and seven platelet concentrates were administered. Cyklokapron, Sulprostone, Methergine and Eptacog alpha were also administered. After packing of the uterus with gauzes, the fascia was closed and the patient was transferred to the intensive care unit. At the intensive care unit, haemolysis occurred as a result of the transfusion of uncrossmatched blood and DIC, antibiotics were given and hypotensive periods were treated with noradrenaline. Computed tomography did not show any cerebral, pulmonary or abdominal abnormalities. The patient received hydrocortisone because amniotic fluid embolism was the most likely diagnosis. Thirty-six hours after PMCS, DIC resolved and the gauzes were removed by relaparotomy. Extubation followed 24 hours later. The symptoms of a paralytic ileus recovered after the administration of erythromycin in combination with a stomach tube and parenteral feeding.Following transfer to the maternity ward an uneventful recovery was seen within a few days. The patient started to remember the day of the induction of labour, became able to perform daily activities and started taking care of her daughter. Two weeks after PMCS, both mother and daughter were discharged without any neurological or other abnormalities. j Sir, Although the study by Attilakos et al. 1 suggests some benefit of carbetocin versus oxytocin, this has to be interpreted with great caution. First, because of the cost of carbetocin (20 times that of oxytocin) a superiority trial is preferable with an a priori delineated range of clinical benefits. Also, the comparison intervention in this trial is not used in current clinical practice because doses of oxytocin given after caesarean section are much higher than in this trial.Second, the use of a surrogate outcome (need for additional pharmacological oxytocics) is questionable because this is a subjective intervention. A sample size calculation based on a clinical significant reduction in blood transfusion would have been a better primary outcome measure. Postpartum haemorrhage is too rare to be the primary outcome measure.The results of this trial do not recommend the use of carbetocin and larger randomised controlled trials with a better methodology are needed before this expensive pharmacological agent should be used in common clinical practice. As the rate of caesarean sections is rising worldwide, the unnecessary use of carbetocin could have major financial repercussions on healthcare systems worldwide. j Authors' ReplySir, We would like to thank Dr Page 1 for his interesting comments regarding our paper, 2 which seem to corroborate our findings. He is correct in saying that we did not 'recommend' the use of carbetocin; rather we provided a balanced overview of the potential benefits and disadvantages (including cost) of carbetocin based on our study and the current evidence. The comparison intervention in our trial (5 iu oxytocin) is not only the licensed dose of the drug, but also the dose recommended in the UK national guideline. As Dr Page 1 suggests, additional doses of o...

For the time being, routine indwelling catheterisation of the bladder for caesarean section remains recommended Sir, Li and Wen's systematic review doesn't show evidence of no effect, but only that there is no evidence of the effect of the placement of an indwelling catheter for caesarean section. 1As stated by the authors, the review lacks power to demonstrate any difference in important clinical outcomes between the catheterised versus the non-catheterised group. Urinary tract infection is a common but clinically less important outcome compared with possible serious perioperative complications, such as postpartum haemorrhage.Besides the methodological limitations of this review (recognised by the authors), the lack of data from clinically important outcomes undermines the rash conclusion that the routine use of indwelling urinary catheters for caesarean delivery patients is not necessary, and is even harmful. The non-randomised controlled trial included mentions that 6.7% of cases of postpartum uterine atony lead to haemorrhage! 2 As stated by the authors, only 0.1% of obstetricians do not use urethral catheterisation, and obstetricians should continue to use (brief) catheterisation until there is evidence that catheterisation doesn't improve important outcomes, even at the cost of more urinary tract infections. There is evidence that catheterisation for no longer than 12 hours doesn't significantly increase the rate of urinary tract infections. As caesarean section is a frequently used intervention worldwide, even small differences for clinically important outcomes are worthy of study by methodologically sound randomised controlled trials, investigating the correct, important clinical questions. j For the time being, routine indwelling catheterisation of the bladder for caesarean section remains recommended Authors' ReplySir, We wish to thank Page et al. 1 for their comments on our paper.2 As they stated, serious perioperative complications such as postpartum haemorrhage are more critical than urinary tract infection (UTI). However, the main disadvantage of catheterisation is that it increases the risk of UTI. Catheterisation of the bladder for caesarean section is to prevent bladder injury, intraoperative difficulties and postoperative urinary retention. So the primary outcomes of our paper were UTI, postpartum urinary retention, intraoperative difficulties and operative complications. Our study found that not using an indwelling urinary catheter in caesarean section was associated with less UTI and no increase in either urinary retention or intraoperative difficulties, based on current available evidence.As for one included non-randomised controlled trial that mentioned 6.7% uncatheterised cases of postpartum uterine atony leading to haemorrhage, 3 we failed to confirm whether the non-catheterised group could cause more postpartum haemorrhage because no information 886