We recommend that the normal OSI range should be 0.7-0.9. An OSI of more than 1 seems to be a useful adjunct in estimating blood loss in cases of massive PPH and in predicting the need for blood and blood products.

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Correspondence Peri-operative optimisationThe recent paper (Conway et al. Anaesthesia 2002; 57: 845-9) is a useful addition to the literature on perioperative optimisation. From a review of the literature, we would agree that the unresolved question is whether or not improvement in postoperative outcome can be achieved by fluid therapy alone without the addition of inotropes or Swan Ganz catheters [1]. However, we do have the following concerns.Firstly, according to the result section, the intervention group received a total of 28 ml.kg )1 of colloid compared to the control group with 19.4 ml.kg )1 . This would represent an additional 8.6 ml.kg )1 resulting in approximately three additional fluid challenges. Assuming a normal distribution with a sd of 16 ml.kg )1 , equal to approximately five fluid challenges per operation, this would indicate that 16% of patients received a 'negative fluid challenge', which is clearly impossible. It is therefore likely that the data is not normally distributed, and therefore should have been presented as median with 95% confidence intervals and subjected to non-parametric statistical analysis. A further confusion arises in the discussion section where it is stated that the intervention group received 15 ml.kg )1 of additional colloid, which contradicts the values given in the result section.Our second concern relates to the patients in the control group who required postoperative critical care. Four of these patients had a documented decrease in cardiac output at the end of the operation. It is unclear whether these patients were inadequately volume loaded or, on the contrary, they were receiving excessive amounts of colloids not guided by oesophageal Doppler. It would be useful to know if the results from the Doppler (corrected flow time, aortic velocity waveform, stroke volume) indicated fluid overload or volume depletion. As the control group received 19.4 ml.kg )1 of colloid, this paper could provide some evidence as to whether there is a risk of fluid overload if such relatively large volumes are given without sensitive cardiovascular monitoring. Indeed, answering this question may well be the major contribution of this paper. A replyWe thank Drs Harten, McCreath and Kinsella for their close interest in our paper on peri-operative fluid optimisation. We are happy to address their points in order. The data regarding additional colloid fluids was subjected to parametric testing after simple histogram analysis and the Kolmogorov-Smirnov test suggested to our statistical advisor that the data was normally distributed. We do accept the limitations of such techniques in smaller populations. We therefore have analysed these data using non-parametric tests. The median (interquartile range) colloid volumes for the Doppler and control groups were 23.7 ml.kg )1 (17-33) and 15.6 ml.kg )1 (9.1-25), respectively. The difference between the groups remains statistically significant p ¼ 0.029 using the Mann-Whitney test.In the discussion, we stated the additional colloid given as 15 ml.kg...

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This chapter is based on the current core curriculum of the Royal College of Obstetricians and Gynaecologists training programme. It covers the relevant anaesthesia knowledge criteria in the management of labour and delivery. The chapter provides succinct and important pieces of information on the following: (1) types and methods of action of analgesia and sedation including narcotics, hypnotics, and non-steroidal anti-inflammatory drugs and their indications and contraindications; (2) types and methods of action of regional anaesthesia including epidural, spinal, and pudendal nerve block and their indications and contraindications; (3) complications of anaesthesia and analgesia including cardiac arrest, respiratory arrest, aspiration, and drug reactions; (4) anaesthesia agents—induction, inhalational, and prophylactic measures; and (5) advice on pain relief.

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