Write short notes on three of the following

a)	External cephalic version (ECV).
b)	Use of obstetric vacuum cup for delivery.
c)	Amniocentesis.
d)	Puerperal pyrexia.

a)	External cephalic version is an operation in which the presentation of a breech fetus is artificially altered to the cephalic position. It is usually done between the 34th and 36th week of pregnancy and have a 80% success rate of correcting the breech.

Before attempting ECV, it is important to assess the patient for any contraindications and to prepare for any possible complications that can arise.

Contraindications to ECV:

1.	Placenta praevia.
2.	Oligo- or polyhydramnios.
3.	History of antepartum haemorrhage.
4.	Previous Caesarean or myomectomy scar on the uterus.
5.	Multiple gestation.
6.	Pre-eclampsia or hypertension.
7.	Plan to deliver by LSCS anyway.

Risks of ECV:

1.	Placental abruption.
2.	Premature rupture of the membranes.
3.	Cord accident.
4.	Transplacental haemorrhage.
5.	Fetal bradycardia.

ECV is performed in the labor ward:

1.	Maternal pulse and BP is recorded.
2.	CTG is performed for 30 minutes.
3.	Confirm presentation of the fetus, location of the placenta, and AFI by ultrasound.
4.	If breech, CTG normal and AFI > 5cm. IV terbutaline 0.25mg in 10ml saline given slowly over 2 – 5 min whilst checking maternal pulse rate.
5.	ECV performed 5 minutes after the terbutaline injection.

Procedure:

1.	Mother lying flat on the bed is placed in the lateral position. Hips and knees may be slightly flexed.
2.	Manipulation is done in a gentle manner without use of force.
3.	First the breech is dislodged from the maternal pelvis and displaced to the opposite iliac fossa to that quadrant towards where the head is to be flexed.
4.	With steady pressure the fetus is flexed and the transverse axis of the uterus is negotiated.
5.	Fetal acoustic stimulation is used when the fetus is almost in the transverse lie of the uterus to facilitate fetal movements enabling version to cephalic presentation.
6.	If resistance occur, further trial of ECV is abandoned.
7.	Monitor FHR and check for PV.
8.	CTG for 30 – 40 minutes after procedure.
9.	Careful evaluation of the mother and fetus before discharge.
10.	Anti-D should be offered to all Rhesus negative discharge.

b)	The vacuum cup or ventouse cup consists of a central traction chain and a separate vacuum cup. It is indicated when there is prolonged second stage, fetal or maternal distress and malposition – to rotate OT to OP position. It cannot be used for preterm delivery, affirming head in breech delivery and LSCS. 

Dilatation of the cervix and full engagement of the head should occur before the procedure. The delivery should be completed within 15 minutes of application. The head, not just the scalp, should descend with each pull. The cup should be reapplied no more than twice. If failure with the ventouse occurs despite good traction, the forceps should not be tried as well. 

Pre-requisites

A: Adequate analgesia and Aseptic techniques.
B: Bowel and Bladder should be empty.
C: Cephalic presentation.
D: Dilatation of os.
E: Episiotomy and Engaged head. 

Procedure:

1.	The vacuum extractor cup is gently inserted into the vagina with one hand whilst the other hand parts the labia.
2.	The pressure is taken to 0.8 kg/cm2, beginning traction with the next contraction after this pressure has been achieved.
3.	Traction should be along the pelvic axis (downwards at 45 degrees) for the duration of the contraction.
4.	One hand should rest on the bell of the cup whilst the other applies traction.

Complications

With good technique and adherence to guidelines the risk of complications to mother or baby are small. Trauma to the genital tract is the commonest maternal complication. Unrecognized injury of the cervix leading to serious hemorrhage has been reported. Most babies will have a chignon (edematous skin bump) at the site of the cup application. Some will also have a cephalhaematoma. Rare serious intracranial injuries will be more likely to occur if multiple attempts at delivery are made. 

c)	Amniocentesis is a minimally invasive procedure used for antenatal fetal surveillance. A thin needle is passed transabdominally under ultrasound guidance into the amniotic cavity. A small amount of amniotic fluid is removed, which contains fetal fibroblasts. This test is usually performed at or after 15 weeks’ gestation.

Diagnostic indications:

1.	Hemolytic disease: spectrophotometric anaylsis of bilirubin concentration in amniotic fluid due to Rhesus immunzation.
2.	Maturity of fetal lungs: measurement of lecithin / sphingomyelin ratio.
3.	Detection of fetal abnormalities: 
-	Chromosomal studies: most important group is those at risk of having Down’s.
-	Chemical studies: neural tube defects and inborn disorders of metabolism. 

Therapeutic indications:

1.	Relieves severe and acute polyhydramnios.
2.	Intrauterine fetal transfusion for hemolytic disease.
3.	Intra-abdominal injection of hypertonic saline or PG for termination of pregnancy. 

Complications:

1.	1% risk of miscarriage.
2.	Abruptio placentae or damage to fetal vessels on surface of placenta leading to fetal death in utero.
3.	Needle may pierce some part of the fetus.

d)	Puerpural pyrexia is defined as a rise of temperature to 38C within 14 days of delivery. 

It is caused by:

1.	Urinary tract infection.
2.	Genital tract infection.
3.	Wound infection.
4.	Breast engorgement and infection.
5.	Respiratory infection.
6.	DVT and thrombophlebitis.

Predisposing factors are:

1.	LSCS.
2.	Prolonged labor.
3.	Artificial rupture of membranes.
4.	Chorioamnionitis.
5.	Instrumentation.
6.	Urinary retention.
7.	Trauma to bladder.

Clinical features:

1.	Fever.
2.	Tachycardia.
3.	Headache and backache.
4.	Tenderness of uterus and adnexae.
5.	Mass next to uterus or vagina.
6.	Profuse foul-smelling lochia.
7.	Spread to parametrium and pelvic peritoneum, causing paralytic ileus.

Treatment:

1.	General and symptomatic:
-	Nursing.
-	Analgesia.
-	Sedatives.
-	Adequate hydration.

2.	Specific antibiotic therapy: empirical before results of culture – ampicillin + aminoglycoside / cephalosporin.