Oxytocin bolus versus oxytocin bolus and infusion for control of blood loss at elective caesarean section: double blind, placebo controlled, randomised trial
BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d4661 (Published 01 August 2011) Cite this as: BMJ 2011;343:d4661
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Dear Editor,
In this trial surgeons were told to operate to a standard procedure,
which is ideal, because variations in surgical techniques could influence
results.
Unfortunately, important steps in surgical technique were kept out of
this standardization.
These steps are so vital for reducing blood loss during caesarean
section that I fear the conclusions of this trial have been compromised.
Did they cut the Rectus sheath with scissors or did they just
separate it by finger traction? [3]
Did they cut the Rectus muscles with scissors or did they just
separate them by finger traction? [3]
Was the anterior uterine wall opened with sharp dissection or blunt
dissection as in Misgav Ladach method? [1] [2] [3] [4] [5] [6]
What was the time of complete uterine incision closure? (leaving the
uterus open for too long inhibits contractility, thus resulting in
prolonged bleeding)
This last fact might explain why young Obstetricians in your trial
had less bleeding during their caesareans compared to older, more
experienced colleagues.
Older Obstetricians talk too much, theorize, take their time.
Young Obstetricians just close that uterus!
[1] http://www.ncbi.nlm.nih.gov/pubmed/10422908
Acta Obstet Gynecol Scand. 1999 Aug;78(7):615-21.
The Misgav Ladach method for cesarean section: method description.
Holmgren G, Sj?holm L, Stark M.
Department of Women's and Children's Health, Uppsala University,
Sweden.
[2] http://medind.nic.in/maa/t05/i3/maat05i3p271.pdf
[3] http://medind.nic.in/jaq/t04/i5/jaqt04i5p473g.pdf
[4]
http://apps.who.int/rhl/pregnancy_childbirth/childbirth/caesarean/CD0046...
[5] http://www.ncbi.nlm.nih.gov/pubmed/14601261
J Perinat Med. 2003;31(5):395-8.
The Misgav Ladach method--a step forward in operative technique in
obstetrics.
Fatusi Z, Kurjak A, Jasarevi E, Hafner T.
Clinic for Gynecology and Obstetrics, University Clinical Center,
Tuzla, Bosnia and Herzegovina.
Competing interests: No competing interests
Uterine atony is known to be controlled by uterotonics including
oxytocin in both caesarean and vaginal deliveries. The intra operative
haemorrhage should also, theoretically be less with uterotonics as the
operation is being performed on uterus that consists of smooth muscels
responding to uterotonics (the contracted uterine muscles closing the
arteries and venous sites of the cut muscels in the incision). One line
in the conclusion from the paper is: Our findings support the use of an
additional oxytocin infusion in terms of reducing major obstetric
haemorrhage where the operator is inexperienced and this approach could be
implemented safely and cheaply into current clinical practice(1). My
interpretation is that even in inexperienced hands because of cntraction
of incised muscles of uterus the bleeding is less as arteries and veins
are pressed and blocked.
Reference:
1. Sharon R Sheehan, Alan A Montgomery, Michael Carey, Fionnuala M
McAuliffe, Maeve Eogan, Ronan Gleeson, Michael Geary, Deirdre J Murphy,
and The ECSSIT Study Group. Oxytocin bolus versus oxytocin bolus and
infusion for control of blood loss at elective caesarean section: double
blind, placebo controlled, randomised trial. BMJ 2011 343:d4661;
doi:10.1136/bmj.d4661
Competing interests: No competing interests
Dear Editor,
The overdistension of uterus (as in multiple pregnancies, large baby
and hydramnios)is known to cause uterine atony and hence excessive
bleeding after the delivery (be it Caesarean or vaginal delivery). So
these should have been excluded from the study. Apart from uterine atony
these may have large placentae (in multiple pregnancies and large babies)
which will increase the placental surface that will bleed after seperation
as it would be in fibroids too.
Competing interests: No competing interests
Don't condemn junior doctors just yet!
We read with great interest the publication by Sheehan and colleagues
on Oxytocin regimes for elective Caesarean section(1). The aims of their
study were to compare an oxytocin bolus regimen against an oxytocin bolus
and infusion regime and prospectively analyse a range of outcomes. After
analysis of their two main outcomes, they found no difference in the
frequency of major obstetric haemorrhage between the two protocols but did
find a reduced need for an additional uterotonic agent in the bolus and
infusion group. As an incidental finding they observed that women suffered
major obstetric haemorrhage more frequently when operated on by "junior
doctors" than with consultants; and that the bolus and infusion regime
reduced the likelihood of major obstetric haemorrhage with "junior
doctors". From this observation they went on to recommend that oxytocin
infusion be initiated at all elective caesarean sections performed by
inexperienced operators due to possible lapses in judgment.
These suggestions in our view are not justified by the research
conducted and are incongruous with previously published work. A study of
1319 women by Nielsen and Hokegard showed that operator skill was not a
risk factor for complications during elective caesarean sections(2). These
findings have been supported in a more recent study of 929 women by
Bergholt et al in Denmark. Their results also failed to demonstrate a
difference in intraoperative blood loss when taking into account the
experience level of the surgeon(3).
Sheehan et al have not given details of the level of training of
junior doctors and how this correlates with haemorrhage. However they have
suggested changes to clinical practice based on what might be incidental
results. In addition there is no mention of potential confounding
variables that may account for their observations. For example consultant
obstetricians are often assisted by junior doctors (ST3 - 7 level) who are
able to perform caesarean sections independently and are therefore both
skilled and competent assistants. However junior obstetricians often
conduct caesarean sections with doctors who are surgically naive.
The authors suggest their findings will be more significant to the UK
health system given the number of "inexperienced operators" compared to
Ireland. Such comments if publicised could result in an unprecedented
number of patients demanding consultant supervision for routine, elective
caesarean sections, because of concern of haemorrhage. In addition
suggesting that routine oxytocin infusion be commenced when caesarean
sections are performed by junior doctors might have serious resource
implications.
This study was neither designed to, or actually answers the question of
how the level of clinical experience correlates with intraoperative
complications. We therefore believe the authors should withdraw their
recommendation that junior doctors should commence an oxytocin infusion
when performing caesarean sections, on the basis of a lack of evidence
provided in this study.
References:
1. Sheehan S., Montgomery A., Carey M., McAuliffe F., Eogan M.,
Gleeson R., Geary M. and Murphy D. (2011). Oxytocin bolus versus oxytocin
bolus and infusion for control of blood loss at elective caesarean
section: double blind, placebo controlled, randomised trial. BMJ. 2011;
343: d4661.
2. Nielsen T. and Hokegard K-H. (1984). Cesarean Section and
Intraoperative Surgical Complications. 1984, Vol. 63, No. 2 , Pages 103-
108
3. Bergholt T., Stenderup J., Vedsted-Jakobsen A., Helm P. and
Lenstrup C. (2003). Intraoperative surgical complication during caesarean
section: an observational study of the incidence and risk factors. Acta
Obstet Gynecol Scand 2003: 82: 251--256
Competing interests: No competing interests