Raising the standard... to unachievable heights?*

Abstract

We read with interest Noblet and Platt’s [1] audit findings and points raised regarding pain relief after caesarean section. We would like to share our experience with a study carried out in our unit between September and November 2008 where we audited our performance against the National Institute for Health and Clinical Excellence (NICE) recommendations for caesarean section [2]. We measured analgesic efficacy using a target visual analogue score (VAS) of < 3 on a 0–10 cm visual analogue scale for pain on movement, as proposed in ‘Raising the Standard’ [3]. Our audit (n = 113) showed that we only managed to achieve overall VAS pain scores of < 3 in 62% of patients at 6–8 h, 72% at 24 h and 88% at 48 h respectively. When we considered the group of patients who received diamorphine either epidurally or intrathecally (as per NICE recommendations), we achieved slightly better VAS scores of < 3 in 75% at 6–8 h, 76% at 24 h and 94% at 48 h respectively. Over 95% of our patients received additional regular non-steroidals and paracetamol. Our audit results thus show that even when diamorphine and optimal additional analgesia were employed, we only managed to achieve the recommended target at 48 h. Despite not achieving the target, 99% of our subjects reported that they were ‘satisfied’ or ‘very satisfied’ with the pain relief offered. We agree with Noblet and Platt that the target for 90% of patients achieving a VAS score of < 3 (out of maximum of 10) is probably unrealistic; however, we would contend that a target score of < 3 (out of maximum of 4) is far too high. We consider that 75% of patients having scores of < 3 (out of 10) is achievable. Women not meeting this target should be reviewed and alternative analgesia considered.