just before the caesarean section. As the cervix was still 9 cm, a caesarean delivery was performed as planned. What are the delivery options available for a deeply impacted head at caesarean section? The options lie between using the push method or the pull method. The push method involves pushing the baby’s head up vaginally, as in this case. The assistant places herself between the patient’s legs and applies pressure with the fingers to push the presenting part upwards, while the operating obstetrician tries to deliver the head from the abdominal end. Telling the assistant how to push effectively from the vagina is important. In a deflexed OP position, this pushing should encourage flexion of the head; if applied wrongly, the baby’s head would become more deflexed, impacting behind the pubic symphysis, making delivery abdominally more difficult. If a difficult caesarean delivery with a possible impacted head is anticipated, the woman could be placed in a ‘frog’ position (Landesman and Graber 1984), rather like the modified lithotomy position for a colposuspension, before the commencement of the operation. This position makes it easier for the assistant to get in between the woman’s legs to push the baby’s head up. This position also enables the obstetrician to release the impacted fetal head vaginally himself with a bimanual technique without an assistant (Lippert 1983). In the bimanual technique, the obstetrician himself delivers the baby’s head with one hand in the uterus to avoid further deflexion and the other hand in the vagina to press the head up. This ‘bimanual’ abdomino-vaginal method of extracting an impacted baby’s head at caesarean section allows more control by the obstetrician, ensuring that vaginal pushing is directed in the correct direction, allowing the controlled release of the baby’s head from the pelvis to the uterine incision. The other method described to extract a baby with a deeply impacted head is the pull method (Fong and Arulkumaran 1997). In this technique, the obstetrician grasps the baby’s feet, performs a semi-version and delivers the baby by breech extraction. To provide extra room for the manoeuvres, extending the uterine incision with a J or T extension might be required. However, the manoeuvre can be performed on most occasions without extending the uterine incisions. A randomised controlled trial (Fasubaa et al. 2002) and a case-control study (Levy et al. 2005) has been performed to evaluate the push and the pull method. Both studies found statistically significant higher rates of maternal morbidity (blood loss, extension of uterine incision, infection) in the push method. In addition, the fetal morbidities (Apgar scores, neonatal admission rate) were worse in the push group (Fasubaa et al. 2002). Perhaps in this case, the pull method of extraction could have been considered. Predicting the long-term outcome for this baby from the CT scan findings and EEG is difficult. Paediatric follow-up is essential. In summary, neonatal skull fractures could occur after difficulties in extracting a deeply impacted fetal head at caesarean section. Observing the baby closely after such deliveries is important. The pull method of extracting a deeply impacted fetal head at caesarean section is an important technique worth considering in reducing maternal and fetal morbidities.

The UK Department of Health established the Healthcare-associated Infection (HAI) Surveillance Steering Group in 2000 to develop a strategy for implementing a national programme for HAI surveillance in National Health Service trusts. A subgroup of this committee examined the surveillance of surgical site infections following orthopaedic surgery. This group oversaw a pilot scheme that was set up in 12 hospitals around the UK to explore the feasibility of implementing a system of surveillance that engaged clinical staff in its operation, provided a process for continuous data collection and could be maintained as part of routine hospital operation over time. A minimum data set was established by the subgroup, and Centers for Disease Control and Prevention (CDC) definitions of infection were used. By March 2003, the surveillance had been undertaken continuously in 11 sites for one to two years, depending on the date of implementation. Only one hospital had ceased data collection. The information was collected mainly by clinical staff, with support and co-ordination usually provided by infection control teams. Data on more than 5400 procedures were available for analysis for four core procedures: arthroplasty of the hip and knee; hemi-arthroplasty of the hip; and internal fixation of trochanteric fractures of the femur. The data set permitted the calculation of risk-adjusted rates, allowing comparisons between hospitals and within a hospital over time. The methodology enhanced clinical ownership of the surveillance process, re-inforced infection control as the responsibility of all staff, and provided timely feedback and local data analysis. The use of CDC definitions permitted international comparisons of the data.

Transmission of vero-cytotoxin-producing Escherichia coli O157 (O157 VTEC) is usually food-borne, particularly from undercooked beef or raw milk, or person-to-person. 1 Advisory Committee on the Microbiological Safety of FoodReport on Vero cytotoxin-producing Escherichia coli. ACMSF, London1995 Google Scholar Direct or indirect contact with various farmed or companion animals has also resulted in human infection. 2 Renwick SA Wilson JB Clarke RC et al. Evidence of direct transmission of Escherichia coli O157:H7 infection between calves and a human. J Infect Dis. 1993; 168: 792-793 Crossref PubMed Scopus (84) Google Scholar , 3 Parry SM Salmon RL Willshaw GA et al. Haemorrhagic colitis in child after visit to farm visitor centre. Lancet. 1995; 346: 572 PubMed Scopus (33) Google Scholar , 4 Shukla R Slack R George A Cheasty T Rowe B Scutter J Escherichia coli O157 infection associated with a farm visitor centre. Commun Dis Rep. 1995; 5: R86-R90 Google Scholar