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Cyclophosphamide-Doxorubicin Ver 1.1

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Regimen Chemotherapy Protocol BREAST CANCER CYCLOPHOSPHAMIDE-DOXORUBICIN Breast Cancer – Cyclophosphamide-Doxorubicin Indication Primary systemic (neoadjuvant) therapy of breast cancer Adjuvant therapy of high risk (greater than 5%) node negative breast cancer WHO Performance status 0, 1, 2 Toxicity Drug Cyclophosphamide Doxorubicin Adverse Effect Dysuria, haemorrhagic cystitis, taste disturbances Cardio toxicity, urinary discolourisation (red) The adverse effects listed are not exhaustive. Please refer to the relevant Summary of Product Characteristics for full details. Monitoring Regimen FBC, U&E’s and LFT’s prior to each cycle. Ensure adequate cardiac function before starting treatment with doxorubicin. Baseline LVEF should be measured, particularly in patients with a history of cardiac problems or in the elderly. Dose Modifications The dose modifications listed are for haematological, liver and renal function only. Dose adjustments may be necessary for other toxicities as well. In principle all dose reductions due to adverse drug reactions should not be reescalated in subsequent cycles without consultant approval. It is also a general rule for chemotherapy that if a third dose reduction is necessary treatment should be stopped. Version 1.1 (Aug 2014) Page 1 of 6 Breast – Cyclophosphamide-Doxorubicin Please discuss all dose reductions / delays with the relevant consultant before prescribing if appropriate. The approach may be different depending on the clinical circumstances. The following is a general guide only. Haematological Prior to prescribing the following treatment criteria must be met on day 1 of treatment. Criteria Neutrophil Platelets Eligible Level equal to or more than 1x109/L equal to or more than 100x109/L Consider blood transfusion if patient symptomatic of anaemia or has a haemoglobin of less than 8g/dL If counts on day one are below these criteria for neutrophil and/or platelets then delay treatment for seven days. Treatment should only be re-started when these levels are reached. Treatment may be resumed at the original dose or reduce the original dose of doxorubicin and cyclophosphamide to 80% of the original dose depending on clinical circumstances. If a second episode of neutropenia and / or thrombocytopenia occurs or the time to reach the eligible level is longer than seven days consider changing or stopping therapy. Hepatic Impairment Drug Cyclophosphamide Doxorubicin Bilirubin AST/ALT Alk Dose (μmol/L) (units) Phos (% of original (units) dose) Dose reduction may not be necessary If the bilirubin is between 20-51umol/L give 50% of the dose If the bilirubin is between 51-85umol/L give 25% of the dose If the bilirubin is greater than 85umol/L omit If the AST is 2-3xULN give 75% of the dose If the AST is greater than 3xULN give 50% of the dose Renal Impairment Drug Cyclophosphamide (consider mesna) Creatinine Clearance (ml/min) More than 20 10-20 Less than 10 Dose (% of original dose) 100 75 50 Doxorubicin No dose reduction generally required Other Dose reductions or interruptions in therapy are not necessary for those toxicities that are considered unlikely to be serious or life threatening. For example, alopecia, altered taste or nail changes. Version 1.1 (Aug 2014) Page 2 of 6 Breast – Cyclophosphamide-Doxorubicin Doxorubicin Discontinue doxorubicin if cardiac failure develops. Regimen 21 day cycle for 6 cycles Where the intention is to follow this regimen with another such as paclitaxel only FOUR cycles may be necessary. Always check on prescribing cycle one what is required. Drug Dose Days Administration Cyclophosphamide 600mg/m2 1 Intravenous bolus Doxorubicin 60mg/m² 1 Intravenous bolus Dose Information Cyclophosphamide will be dose banded as per the CSCCN agreed bands Doxorubicin will be dose banded as per the CSCCN agreed bands The maximum lifetime cumulative dose of doxorubicin is 450mg/m2. However prior radiotherapy to mediastinal/pericardial area should not receive a lifetime cumulative doxorubicin dose of more than 400mg/m². Administration Information Extravasation Cyclophosphamide - neutral Doxorubicin – vesicant Additional Therapy Antiemetics; 15-30 minutes prior to chemotherapy; - dexamethasone 8mg oral or intravenous - ondansetron 8mg oral or intravenous As take home medication; - dexamethasone 4mg twice a day oral for 3 days Version 1.1 (Aug 2014) Page 3 of 6 Breast – Cyclophosphamide-Doxorubicin - metoclopramide 10mg three times a day when required oral - ondansetron 8mg twice a day oral for 3 days Mouthwashes according to local or national policy on the treatment of mucositis. Gastric protection with a proton pump inhibitor or a H2 antagonist may be considered in patients considered at high risk of GI ulceration or bleed. Coding Procurement - X70.2 Delivery - X72.3 References 1. Coskan U, Gunel N, Onuk E et al. Effect of different neoadjuvant chemotherapy regimens on locally advanced breast cancer. Neoplasma 2003; 50 (3): 210-216 2. Wolmark N, Wang J, Mamounas E et al. Preoperative chemotherapy in patients with operable breast cancer: nineyear results from the National Surgical Adjuvant Breast and Bowel Project B-18. J Natl Cancer Inst Monogr 2001; 30: 96-102 Version 1.1 (Aug 2014) Page 4 of 6 Breast – Cyclophosphamide-Doxorubicin REGIMEN SUMMARY Cyclophosphamide-Doxorubicin Day One 1. Dexamethasone 8mg oral or intravenous 2. Ondansetron 8mg oral or intravenous 3. Doxorubicin 60mg/m² intravenous bolus over 10 minutes. 4. Cyclophosphamide 600mg/m² intravenous bolus over 10 minutes. Take Home Medicines 5. Dexamethasone 4mg twice a day oral for three days starting on day two of the cycle 6. Metoclopramide 10mg three times a day when required oral 7. Ondansetron 8mg twice a day oral for three days starting on the evening of day one of treatment Version 1.1 (Aug 2014) Page 5 of 6 Breast – Cyclophosphamide-Doxorubicin DOCUMENT CONTROL Version Date Amendment Header changed Toxicities removed Adverse effects tabulated ≥ removed and written in full Dose modification tabulated Hepatic impairment updated Regimen tabulated 1.1 August 2014 Metoclopramide dose changed to 10mg Bolus removed from intravenous bolus throughout text Mucositis recommendation changed OPCS code updated Dexamethasone TTO clarified Ondansetron TTO clarified Disclaimer added 1 June 2011 None Written By Donna Kimber Pharmacy Technician Anna Bunch Pharmacist Approved By Dr Debbie Wright Pharmacist Dr Ellen Copson Consultant Medical Oncologist Dr Debbie Wright Pharmacist Dr Caroline Archer Consultant Medical Oncologist This chemotherapy protocol has been developed as part of the chemotherapy electronic prescribing project. This was and remains a collaborative project that originated from the former CSCCN. These documents have been approved on behalf of the following Trusts; Hampshire Hospitals NHS Foundation Trust NHS Isle of Wight Portsmouth Hospitals NHS Trust Salisbury Hospital NHS Foundation Trust University Hospital Southampton NHS Foundation Trust Western Sussex Hospitals NHS Foundation Trust All actions have been taken to ensure these protocols are correct. However, no responsibility can be taken for errors which occur as a result of following these guidelines. Version 1.1 (Aug 2014) Page 6 of 6 Breast – Cyclophosphamide-Doxorubicin
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/Media/UHS-website-2019/Docs/Chemotherapy-SOPs1/Breastcancer/Cyclophosphamide-Doxorubicin-Ver-1.1.pdf

Autonomic function test - patient information

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Patient information factsheet Autonomic function test This leaflet provides information about your forthcoming appointment so that you know exactly what to expect. We’ll go into more detail during your appointment and you’ll also be able to ask any questions that you may have. Having an autonomic function test An autonomic function test is designed to look at how your body responds to certain situations. You may be referred for this test if you have had episodes of fainting, collapse or passing out with an unknown cause. It aims to induce your symptoms in a controlled and safe environment where you can be monitored. The results will hopefully explain why you might be having these episodes. Preparing for your appointment You must not eat or drink anything (including water) for four hours prior to this test. At the appointment At the beginning of the test you will be asked to remove your clothes from the waist up and put on a hospital gown. Stickers (called electrodes) will be attached to your chest. Some men may need to have a small area of their chest shaved in order for the electrodes to stick to the skin. A blood pressure cuff will be attached to your hand and your upper arm. This equipment will be used to monitor your heart rate, rhythm and blood pressure throughout the test. You will be asked to do three different exercises: • Some deep breathing exercises. • We’ll ask you to lie flat on a couch and then you will be instructed to stand-up quickly. • You will also be asked to perform a valsalva manoeuvre, which is the sensation you get when you try to pop your ears or blow hard into a tube. You can expect the test to take about an hour. At the end of the test the monitoring equipment will be removed. You may like to bring some food and drink with you for after your appointment, as you will not have had anything to eat or drink for almost five hours. Your results The doctor may be able to discuss the results with you on the day of your appointment. Alternatively your results will be sent back to the doctor who requested the test, which may be your GP or hospital consultant. If this is a hospital consultant you may be given the results of this test during your next clinic appointment. If you are unsure please ask during your appointment. www.uhs.nhs.uk Patient information factsheet Further information If you need help getting to your appointment please contact your GP surgery so they can arrange hospital transportation for you. If you would like further information please contact the non-invasive cardiology department on 023 8120 6404. Alternatively you can visit our website at www.uhs.nhs.uk and search for ‘non-invasive cardiology’. If you need a translation of this document, an interpreter or a version in large print, Braille or on audio tape, please telephone 023 8120 4688 for help. © 2019 University Hospital Southampton NHS Foundation Trust. All rights reserved. Not to be reproduced in whole or in part without the permission of the copyright holder. Version 1. Reviewed May 2019. Due for review May 2022. 1093 www.uhs.nhs.uk
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/Media/UHS-website-2019/Patientinformation/Heartandlungs/Autonomic-function-test-1093-PIL.pdf

Your child's exome sequencing test - patient information

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A guide to your child's exome sequencing test
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/Media/UHS-website-2019/Patientinformation/Childhealth/Your-childs-exome-sequencing-test-2439-PIL.pdf

Reintroduction of lightly cooked egg - patient information

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This factsheet will explain how to safely reintroduce lightly cooked egg back into your child's diet at home.
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/Media/UHS-website-2019/Patientinformation/Childhealth/Reintroduction-of-lightly-cooked-egg-2426-PIL.pdf

Managing food allergies - patient information

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This factsheet contains advice to help your child be prepared, stay safe and live well with food allergies.
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/Media/UHS-website-2019/Patientinformation/Childhealth/Managing-food-allergies-2428-PIL.pdf

Introducing peanut into your baby's diet - patient information

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This factsheet explains how to introduce peanut into your baby's diet, some peanut recipes to try at home and what to do if your baby has a reaction to peanut.
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/Media/UHS-website-2019/Patientinformation/Childhealth/Introducing-peanut-into-your-babys-diet-2696-PIL.pdf

Choosing where to have your baby - patient information

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Choosing where to have your baby Contents Introduction 3 Home birth 4 Birth centres 7 New Forest Birth Centre 8 Broadlands Birth Centre 9 Transfer to the Princess Anne labour ward 10 Availability of pain relief 12 Princess Anne labour ward (obstetrician led unit) 13 Care after you have had your baby 14 Helpful contacts and sources of information 15 Choosing where to have your baby 3 Introduction As giving birth in the United Kingdom is generally considered very safe for both women and their babies, the Department of Health prefer women to choose where they wish to give birth. Every woman’s experience of labour and birth is unique. When deciding where to have your baby you will want to choose the most appropriate place for you. Your decision will be an individual one based on your wishes, cultural preferences and any medical needs you or your baby may have. It will also depend upon whether or not this is your first experience of labour and birth or if you have had a baby before. It is important to discuss your previous birth experiences with your midwife when you are making your decisions. As a centre of excellence for maternity care, University Hospital Southampton NHS Foundation Trust is able to offer a choice of birthplace options, including: The aim of this booklet is to help you make an informed decision about where to have your baby. Choosing to give birth in an environment where you feel relaxed and in control may not only make a difference to your labour but has also been shown to influence your emotional wellbeing after the birth of your baby. However, your choice of birthplace will also influence the type of care you receive, your options for pain relief and your access to medical assistance if complications arise. If you have previously had a straight forward pregnancy and birth and both you and your baby have been well during this pregnancy, recent nationwide research (2011) recommends giving birth in a midwifery-led birth centre or at home. It is important to make your decisions in partnership with your birth partner and midwife, and where appropriate your obstetric consultant. Your midwife and consultant will be happy to answer any questions you may have. • Home • Midwifery-led birth centre: - New Forest Birth Centre in Ashurst - Broadlands Birth Centre within the Princess Anne Hospital • Labour ward (obstetrician-led delivery suite) within the Princess Anne Hospital The safety of you and your baby remains a priority and therefore some birthplace options may not be appropriate for you, depending on your individual circumstances. If this applies to you and you would like to explore other options, you may wish to discuss your preferred birth-plan with a consultant midwife. Your midwife will arrange this for you. Choosing where to have your baby 3 Home birth If you have had a straightforward pregnancy and both you and your baby are well, you might choose to give birth at home. In England, around one in every 50 babies (2%) is born at home, and while this figure varies according to location, it is reflected locally (1.3% in 2011). The advantages of giving birth at home include: • Being in familiar surroundings where you may feel more relaxed. • Not needing to interrupt your labour to go into hospital. • Likelihood of complications occurring. • Likelihood of transfer to the Princess Anne labour ward – please refer to page ten. Likelihood of complications occurring Research comparing the well-being of mothers and babies by place of birth is limited. However, a nationwide study published in 2011 showed that while a planned home birth is generally safe for healthy women having a normal pregnancy, there are differences between women who have laboured and had a baby before and women for whom it is their first experience of labour and birth. • Not needing to leave your other children. Whether or not they are present during your labour and birth is a matter of personal preference. • Significantly reduced likelihood of requiring an instrumental (forceps or ventouse) or operative delivery (caesarean section). The need for intervention such as augmentation (breaking your waters or the use of a drip to speed up your contractions), epidural, or episiotomy is also less likely and therefore you are more likely to have a normal birth. • Individual support by a midwife who will be with you while you are in labour and a second midwife who will be asked to attend the birth of your baby. There are some things you should think about if you are considering a home birth, these include: • If you are at increased risk of complications either at the beginning of your pregnancy, as your pregnancy progresses or during labour you may be advised against giving birth at home. For healthy women having a second or subsequent baby, home birth appears to be safe for babies and offers benefits to both mothers and babies. There are no differences in the well-being of babies between births planned at home or in a midwifery unit compared with planned births in an obstetric unit. For healthy women with a healthy pregnancy expecting their first baby, national statistics show the likelihood of a significant concern with baby arising is higher for a birth planned at home (9.3 per 1000) when compared with a birth planned in a birth centre or an obstetric unit (5.3 per 1000). The health benefits for you as a mother and the increased likelihood of success with breastfeeding associated with a home birth remain the same. It is important that you are aware of this if you are expecting your first baby, as you may wish to discuss this in further detail with your midwife. It is for this reason that a transfer from home to the Princess Anne labour ward is also more common amongst firsttime mothers. • Availability of pain relief – please refer to the availability chart on page 12. 4 Choosing where to have your baby Transfer to the Princess Anne labour ward Midwives are able to quickly detect the onset of problems and if you or your baby needs emergency treatment you will be transferred in an ambulance to the obstetrician-led labour ward at the Princess Anne Hospital for specialist care. If you are planning a homebirth you should be aware of the procedures and reasons for transfer in advance. These are discussed in further detail on page ten, where a comparison with transfer from our birth centres is provided. Making preparations just in case, such as packing an overnight bag and planning child and pet care will make this transition smoother if it is necessary. Planning a home birth You should talk to your midwife throughout your pregnancy about how suitable home birth is for you and your baby, to allow you both plenty of time to ensure appropriate plans are in place. Your midwife will also arrange to see you at home for your 36 week antenatal appointment, to discuss your birth plan and answer any questions you may have. Arrangements will be made for the delivery of a birth box at 37 weeks. This will contain basic birth equipment, in preparation for when your labour begins. Choosing where to have your baby 5 6 Choosing where to have your baby Birth centres Birth centres aim to offer a homely environment with a focus on normal birth. Midwives will care for you during your labour and birth, which is why birth centres are also known as midwifery units. Birth centres are not equipped to perform medical interventions and are therefore only suitable for women with a healthy pregnancy who are expecting to have a straightforward birth. which has benefits for you and your baby, should you wish to do so. Nationwide research (Birthplace Choices 2011) has shown that births in birth centres are as safe for babies as births planned in an obstetric unit. The higher number of normal births and the significant reduction in interventions are also advantages which you should consider. University Hospital Southampton NHS Foundation Trust offers a choice of two birth centres: • New Forest Birth Centre (freestanding) in Ashurst • Broadlands Birth Centre (alongside) within the Princess Anne Hospital There are many advantages associated with choosing to have your baby in one of our birth centres, many of which are similar to choosing to have your baby at home. These include: • Being in surroundings where you may feel more relaxed and more in control of your labour. • Reduced likelihood of using pain relief for labour. • Reduced likelihood of having a drip to speed up your contractions or requiring interventions such as forceps or ventouse. • Increased likelihood of beginning breastfeeding, If you have any questions about these findings, it is important you discuss them with your midwife or the midwives at the New Forest Birth Centre when you arrange your tour. There are several points for you to consider when choosing a birth centre as they differ according to their location. This booklet describes the facilities available and explains the differences between the two locations, to enable you to make an informed decision. It is important to discuss your preference with your midwife. You can access a virtual tour of both Broadlands and the New Forest Birth Centre on our website at www.uhs.nhs.uk/maternitytour. You may also wish to contact the New Forest Birth Centre on 023 8074 7690 if you have any questions or if you would like to arrange a walk-around tour. Choosing where to have your baby 7 New Forest Birth Centre The New Forest Birth Centre is situated in Ashurst on the edge of the New Forest. It offers a safe, relaxed environment for the birth of your baby, with midwives present 24 hours a day so you can have one to one support during your labour. This is a free-standing birth centre and even though it is in a community hospital it does not offer the same facilities as the Princess Anne Hospital. For example there are no obstetric doctors, anaesthetists, special baby units or operating theatres nearby. You do not need to live locally to use the New Forest Birth Centre, it is only six miles from the Princess Anne and very accessible. The centre opened in 2008 and has two bright spacious birthing rooms with modern furnishings. They are fully equipped with: • Birth pools • En-suite facilities • Music and adjustable lighting • Comfortable birthing aids such as balls and mats, as you will be encouraged to remain active during your labour • Refreshment facilities for you and your partner • Views of the garden and New Forest. There are several points to consider if you are planning to give birth at the New Forest Birth Centre. If you are planning to have your baby at the New Forest Birth Centre it is essential that you are aware of the reasons why transfer to the Princess Anne labour ward might be recommended and the arrangements in place should this become necessary. You should also be aware of how likely this is to occur and the implications for you and your baby. Please refer to page ten of this booklet, for more information and a direct comparison with transfer from home or Broadlands Birth Centre. Staying at the New Forest Birth Centre, after you have had your baby You may choose to return home after you have had your baby or you may wish to stay and receive postnatal support from our team of midwives and maternity support workers. Please refer to your copy of the maternity services guide for further information about the postnatal facilities available. 8 Choosing where to have your baby Broadlands Birth Centre Broadlands Birth Centre is suitable for women wishing to have a natural birth in a home-like atmosphere. It is a midwife-led unit, with midwives taking primary responsibility for your care during labour and birth. Choosing to birth here is only recommended if you have had a straightforward pregnancy, without concerns about your wellbeing or that of your baby. It is important to eat and drink while you are in labour, so you have enough energy. Please bring snacks and drinks with you. You can help yourself to tea, coffee and cold water and food will be ordered for you at meal times. Your birth partners need to eat and drink too. Partners can make a small donation for their tea and coffee but they might like to bring in snacks. Based within the Princess Anne Hospital, Broadlands Birth Centre is defined as an ‘alongside midwifery unit’ or a ‘colocated birth centre’ because obstetric, anaesthetic and neonatal services are available within the same building should they be required. Broadlands is on E level – one floor above labour ward. The door to the birth centre is locked for security reasons. You will need to press a door buzzer to inform midwives of your arrival. Broadlands Birth Centre has four birthing rooms, two of which have ensuite facilities. These rooms are equipped with comfortable birthing aids such as balls, beanbags, special chairs and stools and provide a relaxed environment for you and your partner. In addition, there are two spacious pool rooms equipped with adjustable lighting that can be used during labour and/or birth. If you are planning to have your baby on Broadlands it is essential you are aware of the reasons why transfer to labour ward might be recommended and the arrangements in place should this become necessary. You should also be aware of how likely this is to occur and the implications for you and your baby. Please refer to page ten of this booklet, for more information and a direct comparison with transfer from home or the New Forest Birth Centre. Staying on Broadlands after you have your baby You may wish to stay for additional support after you have had your baby, or go home directly from one of our birthing rooms. If you have any questions about the facilities available after you have had your baby please refer to your copy of the maternity services guide or discuss them with your midwife. Choosing where to have your baby 9 Transfer to the Princess Anne labour ward from your chosen place of birth Reasons for transfer Choosing to have your baby at home or in one of our birth centres is only recommended if you and your baby remain healthy throughout pregnancy and labour. Transfer to labour ward may be recommended if your labour is not progressing as well as it should, or if there are concerns about the wellbeing of you or your baby. The reasons for your midwife recommending transfer to the labour ward are the same irrespective of where you choose to give birth. The urgency with which transfer is required will be dependent on the reason for transfer. While the majority of transfers take place during labour, situations can also arise after the birth of your baby where transfer becomes necessary. Your midwife will be able to discuss the likelihood of this occurring with you. Likelihood of transfer If you are planning to have your baby at home or in one of our birth centres it is essential you are aware of how likely you are to transfer to the Princess Anne labour ward. Requests for further pain relief were identified as one of the main reasons for transfer in Southampton, a reason which was not reflected nationally. This may be because: Recent national research has shown that a substantial proportion of women planning to have their first baby at home or in a birth centre are transferred to an obstetric unit, either during labour or immediately after their baby is born. However, the likelihood of this occurring varies according to where they originally planned to give birth. The table presenting these statistics allows you to make direct comparisons, however, when reading this table there are several points you should consider. • Transfer is relatively convenient, particularly from Broadlands Birth Centre, where the number of women choosing to transfer for additional pain relief is significantly higher. • If you plan to use an epidural or remifentanil and you are otherwise healthy with a straightforward pregnancy, you will be advised to begin your labour care in Broadlands Birth Centre and transfer to labour ward when use of epidural or remifentanil becomes appropriate. The number of women choosing to have their baby outside an obstetric setting is considerably higher within the Southampton area (33%) when compared to the national average (7%). 10 Choosing where to have your baby Transfer from planned place of birth Figures for 2011 Chosen place of birth Home New Forest Birth Centre Broadlands Birth Centre National statistics across the United Kingdom Local statistics Southampton and the surrounding area National statistics across the United Kingdom Local statistics Southampton and the surrounding area National statistics across the United Kingdom Local statistics Southampton and the surrounding area Number of women 88% having a normal birth in their chosen location 81% 83% 100 out of 124 81% 77% 368 out of 455 63% 1012 out of 1612 Women expecting their first baby 33% 7 out of 21 67% 144 out of 216 43% 368 out of 854 Women expecting second or subsequent babies Number of women transferring, either during labour or immediately after birth 21% 90% 93 out of 103 25% 31 out of 124 22% 94% 224 out of 239 27% 26% 124 out of 455 85% 644 out of 758 41% 667 out of 1612 Women expecting their 45% first baby 71% 15 out of 21 36 % 43% 40% 93 out of 216 61% 524 out of 854 Women expecting second 12% or subsequent babies 16% 9% 16 out of 103 13% 13% 31 out of 239 18% 143 out of 758 Arrangements for transfer If you are transferring from home or the New Forest Birth Centre arrangements for your transfer may include an urgent ambulance or your own transport depending on your reasons for transfer. Your midwife will also go to the Princess Anne to continue your care. The time taken to transfer you to the Princess Anne can vary. This usually depends on the reason for transferring you and it is important to remember emergency situations are unusual for women who are healthy and who have had an uncomplicated pregnancy. It is not possible to give an average time for transfers from home, as this varies depending upon where you live. The total time taken from calling an ambulance at the New Forest Birth Centre to arriving at the Princess Anne Hospital is 30 minutes on average, but may be quicker. As Broadlands is located within the Princess Anne, the time taken to transfer to labour ward is significantly shorter than if you were at home, or at the New Forest Birth Centre. Transfer is downstairs to the obstetricianled labour ward on D level, either in a wheelchair or on a bed. The time taken to transfer you to labour ward can vary depending on why you are being transferred. However, in an emergency situation, your transfer takes approximately five minutes. When considering these transfer times, it is important you are aware of the care midwives provide during labour and in emergency situations. Midwives are fully equipped to facilitate basic maternal and neonatal life support and ensure transfer remains a well managed situation. However, the resources available to your midwife at home will differ from those available within the birth centres. You should discuss these differences with your midwife, before finalising your decision about where to give birth. Choosing where to have your baby 11 Availability of pain relief Most women use a variety of methods to help them cope with pain during labour. You should discuss the advantages and disadvantages of the methods available with your midwife before you are in labour, so you are able to make an informed decision about what might be right for you. We also recommend attending an antenatal course, as this will provide you with the opportunity to ask any questions you may have. Home New Forest Birth Centre Comfortable Requires you to make Available birthing aids your own hire or Beanbags, birthing balls purchase arrangements. Broadlands Birth Centre Available Labour ward Available TENS machine Irrespective of where you choose to have your baby, you will need to make your own hire or purchase arrangements before your labour begins as TENS machines are not available to borrow from our maternity services. Your midwife will be able to provide you with information about different suppliers. Your midwife will also be able to advise you on how to use your TENS machine, should you wish to use one, and will support you with its use. Birthing pool Requires you to make Two pools are available your own hire or purchase arrangements. Gas and air (Entonox) Available Available Two pools are available Available One pool* Available Pethidine Available** Available** Available** Available** Remifentanil Epidural Necessitates a transfer to the Princess Anne labour ward Necessitates a transfer to the Princess Anne labour ward Necessitates a transfer to the Princess Anne labour ward Necessitates a transfer to the Princess Anne labour ward Necessitates a transfer to labour ward Necessitates a transfer to labour ward Available*** Available*** *This pool is available for use by women wishing to use pools on Broadlands if both pools are in use, or for women on labour ward where use of water has been agreed by either an obstetric consultant or consultant midwife. If you think this may apply to you please discuss your plans with your midwife. ***Availability is dependent on anaesthetist availability at the time of request; please discuss this with your midwife. You will be advised to begin your labour care in one of our birth centres and transfer to labour ward when remifentanil or an epidural becomes appropriate for you. **Please discuss availability with your midwife, before you go into labour 12 Choosing where to have your baby Princess Anne labour ward (obstetrician-led unit) Princess Anne Hospital is a regional centre for maternal and fetal medicine, providing multispeciality, consultant-led care for women who have, or who develop, medical problems during their pregnancy or labour. For these women, birthing in an environment with direct access to obstetricians, anaesthetists (who administer epidurals and general anaesthetic) and neonatologists (specialists in newborn care) is recommended. • A recovery area for women who have had a Caesarean section. • A high dependency unit with specially trained midwives available to care for women who are unwell and need extra care and monitoring, either before or after having their baby. The neonatal unit and operating theatre are on the same floor allowing rapid transfer if necessary. If your baby requires extra care at birth, the Princess Anne has one of the largest regional neonatal units in the country, providing specialist care to term and preterm babies, in a spacious and welcoming environment. Facilities available on labour ward include: • 13 birth rooms and one birth pool – these rooms are equipped with comfortable birthing aids such as birthing balls, as well as additional equipment for monitoring the wellbeing of you and your baby. You should therefore be prepared for a less homely and more clinical appearance. The advantages of giving birth in an obstetric unit include: • On site access to emergency support including obstetric, anaesthetic and neonatal services. You won’t need to transfer if there are problems. • Access to other specialist services, such as epidurals and remifentanil for pain relief. If you choose to give birth in the labour ward an obstetrician will take primary responsibility for your care but you will still be looked after by a midwife during your labour. • A four-bed induction of labour suite – if inducing your labour is recommended you will be asked to come to the induction of labour suite on labour ward at a given time on your arranged day. You will be advised to remain active and walk around the hospital to help get your labour started. Once in labour you may be able to move to your chosen place of birth. This will depend on the reason for induction and you are advised to refer to the induction of labour information sheet and to discuss this with your midwife. You will still have choices about the care you receive and will be encouraged to participate in any necessary decision making processes. It is therefore essential that you discuss with your midwife the possible reasons for inducing or augmenting (starting or speeding up) your labour, the advantages and disadvantages of different forms of pain relief and the reasons for recommending continuous monitoring of your baby’s heartbeat, so you are able to make informed decisions. Choosing where to have your baby 13 Your care after your baby is born (postnatal care) The wellbeing of you and your baby will determine the length of time you stay at the Princess Anne Hospital or at the New Forest Birth Centre. with your midwife (and if appropriate your obstetric team) at booking and throughout your pregnancy. This will ensure you have all the information you need and that your decision is well thought through. Please refer to your copy of the maternity services guide for further details about visiting hours and all other aspects of your postnatal care, as the facilities available vary according to your chosen birth location. It is advisable to read this before your baby is born as this will allow you the opportunity to discuss any questions you may have with your midwife. Decisions about your postnatal care do not need to be made before you have your baby, as your plans may change. However, you may wish to discuss your options with your midwife at your 36 week antenatal appointment. Making your choice It is important to remember that your midwife and obstetrician work together in partnership, so you can make well-informed decisions about the choices available. You should therefore discuss your options When thinking about your own health and circumstances you should also consider the support available to you from your partner, family and friends both during labour and after you have had your baby, as this may also influence the decisions you make. You may also choose to read other relevant information, if you have not already done so and book yourself a place on our course of antenatal classes. This is done via maternity information services and support office at the Princess Anne and your midwife will be able to give you a booking form. Remember, immediate decisions are not necessary, as factors influencing your decision may change as your pregnancy progresses and you may still wish to change your mind after your labour has begun. If you choose to write a birth plan, you should discuss this with your midwife at your 36 week antenatal appointment. 14 Choosing where to have your baby Helpful contacts and sources of information Active Birth www.activebirthcentre.com Association of Improvements to the Maternity services (AIMS) 0870 651433 www.aims.org.uk Birth Choices UK www.birthchoiceuk.com Breastfeeding Babes Room 22 Broadlands Birth centre Open Monday – Friday 10am – 1pm No appointment necessary. 07786 267584 Home Birth Support Group www.homebirth.org.uk Princess Anne midwifery community office West and Central midwifery teams: 023 8079 8513 South, East & Southern parishes teams: 023 8079 5205 Administrator (Mon to Fri, 9am to 4pm): 023 8079 4871 These numbers are for non-urgent messages only. Royal College of Midwives Rcmnormalbirth.org.uk Southampton area homebirth Southampton: Clare sotonhomebirth@nct.org.uk 023 8040 3821 Romsey: Barbara Barbara4c@yahoo.com Email group: http://groups.yahoo.com/group/ HomebirthSotArea Midirs informed choice booklets www.midirs.org National Childbirth Trust (NCT) 0870 4448707 www.nctpregnancyandbabycare.com Supervisors of midwives Southampton 023 8079 6021 Portsmouth 023 9228 6000 ext. 3649 Vaginal Birth after Caesarean Section (VBAC) www.vbac.com The ‘Pregnancy Book’ A complete guide to pregnancy, labour and birth. Visit the Department of Health website to download your copy. www.dh.gov.uk/publications Choosing where to have your baby 15 University Hospital Southampton NHS Foundation Trust birth centres Broadlands Birth Centre Princess Anne Hospital Coxford Road Southampton Tel: 023 8079 6337 New Forest Birth Centre Ashurst Hospital Lyndhurst Road Ashurst Southampton SO40 7AR Tel: 023 8074 7690 Labour Ward Tel: 023 8079 6002 If you need a translation of this document, an interpreter or a version in large print, Braille or on audio tape, please telephone 023 8079 4688 for help. www.uhs.nhs.uk Version 1, published March 2013, due for review March 2016. MAT016.01
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/Media/UHS-website-2019/Patientinformation/Pregnancyandbirth/Choosingwheretohaveyourbaby.pdf

Breast lipomodelling - patient information

Description
This factsheet explains what breast lipomodelling is, what the procedure involves and what the potential risks are.
Url
/Media/UHS-website-2019/Patientinformation/Womenshealth/Breast-lipomodelling-patient-information.pdf

Charging overseas visitors

Description
The NHS is a free healthcare system. Whether or not a person is eligible to benefit from this is based upon their residency in the UK.
Url
/HealthProfessionals/Clinical-law-updates/Charging-overseas-visitors.aspx

Ibrutinib

Description
Chemotherapy Protocol Chronic Lymphocytic Leukaemia Regimen Ibrutinib • CLL – Ibrutinib Indication • NICE TA 429 recommends ibrutinib alone within its marketing authorisation as an option for treating chronic lymphocytic leukaemia in adults who have had at least one prior therapy or who have a 17p deletion or TP53 mutation, and in whom chemoimmunotherapy is unsuitable and only when the company provides ibrutinib with the discount agreed in the patient access scheme. • Performance status 0, 1, 2 Toxicity Drug Ibrutinib Adverse Effect Diarrhoea, musculoskeletal pain, upper respiratory tract infection, bruising, rash, nausea, pyrexia, neutropenia, thrombocytopenia, constipation, atrial fibrillation, ventricular tachycardia, hypertension, onycholclasis The adverse effects listed are not exhaustive. Please refer to the relevant Summary of Product Characteristics for full details. Monitoring • FBC, U&Es and LFTs prior to starting treatment and then every twenty-eight days for the first twelve weeks of treatment. Thereafter if counts are stable monitoring may take place every twelve weeks. • Hepatitis B status prior to starting treatment as re-activation is a known adverse effect of treatment Dose Modifications The dose modifications listed are for haematological, liver and renal function and drug specific toxicities only. Dose adjustments may be necessary for other toxicities as well. Please discuss all dose reductions / delays with the relevant consultant before prescribing, if appropriate. The approach may be different depending on the clinical circumstances. Haematological Dose modifications for haematological toxicity in the table below are for general guidance only. Always refer to the responsible consultant as any dose reductions or delays will be dependent on clinical circumstances and treatment intent. Consider blood transfusion or the use of erythropoietin according to NICE TA323 if the patient is symptomatic of anaemia or where the haemoglobin is less than 8g/dL. Version 1.3 (Oct 2019) Page 1 of 5 CLL-Ibrutinib Dose delay if neutrophils are less than 1x109/L with infection or fever or the neutrophils are less than 0.5x109/L or the platelets are less than 30x109/L. Restart treatment once the toxicity has resolved to grade 1 using the dosing table below. Toxicity Occurrence First Second Third Fourth Dose modification after recovery restart at 420 mg once a day restart at 280 mg once a day restart at 140 mg once a day discontinue Hepatic Impairment Ibrutinib is metabolized in the liver. When using ibrutinib in patients with mild or moderate hepatic impairment, monitor patients for signs of toxicity and follow dose modification guidance as needed. Liver Function Child Pugh A (mild hepatic impairment) Child Pugh B (moderate hepatic impairment) Child Pugh C (severe hepatic impairment) Ibrutinib Dose Modifications 280mg once a day 140mg once a day Not recommended Renal Impairment No dose adjustments are required for patients with a creatinine clearance of more than 30ml/minute. There are no data in patients with a creatinine clearance of less than 30ml/min or patients on dialysis. In this latter instance prescribed ibrutinib only if the benefit outweighs the risk, monitor patients carefully for signs of toxicity. Regimen 28 day cycle until disease progression or intolerance (12 cycles will be set in Aria) Drug Ibrutinib Dose 420mg Days 1- 28 (inclusive) Administration Oral Dose Information • Ibrutinib is available as 140mg, 280mg and 420mg tablets. • The dose will be rounded to the nearest 140mg (up if halfway). Administration Information • Ibrutinib tablets should be swallowed whole with water at approximately the same time each day. Version 1.3 (Oct 2019) Page 2 of 5 CLL-Ibrutinib Additional Therapy • Anti-infective prophylaxis with - co-trimoxazole 960mg once day on Monday, Wednesday and Friday oral Additional Information • The National Patient Safety Alert on oral chemotherapy (NPSA/2008/RRR001) must be followed in relation to ibrutinib. • It must be made clear to all staff, including those in the community, that ibrutinib is should only be prescribed under the supervision of a consultant haematologist or oncologist. • There are many drug interactions associated with ibrutinib. Caution is advised when concurrently prescribing agents that affect coagulation or platelet function or that influence the hepatic enzyme system CYP3A4. • Ibrutinib should be withheld at least 3 to 7 days pre- and post-surgery, depending upon the type of surgery and the risk of bleeding. • Grapefruit and grapefruit juice, and Seville oranges, should be avoided while on ibrutinib Coding • Procurement – X • Delivery – X References 1. Byrd JC, Furman RR, Coutre SE et al. Three year follow up of treatment naïve and previously treated patients with CLL receiving single agent ibrutinib. Blood 2015; 125 (16): 2497-2506. Version 1.3 (Oct 2019) Page 3 of 5 CLL-Ibrutinib REGIMEN SUMMARY Ibrutinib Cycle 1 onwards Day 1-28 inclusive 1. Ibrutinib 420mg once a day oral Administration Information Oral Chemotherapy Ibrutinib tablets should be swallowed whole with water at approximately the same time each day. Avoid grapefruit and grapefruit juice, and Seville oranges while on ibrutinib. Always check for drug interactions. 2. Co-trimoxazole 960mg once a day on Monday, Wednesday and Friday oral Administration Instructions Co-trimoxazole 960mg once a day on Mondays, Wednesdays and Fridays. Please supply 28 days. This may be dispensed as 480mg twice a day on Mondays, Wednesdays and Fridays according to local practice. Version 1.3 (Oct 2019) Page 4 of 5 CLL-Ibrutinib DOCUMENT CONTROL Version Date Amendment Written By Approved By 1.3 October Ibrutinib capsules changed to 2019 tablets Nanda Basker Pharmacist 1.2 February 2018 Co-trimoxazole added Dr Deborah Wright Pharmacist Ventricular tachycardia added 1.1 September to adverse effects 2017 Hepatitis B status added to Dr Deborah Wright Pharmacist monitoring 1 February 2017 None Dr Deborah Wright Pharmacist Dr Deborah Wright Pharmacist Rebecca Wills Pharmacist Rebecca Wills Pharmacist Dr Helen Dignam Consultant Haematologist This chemotherapy protocol has been developed as part of the chemotherapy electronic prescribing project. This was and remains a collaborative project that originated from the former CSCCN. These documents have been approved on behalf of the following Trusts; Hampshire Hospitals NHS Foundation Trust NHS Isle of Wight Portsmouth Hospitals NHS Trust Salisbury NHS Foundation Trust University Hospital Southampton NHS Foundation Trust Western Sussex Hospitals NHS Foundation Trust All actions have been taken to ensure these protocols are correct. However, no responsibility can be taken for errors that occur as a result of following these guidelines. Version 1.3 (Oct 2019) Page 5 of 5 CLL-Ibrutinib
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/Media/UHS-website-2019/Docs/Chemotherapy-SOPs1/CLL/Ibrutinib.pdf
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