have a place in midwifery and modern medicine today it's low cost it's low maintenance and there's very simple training that's required and it's effective in retaining fluids and nutrients for use in fluid replacement therapy and to correct hypoglyemia and prevent death and that is the end of my presentation so we can open up for questions comment thank you annie that was um i'm not a medical person i'm not a midwife as my friends on the committee know but i found that absolutely fascinating and sounded so blindingly obvious the way you described it it was really interesting so any questions for annie please linda asks is this used much around the world um i honestly haven't heard of the use of proctoclysis very much around the world which was kind of what sparked my fascination with it um i have heard of it very briefly at a midwifery conference that i attended and the midwife that was presenting kind of like hit it and then ran away so that wasn't the main um focus of the presentation and i was like well how is this and what is this and how can i find out more about this and as i was doing my research it was actually very very difficult for me to find information about proctoclysis at first because i didn't know the um medical or latin terminology for it and so nutritive enema wasn't popping up anywhere in any of the scholarly journals and very slow enema wasn't popping up um proctoclysis came up in let's see it was more so in the use of wilderness medicine and then certain like you know seasoned midwives that i've talked to know about proctoclysis so it's not probably not used much around the world probably more people could benefit from using it because like i said it i mean it can save a person's life well we can we can see that melissa has used it but i haven't seen anybody else say so yet and melissa would you mind sharing with everyone what you're experienced with it was let me um switch on melissa's microphone okay melissa i've given you the microphone um so if you want to talk us through it that would be great okay thank you i had a uh client who had pretty severe hyperemesis and he used the nutritive enema to help her um it slowed down the amount of that she was vomiting and she was also able to um get some energy back the process we used was very similar to what the presenter showed and we infused very very slowly with just in the comfort of her of her home in your own bed and she actually ended up keeping the enema fit and used it um about every other day through the first trimester and that got her through so chances are if she hadn't had that option available she would have had to go to the hospital for ibe care right yeah there there you go that's yeah hyperemesis a lot of women end up having to go to a hospital i know actually all of the women on my mother's side of the family suffered severe hyperemesis in the first trimester and they all had to be um hospitalized for a week or more and if this option was available to them they probably wouldn't have to you know be in a hospital they'd be able to stay in the comfort of their home and we could probably get them on some food a little bit sooner than um what they were able to do so yeah excellent okay any other questions or shared experiences it's interesting to me that Linda who's on the committee and has been 44 years a midwife has never even heard of it until you presented Annalise yeah good to have in your back pocket now yeah i think that's a common comment we've seen go by the point is that i don't work in an area where there is um a need for this because everywhere i've ever worked we've had people who could administer ibe fluids or you could get them to somewhere where they could be administered very quickly so i suppose it's not really something we would even think about or need to think about it's a good point we don't have a deal of wilderness do we around our around here nope not even in scotland Melissa says right now there's an extreme shortage of ibe fluids in the U.S. so this is a great option i did not know that Melissa and i'm sure even especially for midwives to get their hands on some ibe fluids if there's a shortage will probably be the last to get if that's the case so yeah um probably very useful in nipal right now carianne says yeah and there was also a i think in that general region there's some medicines that aren't or drugs i should say that aren't even available via ibe bolus or oral so they actually literally have to do um a rectal fluid infusion infusion sorry um for certain nutrients like i think phosphate is one of them and there's a couple other drugs like in india and nipal area so they actually i suppose then we could say that they use that in that region of the world more frequently so if anyone wants to do more research that might be some indian or nipalese doctors might be one of the first have probably have a good um wealth of research and case studies using practicalices interesting point from layla in iran she says layla says we have to struggle with our medical colleagues to convince them to administer and accept it yes this is true especially i mean if they've never heard of it they wouldn't know what the benefits are um yep yeah i can imagine kind of the struggle of midwife in many countries yes in general they don't know so they fear and yeah it's a it's a struggle melissa says distilled water is also recommended for the retention animal yeah yeah that's a good point if you're not pulling it from a river okay well we've got still got about still got about five minutes for more if anyone has any more points or questions oh carian says that some medications are administered via the rectum in australia interesting yeah my facilitator says that in new zealand also and linda says in the u k as well so there's their proof that the rectum absorbs drugs or anything just as well as you know avanus or introsias um therapy they use the rectum for administering medications there's their proof right there gene wants to know what medications are administered via the rectum melissa says cytotech miso mesoprestin uh-huh diclofenac rectofenac what in uh paracetamol in new zealand megan says they use um they do use a rectal food infusion of some sort after a mother is hemorrhage but they only administer after suturing so yeah if you want if you um are able to manage that hemorrhage without administering the therapy first and you suture and you just kind of want to top up her blood volume um so that she feels not woozy it might not be emergent but still a good idea um if she's blood more than normal we'll have to administer the therapy okay a couple more minutes and then we'll need to bring this to a close so we can change over for the next presentation but we can see people are really interested in um in what you said in related experiences i'm so glad that i could share this okay i think oh just see what megan has to say and then i think i'll probably draw it to a close um all right well thank you everyone and i hope you can all use this information in the future and happy international day of midwifery again okay everybody um thank you very much for all your um for your contributions and thanks once again to annie for a really interesting presentation really well delivered i'm going to turn off record now