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Re: Utility of the bladder flap at cesarean delivery: a randomized controlled trial.

To the Editor: We applaud Viney et al for their attempt to evaluate possible ill effects of a common practice during cesarean delivery: intra-abdominal irrigation.1 The investigators conclude that irrigation increases intraoperative nausea without decreasing postoperative infectious morbidity. These results may influence future guidelines. It is therefore imperative that the intervention in question be well defined. We would like to point to variables that question the homogeneity of the intervention. Firstly, the temperature of the irrigation fluid is described as “warm to touch,” a barely replicable condition. Secondly, a varying volume of “500 –1,000 mL” adds to the inconsistency of the intervention. Thirdly, the technique of irrigation is not well detailed. Was peritoneal traction used if placing the fluid higher up in the cavity? Because the authors theorize that the increased nausea is attributable to peritoneal irritation, it becomes important to rule out excessive handling of the peritoneum as a contributing factor. Fourth, what was the position of the patient (degree of Trendelenburg, if any) during irrigation? Finally, was the irrigation fluid suctioned or left in the abdominal cavity? Theoretically, this might influence the secondary outcomes of postoperative gastrointestinal disturbance and maternal infectious morbidity. Although we concur that this study “followed the same design as two previously published studies,” we are afraid there are not sufficient details of the intervention to allow replication of the trial as laid out in the CONSORT (Consolidated Standards of Reporting Trials) 2010 statement.2 One weakness cited by the authors is the variable thresholds of anesthesia providers to inquire about nausea. Yet, the primary outcome was “any unsolicited patient report of nausea, any emesis, or receipt of any antiemetic.” Although a differing threshold to administer an antiemetic may be unavoidable, an inconsistent solicitation of nausea symptoms jeopardizes the very methodology that the investigators laid out in their study design.