J.Noblet and F. Plaat[1] have raised an interesting point about the unachievable standard suggested by the Royal College of Anaesthetists (RCoA) [2] for analgesia after caesarean section. At Leicester General Hospital, a unit of 4500 deliveries per annum, over the last six years we have annually audited our performance against this standard. Our findings have consistently been similar to the audit results from Hammersmith Hospital.

The standard suggesting that following caesarean section> 90% of women should score their worst pain at <3 on a VAS 0-10 has never been achieved on our unit. On average, over the six year period only 18%of women (Range 6%-34%) had a worst pain score of <3.

In contrast, patients’ satisfaction with their analgesia has been consistently high. An average of 93% (range 83-96%) of patients were satisfied or very satisfied over the same period, against the RCoA standard of>90%. Acting on these audit results, in an effort to achieve the ‘holygrail’ of >90% of patients with a VAS<3, we have modified and improved our analgesic regime. Over the years we have tried and audited various combinations of :

·   Regular and prn co-codomol either 8/500 or 30/500

·   Regular diclofenac either PR or oral

·   Regular paracetamol and Dihydrocodeine as required

·   Oral morphine 3 hourly, then 2 hourly as required

·   Epidural diamorphine at the end of the procedure

·   A second dose of epidural diamorphine 8 hours later if

  necessary

·   Intrathecal diamorphine

This has proved to be a Sisyphean task, as our efforts to optimise our regime have not achieved the results demanded by the RCoA standards, and our interventions have not resulted in any improvements on the pain scores recorded. Nevertheless, patient satisfaction scores have remained high.

We agree with J.Noblet and F.Plaat that the time has come to reconsider the standard set for the pain relief after caesarean section, and to reformulate the proposed standards.

M Chauhan, E Hart, N Hickman

Leicester UK

Email:mamta.chauhan@uhl-tr.nhs.uk

 References

1.  Noblet J, Plaat F. Raising the Standard…to unachievable heights? (letter). Anaesthesia 2010;65:88.

2.  Pickering E, Holdcroft A Pain relief after Caesarean section. In: Kinsella M, ed.  Raising the Standard: A Compendium of Audit Recipes, 2nd edn. London: Royal College of Anaesthetists, 2006: 168-9.