86 discharge. Due to the concerns about prescribing codeine to mothers who breastfeed, we now prescribe dihydrocodeine for supplemental analgesia or as regular alternative analgesia for those women who cannot take NSAIDS.5,6 For women who require it, dihydrocodeine can be dispensed directly from the postnatal ward unlike alternative analgesics such as tramadol, which require hospital pharmacy dispensing thereby delaying discharge. It had been our regular practice to prescribe diclofenac 50 mg 8-hourly as our NSAID of choice for postnatal analgesia on the ward and this led some women to perceive the change to ibuprofen at home as step-down analgesia and to be therefore suboptimal. We now prescribe 6-hourly ibuprofen 400 mg in addition to regular paracetamol, as this dose is equipotent to diclofenac and provides consistency for the women following discharge.7 To ensure that we have a consistent practice for postnatal analgesia, we have produced a guideline and flowchart to be used by all obstetric anaesthetists and obstetricians in our hospital. We hope our experience and our patient survey findings may be helpful to other hospitals as they develop ERPs and improve the uptake of early discharge following caesarean section. T. Christmas, J. Bamber Department of Anaesthesia Cambridge University Hospitals NHS Foundation Trust Cambridge, UK E-mail address: Tracey.Christmas@ Addenbrookes.nhs.uk C. Patient Department of Obstetrics Cambridge University Hospitals NHS Foundation Trust Cambridge, UK

References 1. Aluri S, Wrench IJ. Enhanced recovery from obstetric surgery: a UK survey of practice. Int J Obstet Anesth 2014;23:157–60. 2. Lucas DN, Gough KL. Enhanced recovery in obstetrics – a new frontier? Int J Obstet Anesth 2013;22:92–5. 3. The Rosie Hospital. Pregnancy, labour and birth: going home. http://www.cuh.org.uk/rosie-hospital/pregnancy-labour-and-birth/ going-home [accessed July 2014]. 4. Pain relief during pregnancy and after birth. Patient information leaflet. Cambridge University Hospitals NHS Foundation Trust. http://www.cuh.org.uk/sites/default/files/publications/PIN3545_ pain_relief_during_pregancy_and_after_%20birth_v1.pdf [accessed July 2014]. 5. MHRA. Codeine for analgesia; restricted use in children because of reports of morphine toxicity. Drug Saf Update 2013. http:// www.mhra.gov.uk/Safetyinformation/DrugSafetyUpdate/CON29 6400 [accessed July 2014]. 6. Palanisamy A, Bailey CR. Codeine in mothers and children: where are we now? Anaesthesia 2014;69:655–9.

International Journal of Obstetric Anesthesia 7. Collins SL, Moore RA, McQuay HJ, Wiffen PJ. Oral ibuprofen and diclofenac in post-operative pain: a quantitative systematic review. Eur J Pain 1998;2:285–91. 0959-289X/$ - see front matter

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http://dx.doi.org/10.1016/j.ijoa.2014.08.003

Routine cell salvage during elective caesarean section: a pilot randomised trial Whilst there may be an argument for using intraoperative cell salvage (IOCS) during caesarean sections in which significant blood loss is expected, there is little evidence to support its routine use.1 There are no data about differences in effectiveness between elective and emergency procedures in terms of blood loss, clinical measures, outcomes important to the mother and cost. A high-quality randomised controlled trial is needed to address these questions. We have conducted a pilot study in a single site that addresses feasibility of recruitment and randomisation of women, the data collection process itself, and provides limited data on the primary outcome measure for the substantive trial. Women undergoing elective caesarean section were considered eligible to participate unless they were known or suspected to have placenta accreta, bleeding disorders, sickle cell disease, malignancy, significant thrombocytopenia, significant antibodies rendering cross-matching of blood difficult or held beliefs that precluded blood transfusion. Participants were randomised via a central randomisation service to a standard caesarean section without IOCS, or IOCS deployed from the beginning of the procedure. Preparation, anaesthesia and monitoring conformed with standard practice, using either spinal or general anaesthesia. For women allocated to IOCS, before delivery standard suction apparatus was used to reduce the volume of amniotic fluid taken into the cell salvage machine (Cell Saver 5+, Haemonetics, Braintree, USA). The default processing settings on the cell salvage machine were used. Once enough blood had been suctioned to allow processing and washing, the machine automatically started processing and any blood salvaged was returned to the patient. No swab washing was performed. Women randomised to standard treatment could receive IOCS if clinically indicated. Any decision to transfuse allogeneic blood was a joint decision between the anaesthetist and obstetrician and irrespective of allocation group. Postoperatively, transfusion criteria were at the discretion of the local care team, but usually transfusion was indicated if the haemoglobin was