A new classification for caesarean section was developed in a two-part study conducted at six hospitals. Initially, 90 anaesthetists and obstetricians graded ten clinical scenarios according to five different classification methods--visual analogue scale; suitable anaesthetic technique; maximum time to delivery; clinical definitions; and a 1-5 rating scale. Clinical definitions was the most consistent and useful, and this method was then applied prospectively to 407 caesarean sections at the same six hospitals. There was close agreement (86%) between anaesthetists and obstetricians for the five-point scale (weighted kappa 0.89), increasing to 90% if two categories were combined (weighted kappa 0.91). We suggest that the resultant four-grade classification system--(i) immediate threat to life of woman or fetus; (ii) maternal or fetal compromise which is not immediately life-threatening; (iii) needing early delivery but no maternal or fetal compromise; (iv) at a time to suit the patient and maternity team--should be adopted by multidisciplinary groups with an interest in maternity data collection.

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Daily measurement of CRP is useful for monitoring the course of microbiologically-proven sepsis in ICU patients, and may be used to indicate successful treatment.

SummaryThere has been little published work defining 'normal' thromboelastography (TEG Ò ) values in healthy parturients, and few large studies defining reference ranges for traditional coagulation tests in this patient group. Our aim was to establish peri-operative reference ranges for TEG and for standard laboratory coagulation tests in our pregnant population. Fifty healthy term parturients presenting for elective caesarean section under spinal anaesthesia had blood samples taken pre-operatively, on arrival in the recovery room and, in a subset of 33 women, 4 h after routine thromboprophylaxis with enoxaparin 40 mg. All three samples had TEG analysis, the first and second having standard laboratory coagulation tests in addition. Reference ranges for our pregnant population were established, demonstrating a hypercoagulable state in term parturients and a significant effect of enoxaparin. The standard coagulation reference ranges were within 98% of the local non-pregnant ranges. These reference ranges provide a useful comparator for peri-operative TEG and routine coagulation analysis in term parturients. Accepted: 26 January 2012The recent decline in direct maternal deaths in the UK has been attributed largely to reductions in deaths due to thromboembolism, and, to a lesser extent, haemorrhage [1]. With increased awareness and more widespread use of thromboprophylaxis, and the ever-present risk of maternal haemorrhage, greater importance is being placed on the assessment of coagulation status and blood product replacement during the peripartum period.Thromboelastography (TEG Ò ) is a relatively new near-patient monitor of coagulation in UK labour wards, although its use in cardiac and liver surgery is long-standing [2,3]. The TEG evaluates the mechanical strength of clot during its formation, via the torsion in a pin suspended in an oscillating heated cup that contains the blood sample [4], leading to a graphical output (Fig. 1). Compared with traditional laboratory coagulation tests, the TEG takes into account the dynamic interaction of plasma (clotting factors) and cellular (platelets) elements that occurs during in vivo clotting, thus indicating overall 'clot quality.' Test protocols can

SummaryWe conducted a prospective double-blind randomised trial to compare bupivacaine 0.5%; a 50 : 50 mixture of bupivacaine 0.5%/lignocaine 2% with 1 : 200 000 adrenaline (final concentration); and lignocaine 2% with 1 : 200 000 adrenaline for converting a low-dose labour epidural into a block adequate for emergency Caesarean section. Ninety patients were studied, 30 in each group. There was no difference between the groups in the time taken for bilateral loss of cold sensation to reach T 4 . Onset time was unaffected by the existing sensory level pre-Caesarean section top-up; the number of low-dose top-ups in labour; the total dose of bupivacaine in labour; or maternal weight or height. Three patients in the lignocaine with adrenaline group had blocks that reached the cervical dermatomes and three in the same group required general anaesthesia for inadequate anaesthesia, compared with none in the other groups (both p ¼ 0.04).