Objective To compare the influence on caesarean section morbidity of uterine exteriorisation or in Design Randomised controlled trial.Setting Princess Anne Maternity Unit of the Royal Bolton Hospital, UK. Population One hundred and ninety-four women undergoing delivery by caesarean section.Methods Two intra-operative readings of arterial pulse rate, mean arterial blood pressure, and arterial haemoglobin oxygen saturation were obtained. Pre-operative and day-3 haemoglobin concentrations were determined. Intra-and post-operative complications, puerperal pain scores, and febrile and infectious morbidity were assessed. A postal questionnaire was used to assess morbidity six weeks after delivery.Main outcome measures Intra-operative changes in pulse rate, mean arterial blood pressure and oxygen saturarion; peri-operative changes in haemoglobin concentration; incidence of intraoperative vomiting, pain, intra-and post-operative complications, and febrile and infectious morbidity; immediate and late puerperal pain scores; satisfaction with the operation. ResultsNo clinically significant differences between uterine exteriorisation and in situ repair were found in pulse rate, mean arterial pressure, oxygen saturation and haemoglobin changes. Likewise, the incidence of vomiting and pain was similar. Vomiting occurred in 10% of all the women, and 57% of all pain complaints occurred at the initial skin incision. There was a trend towards higher immediate and late pain scores in the exteriorisation group, reaching statistical significance on day 3. Overall, pain scores averaged 6/10 on day 1 despite patient-controlled analgesia, and three-quarters of all women reported persisting pain on day 42. Intra-and postoperative complications, febrile and infectious morbidity, and duration of hospital stay were similar in both groups. ConclusionsWe have demonstrated that uterine exteriorisation and in situ repair have similar effects on peri-operative caesarean section morbidity. Intra-operative pain reflected adequacy of anaesthesia, while vomiting reflected adequacy of pre-operative preparation of patients.Exteriorising the uterus at caesarean section is a valid option.situ repair.

A prospective randomised study is reported comparing a single peribulbar injection into the medial compartment of the orbit and the standard two injection peribulbar technique. One hundred and seven patients undergoing elective intra -ocular surgery were randomly allocated to receive either a single medial injection, or two injections, using prilocaine 3 Qh with .felypressin. Akinesia and pain during surgery were assessed following the injection(s). There was no signijcant dijierence in pain during surgery and globe akinesia between the two groups. The single medial peribulbar injection is as effective as two injections using prilocaine 3%.

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We present the case of a pelvic fracture in a 69-year-old man with Child–Pugh class C cirrhosis who presented to the Accident and Emergency department after a slip on wet grass. After initially being systemically well, he became haemodynamically unstable in the Emergency department requiring resuscitation via the massive transfusion pathway. He was admitted to intensive care unit for resuscitation following a CT angiogram which showed no arterial bleed, but significant retroperitoneal haematoma. He received a prophylactic embolization of the internal iliac artery 2 days later and his acetabular fracture was managed with skeletal traction. He died 7 weeks later as a result of his liver failure. We propose that a high index of suspicion would have led to an earlier diagnosis of his venous bleed and earlier transfusion.

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