We would like to thank Toozs-Hobson and colleagues for their interest in our work.
Toozs-Hobson et al. appear to have drawn different conclusions to that represented by the data. In particular there is no significant increase in the duration of operation or length of post-operative stay if the uterus is exteriorised and their assertion that there are trends in this direction are not substantiated by our data.
They mention the interesting aspect of the apparent increase in blood loss when an epidural compared to a spinal anaesthetic is used. The choice of anaesthetic was not part of the original hypothesis which focused on exteriorisation of the uterus. Data derived concerning the anaesthetic technique is therefore of questionable validity with respect to the blood loss associated with the operation. In addition one must consider that the majority of the women with epidural anaesthesia also had caesarean sections in labour and the majority of women with spinal anaesthesia had caesarean sections before the onset of labour. If the comparison of spinal and epidural anaesthesia is to be tested rigorously it should be the main outcome of a separate study.
Toozs-Hobson et al. also assert that the two women who underwent general anaesthesia militates against the recommendation of exteriorisation. This finding was also not statistically significant. One woman had her regional anaesthetic changed to general anaesthesia prior to delivery of her baby; this change was not associated with exteriorisation of the uterus.
Blood loss at caesarean section is extremely difficult to assess and we feel that our technique of pre- and post-operative haemoglobin estimations, taken at standard times, gives a representative indication of intra-operative blood loss.
We stand by our conclusions that exteriorisation of the uterus should be recommended as the method of choice for trainee surgeons.