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So, um good thing everyone. My name is me and I am a specialist registrant of SG and I'm also the chair of um jobs, the Junior Obstetrics and Gynecology Society. Uh I'm really honored to build upon the initiatives that was started out by my predecessor, uh Doctor Cathy Monte in the introduction of breakout rooms in jobs uh and a side effect meeting last year. And today, I'm very excited to introduce a not new topic to this forum. Um a skill that is now although lost to many trainees of our generation is now experiencing uh a resurgence. So our focus for this session is to teach the Breach workshop program which is dedicated to the vagina bridge delivery in the upright position. This program has been conducted in a number of worldwide Congresses under the leadership of Pro Frank Lewin, who is the president elect of Babcock J. Bought and um bought in Colleges of G and the NFI. He's also the president elect of Figo. And remarkably, for the very first time as well, we are hosting this workshop here in Ireland and I believe it's also the first time that we are having it in such a format as well. So this program is divided into two parts. Today, we're having the first part of it um where we will be establishing the theoretical foundations of vagina bridge delivery in the upright position part two, which will take place um during the meeting itself as part of the breakout room session, um It will offer you a hands on experience um more of a practical exploration of what you have learned today in theory. Now, we've opened this webinar to everyone. Um Recognizing that a lot of you have not had the opportunity to confirm your schedules yet and be able to book your spots. So for those who after this continue to be interested in the hands on experience, please remember to book your slot when you register for the jobs and a scientific meeting. Um Now the availability of the spots are limited. So while the attendance at the meeting itself is complementary for all the trainees uh participating in the breakout room session itself will incur a fee of about €20 per person. Um And should you also find yourself inspired to gain a more practical experience after these two parts with real patients? Uh I highly recommend planning a visit to the Frankfurt Unity Hospital. This hospital is now actively set up as a 1 to 1 exchange experience, something that I was personally part of as well um back in July and that was only possible through drugs uh travel research Bursary. Now, this opportunity is available to all op members including scheme and non scheme trainees as well as young specialists. What is considered as um by op as up to three years postspeciation. So you can check this out on the website up here is the link talk dot eu 1 to 1 exchange and now it great. It's, it's my great pleasure to introduce you to a friend and a colleague. Doctor Ferry B, um who's a past and top president since undergoing the teach the bridge training himself as a trainee. A few years ago, he's now known as the bridge expert in his hospital in Haa Netherlands where his now a junior consultant and is training his colleagues in offering women the option of having vaginal bridge delivery in the upright position. Aside from training his own hospital colleagues, he's also an experienced trainer for the teacher to breach workshops, having conducted workshop trainings in Oslo in Paris Krakow and the nes course. He's also the current uh vice president of the Dutch Bridge Group and where they now have a vagina bridge delivery training for all consultants uh of trainees and midwives. And that has helped treat and currently planning to increase up to four years itself next year. So a little bit um before we move on a little bit about the rules of um this moderation. So his presentation is kind of somewhat divided into three segments and at the end of each segment, we'll have a dedicated uh Q and A session itself. Now, we have a chat box there. You can feel free to use that checkbox and address the question to everyone or you can also direct the question to me if you would prefer to remain anonymous. Um This is your chance to clarify any doubts and enhance your understanding. Please remember there's no such thing as a stupid questions. This is something that we all have not that much. I mean, certainly I asked a lot of questions when I was first introduced to this. Um This is a really rare learning opportunity. So please feel free to ask anything, anything that you think like you, you could just think of basically and Barry is here to answer it all. Like I say, this is a very kind of informal way um of learning as well. So without further ado I'll let Barry then take it from here. Thank you very much me for the uh introduction. Um It's an honor for me to uh present to teach the bridge to Irish trainees. And um if I understood, well, also Irish consultants um as we already uh said, this, uh this is uh hopefully a little bit interactive uh uh talk. So if there's any questions or comments, please uh uh please let us know and I'm also very happy to, to train you hands on next week in Dublin. Um So if there's anything you want to um have more clarified. You can also ask your questions next week, uh like when we meet face to face. So, uh teacher Bre is a, is a project started by the Frankfort Bre at Term group. Um and a couple of the teach to breach trainers and you can see on the screen, um we were trained to teach the breach for the Fal Congress two years ago, which should have taken place in uh in, in uh Australia, but didn't take place in Australia due to COVID but was online. And then we uh started the first teach to breach in six places around the world with an internet connection for the theoretical part and hence on uh part in um uh in six places o over the world. So uh what we're doing today is basically the same. I'm teaching you the theoretical part now and the practical part uh next week, the Fr the Frankfurt bre a term group. No. Yeah, he is trying to survey the impact of the tri uh teach the bridge uh project. Uh So we're asking every one of you to especially those who will have the hands on training next week to fill in the survey, you can uh scan this QR code and fill the survey uh on your mobile phone. Um And whilst you're doing that, I will continue uh with the first part of the lecture. So uh I asked me to share the QR code as well in the, in the chat. So you can uh use the link in the chat as well. So just to get started and everyone knows what happened with Bree, the vaginal breech deliveries in 2001 after publication of the term breech trial, the same happened in Frankfurt. Uh and so, uh vaginal bridge deliveries dropped from one moment to another and increase uh cesarean section rates um for the indication of uh breech deliveries. But fortunately, in Frankfurt, as you can see, they start the, the uh project and uh slowly increase the amount of uh vaginal bre deliveries uh in Frankfurt. Uh Although I have to say that is a little bit biased because uh there's only two, um there's only two hospitals in the uh has a region uh in Germany who is performing vaginal breech deliveries. So people are referred from all over uh the province to Frankfurt uh for a vaginal breech delivery. So the first thing we should um clarify is uh what is pathology and what is uh normalcy or, or what is the no variation of normalcy. So my question I usually ask when we meet face to face is if you see this picture with the leg of the baby hanging out uh is this pathology. And what should you do at this moment? Usually many of the um participants say I would do a Cesarean section at this moment because this is pathology. But if you see what is actually happening in the picture and you see that there's a foot out, there's a part of the leg out and there's even the knee of the baby also out. So that means that the hips of the baby are um expected shortly. They are well uh engaged in the um in the uh pelvis of the mother. So the b this baby will fit and will be able to be born without any intervention. So talking about interventions, if there's an indication for intervention, uh which is necessary to decrease maternal and fetal morbidity and mortality, then that should be called pathology. If a situation resolves spontaneously. Uh and when there's no intervention needed to um to, to decrease fetal and maternal morbidity and mortality, then you can call that a varia variation of normalcy. And I hope that later on you understand that this what you see happening on the picture on the right uh does not need any intervention and it is a variation of normalcy. What is actually causing the pathology is not the breach. It's basically the position of the mother. Here, you see a cephalic birth and as you can see the hands of the um of the doctor or midwife uh have to be used to uh to uh help the baby uh being born. But when you're turning the, the woman upside down, that is not necessary anymore. So in that case, you can speak of variation of normalcy. And the same um thing goes up for the uh for the bridge. As you see here on the left, you see the Brock maneuver being done with a uh on a woman on ins position. And if you see the same textbook from the other side, then there's one big question that you can ask yourself uh especially in the picture on the bottom. Why are these hands there? These hands are not necessary anymore because the gravity helps the baby moving in the right direction. Thus, uh if you conclude, con conclude that uh you don't have to touch this baby anymore, uh in order to uh uh prevent uh morbidity or mortality, then this is a variation of normalcy. And that's why the uh upright breech delivery is uh uh something we are trying to uh to learn uh to our colleagues everywhere in the world. Well, we should, we should have some scientific uh evidence for that, of course, because otherwise you are doing something which is not uh evidence based. So that's what they did in Frankfurt. And uh they started with just a research to check um the differences in uh between primary cesarean sections, uh upright bre deliveries and uh Supine bre deliveries. And when comparing upright to spine, you see fewer maneuvers necessary up to 70 80%. Um which means that in the Supine uh position of vagina bridge deliveries in 100% of the cases, there were maneuvers necessary. But in only what, 30 to 2020 to 30% of the supply um vertical bridge deliveries, there were maneuvers necessary. There was a shorter second stage of labor, uh and decreased Cesarean section rate compared uh between upright and Supine. And there was no significant significant difference seen uh between upright vaginal breech deliveries and plant cesarean sections. Uh When we're talking about fetal mor morbidity. So what does um the vagi upright vaginal bridge delivery look like? I if there's no um intervention needed. Let's see this movie, you see the um delivering uh lady on uh in, in uh upright position. This is uh uh Frankfurt midwife delivering her baby is one of the first breech deliveries they did up in upright position in Frankfurt. You see the baby, the baby's buttocks being born in anterior posterior position. Uh You can see it's a boy and it's uh uh there's meconium uh coming which is completely normal in bridge delivery. So when we're waiting for the next contraction to come, there is something uh very important um that you can actually see because of the upright position, what is happening, you can see from the outside, what is happening from the inside. What you will see next is that the baby is um making an external rotation and is presenting itself with the abdomen towards uh the doctor, the viewer in this case. So, um if that happens, then that also tells you what is happening inside? It means that the uh shoulder girdle is also rotating into the pelvis of the mother. And if that happens, then there's no problem to be uh uh expected with the birth of the shoulders, uh and then the head of the baby will follow very soon as you will see. So there's the next contraction coming here is the Botox being born. If they remove their hands, then you can actually see that you see the legs of the baby, the legs will drop down spontaneously. You look at the umbilical cord and the belly of the baby, meaning that the shoulder girl of the baby is fine and the arms are born spontaneously followed by the hat. So what should we, we discuss with women when they are having um or expecting a breech delivery? Maybe before I start with this. Um uh I can ask me whether there's any questions so far. No questions, everything clear. All right. So when we're talking uh with women about uh they're expecting a breech delivery, there's a couple of factors we have to discuss, we have to discuss the um the parity, the duration of pregnancy, epidural birth weight, um uh whether they had a Cesarean section in history. Uh We have to talk about the neck of the baby, about Petric and about uh uh the, the posture of the baby. These these factors are also factors that are mentioned in international uh guidelines and especially uh well, a lot of the guidelines tell that there is a couple of uh things that aren't strictly necessary for a breech delivery. For example, expected fetal weight in the ACOG guideline, which is should be between 2500 g and 4000 g. What happens when the baby is over 4000 g? Um No, they say uh the, the echo guideline will say there's no room for vaginal breech delivery and the same for uh the British guidelines. Um For example, you see the hyper extended neck on ultrasound, which is a contraindication for uh for vaginal bridge delivery. You see high estimated fetal weight above 3.8 kg um which is a contraindication. Um You see footling presentation uh and uh evidence of antenatal compromise. Is this true? And is are these factors things that really don't uh allow uh women to do a vaginal breech delivery? That's what they um what, what the fra a team um re started researching uh in an um well ever growing uh pro prospective cohort and they included all uh vaginal intended deliveries in breach position between 2.5 K GS uh from 37 weeks of gestation. And in the meantime, they have almost 3000 vaginal deliveries uh intended vaginal deliveries in their cohort. They use the, the modified premotor score for severe fetal morbidity. Uh As was al also used in a French Belgian uh cohort uh called the primo uh premolar cohort. So um this is very, this is the newest, this is the newest numbers. Uh and you see 2938 bre presentations, a term of which almost 2000 more intended vaginal deliveries. Two thirds of them shows a vaginal delivery and about 1300 delivered vaginally. So you can see uh that 66% of the intended vaginal deliveries in this cohort did is um end up in a vaginal delivery as well. So the factors that were mentioned that we should discuss with the patient. Uh First of all of it is the the birth weight of the baby, the expected birth weight of the baby. And as I said, they included all babies expected to be between 2500 and 4.5 kg S. Why is the 4.5 kg the upper limit that is because um they consider 4.5 kg S as a contraindication for whatever vaginal delivery, whether it's cephalic or uh bridge in Germany and the um babies be below 2500 g were excluded because that's a completely different um uh group of patients. So to say uh premature and uh uh dismature, um babies, they uh show very different uh figures uh and outcome results uh of vaginal breech deliveries. But in this cohort between 2500 and 4500 g, um there is, was no uh the um there was no difference uh in uh fetal um uh outcome. As you can see in the lower uh graph and uh in the upper graft, you can see that the Cesarean uh rate uh increased while the uh um the birth weight increased. So, meaning that if you talk to the woman with a baby, uh expected to be 40 above 4 kg. Can she deliver vaginally from the bridge? Yes, she can. It's safe because the outcome for the baby will be the same, but she should know that she has a higher proba probability of having a Cesarean section. The same me. Uh The same uh findings were uh found for uh induction of labor. Can you induce uh the delivery of uh a bre? Yes, you can. Uh There is no um uh there is no difference in uh uh premo the outcome uh between those two groups, but there is an increase in Cesarean section rate in, in the induction of labor. So, meaning that if you start inducing deliveries, um any of breach deliveries, then they should know that you will have a higher Cesarean section rate. And again, the same uh for vaginal breech after Cesarean. Um can you do uh vaginal breech after a Cesarean section? It so may sound a little bit odd. But as you can see in this, in these figures, you see that almost 50% or well, less than 50% of the women uh had ac section and uh compared to the uh pre uh uh milli mi power women. Uh that's a little higher and the, the numbers are not big. It's only 37 women who tried to in uh who intended the uh vaginal breach of uh Cesarean. Um But as you see, there's no difference in fetal morbidity and there were no uterine ruptures reported in the study cohort so far. So, is it safe? You can say it's safe. I uh is there a high chance high possibility of having a Cesarean section? Yes, there is high, high possibility of a Cesarean section premie Paris for multi power women. Well, as you can see here in this uh in this table, you see there's no difference in fetal morbidity according to primo. Um There, you may even say that there's a uh it, it seems like there's a little less morbidity in the, in the uh multiparous uh women. Uh But they're for sure. Uh uh a smaller um rate of cesarean infection in the multivirus women. And that's a rate on below 20%. And uh well, in general, you can say that in some countries, 20% is a, is a uh is a very good result for um for Cesarean section rate. Uh And, and especially in breach. Um so no, significantly sig significantly increase in fetal morbidity in pre vs women. Uh But women have to be informed about the high Cesarean section rate when it's their first baby. And don't incl exclude them from a vagina breech delivery. One of the most interesting things they, um, they researched was the, uh, footling presentation, uh, compared to the complete or the Frank Bridge presentation. Again, higher rate of cesarean infection 42%. Uh, but maybe it's, um, interesting to see that, uh, the other, uh, 25 did, uh deliver vaginally and I can ask the question, how can a footling like a real footling with the feet down legs and uh extended uh how can they deliver vaginally? Well, they do start the delivery in a foot length presentation. But as you can see that there's more than 50% chance that they change the foot length presentation during the delivery uh to complete uh breach and the liver as complete breach in the end fetal morbidity was not seen in this uh 42 footlings. And uh and no, uh of course, uh the, the this can um you can conclude that uh it's even safe to wait and see what happens with the footling in uh in labor. Of course, as long as the membranes are uh still not ruptured yet. Other factor to be considering is the hyper extended neck uh on ultrasound, uh which is uh incorporated in many guidelines. But the evidence for problems um of um uh of, of the hyper extended neck uh is um based on a couple of case reports from like the seventies in the meantime, we have the 20 weeks ultrasound on almost every w um uh pregnant woman and the fetal morbidities uh are usually picked out um early in pregnancy. So the neck extension ultrasound um during the delivery is just a um uh a moment uh and can change uh uh quickly because the the biggest problems are expected uh in the babies with the neck, um um congenital abnormality, um abnormalities in the neck. Uh So neck extension ultrasound uh is a questionable exclusion criteria. Uh One last thing is the pelvimetry, which they did on all premi pairs women prior to the vaginal breech approach. What they did is MRI M uh MRI scans and they measured the obstetric conjugate and into tuberous distance as you can see in the pelvis, uh the pelvic inlet uh is, is um uh defined as the uh obstetric conjugate as you can see here. And um if you want to know, do we have to do mm uh MRI scan on every premium pars woman who wants to do a vaginal brace delivery, my answer would be no because uh you can also measure it with um uh with your hands as you can see uh as it's shown in, in the picture here. Um But for uh scientific purposes, they uh did the MRI scans in Frankfurt. And next week, we can uh uh we can uh uh try this out on the, on the uh on the front uh on the on the mannequin, then the, there's the, the, the exit, the exit of the, of the femur pelvis, which is uh defined as the um intertuberous distance. And that you can also uh measure with your hands as shown on the picture below. Why is this important or why could this be important to do pelvimetry? Uh That is because as you see, um there, uh if the, if the obstetric conjugate is less than 11.5 centimeters, there's uh uh hardly a chance of a successful vaginal breech delivery, um 100 per, almost 100% ended up in cesarean sections. But if the uh obstetric conjugate is larger than it is 11.5 centimeters or larger, you don't see any difference uh anymore in success rates for vaginal deliveries. The same for uh the in intertuberous distance. If the in intertuberous distance is less than 10.9 centimeters, then um there's no chance of a successful vaginal delivery, vaginal breech delivery. Uh But if it's more than 10.9 then you can see no uh further difference of success rates. How about epidural can we give epidural to um uh our bridge uh deliveries? And, and does it, um uh does it change the outcome? Um There's no difference uh uh there's no higher cesarean resection rate uh seen and the, the uh outcome of the fetus is, is um the same, but of course, you can see that there's more epidural anesthesia given to prepar women is, uh, epidural, um, uh, associated with cesarean section or perinatal morbidity. No. Can we give an epidural to, uh, women who are delivering in breach? Yes. Uh, how, how about learning the breach because that's what we're doing right here. And one of the, uh, reasons that I started, uh, teaching breech deliveries, uh, when I was a trainee is that, uh, trainees, young people, uh, tend to learn, uh, new skills uh faster and are not bothered by any um uh previous experience. And that's also what they saw in uh their uh in their publication, which they uh uh showed the learning curve for uh um uh the upright breech deliveries. The younger uh the younger colleagues tend to learn it a lot faster and used less interventions compared to the obs um the experienced ob So that's about the uh the mo the more scientific part of this uh talk. Uh Is there any questions about uh sorry I sent to you im uh muted you. Yeah, you, you muted. We do have a Yeah. Yeah, sorry. Um Cause there was someone um Yeah, we do have a few questions. Um So the first question is you men, I think uh someone mentioned that you state that um the Frankfort team used MRI to measure the woman's pelvis, but uh that's not really nec necessary. So the question was, is the measurement with the finger adequate? And if you would, what method would you use to measure the women's Pelvis in Netherlands? Um Actually, to be honest, I have to, uh, tell you that, um, I don't measure the, the Pelvis. Um And in the Dutch uh bridge working group, we recently decided not to promote that uh, too much, but since this is the teach to reach, uh, and I want to show a little bit of how bre works. I think it's, it's good to, um uh good to, to show you how you could do it if you want to do it. Most important is that uh if you're looking at these figures, the women with um with um obstetric conjugate below 11.5 are usually also the women with the intertuberous distance. So these women have small pelvises and the problem uh of having a small obstetric conjugate is that the p the, the, the um the pelvis of the baby. So the bridge does not engage well into uh the birth canal. So the obstetric conjugate is the entrance of the birth canal. The uh in, in intertuberous distance is the uh the exit of the birth canal. So we're all worried about the head of the baby which is not born and the head of the baby uh could be obstructed because of the in intertuberous distance being too small. But since it's the obstetric conjugate, which already causing the problem, you will see that there's a, a prolonged labor during the first stage of labor and then probably it will end up in the Cesarean section as you can see in this graph. Um So it, it does really, uh it's not really necessary to measure to do the pelvimetry because you will see it during the delivery without the risk of the head, which uh uh which doesn't want to be born spontaneously. So if the bridge enters the pelvis and and can also exit the pelvis, then there will also be enough room for the head. So essentially, you're saying that it would just declare itself, don't really need to use something fancy like an MRI, which is certainly a problem for us to get in Ireland. So, and you should, you should, you should for sure you should not do the MRI. That's also not what teach to breach uh preaches. Uh You can use your fingers as you can see uh on this draw in these drawings to measure if you know the, the, the length of the, of the middle fingertip uh until the synthesis and if that exceeds uh 12 centimeters, then that that must be enough. So you put your middle fingertip on the promontory and you measure the distance until the synthesis. If that exceeds 12 centimeters, then the pelvic inlet is uh is is large enough. If you want to measure the intertuberous distance, you don't have to put your fist into the patient. Uh as you may uh think if you see this picture blow, but you can just put your fist outside, uh, on the, um, uh, a tuberal. Um, how do you call that, um, parts of the, of the, of the femur pelvis? And if you measure 11 centimeters with your fingers like this, in my case, this is 11 centimeters. A fist plus plus one of my fingers. If that, if there's still movement between the, uh, tuberal, uh, bony uh structures, then that means that's more than 11 centimeters and there's, there's enough uh space and this is one of the skills that, uh if you sign up for the part two of the tissue breach, you'll be able to, um, kind of be training it and to, to check out your own fingers as well. Um The next question as well, someone has asked, um, regarding the position, the birth position because we're in the tissue bridge, we're advocating for uh delivering vagina breech in the upright position. Did you find whether there was a preference for the birth position, whether depending are they MS or primates as well? And in addition to that as well, um, someone has the, the same person has asked if you found it tougher to deliver the second, um, twin who is breech in a Mos or primate. I think what I'm gathering here is that, that the fact that the amounts or primate matter in when it comes to Vagina Bush delivery, um, the multiple primate, whether that matters. Yes. Uh Yes. As I, I've shown you in this um graft, the, the, the primates have higher chances of having, having Cesarean section compared to the MS. But the outcome, the neonatal outcome doesn't change. It doesn't differ as you can see in the P value of 90094. And, and is there uh what the person typing to me now is which position is better, whether in, in MS or primates? Is there a difference in the position? Whether is it better for motifs to be in Supine or upright position? Uh We don't know because this was not uh researched in that sense. Um This, this, this, this question was answered in this uh in this publication and they did not um separate the groups, they did not do a subdivision of, of Pri primip and mds. Yeah, the, the upright and the Supine women. Um So 4040 women delivered in Supine and 230 women in upright. OK. Uh Another question as well is someone's asking if there is a breakdown of when the Cesarean section happened? Whether is it a failure to progress before the breech baby is in the pelvis or is it because of nonreassuring uh trace? And as a slight question as well is what would the intrapartum fetal monitoring recommendations be because what they're saying, what they are thinking is that most operators, obstetricians, both supporters are worried most about issues happening with the ent once the bridge is on its way out because we're often told about head entrapment. So that's the reason um for this question. Yeah. So the head entrapment, uh I hope we can um, uh, show you that, that uh will not be the problem because of uh the fact that if, if the, if the Pelvis is large enough for the bridge to en engage, then it's also large enough for the hat to be passing through. And there may be uh some intervention needed to deliver the hat obviously, but we'll come to that later. And if we are talking about what the reasons for Cesarean sections were, then, uh they did not specify that uh too much. But um um it could either be uh obstructed labor or fetal uh uh uh uh fetal uh uh problems. And then I think the last question that we take for now as well is um someone is asking that are women in epidural act like II think uh what I experienced in Frankfurt is that a lot of them would have walking epidural. So where the dose is slightly a bit different and, and less than what we have here in Ireland. Most of the women with epidural here in Ireland would not be able to um be as small bowel. So they are wondering if the women in who have an epidural, would they be able to switch to an all false position? Did you find any of that issue? In Netherlands perhaps. Uh, I haven't seen that issue in the Netherlands. Um, sometimes, uh, women have uh uh weakened mobility. Um, but with a little bit of help, they can still be put in an upright position. Ok. I think we move if they cannot move at all. Yeah. Well, then there's only one, then there's only one solution and that's leaving them on the back. Ok. So I think we, we'll move on a little bit now. There, there are a few more questions, but I think we'll move on there a little bit with the rest of your presentation. All right. So the, the, the best part is yet to come. The practical part, we're going to talk about the birth birth mechanism and about the interventions that you can do if necessary. So just something about the birth mei mechanism in cephalic birth. If you, um if you examine a baby in cephalic position, you palpate the skull and you um um well, so in order to, to put to, to know how the baby is positioned in the pelvis and we monitor the descend and the internal rotation of the baby. Um As you all all know, if you palpate baby in breech delivery uh in breech position, uh you should do basically do the same. You palpate the bony structures of the of the uh of the baby, not the, not just the buttocks because the bony, bony parts are the most important parts and I always say the Botox can, can trick you. Um So we monitor the front bridge and you see that uh the baby enters the pelvis uh in transverse position. And then there is an internal rotation happening while the baby is uh engaging into the pelvis uh until the baby's breach is in ap position. Um And uh sometimes movement is important by moving the pelvis of the mother. You can help the baby engaging if it doesn't uh uh engage spontaneously. So, what they do in Frankfurt is uh um put uh women already on the chest position during uh the uh first stage of uh of uh labor when um there's uh uh improvement of the baby's position ne necessary. Sometimes they do the reversal techniques which is like um uh actually a Mexican technique uh to move the pelvis of the mother. Um like this when they use a scar to scarf to uh uh hold the mother's uh uh hips and they move them from the left, from left to right. In the end, it's very important that the hips of the baby end up in the pelvic inlet, uh especially the front uh hip. The anterior hip should be past the synthesis uh when um uh you want to start the second stage of labor. So, uh position of the fetal spine should be completely at three or nine o'clock. Uh in order for the hips to be in anterior posterior uh position and uh the uh Eliquis uh on the side of the anterior side should be um uh past the synthesis. You can see it as uh in this graph as well. Um The um dilatation uh of f of like four centimeters and the Botox are not yet well and internally rotated. Um And wht the dilatation proce progresses, uh the uh internal rotation of the Botox uh uh move to ap position and then the pelvic inlet uh is the red line and they um started the ultrasound on ultrasound uh uh uh survey uh of the position of the, of the hips um uh during the delivery. And then there was uh they called it the I pub sign uh which is negative if the um I if the uh breach is not yet engaged. So, as you can see on this, on this ultrasound picture, as you can see the, the, the femur of the baby completely above the symphysis. Um again, this is negative eye pubes, but then if it uh engages into the pelvis, it becomes in positive eye pubes which is shown on this picture. And then you see the upper uh leg of the baby uh is a little bit uh in the shadow of the symphysis and is well engaged. Do you need um an ultrasound for that? Not necessarily as you can see in this um in this table, you see that um eye pubes uh and vaginal examination uh more or less have the same results. Uh But what is interesting is that um and that's a little bit hard to, to see from this table. But II will explain you is that if, if the bridge is uh beyond the synthesis, if beyond the um uh Pelvic inlet, then there's a 92.5% chance uh of uh successful delivery. If not, then there's a 46% chance of uh cesarean section. So, meaning negative, negative I pubes, negative I pubes is a means is 46% chance of cesarean section. Positive eye pubes means a 92.5% chance of a successful vaginal breech delivery. The hands on part something which you, which you can do when um uh the breech delivery does not progress in the second stage. Uh is extraction of the food in a complete breech delivery. What's the problem in these cases is the problem that the complete breach has a increased fetal circumference uh due to the cross leg sitting uh as well as the effect which uh uh is caused by the cross leg sitting. The clinical observation you see is the prolonged prolong to uh the clinical observation you do is um that you observe a prolonged second stage of labor. And um there is obstructed, obstructed labor in second stage and also painful labor because of the of the feet of the baby uh pinching into the vagina walls. So then uh what's must have for vaginal food extraction, complete breech delivery. That is a good analgesia because it's a painful procedure. Uh the cervix so should be fully dilated and the buttocks uh should en have entered the pelvis. So can I put uh epidural anesthesia is not um uh serious. It's not 100% must have. You can do it without because it's impossible to give an epidural before you uh decide to do the f food extraction. Bye. So how you do the procedure? You can do it both in upright or in supply position, not necessarily uh upright and you um you palpate uh the uh the delivery woman and uh you choose the easiest to reach foot, you pick the f you uh grab the foot between two fi your two examining fingers and um do that firmly, then you pull and stretch the leg um until the food is born. Uh Don't just, just ex um extract the foot and not the whole baby. So it's not a breech extraction afterwards. The, the um the circumference of the breach is decreased. Uh And the breach can uh um um progress spontaneously. So you basically um and make sure that uh uh that you solve the problem which is causing the obstructed labor uh and know that you have to uh change uh the uh patient in upright position. Um um Because from this moment on the delivery can progress very fast to see it in the part. Um Again, the, the bridge is engaging uh in trans uh is uh descending uh into the pelvis and uh making the internal rotation. In this case, it's a complete bre you start pushing and then during the pushing phase, the delivery uh is obstructed. So you remove one of the feet and uh delivery can progress spontaneous. 2nd, 2nd intervention you could do is when there's a problem with the, with the shoulders of the woman uh of the baby, uh which is basically shoulder dystocia and bridge. So as I already told you, the baby should rotate externally uh in the uh manner that it shows its belly and an umbilical cord towards the, the viewer. But if it doesn't do that, if it stays uh um in anterior uh posterior position, then um and then there's a stuck arm on the symphysis, we can solve that by rotating the baby uh by putting your thumbs on the shoulders of the baby, rotating the baby 100 and 80 degrees and 90 degrees back until you reach the position that you want. Uh That's the position of the shoulder girdle uh in transverse position in the uh uh pelvic inlet. So turn 100 and 80 degrees, turn back 90 degrees. And then that's what you see uh following. You can um perform a frank's nudge, which is a push on the shoulders to uh help the a uh flexion of the neck of the baby. And um and get the baby's headboard. We're going to show um two movies. Now, the first movie, there's a uh uh uh Lowen maneuver performed in the second movie, there's a Frank Ntch performed. This movie takes time, takes some time. As you see, the baby is uh uh born with one leg, second leg is born and then uh you are looking at the lateral side of the of the baby. The left arm is also already born, but the right arm still not born. The baby is not rotating externally. So that means that there is a problem with the uh right arm uh behind the pub uh behind the symphysis, put uh thumbs on the shoulders and rotate 180 degrees and rotate 90 degrees back then performed the frank notch to support the head delivery. And in the next movie, you can see a bit more clear. Sure. The reason for the bare hands is a patient's allergy to uh to cloves just uh to inform you about that was the hands on part. And just to summarize upright brief delivery is more physiological. It causes um it, it needs less maneuvers. Um And um vaginal breech delivery um is not pathology but a variation of normalcy. So you re in upright position is easy to learn. You've seen uh it a little bit today and hopefully next week, uh I'm going to show you uh how it's uh done in uh uh practic uh in, in practice. And uh well, for general brief delivery is safe under physiological and circum circumstances and of course, an experienced companionship. And I hope that you have also seen that uh if we teach you next week, then uh you can practice that a couple of times and then you can be uh an experienced companion very, very soon. Thank you very much for now. Uh Are there any questions left? Thanks very much, very for that, very, very information. It's uh no matter how many times I have heard this lecture and watched the videos, it always really just fascinates me, really captures me. And uh II think this is the first time I heard about that um the hand without the gloves like now, I know there's an explanation for that. Um Yeah, so some of the questions we had there um was that I think they're referring to one of the videos, I think uh that was the one where profin appears to be applying fundal pressure. So they just wanted to clarify that. Was there? What was the, I suppose if the need, what was the reason for the fungal pressure relief? The reason for the fungal pressure um is that um this is just a part of the, of the, of the movie, the movie takes about seven minutes in total. Um So this delivery took a long time and there was uh something needed to um to speed up the delivery progress and um you can do that by uh performing fungal pressure. So the, the like, let's say the, the point of no return is already way um uh past. So, um in this case, if the baby is, is, is delivered so far, you should uh deliver vaginally, uh Cesarean section is basically impossible. So apply um applying fungal pressure, you try to uh speeding up the process. Would they, would it like uh in, in Ireland, we use a lot of Oxytocin, would that be at the running at the same time as well? Cause I know I know that in Frankfurt, obviously they were doing inductions as well, but they were very careful with the usage of Oxytocin. Yeah, in Frankfurt, they do induction of labor with miSOPROStol. Only. Uh my experience in the Netherlands is that we do use Oxytocin like we use it in Cephalic uh uh deliveries. There's no, you would, you would use no difference for me. OK. And someone else, what I, what I do is when I start pushing, when I start to the second stage, I make sure that there's Oxytocin uh ready to um uh start meaning that uh if I ne if I do need it, then I don't have to wait for it to be prepared and et cetera, et cetera. So in my practice, they all have an IV line running IP line and uh Oxytocin ready to start that would be very similar here in Ireland then um and one of the question, the next question we got as well is that so I think cause a lot of this is focused on delivering in the upper position, especially after seeing your video. They are just wondering that if the woman was to deliver in this position without any sort of perineal protection. Uh How safe is it? I suppose you're referring to how like, II think you presented the information about perineal tears. But what about obstetric uh Inosin injuries? What are they more likely or no, they're less likely because of the upright position. It's not necessarily proven in uh the um, in the studies, but uh there is uh quite some research done on this and uh upright position has a benefit um for uh uh obstetric anal swing to injuries uh compared to uh Supine position. So, um, in that essence, uh Peroneal support, yeah, is not necessarily uh applied, but you can do that if you wish. It's not that you are not allowed to touch the woman or something like that. But, um, uh, well, if, if we do like uh uh cephalic deliveries in upright position in the Netherlands, we don't apply perineal protection as well. Ok. Um II think having observe, um, and experience that in Frankfurt as well, I think another reason why you don't really need per protection or you, that the perineal protection doesn't play too much of a role in this case is that with, like you say, in that position because of gravity, the baby is kind of like kinda hanging. Uh how to say if the pressure is actually not even on the perineum so much, isn't it? That's, that's what I have observed myself. And the, and then the breech, the breech is a little softer compared to the head of the baby. Uh And if you look at the uh at the nordic uh uh maneuvers, you know what you do, but to protect the perineum, uh if you, if you slice it up into parts, then you see that the lifting of the head is the most important and not necessarily squeezing of the perineum. So the lifting of the hand is not necessary uh because of the upright breach, uh the upright position of the mother because the gravity does the lifting exactly. Um And then the last question I have here as well, something that sounds very interesting because in Ireland, obviously, we are a health system that practice. Um they in section for a bag uh for, for breach presentations. Not only, yeah. Um It's just that I in, I suppose a lot of the participants here, a lot of us would be trainees. And we, what what they're wondering is that how would you recommend for trainees basically in a hospital or in a health system setting where Cesarean section is the mode of delivery that is recommended for uh bridge presentations. How, how do you stop this? How do you start this change? Um, well, talking about, uh, talking about this, um, when I speak for myself, uh I started doing this when I was still as a trainee. And, uh, there was a, a woman who wanted to, uh, uh deliver vaginally over bre and, uh, I just started putting her on, on, on all fours and deliver the baby, uh, with my supervisor next to me. But, ok, that's, that's someone who's already planning to deliver vaginally. Uh There's another story from Turkey, uh, one of the breach trainers from Turkey. Uh, she just started, um, counseling patients, uh with a breach for herself and planned deliveries, uh, when she was on call and started doing the vaginal branch deliveries. And yeah, there's someone, there's someone who should start and that's the simple answer to an in to a, to a, to a very complicated question. Yeah. Uh, if you start and people see that you have good results, um, and talk about the vaginal bridge in upright position, uh, in your, in your setting. Uh That would be my advice. So this project is called Teach the Bridge. Not because I am going to teach you how to perform a vaginal breech delivery also to teach you how to teach Brees to others. So, um, just, just, uh, the, the, the, the, the practical, um, things I'm going to, um, uh, practice with you next week. Uh, do it with your colleagues when you uh have a uh uh uh when, when there's a on call, which is not, which doesn't, doesn't contain many uh deliveries. Just go to man with your colleague and, and, and, and, and, and practice together uh teach, teach your colleagues how to do it and uh maybe, maybe this uh oil stain starts growing, growing. And as you've, as you've seen in the, in the growth of uh of the number of the general bre deliveries in Frankfurt. Um We don't expect that in two years from now, everyone starts doing vaginal breech deliveries again. Uh But hopefully 1015 years, it maybe come a bit more. Uh come on again and just to share a little bit uh for, there were a lot of new people who joined in as well. So the uh the network of trainees from sa has a 1 to 1 exchange program and there is an opportunity to visit the Frankfurt Hospital. You, you can go there from ranging from one week to four weeks um to just experience uh observe an experienced um bridge deliveries because this is a unit that has about 200 vagina bridge deliveries a year. So you get easily. Um in my two weeks there, I saw about uh five vagina bridge deliveries and, and a lot and a lot of those uh that had like that needed interventions. So you have um the study leaves um to go and apply for this. So I think, I think it's a great experience because a lot of us um would not have had seen any vagina b deliveries at all, even in a twin delivery. Certainly, that was the case in self uh where I have worked 10 years in obstetrics and have not even witnessed one vaginal bridge delivery. And then easily in this unit, I had seen um enough to make a very lasting impact and enough to kind of make me feel a bit more confident. The next time that I encounter a vaginal uh a bridge presentation. So like I say, this experience, you don't um you need to pay for your own flights and the accommodation. But the good thing about the Frankfurt Union Hospital is that they have an accommodation on site. So the I think the room fee is about maybe €10 per day. So it's very affordable really. Um and and just the the flight which is a very short distance from here and your your food, the team is very, very friendly. You don't need to speak uh German. It's certainly very helpful. You don't need to, they all speak great English, uh great opportunity to try to learn your German as well and your midwives. Um the trainees, the consultants all very friendly, very engaging love to teach you uh everything you really want to know about which are bridge deliveries. Yeah, so that's a bit of my pitch about this. Um are there any more questions from anyone else if you would like to? I didn't get any more. Maybe I, maybe I just want to add a little bit. Um, even, even if, um, even if you don't do vaginal bridge deliveries in your, uh, department at all, it's still impossible of, it's still important to learn these skills because there's always the possibility of, uh, let's say the, the woman entering your department with one leg out uh as you've seen on the picture and then you should know what you should do because doing a Cesarean section on that woman is way more difficult, then just put her on all four and wait. And if in these, in these cases, you can do this with your patients. That would be uh a great example of uh um yeah, of ho how it could be done, let's say um my colleagues in my department uh would have done a Cesarean section uh on this woman a couple of years ago when the baby had the leg out. But uh I think it's now four weeks ago that one of my colleagues, not me myself, but one of my colleagues waited, kept on pushing and deliver the, the, the baby spontaneously. And that's I think the, the big um achievement of the teach to bridge that. Um Yeah. Uh If you don't do it yourself, it could also be one of your colleagues uh performing um vaginal breech deliveries according to this. Uh um Well, according to this project and just another reminder as well is that um the space for the part two breakout session is quite limited. Um So if you want to kind of have a more kind of hands on experience, uh fry will be there as well on that day. He's very kindly agreed to be our facilitator for the whole um for the, the drug portion of the event you will need to register um and pay for this separate session uh according to your own time schedule. Um So remember to do that when you are signing up for the uh drugs and a scientific meeting. If you have already signed up for the drugs and a scientific meeting, just reme um you can actually amend your registration and add that on um on that note um before you exit because it's really important that the teacher bridge is something that continues to happen and kind of um showing our presence. Um It's one of the things that we can advocate for this kind of training and education if let's say, um if you're all comfortable with showing your camera, showing yourself and we can take a group picture cause this is what we usually do at the end of the workshop. And that can be like our group. So if you don't mind turning on your camera, so we can take a group picture, we would be very grateful for that as well, so I can see everyone is like all makeup, I guess a minute or two before everyone who wants to turn on the camera is there. Um So yeah, if you can always smile straight into your camera and I'm just going to check that. It's taken brilliant. Thank you very much for your participation and for all your questions. That was what I would consider as really successful. So thank you very much for this and we hope to see you on Friday 24th, that's next week. Um Yeah, thank you. Um We will tell you how you can access the. Uh No, we um this all will be recorded. Um Dara Dylan from our CPI will edit it for clarity because I've already.