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Okay, thank you very much for joining on time everybody and I hope you're staying well and having a good evening. Uh So my name's Anamika Banerjee. I'm a foundation year one or academic foundation training at the University Hospitals of Leicester. And today I'll be hosting your talk. My role as part of Bima is the academic need. And today we're going to be having a talk on obstetrics predominantly on the pregnancy pathways modes of delivery and also postnatal care delivered by lovely guest speaker, Dr Sarah Hangem. So just to go through a little bit of housekeeping before we get started and just the basic ideas. So uh some of you may be new to Bima, some of you may have joined our previous events, but just a little recap as to where we are and what we do. So Bima is the British uh Indian Medical Association. And we're a national organization aimed to well designed for medical students and medical trainees and various healthcare professionals aiming to try and bring further opportunities for learning, training, networking purposes as well as research and also just and offer areas to be able to get together with socials and charity events as well. Uh We have a lot of events going on throughout the year every year. So if you do want to learn more about us, don't hesitate to contact us and you can find us on our websites on social media pages as well. So as I said, some basic housekeeping as we would, well, most meetings, so if they can request everyone to please keep them microphones and cameras muted, but there will be opportunities to participate in interactive sessions with Q and A's throughout the talk, which you can have opportunities to run mute or, and participate with the chat and uh to speak all that, you know, when that will happen. Of course, the meeting itself is being recorded and will be made available to our members for of vision and you know, re reviewing purposes and within part of that, please do remain natural common sense and a bit of politeness throughout the talk where we refrain from using any offensive or um other language. And if you do have any questions or queries throughout the chat or throughout this talk, please do let us know we're always happy to help. And if there's any technical issues, please do, let me know as well. Okay, without whatever I do, I'm going to stop my screen shirt and hand over to our speaker. Okay, good evening everybody. Um Thank you all for joining on a Tuesday evening. Uh I'm sure you know, you have better things to do on this fine evening. But thank you for joining and uh thank you to the beam a team for organizing this as well. So quick disclaimer um slide about bima and a little bit about me. Um So I now work as an S T One training in Obstetrics and Gynecology in Leicester. Um Although I did train in London um uh and graduated from King's College London. Um I also did academic foundation program uh with an interest in medical education. So one of the things I'm passionate about is um taking all of you through that journey of ensuring that before you come into my shoes someday, um You have clarity on what you're experiencing and what you're learning. And today is just a short snippet of that focusing on pregnancy care and the pregnancy pathway. Now a little bit about the aims of this session. Now, today, I hope to take you through the journey of a pregnant woman in the NHS um and cover some if not all of these different um pathways and factors that play into the role of pregnancy um in women's antenatal intrapartum and postnatal journey. Now, I do appreciate it's a lot that I'm hoping to cover. Um But what I a couple of disclaimers for me is actually a lot of what I'll cover may lend from my experience in my trust. So it's important to appreciate that some of the hospital, a lot of the hospitals um across the country may have slightly varying ways in which they do things but should hopefully have similar um guidances because the guidance for National National um um there's a little bit of an echo coming from someone on to slide. So I'm hoping uh it's not me. Um, the other disclaimer is that I'm trying to avoid or I'm going to avoid covering all the things that you guys can study in a textbook. I e the theoretical aspect of pregnancy because that's something we can watch youtube or use the different sites to learn. What I'm actually hoping to cover today is the practical in the ground. In reality. What happens in a pregnant woman's journey? And how are the different things and different services? How do they come together to ensure that a mom and a baby are safely brought into this world? Because that's something I personally didn't get to learn much about in medical school or even get privy off during my placement until quite honestly, I started my job in this specialty. Um So if there's any questions, um I'll have to warn you my chat. I can't really see my chat um while I'm screen sharing. But if you pop the questions on the chat, I'm sure I'll be able to have a look at the end and we'll open up the question and answers at the end as well. And if there's any issues at any point and you can't hear me. Um please uh Namika do stop me so I can fix my technology. Yes, not to worry. And I can also read out any questions or answers through the chat throughout the talk as well if you'd like me to. Uh Fantastic. So I'll maybe take a pause or a breather at certain points. Lovely. Thank you. So, the first question is why do we care so much about pregnancy and pregnancy care? Now, the there is an independent audit um that is done or an audit and review that looks at um maternal and fetal outcomes and that's the embrace report and that is done nationally across all the different hospitals in the UK. And it's done periodically. And the funny thing is or not, the funny thing. The reality is pregnancy is not a disease compared to every other specialty. We go to the hospital, we go to the hospital because we're ill or run well and we want to get better and there is a certain element of things or factors beyond our control um where we have tried everything that we could, but the illness is not something that we could necessarily kill. However, pregnancy is a slightly different ballgame. Pregnancy is not to know this and it's not a disease. It is a physiological pathway or a path that um uh a woman, uh you know, the female sex has been blessed to go through as a journey. But the statistics is while the UK has done very well. Out of the roughly two million women who gave birth between the years 2016 to 2018, we still had a 566 rate of mortality either caused by direct of stay trick complications or indirect complications. Um, and some of these women died within the first six weeks of giving worth or within during the course of pregnancy. Now, that's a significant number, that's 566 maternal deaths. Um And of course, we're not even um covering the, you know, a number of babies um or neonatal deaths or stillbirths that happened during the course of pregnancy. So, hence, the NHS has taken so much care um to ensure that all the different pathways, guidelines are acted upon in the best interest of the women. Um taking into account various factors and some of these factors um that have affected pregnant women are multi fold and they're only getting more complex with our multicultural and are continually evolving population. So you can see factors like um smoking, overweight or obesity, even factors that we may not think matters so much like unemployment, um being a non UK citizen or living in a deprived area, all of these things cumulatively affect an outcome of a pregnant woman significantly. And when they add up, that risk only presents itself multi bold. Hence, pregnancy care is more than just the medicine. There is a lot of biopsychosocial involvement that goes on actively. Um and is taken uh upon quite seriously across most if not all trusts in the UK. And when trust do not meet some of these antenatal or intrapartum care pathways, they are heavily scrutinized upon an independent reviews are taken. Um because every adverse outcome is uh analyzed, investigated at a local level and if needed be escalated to regional and national bodies as well. So it all sounds a bit scary, but actually, it's a joyous process as well. Now, the other thing I'll have to touch upon as well is that there is a significant ethnic and racial disparity in um how women perform uh during the course of pregnancy in terms of their outcomes. Now, the embrace uh report has shed light on this in 2020. However, work is still being undertaken in individual hospitals to try and underpin exactly why these disparities are happening at a local level. And what are some of the end of us that hospitals can take in partnership with communities to ensure that this number is as low as possible across different ethnicities. Um So we do have to acknowledge that as well, especially in an ever growing multicultural population that we live in. Now, this is again a very, very quick nutshell. So, you know, simple facts, 40 weeks is the pregnancy stage uh divided into three times trimesters uh from the obstetric point of view. So we've got the first five weeks which is all about the granular cellular dividing an implantation that happens. And then up until the end of the first trimester, um until about 11 to 14 weeks, we have that sensitive period of development. Um You know, where all the different um embryo logical origins are evolving into the different organs and different systems. Um And then we have the 2nd and 3rd trimester where the focus is predominantly on the continued growth and development of the sweetness that hopefully um by the end of the 40 weeks is fully cooked and ready to come out. Now, at different stages, uh there are different risks and this is where embryology kicks in. Um So everything that you know, happens in a non pregnant woman when they become pregnant, right from every substance, they take two every environmental exposure. Um They undertake all can have the potential to affect the foetus that is developing in inside. So if we look at from a hospital perspective or from an obstetric perspective, even every medicine, every environment, uh every uh thing that woman is exposed to, there should be some sort of an alternative guidance for what happens when that woman is pregnant. And how do we go about that? Because we're not just taking care of one, we're now taking care of too. So this is a very generic um NHS um pathway of what happens um from the point a woman becomes pregnant to the time after a woman delivers so I'll try to unpack this slowly, but this is a very big summary. So at some point, hopefully a woman should recognize that she's pregnant and, you know, uh it's scary but sometimes women don't realize that they're pregnant. Um, not too long ago, I had a woman who had come to the maternity assessment unit who thought she might have been pregnant but only realized she was pregnant and when she came to us, she was 27 weeks pregnant and that's almost seven months. So it can be quite scary. Um if women don't recognize that they might be pregnant. So, but in a normal case, you know, a woman will sense changes um or symptoms or, you know, have missed her period and they will pianistic, take a urinary pregnancy test. Now, from that point onwards, um most hospitals or units will have the opportunity for women to either self refer um to the local maternity unit or actually inform their G P that they are pregnant and then they get put on this antenatal system um that then takes care of their pregnancy for the rest of the journey. Now, at some point between anywhere between nine to hopefully 12 weeks, they will be invited for a booking appointment with a community midwife or hospital midwife. Now, this booking appointment is quite important because that's the first time a midwife um takes a full history um and uncovers all the different factors or risk factors that that woman might encounter during her pregnancy journey. And we'll see more of that in the next slide after that point. Um between that time as well, between the 9 to 12 weeks, that also be a dating scan. Um where there will be an early pregnancy scan where the woman can know exactly um what her estimated due date is um combined based on her last menstrual period and also the um postulated head circumference, which will then predict um what the estimated delivery date after that. Um At that point, if the woman ops for a screening test and this is something that's quite important. A lot of women do decline screening tests. Um but if they opt for screening tests, that are also taken as blood tests um in the triple um screening test, um and if the if everything is negative and normal, then the second kind of main encounter that happens is around the 20 week scan at which point. Um the woman goes through a detailed um fetal anatomy and growth scan where all the different organs of the babies looked at because at this point, all the primitive development should have happened. So all the anatomy, the basic anatomy should have been formed. So there's any anomalies. This is usually picked up at the 20 week scan. The site of the placenta is also determined at this 20 week scan and if the couple wishes full, um the gender of the baby or the sex of the baby can also be revealed at this 20 week scan after that. Um If the woman is completely low risk, which actually most women are or many women are, then they only have appointments with their community midwife um at the G P setting um at periodic times throughout the pregnancy to measure the size of their bump, which we call the symphyseal fungal height as well as discuss concerns how they're feeling and plant their delivery. And at some point, hopefully around the 40 week time period, the woman then goes into labor and delivers. Now the N A D nice um the National Institute for Clinical Accidents. The Nice guideline recommends um 6 to 8 touch points between a midwife and the pregnant woman for a completely low risk pathway. Um just to ensure that there is constant and consistent support available throughout the pregnancy. Every woman is also um signposted to the numbers of how to reach their maternity assessment or a community midwife at any point um day or night. So compared to the rest of uh other specialties um in pregnancy on obstetrics, we have a very close contact with our mother's. Um and they have access to somebody in the pregnancy service at all points um during their pregnancy uh during the time of their pregnancy. Now, this is a quick whistlestop tour and at different points. Now we'll try and focus in on the different elements. So at the time of the booking. Uh like I mentioned, these are the routine bloods that are taken. Um And of course, everything has to be done with the women's consent. Um And then you might be surprised actually if things are not explained properly. Um Women, couples for whatever reason, um mean decline um Some of these tests and, and that is also within their uh right, if they have the capacity to do so. So it's very important to explain why these tests are important and what they may help um in terms of the outcome and the planning um during the pregnancy. So the full blood count is taken and if the woman is anemic or far to be anemic at the time of booking, then uh iron tablets um as well as uh enhanced folic acid is recommended at the start of the pregnancy and iron tablets are usually carried on throughout the pregnancy. All women undergo HIV HEP B and syphilis screening as well. And uh if the patient's consent, they also opt for the triple screening test um which is a test for the three Trisomy. So Trisomy 12, 18 and 21. Uh urine dip is also uh taken uh uh to pick out any signs of a symptomatic bacteria in the urine because you can imagine everything in pregnancy. We have to be more cautious about infection risks, especially in the first trimester and a full thorough history is taken um from the woman. So this includes, you know, typical medical history um as well as previous obstetric history. And, you know, there's a level of detail that we go into. So, you know, at what um uh years they deliver their previous uh Children, how did they deliver their Children? Was it uh an emergency type of situation or was it a completely low risk spontaneous vaginal birth? Were there any complications to the mother or baby at the time of birth? Um and so on. And there's also gynecology history that's taken, you know, have they been up to date with their smears? Have they had any abnormal spears in the past? Have they had any sexually transmitted infections? Um Any uh Gynie cancers in the past, etcetera. Um Family history is also important because that can influence some of the risk factors and management off the women throughout the pregnancy. And what we also pay attention to is the social aspect, which is quite important in the context of obstetrics. A woman is carrying a child throughout and if she doesn't have the ability to care for or there are um issues that affect um the ability for a woman to safely carry her baby to term that needs to be flagged up. So the support, the relevant support can be given to the woman. So things like safeguarding concerns, um history of female genital mutilation which I'll touch upon um later um smoking substance, misuse alcohol. Um and the necessary referral to those services are also discussed with the woman at this time of um booking especially for a multicultural, diverse ethnic population. Um In certain cases, um housing um occupation partners and or family support situations are also explored because if the woman needs support, then specialist midwives in the trust can also give that um ability to help. You know, for example, I've had pray women have come through her homeless. Um And it's scary, but specialist midwives can then step up to then help work with the council to find a house, find the relevant um resources and equipment that the woman needs to carry her baby as well. So these are all the different things that we look at at the time of booking that also helps determine that journey of a woman. So there's a quick whistlestop tour of the triple and quadruple screening tests. Um And in certain cases in the dating scan, the nuchal translucency, which is that space um at the um baby's spinal cord at the time of early pregnancy is also determined, which can also lend um to uh an anomaly diagnosis if the nuchal translucency length is uh increased or decreased. Now, if there are any abnormalities that come back in the triple or the quadruple screening tests, then the couples are usually canceled um for further invasive testing. And that can come in the form of chorionic villus sampling, which is suitable between 11 to 13 weeks of pregnancy, uh 13 plus six, sorry or amniocentesis, which is suitable between 15 to 20 weeks. Um Now, that is invasive testing and now carries risks as well. Um risks of um spontaneous rupture of membranes, induction of preterm labor, um risk of miscarriage. So that is a careful discussion that now happens, not with a midwife, but now with an obstetric team. So at this point is where the obstetric team are steps in if there are issues that are picked up with um abnormal screening test. So up until this point, um they may not even need to see an obstetric team. Nice to just have one question in the chat for you. Um There's a question asking why is AFP uh you, you three and HCG low or hide the different conditions? Oh, gosh, if I went into that, we'll spend the next hour um going through that. But um different trisomy conditions have different um metabolic in, in a very, very summery nutshell. They have different metabolic constituents and the way they present um the different hormones um that wait at that early pregnancy now start to be affected. Um So with neural tube defects, you don't have that issue with HCG and um estradiol, but the alpha feta protein can be presented high. Um But rather than me giving you a very half baked answer, um the where I recommend um where I get my best information at your stage was actually the resource which I'll put at the end, which is teach me OBGYN um, dot com. And they explain actually the mechanism of how each of the trees, any conditions, um, have these presentations of various, um, hormones. Um, and what we also have to take into consideration is this may not be completely, um, foolproof either. So we do, we take the triple screening with the nuclear translucency. Um, but even with that, there is a degree of false positive test that can happen, which is also what the couple's account so forth. So you can imagine how parents can sometimes um if they've had previous negative experiences actually decline the screening tests altogether. But this is why we cancel them because if they have an early awareness of these try Sammy's on neural tube defects that can affect um not just the short term but also the longer term quality of the child at hand. And that detailed informative plan informed planning is important um from both the psychological and social perspective, but also from a medical legal perspective um for the parents. Um So sorry, that didn't fully answer your question, but that would have to be a separate lecture on its own. Now, unfortunately, um not all of our women are low risk. So we have different women who present with different risk factors. And one of the main things that were seen in the slides coming up is preeclampsia and fetal growth restriction. So this would usually manifest um with some of these risk factors. And if we find at the time of booking that a woman has some of these moderate, either two or more moderate risk factors or one high risk factor, then to try and mitigate this risk at an earlier stage, we recommend commencing aspirin um in pregnancy from 12 weeks and sometimes carry that on up until 36 weeks of gestation. Now, these slides are pretty self explanatory but um with a moderate risk factors um include, you know, actually being pregnant, not having previous pregnancy. Um maternal age over 40 B M I of greater than or equal to 35 A family history of preeclampsia being pregnant after 10 years. Um So having a gap of 10 years between pregnancies and multiple pregnancy. Um any women with autoimmune diseases, preexisting diabetes, mellitus, or chronic kidney disease or a history of chronic hypertension um or preeclampsia in the previous pregnancy automatically fit the high risk factor, high risk factors and they recommend aspirin 75 mg a day. Now, some trusts actually recommend aspirin 150 mg a day as well. So that depends on individual hospital and individual trust guidelines, but the minimum is um 75 mg. Now, that is for the preeclampsic site, but we also have other factors that can affect um growth of the baby. So this is also take into account and this includes if there's a history of drug use um smoking at booking previous baby had there was a previous stillbirth or a small baby um as well as um any of the other medical maternal medical histories. So at this point, when the woman no longer becomes low risk, that's when us as the obstetric team start to step in. Um And the community midwives start to refer these women to either relevant clinics if they need to be followed up in the clinic, um or bumped up to um specialist midwifery care. Um So in our trust, we have midwives who look at um diabetes and high BP um very closely um as well. So that pathway kicks in. The other thing that I will say at this point is pregnancy is a dynamic thing. So it's not a fixed okay. If you're low risk, you're going to remain low risk throughout your pregnancy care. Know, um women can get upgraded at any point um during the pregnancy to moderate or high risk pathway. So at any point, things can change and uh we have to accommodate for that dynamic nature of pregnancy. Hi, sorry. Before we go to the next one, just one question regarding preeclampsia. And they're asking, can my views himself, it be given as a seizure, prophylaxis in severe preeclampsia or is it only indicated in a Columbia? So we don't give um so we only give magnesium sulfate in two contexts. Um We give that in um eclampsic at least in our trust. We only give it if there's signs of preeclampsia. Um uh The woman is teetering towards um eclampsia um or if there's um severe preterm labor. So less than 24 weeks of gestation um uh for fetal neuro protection because the role of magnesium sulfate is pretty predominantly neural neural protection. Um Magnesium sulfate is a very dirty drug and I'll come to preeclampsia in a bit as well. It's a very dirty drug. Um Magnesium affects the stability of the cardiac membrane. So even when we give the bolus dose, we have to be there and monitor um the woman's cardiac um activity and be ready to act if there's anything that's affecting that point, uh the heart at that point. Um So it's not a very um simple drug to give. So, actually my last eight months of working, I've only seen three women being given magnesium sulfate. So it kind of tells you um that we reserve it for the most severe forms or if the woman um is delivering an extremely preterm baby. Um but the baby is viable. So um uh from the 24 week mark, sorry, not less than 24 weeks, from the 24 week to the 32 week mark. Um That's what I meant. Um So yeah, so you can um but it's reserved for the most severe forms of preeclampsia and or um eclampsia, but not given routinely for uh reflexes. I hope that answers your question. So we then go on to the 20 week scan. So this applies to every woman who goes through the antenatal pathway. So, in a nutshell, what happens in a 20 week scan is every part of the baby is looked at um the every organ system or every organ. If you can think of starting from the phase, the nose, the lips, um the cleft, uh the mouth, the heart, the lungs, the kidneys, the diet from um all the four limbs. Uh and the spinal cord, what also happens in the 20 week scan is a growth uh scan is undertaken. So here, um with very specific parameters which um if you guys get an opportunity to shadow or go to a scan clinic, they'll explain um that the baby's head circumference is measured, the baby's abdominal circumference is measured and the length of the femur is measured. And this gives us an idea of how big or small the baby is in a far more accurate manner than measuring the being bump. Dopplers are also taken. So, what do we mean by dopplers? So how is the blood flow um throughout the different areas um of the baby development? Now, there's the, at this point, the umbilical artery um dopplers are taken. So that's the measuring the level of oxygenation that the baby is receiving the uterine artery flow um is also measure it. So that gives you a little bit of an idea of the placental perfusion. Um the middle cerebral artery flow is also measured. So how much brain perfusion is the baby getting and the doctors, the nurses flow? So there's a lot, there's shunting that takes place um up until the point of delivery. So how is this shunting flow taking place? And is it a smooth laminar flow or is there any obstruction? I'm not going to go into any more detail than this because until you actually enter specialist training, um you won't need to know anymore than this in terms of um what happens in a detailed 20 week scan. What I also forgot to mention this slide, but it also happens in a details can is measuring how much amniotic fluid there is as well. So is there too much amniotic fluid? So uh is there signs of polyhydramnios or is there two little amniotic fluid? So all signs of a legal hydramnios? So that also is taken into account. Now, like I mentioned earlier, if the woman is completely low risk, our part after this 20 week scan, the women may not need any other scans at all up until the time of um delivery. So uh 20 to 40 weeks is a good 20 week gap, but women do perfectly fine if they have no risk factors. So we don't need to over medicalize the pregnancy pathway here either. No, you might ask. Okay. So we've done one scan at 20 weeks. But how do we measure or ensure that the growth of the baby is okay. How do we know we're not putting a scanner in? So uh we've had lovely people who have developed ways of doing that without needing to actually scan the woman each time because you can appreciate how much resource that can take up from the scan department. Um but also um ensure that it's done in uh the most accurate and safe way as well. So here, I'd like to introduce the growth assessment um tool or the gap tool. So the growth assessment protocol, sorry, um the gap tool. Now this was developed by the perinatal institute. Um after realizing that actually every woman will have a different bump and a different size of the baby based on their own characteristics of them, their partner, their ethnicity and what they're booking weight and their body mass index is and how have they had any previous pregnancies as well? So these charts are personalized to every mother and every father of that baby. So you can think about everybody having their own personalized growth chart. Now, this is what a normal growth chart looks like. So you have the bundle height, which is what is measured um against the gestation period which goes up to 42 weeks. So midwives are trained to do this beautifully where they take a tape measure um and measure from the top of the pubic synthesis up until the top of the fund assess and that's how they measure the symphyseal fondle height or otherwise known as, as HEP H that also then gives a rough weight of the baby scan, uh, the roof of the baby's weight based on the fund or height. But again, that's not as accurate as a scan based weight. Each of the different, um, growth charts also have different center aisles marked on them. So most babies should sit between the 10th, which is the dark line below er dark line and the 90th which is the upper dark line. And the growth should be a smooth trend. If there's a smooth upward trend, then the baby is growing. Well, however, sometimes that might not be a case. So if we find that actually there's a little bit of discrepancy that happens between um the two measurements. So the slope is not as smooth as it was. This then becomes an indication or one of the indications for the woman to have a repeat scan. So she then has more scans than what she normally would. There are other indications for repeat scans in a pregnancy pathway which I'll come to next as well. And this is a quick kind of um graph summary. Um You guys don't need to know this in this detail, but just to give you a bit of awareness of what happens um for women who may not be classed as low risk or actually they don't have the uh normal or smooth S F H trend. So in any of these cases, or actually, if they're not suitable for S F H because they have a larger BM I or are multiple pregnancies or have multiple or large fibroids, then they will be now escalated to enhanced scan pathway. So at this stage, they may have um at the individual discretion of the consultants care, they're under, they may have four weeks scans um with measurement of dopplers or if there's a little bit of worry, they may have two weeks scans um with measurement of the growth of the volume of the amniotic fluid and doctors. And if at any stage, there's a serious concern that the baby is not getting enough oxygen, there's not enough fluid um or things are just not looking okay, the baby is not growing. Then that conversation that happens between the obstetric consultant and the mother to plan the time of delivery. And this there's always going to be a cost benefit analysis. Um the risk of delivering that baby earlier than need. But actually the benefit of taking that baby out of the environment that it no longer is happier. So that is a very careful and a very um case by case decision that takes place, there is no hard timeline that is in post. So as soon as a woman will need an enhanced scan, she now again comes to the obstetric team, she's no longer managed by just the midway free team. So this is now again, an upgrade of um, upgrade or a bump up of the risk pathway that the woman goes through. Now, a couple of points that I put out here, we don't generally do scans. Um, more than, uh, or more frequently than two weeks. Um When I say scans, I don't, I mean, growth scans, we don't do scans, um, more frequently than every two weeks. Does anyone want to guess why I feel free to and meet if you'd like to contribute or you can message in the chat? Okay. So we've got one responsible cost to the NHS or insignificant growth in such short time and stress to the mother. Okay. Um I wouldn't say so much about the cost. That is a consideration. Yes, but actually um there is no exposure because it's ultrasound scanning. So there is no radiation exposure or harm to the baby. Um Stress to the mother. Yes, but more importantly, um it's about the kind of um discrepancy operator um used versus the growth um that we would expect below less than two weeks. So if you stand a woman too often, um and it's an ultrasound scanning, right? It's user dependent how I measure a head circumference will have some variation, a slight variation to how um uh for example, Anamika will measure uh scan a baby. So what that then does is if a woman has a scan, see a few days apart or a week apart. And there is a significant user discrepancy that can actually lead uh two false diagnosis of uh some sort of a growth um anomaly and subsequently can a stress the mother out but also lead to decision making that may not be accurate. So that's why we're very heavily um scrutinized or any scans that happened more than um closer than two weeks apart. However, women might still be brought in for scans, um ultrasound scans to measure the dopplers and that can happen um even weekly. So if there's any concerns that the placenta is not working as well or the baby is not getting enough oxygen, then the dopplers alone can be measured weekly, but the growth scan has to have has to have a two week um interval. Now, the next thing I'll quickly touch upon is the oral glucose tolerance test. So just gestational diabetes is something that we do um worry about because it can have um significant foetal risks um such as macrosomia, um small for gestational age babies, so small babies and also large babies as well as um developmental delays and issues down the line. So if the women meets um risk factors are indicated as um written. So if they have a B M I of 30 or more, if they've had a previous big baby, a previous history or a family history of diabetes or come from any of these ethnicity origins, then between 24 to 28 weeks, they'll undergo the oral glucose tolerance test. So here they drink 6 50 g of glucose in approximately 1 50 to 300 miles of water and the fasting and um two hours post glucose levels are measured. And if they are elevated, then the woman is diagnosed with gestational diabetes. And now again, she then bumps bumps into obstetric care. So she will then have diabetes clinic appointments. She will, her, she'll be um given one of those automatic um diabetes um glucose measuring kits um if suitable um and will be heavily monitored as well between the diabetes specialist nurses, um the diabetes consultants and the obstetric consultants. Um So there's a lot of care that takes place for women who are diagnosed with situational diabetes. Now, the other thing that I've not um really focused on in this presentation, but any woman with preexisting diabetes, whether that is type one or type two automatically will not be classed as low risk and will also have continual monitoring and support between the obstetric and diabetes teams throughout her pregnancy because there is also a risk that her diabetes can worsen um during her time of um pregnancy and the need of uh the tolerance as well as the um use of insulin. Um, if or if she's not used, an insulin can actually um increase in terms of requirements. So there's heavy monitoring that takes place as well throughout pregnancy. Now, when a woman no longer is in low risk pathway and now needs more support everything. Um As we, you know, go through our medical school training is done in a multidisciplinary team. Now, the reason we undertake an M D T approach is because a it doesn't put one person on the sole bearer of decision making, but also it allows different people with different areas of expertise to come together and take a decision that works in the best outcome of the woman and the child. So these are some of the M D T clinics um that run throughout uh pregnancy that a woman may present to if she's got any of the risk factors. So, if a woman has pre existing diabetes or is diagnose with gestational diabetes, she will then have specialist diabetes clinics and can be followed up as frequently as every four weeks to even every two weeks or every week based on how compliant, how high risk and all the other factors that come into play. If she's got pre existing hypertension, essential hypertension or is diagnosed with preeclampsia, she will then present to the hypertension clinics. And we'll also have a follow up with the hypertension midwives outside of the clinic setting as well. If she has any underlying hematological conditions or has a history of sickle cell beta thalassemia or any of the other rheumatological conditions, then there's a joint hematology, obstetric clinic that also can run if she's got any other underlying medical conditions like asthma COPD, pulmonary fibrosis, autoimmune, rheumatological kidney, you name it. Um this is where maternal medicine clinics come in. Um I recently attended a regional training day which was very informative that actually shed light on how there has been some of these embraced reports that I talked about earlier and other reports have um lent to regional maternal medicine networks being formed because you can appreciate we have tertiary centers which are big hospitals and then you have the smaller district hospitals. Now, smaller district hospitals may not necessarily have the resources and capacity to accommodate some of the high risk complex um pregnancies where the woman has three or four medical conditions. So now um they come to a regional network where the decisions happen at this regional center hub where you have the expertise um of different consultants who come together to manage this woman's condition um and uh the pregnancy as well and look at everything side by side. So that's something that has started to form in the last six months across the country. Regional maternal medicine networks. If a woman has had previous recurrent miscarriages and is at risk of miscarriage and pregnancy, there's also clinics called the prematurity Prevention Clinic that can happen. And here um in the earlier part of pregnancy, the woman's um cervical length is measured. And if it's found that actually the cervix is a bit too short or is starting to funnel inwards or III the pregnancy sac is descending downwards. Then what we know uh we call a circ lage is if the woman is suitable may be inserted. So in layman's terms, the sir clashes basically a stitch that goes around the um between the external and internal cause of the cervix and basically pulls it tight and prevents the pregnancy from uh resulting in miscarriage. It's not completely full proof, there's still a risk of miscarriage. Um but in many cases, it helps um keep the pregnancy viable um for as long as possible. Now, mental health is not something that we can take lightly and especially the combination of estrogen progesterone fluctuation lends women to have um exacerbating mental health conditions if they already have a pre existing condition, especially in the postpartum stage. So if they have a history um of anxiety, depression or any of the other mental health conditions, then specialist mental health clinics and mental health nurses also come in in some hospitals, especially where we have a diverse multicultural population with especially populations of women who come from countries um that are known to practice female, female genital mutilation F G M clinics, happiness. Well, so there's about five in London, um one in Leicester, one in Nottingham as far as I'm aware in the Midlands. And these clinics are um touch points for women who've had F G M done too, very much, assess the extent of F F G M that they've had done and planning towards delivery because if they've had type two or type three F G M where actually the a large portion of the entirety um of their um labia is sewed, then they won't be able to deliver vaginal e um safely. So then things need to be planned um to open up the vaginal canal and done safely um Either before or at the time of delivery. Um and, and a detailed conversation takes place with a woman. So that's the F G M clinic. Now, another clinic or another touch point that can happen is if there are any issues with the baby. So either um at the, at the 20 week scan um or uh following the the invasive testing, if there is some sort of a fetal anomaly present, whether that's a cardiac anomaly, uh congenital diaphragmatic hernia, arenal anomaly or anything, you name it, then this is almost your um the top of your pyramid care that takes place with specialist consultants who are specialized in maternal and fetal medicine, who will then take responsibility for scanning the woman um regularly and counseling the women um or the couple on the best approach going forward, taking their interests in to come and involving the neonatal teams as well. And there are more. So I've only mentioned a small proportion of multidisciplinary um clinics that can take place, but there is more as well. I'm going to take a quick pause there. Does anyone have any questions, there was one question posted earlier that didn't address. Um So there's a question regarding, I guess uh risk grieving which asks is B M I pre gestation relevant for borderline B M. My mother's um if, if the person you ask the question, it didn't feel once, do you just elaborate on the question that might help last speaker, I'd provide an adequate answer. Um Sorry, I typed that wrong. What I meant was um is when we say B M I as a risk factor for the pregnancy, are we referring to the pre gestation? BM? I, so particularly in mothers who were already borderline, presumably we don't mean to be M I while they're pregnant. Yes. Yes, yes. Um Sorry, I should have clarified. Absolutely. So anything B M I is always taken um or even weight is taken at the time of booking. Um So that determines the risk throughout and actually um sounds a bit counter um productive. But even at the time of delivery, when we're planning mode of delivery, um we take the booking B M I and the booking weight into account rather than the B M I at the time of delivery. Um because the expectation is that a woman does not significantly jump um B M I S um to the point that she now goes through a different um risk pathway. But of course, if there is a significant discrepancy um of a woman's um weight throughout the pregnancy that does get flagged up and especially at the time of delivery, we always ask, okay, this was her booking B M I but this is her current BM I. So there is a significant increase and now that will need to take into consideration when we're planning her delivery care. Um So I hope that answers your question, but it's usually the booking BM I that plays a role throughout the pregnancy. No, if a woman has completely low risk or at any point in the pregnancy, we have services called maternity assessment units. So these are what you can think of as many a and ease or mini urgent care centers for pregnant women. And they are open usually 24 7 in every hospital and is the first port of call for a woman to come in. Now, these uh centers are usually run by midwives who will then triage um their situation and then call the obstetric team to review the patient um if needed. Now, these are some of the common things that can present in pregnancy uh into the assessment unit. So um um is not happy with. The first thing is the mom's not happy with the baby's movement. What usually happens here is we then uh if they're above 26 weeks because it takes about 26 weeks, the babies um pattern of movement to be established. So if they're above 26 weeks, then we put them on a fetal monitoring, like a continuous um uh C T G, which is the fetal monitoring. And if that's completely fine and it's their first episode and they're otherwise low risk, we don't do anything further. Now, if this is their second episode or they've got certain risk factors that um put them, puts the baby at risk, then we then make the decision of, do they need another scamp um to see how the baby's growing. Um if they have not had a scan in the last two weeks, if they've had, you know, multiple episodes of reduced fetal movements and they're reaching um time of delivery. So they're already term, you know, about 39 weeks. Then with the senior team, we then take a decision of actually, is it now time to bring the baby out because fetal movements are reduced, fetal movements is often a first sign that the baby is presenting with some sort of hypoxia. Um because moms are best at knowing the pattern of their baby's movements. So that's something you take seriously. Another common symptom that can happen in pregnancy is abdominal pain. Now, in many of these cases, that is usually pregnancy related abdominal pain. So as the bodies accommodating to this growing baby, the mom might have pain arising from the ligaments from the muscles and the stretching. However, we also do need to take abdominal pain seriously because it's more serious things like placental abruption um where the placenta separates or starts to separate uh from the uh uterine award um that can manifest as abdominal pain if they've had a previous Cesarean section. And they've had a rupture of that scar. The scar breaks down inside the uterus. Now that can present with dramatic abdominal pain. Um or actually, if they've got something that's non pregnancy related like appendicitis, kidney stones or colecystitis that can also present as abdominal pain. So, abdominal pain is a big thing that comes up to our doors. The other is vaginal bleeding. Um So again, vaginal bleeding can happen. Um Some, you know, uh innocuous, but others can be insidious. So we'll need to look into why they're bleeding vaginal e and have a look at the neck of the room to see if there's anything uh that's happening that's actually contributing to preterm labor or is there a sign of the cord bleeding or the bleeding coming from the placenta? Um and so on and so forth. I know you guys have already had a lecture on obstetric emergencies. So all these things are usually covered as part of obstetric emergencies. Another issue that can arise is actually um have the water's broken. Um And depending on, at what stage their waters have broken, that can lead to different management. Um DVT. Um So for development of clot in their legs that can travel up to their lungs. So DVT and VT um can, is a big risk factor in pregnancy because pregnancy itself is a risk factor. Um, so that's something that we'll have to keep in mind. Um, and other things, you know, if they have headaches, if they feel unwell, if they're vomiting, um, they've got pain in their leg if they have swelling. Um, you name it. Um, a lot of symptoms can arise, um, that women present it and you can understand anything that, you know, feels abnormal, causes worried to the woman. So we always say if you're worried about something, you'd rather come get it checked out than stay at home and shrug it off. So we have a lot of women who do come in, especially ones who are anxious that something might be going on and it becomes our responsibility than to assess and make a plan and see if that woman needs any follow up after the point of presenting to our assessment unit uh for continual care in many instances, if there's one or two episodes and it's completely, you know, um benign, there is no risk in the pregnancy. This does not mean that the woman is now automatically classed as high risk or moderate risk. She can still carry on in the low risk pathway and doesn't need to see an obstetric team after. Sorry, we just had one question regarding management of bleeding during delivery of the placenta. Uh They're asking when we use Ergometrine or Oxytocin for the management. If there's any bleeding during delivery of the presenter. So during the delivery of the placenta, uh okay. So I'll come to the users of Oxytocin um Dobrin and other um uterotonic. But typically we give uterotonic um to bring the tone down of the uterus at the point of delivery or after the baby has been delivered. So you when you have bleeding or you know, significant bleeding that can lead to postpartum hemorrhage or you're worried about risk of postpartum hemorrhage. It's important to understand why the woman is bleeding. So if the bleeding is tone related, then yes, you can give ergometrine oxytocin um carboprost or in other cases miSOPROStol to help um contract the uterus. But if the bleeding is coming um due to another cause such as a trauma because the woman has had a tear or um lack of thrombin. If she has some sort of coagulopathy, um or actually, there's a retained placenta that's, you know, contributing to the bleeding, then giving you tra tonics may not necessarily help in that situation, then you have to identify what you can do to address the three other teas. So you call it the forties, tone tissue from trauma and trumpet. These are the forties of postpartum hemorrhage. I hope that answers your question. So now a quick um whistlestop through preeclampsia again, preeclampsia is one of the big things we want to rule out. Um when a woman comes with any symptoms, um that could be pre eclampsia because preeclampsia is can be quite dangerous, um both maternally and fatally. Now, preeclampsia um presents classically as a triad of symptoms. And while the exact mechanism is poorly understood, um the reason for preeclampsia is um attributes to some sort of poor placental perfusion because of abnormal placental implantation. Um Many have tried to study the exact cause of this and there are several theories um right from endothelial dysfunction, too abnormal spiral artery formation um to signaling molecules that have been, you know, heightened or inflammatory responses. Now, I leave those of you who are nerdy enough to look into that, but there's some sort of poor placental profusion ultimately. And preeclampsia usually is diagnosed after 20 weeks of gestation. So, if a woman has a high BP before 20 weeks, we usually don't diagnose preeclampsia at that stage. The triad of symptoms are protein in the urine, rising BP. So, greater than 41 40/90 across a mean BP profile. So, not just one pro uh BP reading, but a mean profile of 4 to 5 readings done every 15 minutes. Um And Adama says swelling. Now, why do we worry about preeclampsia? Um Like someone mentioned earlier, preeclampsia can manifest to eclampsia and that's when it starts to affect um a woman neurologically and this can lead to a whole host of complications maternally and fatally. So you can go into hemolysis, iss and liver um uh issues in the form of help syndrome. You can become coagulopathic. Um you could have kidney injury, um respiratory distress, um permanent brain damage and even death. I had a woman um in our labor board who was about 28 weeks pregnant, um had a pre eclampsia that was, you know, contributing to acute adult respiratory distress interim, she was needing oxygen support. Um We had to step her up to I T U and luckily we didn't intubate her because if we had had to intubate her, that would have been a time for delivering the baby because babies don't do well with um ventilating mother's. So she was reaching that stage. But luckily she turned a corner. Uh so it's, it's a pretty serious um uh condition, preeclampsia if not managed properly and likewise, fatally um growth restriction, prematurity, um lack of lung development and respiratory distress, um uh abnormal placental abruption which can um cause fetal hypoxia because there's no oxygen going to the baby from the placenta and intrauterine fetal death as well. No, there's so many other things that can happen in pregnancy. But um it'll be quite impossible for me to cover everything. But these are some of the things um that can manifest, but now we're gonna come to the time of delivery. Now labor, now the thing I'll have to keep saying again and again, like because as a self reminder as well, because in the world of obstetrics, we usually see the patient's who are not low risk. So we seem to think that uh everything um is high risk and you know, everything can become complicated. But actually the proportion of patient's that we do see is a very small proportion in comparison to those women who deliver completely normally without our intervention at all. So in a completely low risk pregnancy, a woman can have an entire pregnancy and delivery care without ever having to meet a doctor. And I think that's important for us to remember that actually, it's not all doom and gloom. So in this case where it's spontaneous labor, woman goes into labor and it's completely low risk, she can even opt for some of the, she can design her birth plan and her delivery plan. And you know, a lot of women choose to labor in water or labor on land, um use, you know, uh alternative therapies to help bring down the stress levels um deliver at home. And all of those things are managed by various home birth teams and community midwives and the women undergo pretty beautiful delivery. However, in many cases where we come in is when actually the woman is no longer higher, low risk. And rather than in certain instances, rather than waiting for the woman to labor spontaneously. Actually, it might be safer for the woman to be induced because we don't want the woman to cross a certain point that now becomes detrimental to the baby as opposed to carrying on the pregnancy. That's when we talk about induction of labor. Now, there can be many reasons a woman can be induced. And this is usually a decision that is taken by a senior of static team colleague um in um conjunction with the woman at hunt and can also happen at different gestation points. So for example, for twins, D C D A, twins, dichorionic diamine attic twins, um we recommend induction or any form of delivery at 37 weeks, which is the, the cut off for term because we don't want the babies to suffer any point after. Whereas sympathy, other risk factors like um maternal age and gestational diabetes can wait to be induced at 40 weeks on 39 weeks and sometimes you have prolonged destinations, the women who wait and wait and wait and actually, it's been, you know, more than uh it's been almost two weeks uh past 40 weeks. Uh And now they need help in inducing. Um So that's called uh prolonged gestation or um late uh or delayed um labor in different trusts. So, these are some of the various reasons that can women can be induced and the induction of labor happens at different stages. So what usually happens is there is a whole discussion that happens with a woman before hand on the process of induction. And the first part of induction is a woman comes in um and her cervix is examined. So we examine her cervix to see if, how dilate, what's the dilatation of her cervix, the length of her cervix? Um Can we feel the presenting part of the baby if we can or if not, uh what's the consistency of and the position of the cervix based on that? We give a score and this score is called the bishop score. Now, for anybody to be suitable for the waters to be broken, which is the amniotomy stage, The bishop score needs to be a minimum of six um into the combination of these factors. So if the bishop score is not six, then we need to give something to help the cervix get ready for labor. So this is the cervical ripening and the dilatations and the thinning of the cervix that you study in your textbook in the first stage of latent face of labor. So this can happen in the form of vaginal prostaglandins where we give a pessary of a prostaglandin that goes behind the cervix and sits behind the cervix or um 24 hours um or we can, if there's a little bit of an opening of the cervix, we can try a mechanical delectation of a balloon catheter. Now again, this happens in different um guidelines in different individual trusts. But this is broadly the two types of dilatation that can happen to help the cervix get ready. Once you've reached a bishop score of six Araba, you then break the water and this is called A R M or artificial rupture of membranes. But you have a little um your hook and you guide your finger in a blind procedure, feel the balloon and then you break the waters. Trust me. Our midwife colleagues are way better than this than us because they do it every day. We generally don't do them. And then we have, we go on to step three, which is augmentation of labor. This is when um we want to help the women have regular contractions. Um that gets her from uh three centimeters to 10 centimeters so that she can be ready to deliver. Um And sometimes to help if the woman is not laboring, having contractions regularly, um We then give Oxytocin um that runs as a slow infusion um that can be titrated up. Um uh And we monitor the baby continuously. Um And that helps the women have a steady labor process. So that's the induction of labor process in a nutshell. Now, you can imagine how uh some, I think there's some book that says that uh the delivery process is equivalent to the breaking of 30 for bones um in terms of pain. Um and women are troopers. So a lot of them do this without, you know, needing any pain intervention or actually just simple pain measures like paracetamol and dihydrocodein. Uh Sometimes they do use gas scenario as well, which is um enter knocks, um that gives um nitrous oxide that allows them to inhale it and uh give analgesia as well. Alternative pain measures like using the pool, essential oils can also work in a low wrist setting. Sometimes women may opt for a pethidine, which is an intramuscular injection once only that is a week. Uh fast acting short length opioid receptor agonist. So it's not as strong as morphine, but it helps with pain management, but it can make women sick. Um So usually prescribe cycles in with pethidine. And also we warn them that babies may come back, come out a little bit sleepier because any opioid crosses the blood um can have the uh the stronger ones do cross the placental barrier. So the babies can be born a bit sleepier. And finally, a lot of women do opt for the epidural, which is where our anesthetic colleagues come in and insert uh the epidural um catheter um between L2 and L3 um lumber spines in the inter virtual spaces. Now, if at any certain um the premises, if a lower risk woman, once an epidural or the woman is not low risk um and has something else going on and has spontaneous labor or if the woman is being induced when we reach the active stage of labor. So that is between the three centimeters to 10 centimeters. The woman will need continuous fetal monitoring. The reason is because things like Oxytocin um to augment labor, epidural um or anything else that already the woman has as a pre existing factor, maternally or fatally can all contribute to babies not being happy inside. So, continuous fetal monitoring ensures that anything that happens at this point because this is now the most critical stage, um we can catch it and plan for delivery accordingly. So, as continuous fetal monitoring in a nutshell is we have two lines. So the bottom, it measures the uterine contraction in a 10 minute span. So that's between the two um axis, that's 10 minutes and the top line which is the baby's heart rate. So we usually look for what is the average baseline um of the baby's heart rate is their good variability um of the baby's heart rate. So it's not just a single squiggly line, but actually there's a good spikey spike. Um Is there acceleration? So the baby's heart rate goes up um above 15 BPM for a short length above the baseline and then comes back down. We call that acceleration. That means a happy baby or are there any decelerations which is not a happy baby? Are there any dips in the baby's heart rate if there are any dips in the baby's heart rate? Um And that was just shown in the second fatal monitoring um in the area B which is actually a significant bradycardia. Now, that is a reason to deliver the baby soon. Um because any bradycardia that prolongs um within nine minutes, we'll have to take a decision and within the 12 minute, you need to aim to deliver the baby to prevent hypoxic ischemic and Keppel opathy. In layman's terms, brain damage to the baby that can be quite permanent. That's Brady cardio. Um I won't go into continuously to monitoring because that's a whole different topic again on its own. Um But there are different types of situations that can evolve ultimately, the decision for an obstetrician um at any point during the women's labor as is the mom okay? Is the baby ok. If mom's not okay, why is mom not okay? Can I fix anything that can make mom better? I e is she having a temperature? Is she feeling a bit unwell if baby's not? Okay? Why is the baby not okay? Can I fix that with simple things like changing the mom's position, giving the mom some fluids? Um Or if the baby is the baby really unhappy is that if the baby's unhappy and it's showing that it's unhappy, then it's time to bring the baby out. So that rapport and relationship between the obstetric team, the midway free team, the anesthetic team and the woman is crucial in keeping that mom are as happy as possible throughout this process because anything can happen, anything can change. And you can imagine being that mother, if you're being told that something is not okay, you need to be able to trust your team and let them take that decision. Um and work together as a team as well. Then we come to the time to deliver. Now, this is just a quick uh kind of graph to show the movement of the baby that happens um as it descends down the um cervical canal. Um So we classify the baby in terms of its station. So is it uh and the station is in relation to the ischial spines, if you remember anatomy. So if the head is below the Eskil spines, you know, towards the external world, then that is plus one and plus too, if it's inside or you know, above the scales mine, then that is minus one and minus two. What is the presenting part of the baby is at first head? Um And if so what position of the head is it in normal? Um most optimal position is direct. Oh A if you, if you hear that buzz, but it means that the baby is bang on face to the head down, the face is seeing the floor and the posterior fontanel you can feel now if the baby's faces looking at the ceiling, then it's occipet posterior. So it can be delivered vaginal e but it's a little bit trickier um and can be a bit more difficult um in terms of the passage itself for the baby, um if it's in any other position, uh such as occipet transverse of the babies sideways or slightly rotated, then um the obstetric team may need to intervene, to help manually rotate. Um the baby's position to help us delivery. Sometimes babies do it on their own. They're brilliant creature's or if the baby completely has a different presenting part, then more than often not vaginal delivery may no longer be safe. Now, at any point, um right from uh you know, the early stage of labor to fully dilated pushing women, we may need to intervene. So typically, if the baby, you know, mom's fully dilated mom's pushing, but for some reason, the baby is not happy. Um but it's there, it's right there. So then uh if the mom is pushing, well, we may then um advice to assist with a a suction cup delivery or a vacuum assisted delivery. Um In many trusts, we use a Kiwi device, but other trusts can use alternative vacuum device. So you basically put a suction cup, um inflate the cough to a bit of pressure and then you use that pressure as a bit of traction to bring the baby's head down with the mom pushing as well. There are risks that you have to warn in terms of the baby's head being a bit more swollen, um needing to give a cut or an episiotomy to widen the birthing canal, which um if not, the mom can have um severe test. Um And in some rare cases, uh the baby can have bruising or any form of bleeding because of the trauma of deception cup. So that's something we want. Otherwise you can also help with the forceps where you have these kind of tongue like forceps that you put on either side of the babies is you look. And then in this case, when the mom, if the baby's head is a bit higher, uh or the mom is not pushing very well, you can then use the forceps to guide the baby down. In some cases if the mom is not fully dilated, um the baby's head is too high, the position is very awkward or actually the mom does not want um an operative vaginal delivery. Um Then we then have that conversation for a Cesarean section. Now cesarean sections can happen electively. So I I E um it's already predetermined by either the mom, the parents or for a medical reason that it's safer to deliver via C section. So that is an elective C section done at a planned stage or an emergency C section where this is actually not a day decision taken electively, but there is something not quite right and it's safer to bring the baby art via Cesarean. Then the continuing vaginal e that's an emergency C section. And that happens in three categories. Category one is the most emergent C section that needs to happen within 20 minutes um of the time of delivery uh from the time of decision to the time of delivery. And that includes getting the anaesthetic ready, getting the theater ready, getting the woman into theater, getting the drapes in um making the cut and delivering the baby. So 20 minutes is not a long time. Category two is 40 minutes. Um There is some sort of maternal fetal compromise but it's not emergent. And then category three, which is within uh 60 to 1, 20 minutes. That is where actually we want to bring um sorry, category three is within 24 hours. So we want to bring the baby out, but it's not urgent, but we don't want to wait and it's not a planned delivery. So those are the three types of cesarean sections. Now, cesarean sections, I'm not going to go into any more detail, but they are major abdominal surgery. Um and every abdominal surgery that does happen, introduces a further risk in the next pregnancy in terms of the planning um for the next pregnancy or even any other um future surgical considerations that might happen. So it's not a decision to be played lightly. Um And even if the mom wants a Cesarean section, it's important to outline all the risks uh and the benefits and make sure that the mom and the partner our best informed to make this decision. Now, babies are born and there's the postnatal care. So we don't just say bye bye to the mom. Once the baby is born, we also take care of the postnatal pot. So here there are typical touch points between the midwifery team and the mother. So day one, day four, day seven, day 14 and even extending up to day 21. Now, um the moms also have access to the maternal assessment unit until six weeks, post um delivery postnatally. Um So if there's any issues with the mum six, up until six weeks after, they can come to our maternity assessment anytime. Now, if they have had significant protein in the urine or preeclampsia, um that has needed them to be delivered. Um Then we do monitor them to a resolution after because preeclampsia can still manifest um up until 72 hours post natal e and that can be quite significant and severe and present even like eclampsia and protein in the urine if it's still dramatic. Um after 2 to 3 weeks, they may need extended um uh door to power in or vte prophylaxis because they lose the clotting factors um because of uh the changes to their urine. So, um and, and the kind of uh the diffusion pathway that takes place. So that means that they lose the ability to um break a clot. They are at higher risk of forming clots. Uh So in a nutshell, preeclampsia and protein urea, we need to monitor quite closely close knit early as well. Um With gestational diabetes, the hope is um once they deliver the diabetes goes away, so they don't need any other diabetes care after. And this is, but this is only the context of gestational diabetes. And the same thing goes for obstetric cholestasis. So, if they've had any increased bile acids, um or uh liver function during pregnancy and we think it's obstetric colist Asus. Once the baby is delivered, things go back to normal. If it's not gone back to normal, then we need to identify why that may be and look at other factors or other causes. Now, the final thing I wanted to touch upon is when things don't go to plan. Now, we all want every mother to go home with a baby, but sometimes that may not happen. So if a mummy loses a baby before 24 weeks of gestation spontaneously, we call that a miscarriage. If there is a death of a baby that happens in utero or before it was born after 24 weeks, then that is a stillbirth. And if a baby is born alive but dies within 28 days of life, then that is the you natal death. Now, this can happen for many reasons. Um And in each case, the support that is given to the family um at the time of delivery and after all the way to their next pregnancy um makes a significant difference in how they view um what's happened and how they move forward. So in our hospital trust, uh and I would expect the same with most hospital trusts. Um compassion is at the height here. So if they, if the babies died um in neutral like a stillbirth, then, you know, having that difficult conversation, confirming the stillbirth, giving the parents a privacy. Um and um inducing the labor um then becomes the kind of mainstay. And even after the baby is born, um there are many services um and specialist midwives who try to make the experience as human as possible. So, you know, having any memories that the baby might um that their parents might want to keep photos that they might want, taken memory boxes that they might want um given. So all of those things happen along with that understanding why the baby has died is also important. So, in many cases, um perimortem um um also takes place unless the parents don't consent, the placenta is usually sent to histology as well to try and understand what's going on that has contributed to the baby's death. Usually the um parents are supported after discharge. Um The postnatal care continues and you can imagine if the um mom's delivered um and the body is recognizing that deliveries happened, the mom will start lactating. So how do you stop the lactation as well? And how do you support that woman through that really difficult emotional period? Our specialist midwives come in, then they're usually invited back to the hospital for an appointment with an obstetrician to try and debrief or go through why um the baby could have died. And if they're planning for any future pregnancies what measures we can take in place um to support the next pregnancy or even support the prenatal um time period as well. If they fall pregnant the next time and many of them do, then they are then managed by special services called the Rainbow Services um which happening, which have um which take place in many hospitals. And these Rainbow clinics are again jointly run by obstetric consultants and specialist midwives um that follow the moment child, uh the mom, the parents throughout the pregnancy because you can imagine how anxious they must feel, how they have those previous memories and everything um maybe heightened. So there's a lot more kind of care and a single um continue continued care pathway that takes place. So rather than see 10 different consultants, they have the one consultant that they followed throughout um the antenatal time period and during the intrapartum time period as well. So the Rainbow Clinic is a very special clinic. Um But it's quite blessed that in the NHS, we do take these things into consideration um and also give that holistic care to our mothers. Now, I've tried to cover what I've learned in the last eight months of this facility in one hour. So, you know, not an easy kind of tasks. I do apologize for overwhelming you all with kind of the whole pregnancy pathway in its shell. But these as soon as the resources that I found useful and the more resources Um So do you feel free to take a look? Um But it is complex, it's dynamic and it's personalized. So, until you come on to the job, everything seems a bit alien. But um it is quite wonderful and special and that's what I love about X Tetrick. And thank you for listening and I'll open up to any questions now. Thank you so much for such an incredible talk. Um I think that was so very thorough and very holistic and I'm sure everyone has agreed and enjoyed the talk very much. Thank you so much. I'm just going to show my screen and also have a look at any questions that come through everything one second. Um Okay. So there were a couple of questions that came in earlier that I didn't get a chance to address. We can do it quickly. I'm aware that we're short of time, but we'll just take 2 to 3 questions. Um So I think there was okay. So we had a question on how does uh eclampsia lead to help syndrome? And also what, what exactly are the causes and arrangements uh for the platelets and liver function? Um I'll leave the start with that one best and then I'll move to the next one. Uh short answer. We don't know. Um uh the exact mechanism is not understood and that's the challenge with Preeclampsia Center. However, there is um the kind of um some of the uh pathogenesis involves an enhanced inflammatory response, a bit of a dilution Elif ect um that wipes away some of these platelets and clotting factors. Um And that can all contribute to um deranged liver function, um reduce platelets um and uh contribute to this elevated BP as well. But honestly, the short answer is we actually don't know. Um uh And, and that's what makes preeclampsia and eclampsia quite challenging uh to prevent. Um And that's why. Uh yeah. So like, you know, even like a quick kind of Google search in terms of the mechanisms, you know, there's uh some sort of genetic factors, uh circulating oxidative stress factors, um auto antibody, he's pro inflammatory factors, vascular dysfunction, vasospasm, capillary leaks like all of these different things in varying forms can cause um preeclampsia and that can result in help. But the nature, the exact part of genesis is poorly understood. Thank you very much. And uh one last question, um how clinically significant is present syndrome P R E S and uh delegates of that, they haven't seen it, but they've heard it. It's only one case and not sure how they would manage it. Ah So Press syndrome, I'm glad you asked that because actually a month ago, I saw my press my first ever um Press syndrome. So for everybody else presses posterior reversible encephalopathic syndrome. Now, um it usually has an acute onset and most people experience a range of symptoms like headaches or seizures, but can also have, you know, uh focal neurological symptoms without any particular neurological pattern. So press people postulate is a complication of preeclampsia, but actually can also manifest with a preeclampsia being um diagnosed. And I'll try to explain press as best as I can through the case that I saw or that came through a maternity assessment. So this was a 34 weeks pregnant woman who would come in with a sudden episode of visual loss, like, you know, completely fine was in the shower and then suddenly lost the ability to see. She came to our unit otherwise, has no other risk factors in pregnancy completely well and normal BP um and has migraines but has never had migraines presenting in this way. She came in with a kid uh and her husband and you can understand how panicked she must be because she can't see anything. When we did the full neurological examination, there wasn't anything that we could point to, she had a bit of generalized weakness um but had full range of motion. Um I felt very tired a little bit in coordinated um but normal reflexes but of floppy tone, um but no other cranial nerve defects. So, you know, from a, from a neurological standpoint, there's no particular area that you can say has contributed to this. So we then um took her bloods, BP is normal. The urine dip is one plus of protein which is not very significant and we immediately called our neurological teams. And there could be a range of things that could contribute to this. So the main differentials are stroke, a severe form of rare migraine press um or some sort of uh ischemic attack, um T I A or in some rare cases functional, but we can't really say functional until we rule everything else out. So we then we're in a hospital where actually we didn't have an A and E because we work in Leicester works in a kind of a shared care split hospital model. So we then blue lighted her to our sister, I mean the our sister hospital in the same trust, the royal infirmary where they have an A and E and access to all the other medical departments. And um long story short for press, the you might consider doing an MRI or an MRI angiogram or an M R venogram, but actually it can come up completely normal as well. But if you're suspecting press um over anything else and you have a and the woman is 34 weeks. Um So delivering the baby isn't going to be uh detrimental and there's no other diagnosis. You can identify like a stroke or any scheme ick attack, um then deliver the baby delivery resolves the symptoms. Now, if you don't deliver the baby and she has a diagnosis of press, then you're risking um stillbirth for the baby because there's some sort of perfusion. Um a theology that's taking place and of course, um permanent ciena's damage for the woman. So once you deliver the baby safely deliver the baby, um the symptoms should resolve. It's quite poorly understood. Um It's not, it was only first described in 1996. Um So it is quite scary but in cases like press, um that's where we have a multidisciplinary input. So in this case, we had our neurological teams, we had the neurosurgical teams, we had our obstetric teams, the anesthetic team, um and uh economy. Well, one more specialty who all came together, uh the ophthalmological team as well who all came together to try and arrive at a diagnosis. So um approaching these in a multidisciplinary scenario always helps. Thank you so much. I think that's all the questions for the evening. Um So thank you very, very much. I'll to actually have had such a fantastic talk. Lots and lots of thank you from uh attendees as well and thank you all for joining us and staying with us for the talk. Um So I have released the feedback form in the church and also the QR code is on the screen. We'd be very, very grateful for any and all of your peak back and that will help us to continue improving and delivering more events that are located to what you need. Um If there are any more questions you're welcome to ask if not. Um I believe we'll bring the meeting to an end. So I'm just going to stop the recording now. Thank you all so much for joining. Thank you for having me. I hope it was useful.