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• W2989135170 abstract "Editor—I read with great interest the article by Butwick and colleagues1Butwick AJ Coleman L Cohen SE Riley ET Carvalho B Minimum effective bolus dose of oxytocin during elective Caesarean delivery.Br J Anaesth. 2010; 104: 338-343doi:10.1093/bja/aeq004Abstract Full Text Full Text PDF PubMed Scopus (106) Google Scholar regarding the determination of the lowest effective bolus dose of oxytocin to achieve adequate uterine tone during elective Caesarean section. The authors state that exteriorization of the uterus was performed at the discretion of the obstetrician and that subsequent uterine massage was performed. It is not clear however whether exteriorization was routinely performed or whether the uterine massage occurred on some occasions with the uterus having not been exteriorized. If exteriorization rates varied between the groups involved then this could potentially be a confounding factor affecting oxytocin delivery to the uterus and the obstetricians’ ability to both perform uterine massage and assess uterine tone adequately. Varying rates of uterine exteriorization (UE) and potential differences in the quality of uterine massage could explain the differences between the observed levels of uterine tone between the groups. The authors accept that the uterine massage technique was not standardized in this study and that the combination of uterine massage and prophylactic oxytocin are important in the management of uterine tone. They go on to suggest in their discussion that the routine use of 5 units of oxytocin during elective Caesarean delivery (CS) can no longer be recommended, as adequate uterine tone can occur with lower bolus doses of oxytocin. However, they fail to clarify in their final recommendation that this tone is due to the combination of exteriorization and uterine massage combined with the lower oxytocin doses. There is a significant difference in the rates of hypotension between the 0 and 5 units of oxytocin groups, however presumably no significant difference between the other groups (although the P-values are not given). This in combination with no significant reduction in other endpoints such as nausea and vomiting combined with the increased rates of rescue doses of oxytocin required in the lower dosing groups mean that a reduction in dose of oxytocin seems without strong evidence. In addition, UE has been linked with both increased nausea and vomiting2Nafisi S Influence of uterine exteriorization versus in situ repair on post-Cesarean maternal pain: a randomized trial.Int J Obstet Anesth. 2007; 16: 135-138doi:10.1016/j.ijoa.2006.10.009Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar and visceral pain on day 1 and 2 post-delivery,3Siddiqui M Goldszmidt E Fallah S Kingdom J Windrim R Carvalho JC Complications of exteriorized compared with in situ uterine repair at cesarean delivery under spinal anesthesia: a randomized controlled trial.Obstet Gynecol. 2007; 110 (17766602): 570-575Crossref PubMed Scopus (38) Google Scholar and these symptoms should be considered if considering routine UE and massage. Furthermore, if this combination of exteriorization, uterine massage and a reduced oxytocin dose is to be recommended, it should be with the proviso of anaesthesia by spinal anaesthesia (the method specified in this trial) rather than epidural anaesthesia (as performed for some elective deliveries). The depth of block during epidural anaesthesia is in my experience not usually adequate to allow for exteriorization and massage with the guarantee of lack of maternal visceral symptoms. Editor—We wish to thank Dr Breeze for his interest in our study,1Butwick AJ Coleman L Cohen SE Riley ET Carvalho B Minimum effective bolus dose of oxytocin during elective Caesarean delivery.Br J Anaesth. 2010; 104: 338-343doi:10.1093/bja/aeq004Abstract Full Text Full Text PDF PubMed Scopus (106) Google Scholar and we appreciate the opportunity to respond to his comments. The prevalence of hypotension in study groups was displayed in Figure 3, and we confirm that statistically significant differences between groups were found only between groups receiving 0 vs 5 units of oxytocin. We acknowledge that our study was not powered to investigate oxytocin side-effects between groups. However, our findings support those of previous studies (referenced in our study) that have shown important cardiovascular side-effects with doses of 5 units. As stated in our study, uterine massage was performed in all patients, and the use of UE was designed to reflect common surgical practice in North America for patients undergoing CS. The proportion of patients in each group who received UE were as follows: 0/15 (0%), 2/15 (13%), 1/14 (7%), 2/15 (13%), and 0/15 (0%) for patients receiving 0, 0.5, 1, 3, and 5 units of oxytocin, respectively. We found no statistically significant differences in UE between groups (P>0.05, Fisher’s exact tests). To our knowledge, no previous studies have assessed the potential impact of UE on attaining adequate uterine tone during CS, and it is likely that surgical practices vary between institutions. However, results from previous studies comparing UE vs in situ repair (including a Cochrane review) suggest that perioperative blood loss and postoperative haemoglobin values are similar for both techniques.3Siddiqui M Goldszmidt E Fallah S Kingdom J Windrim R Carvalho JC Complications of exteriorized compared with in situ uterine repair at cesarean delivery under spinal anesthesia: a randomized controlled trial.Obstet Gynecol. 2007; 110 (17766602): 570-575Crossref PubMed Scopus (38) Google Scholar, 4Jacobs-Jokhan D Hofmeyr G Extra-abdominal versus intra-abdominal repair of the uterine incision at caesarean section.Cochrane Database Syst Rev. 2004; (15494988): CD000085PubMed Google Scholar, 5Coutinho IC Ramos de Amorim MM Katz L Bandeira de Ferraz AA Uterine exteriorization compared with in situ repair at cesarean delivery: a randomized controlled trial.Obstet Gynecol. 2008; 111 (18310366): 639-647Crossref PubMed Scopus (39) Google Scholar We wish to emphasize that in our study, the prevalence of adequate uterine tone with low doses of oxytocin and with placebo at 2 min was high (73–100%). Our findings support those of Carvalho and colleagues6Carvalho JC Balki M Kingdom J Windrim R Oxytocin requirements at elective cesarean delivery: a dose-finding study.Obstet Gynecol. 2004; 104 (15516392): 1005-1010Crossref PubMed Scopus (186) Google Scholar who reported an ED90 oxytocin (0.35 units) in patients undergoing elective CS without UE. Although we provided secondary outcome data for uterine tone assessment after 2 min, our study was primarily designed to investigate oxytocin dosing for achieving adequate uterine tone at 2 min after delivery (as opposed to an investigation of oxytocin dosing for maintaining adequate uterine tone after initial oxytocin injection). Clinical practice in the UK suggests that oxytocin is commonly given as a 5 unit bolus, with 20% of clinicians using an additional oxytocin infusion for the maintenance of adequate uterine tone.7Wedisinghe L Macleod M Murphy DJ Use of oxytocin to prevent haemorrhage at caesarean section—a survey of practice in the United Kingdom.Eur J Obstet Gynecol Reprod Biol. 2008; 137: 27-30doi:10.1016/j.ejogrb.2007.04.007Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar As the half-life of oxytocin is short, further work is needed to better investigate the use of oxytocin infusions for the maintenance of adequate uterine tone. We note that a recent study has reported that the ED90 for oxytocin as an infusion for elective CS is 0.29 units min−1.8George RB McKeen D Chaplin AC McLeod L Up-down determination of the ED(90) of oxytocin infusions for the prevention of postpartum uterine atony in parturients undergoing Cesarean delivery.Can J Anaesth. 2010; ([Epub ahead of print])PubMed Google Scholar The studies assessing intraoperative pain, nausea, and vomiting related to UE referenced by Dr Breeze need careful interpretation. One compared post-Caesarean pain outcomes in patients receiving UE or intra-abdominal repair during CS.2Nafisi S Influence of uterine exteriorization versus in situ repair on post-Cesarean maternal pain: a randomized trial.Int J Obstet Anesth. 2007; 16: 135-138doi:10.1016/j.ijoa.2006.10.009Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar However, there was no standardization of anaesthetic technique (patients received general anaesthesia or neuraxial anaesthesia), and the study included patients undergoing elective and non-elective CS which limits data interpretation. The other study observed increased nausea and vomiting and non-significant increases in intraoperative pain with UE compared with in situ uterine repair; however, sample sizes were small in this study.3Siddiqui M Goldszmidt E Fallah S Kingdom J Windrim R Carvalho JC Complications of exteriorized compared with in situ uterine repair at cesarean delivery under spinal anesthesia: a randomized controlled trial.Obstet Gynecol. 2007; 110 (17766602): 570-575Crossref PubMed Scopus (38) Google Scholar Postoperative pain assessments on days 1 and 2 were not assessed in this study. In contrast, Coutinho and colleagues observed no differences in intraoperative nausea and vomiting during CS with UE and included relevant commentary on the potential benefits, as well as disadvantages, of UE on surgical outcomes.5Coutinho IC Ramos de Amorim MM Katz L Bandeira de Ferraz AA Uterine exteriorization compared with in situ repair at cesarean delivery: a randomized controlled trial.Obstet Gynecol. 2008; 111 (18310366): 639-647Crossref PubMed Scopus (39) Google Scholar Although the further work is needed to evaluate surgical outcomes in patients receiving UE during elective CS, we strongly disagree with Dr Breeze’s opinion on the use of spinal anaesthesia (instead of epidural anaesthesia) for patients receiving ‘reduced doses’ of oxytocin, uterine massage, and UE during CS. There is no evidence to justify a change from epidural to spinal anaesthesia if intraoperative UE and uterine massage is anticipated, irrespective of oxytocin dosing during CS. The prevention of intraoperative breakthrough pain during CS is dependent on achieving adequate surgical anaesthesia, which can be achieved with successful activation of a labour epidural. Early recognition of inadequate labour analgesia and careful block assessment of surgical anaesthesia have been shown to be important factors in reducing the incidence of failed conversion of epidural labour analgesia to anaesthesia for CS.9Halpern SH Soliman A Yee J Angle P Ioscovich A Conversion of epidural labour analgesia to anaesthesia for Caesarean section: a prospective study of the incidence and determinants of failure.Br J Anaesth. 2009; 102: 240-243doi:10.1093/bja/aen352Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar We believe that our study adds to the increasing body of evidence that smaller doses of oxytocin promote adequate uterine tone after delivery, minimize side-effects, and should be utilized for elective CS. None declared. Butwick A. J.* Carvalho B. Stanford, USA * E-mail: [email protected]" @default.
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