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So I love my I'm going to get now by have seen. I saw her on my Sofie well for a little bit about second stages by way of context and then concentrates on the munchies on different One hasn't had a chance to see their system of paper GM, as you well know. That's not Rebus evidence, really on the second page, but we try to capture what happened. Was together so well, though it starts, actually, some rising and remind everyone does not have a target. I think that's really important because I still get sometimes talking about that just has like a TV. I was direction great that were very clear. There was no profit. It's what people on every every Cordiant like I think it is important, you know, that's the infection allies globally. Um, one of the biggest reasons cited that is college is a fear of instruments, both on a lot of skills. We heard about that already. Did we need to be focused on no only trading the cystic child birth today about attitudes, reasons why we're not be more similar. Nolan's that Hard Africa admitted that waiting Saban's because you know so you've been feeling jumpy and affection. Challenge of colleges, types of years of watching Do you travel in assisted living is really the father of politics. State program. You across all Sergio. I think three wasn't saying second stage for all of us, it's probably we were general birth ourselves is the most dangerous part of our lives. Are saying it's dangerous for babies potential, but it's also potentially dangerous into the leg stays. We've already heard of today about difficulties. The second stage sorry in sections it's not doing difficulties are infections, but more difficult. Tomorrow. There are some ladies and cockroach review to tell us whether we should be using lotions on full detail. But maybe we can discuss that later off. Jesus, what we're going to talk about today, I have to say for me personally, trying to the north of England, we were training fall, so I paid. It looks like later in life and my train my duty to do it properly. But it does make a mustard difference with this one people. So many with Oh, don't Have you seen it? This is tender. A cops were looking at whether on long device my attention being alternative to both on Tues on full sex and the initial results off by promising. But we have to watch the size you have to think it has. I know in another station look more weight detail. But I think this is really reported that you recognize this as an emergency well trained in what to do. If we're going to attempt vaginal with assisted vaginal births when they might be difficult, we do need to know how to push the baby's head back up bullying. That's because I think it's very important that our knowledge base is all covers across order being stables, not just a specific techniques assistant, actually, although we estimate that it only happened due for sent in the UK, where the difficulty with people have actors Italian, it has to be in terms of all the station. So they talk about this more time, and I'm sure they work different from you. This, that we're looking at trying to on the side of states of that. So we'll send in stage safety generally. Take that we're no longer fixating on reducing, moving away from too much too soon to to make sure we optimize the bosses bacteria that we do. Caesareans of bike place, I'm sure. Six I told. Do you have a big problem with this if I have Yeah, with professional. But nothing is like a negative using horses. Look at how it works. Seen on the train together in that decision making, I don't really think about what's the best thing for that woman. So these are the big things workshops that we do will be doing on a lonely, and I'm going again next year. This is the last, But that's your life. What we did actually in the virtual, So it's quite exciting to be all that. So we don't focus. Direct this particular shop, particularly on juice. Is that any better thinking? Is that back to the people on line? But I you know, like I'm great. Lastly, any thought we have to use to use that was a pain to it, like I have to go to learn new tricks on me. It was a revelation every so then how to use a bunch he's probably on, and what we really need to do is to focus on that flexion point. So those you attrition say I I love cheese cheese for me and every days, and I say it was just which I did. I was young. I had the UTI absolute sure the position of the baby before we would come along to use 11 innings. Do it five points. So imagine infection. What it said on the when you work shows almost like they said, it's just now. And that's why the united facing up on the babies. That was recent to me, to the way from that cost a fortune on where you do the combination. That's what I need to do that. So I said he was just saying, This is really in quarter. You thinking like in egg? If the baby's a simplistic, always in my position on the diameter, so great and therefore you end up with a relative to help support in, even though the actual diameter would victory the total health that is really cool to be thinking about how to flexible he's had and why, and actually you never fractured politically. Actually, Black surveys has, by the way, it's those little so well she flaccid eyes had it will come out. So this is looking at blacks and the lady had based on. That's in that much of a point lights. And if you do on the failure way upon to use is only 4%. I think that's really important because we're open close, not higher. Actually, you can, actually in the seventies, said, If we get that election point, if you just put the bottle and you just put a cup on hoping that it's lower than it should be and this is what so But you might have seen these. Unfortunately, he's in the past, I think, given the Jews about name, whereas if we use it properly and safely, this will know that you got back from being tried myself. So what it comes to choose in the cup? It's very important. We got a call from a new that was possible, particularly off steering oxidants, posterior positions. So anything that has to be one thing, that direction, that's quite a long way away, and it's really important that we get the Cup right back, which is difficult to do on the old cups that we used to use with that vacuum was anyone use us also. Yeah, I used to like with on the bed. Let's come. Actually, also like this one. You can leave, but that's that's really important to do that the New Jersey is really important is to show you again, have some of the old bones walls. You come back back on that. So this is just a little bit of time. So you want to do something? And if I lay back, tortures quite warm is to the pain place. There's a seven straight in, like so people cereal on 10 ounce three sent me to the way on that before faction Point is, So we need to know what his Ishan of a little back, please. And follow that material is Hold on that, huh? You want to get with this way? You have the Cubans got C cup in the Syrian like you just said you did. You did well with affection points. I'm always down the line. Say say it was distressing. Hear that a pushing? What's this? Do you want the sensor off? He would have to be sent actually here, So I feel like this is pushing it down. The line allows it, which is why you have infection. It's seven So that's the biggest thing to do it because there's a little tendency, especially. You have got some experience before she actually you should be okay. But actually it's always in the midline, and that's one of the big There is always in the no, I said it was just saying It's really important to measure. So imagine from the Troy Tous with flexion parties that medicine so that you have Ms is on the sand, so you're more likely with your right. So the next thing is to create a vacuum on those in today and she goes back to using they. Some people like to use techniques you in order to be a spray conception with vacuum. You need to put a little pressure on it just outside. And then it's also about nothing. You touched base. Sexy connects feel that sense. It's well, See that shot? You heard People's and it's getting bored. Kind of used to think it's inside. I'm following the hell this that same time. It swells when sure you go up. So actually my father heard of the pelvis, has it comes around, but that's in the traction is really important, actually interesting and I didn't get to stay in the debate, but the meat chicken would like to do to you so actually backs of the doctors doctors way. Some of the pelvic have a little physiology. That's what we do. So actually like that, because sometimes the temptation, if you could expect to think what I would do very quickly. And actually you don't You always thought that extra effort to take time allow the parent to stretch, try and minimize the taps. Perry. I'm following access it. Help this as well. So I said we should do the non funny. How important Study that on, to pass on that one before you. Really important. All the happens when the baby's head is not coming is that normal physiology is sold forever. Reason whether that's powerful position. Did you get a collection points and just I mean it will, but it's up. So selection back in quarters, so show you the measurement between the tried this on the election point is very important that we get, and this is what I was saying that the last appointment say in the midline which, uh which is just a revelation. But I believe it, so I'll just be quick because it made me sort of want to have a quick go with. So So how does anybody we wouldn't put you on the spot? Look how you told Just really great below that in stage, obviously, in short, in a second station, the benefit of the obvious reasons seems like yesterday about whether HIV is a culture sent a shin. It isn't particularly, but it But it measures, you know, show how high load is. So I think that's something you need for that session, particularly without sleep. We're looking at training in countries where the HIV prevalence is important. Um, when so it is not related. Strictly speaking, we shouldn't Most of those probably do if we're confident that that's kind of a bit outside. But sometimes you just have to do what we think. It's the nasty one she's originally described. You said it was not as the surgery wasn't don't know, and very importantly, make sure you always attacked me in unless he's do you want to? Sometimes we just need to go out or looking off having assistant assistant, so I'll say just any questions, other, any problems, he is a little sad, but you promise Great. Okay, so you feel that people, It's not. I remember so I thought I just needed a way. You say you were older? Yeah, he's a very good question. I think it has to end. You have insomnia. And I slept Friday. Know, I feel I mean, it was low. I think that's the station. And I great, you know, where you what is it began almost accusing. So I remember eating Find out of my I think, yeah, I think, by the way, I think in this situation what I usually do, because I think it I don't think this is like, I think I'm having a really online somebody's asked, How do you measure the finger length when you're doing it on Tuesday? Livery. So the thing that I would say so most things about these except me touch milk. So you made it from the enjoyed just went for his literally with your fingers, although he has a guide on it for life. So that's how much, literally the beginning find the posterior Contin I'll go three centimeters from It's a long substitute teacher, and then that's a 30.2, which oh, so she was saying It's so. It's usually near the channel. No way. So you have to measure that by five in Lotus and then measuring in addition to that. So it's not like that science. But a rough guys number send you to the point now. Usually thank you on. Unless if I wanted him on some of my office with a metal cups. What's your files? This is what it is. Go access today. Six. General, I think he has been attraction with with Mexico's. I think I think when I was talking difficulty is that it's something It's a little setting. I think it will be useful. Is a big issue with active? No, just no way. Should be looking up supporting a usable for weight. Yes, I am. He monitors. We did one. This attraction caved us for a huge around. Busy 1 lbs. Okay, but it's different with this. Manages change way into that. So I see that. Yeah, that's less than you might think, isn't it? It's one. Yeah, I've got five more minutes left in this room. So if anybody wants have a girl or have any other questions? Oh, bill based around you want, if you want. I'm telling you. Yeah, So I said before because I have colleagues one being low setting I e um, So just a people working in places holding his last year. I do. It's course if you wait. Wait, He's hard to get the numbers Also. Night. So you what, like this way? So great. So let's see. So this is you have to be trying way. Wait, wait. Cultures that, you know, looking back to when I stopped using it was it was really sick. And you are you I just really these about having people like Just, like, stayed on some things on the ground, Supported these sounding that. Actually, no, you don't say that in several exception of getting the you know, the drive is actually very Yeah, yeah, yeah. Thank you very much. I think that's all we got time for in this groups on Lucy is gonna take this group on to your next workshop way. People that asking They did awesome. Yeah, online people. So you can now leave this session and select a new session. Okay. Hello. Is that better? Oh, no, It's all right. I'll see your your colleagues know you, that's better. And then I'm positive. And your your number is all right. Right high People who have just arrived. Can we check on you? Hear us? Doctor writes. Just gonna check the microphone, See if you can hear. Can hear that. Hello can hear us. You're welcome to call me Alison. Catherine, by the way. No said anything yet. I think so. They can show them properly and thank you. Bring him here. Just get a minute. Yeah. Oh, so I think I think it's all right. They say they can hear it. Yeah, So we shall we start that? And so I'm also might I'm going to just run through some basics off second stage because I think it's really important that we put volunteers in a context. I know that you're gonna be speaking about forceps in more detail. That workshop tomorrow on there's another workshop on impacted fetal head, but I think it's really important that we look at everything in the round. If anyone hasn't managed to see this, obviously, I would say there something is a good paper. There isn't a great deal off Rebus data when it comes to second stage management, but we have tried to gather what there is ourselves and the confederation of mid wives. So it's it's worth looking at this. We will need to be updating that even in the next few years, actually, so I don't need to tell anyone. The Caesarean section rate is rising. I'm glad on a pill often to do actually is here, because it's really important that we remind people that we don't sell. Your section right has to be 10 to 15% anymore. I think it's really interesting when we talked to doctor colleagues and midwifes around the world. What are the reasons that we are doing? Our office is Aaron sections. Increasingly, some of you will know much more than then I'm saying here, but just very basically like of skills and assisted vaginal birth is often quoted as worn off. The reasons Glenn Molehills, some of you may know, is a doctor in pop in New Guinea on he's been a really champion of assisted vaginal birth, and he stood up it a conference a few years ago. Very mold. Lee quite rightly challenges ultrasound a water. You was a little comment Fiego organizations want you doing about assisted vaginal birth training very similar to Barber Nolan's who Andrew Weeks was talking about. He was working with substance or in Africa and seeing women waiting for cesarean hours and hours because nobody knew how to put on a gown to Scott. So this is really important, And this is why we started this quest to trying that people trained in second stage skills. Being in the second stage is the most dangerous part of all of our lives. Assuming you were heart of a journal birth one day, going through our mothers Canal is the most dangerous Stay off our lives by a long way. He's also very dangerous for the mother. We know that it was oxygen levels drop very quickly in the second stage. We know also that Mother has potential to bleed on, have other complications, sepsis and so one of the second stage. So second stage skills are absolutely crucial, and I'm really glad that we're focusing on them today. There's a lot of discussion which we can talk about later chemo or forceps, whether we choose one or the other. I was trained in the north of England. We tend to use full set. So that was my training. Initially, I came to you on Tuesday relatively late in life. I don't want telling you I had to kind of re learn promptly how to use one two's, because when I was a youngster, we would just talk just to put the bomb, to use our and pull on. Now, obviously, our training is a lot more skilled and sophisticated, which makes a month of difference. There is a cop from review is quite old. Know I I don't know of any back today to sense, looking at how we choose between Vacuum and four sets that maybe we can talk about that later. I think it's worth mentioning. Oh, Dawn. Anyone who knows him drink holes in his work on him is high. I'm hearing this, and it was developed by someone in Argentina car mechanic, actually looking at the physics and what happens in childhood. The old on theoretically is good because you don't need to know the position, but but I think it's still working progress. I think it's really interesting to see what happens as old all goes through. Its trials impacted little handle just mentioned because I think it's important and one, but trading an assisted vaginal birth. It's really important that we know what to do when the baby's head gets stuck. And I know one of the other work shops were gonna be looking back in a lot more detail. But it's important because it leads to think about because although it only happens in probably 2 to 4% of cases, actually it's double that in terms of the case that then go to ST Gatien. So intention, very complicated and something that we all need to know how to manage. They're very different maneuvers, but I think that the key point for May is to know the position of the baby's head before you go for cesarean. Even if you're going to do a cesarean knowing where the baby's head is being able to flex it, you could break the top much more easily on that will come on, too, with the vantas is well, so just before we move onto onto specifically, I would say take the key, take off messages here that's safe to a second state is that we have to optimize. This is Aaron section rate. Use Robson's criteria. Listen to women. Don't use what we think is a target that was in days gone by. I really class that the soma twice a mid wives in the room, Any conference doctors, no other rational. So I'm It's really important that we all work together with the team, no matter what our professional, what are rolling in terms of supporting women. I'm not that well trained together. This is one of our workshops. This is probably the last time we did a a proper happens on face to face. It's really great to be able to make today. Hopefully, we're going to get back to doing that all the time now. So just mentioned the late, great album blocker on. Also here is Ross who so his colleague who trained may involve in twos. We're just going to talk about the importance of the collection point first, so you're embarking upon to use, unlike what I described when I was a youngster, when someone says, Just put it on, however, you think I'm ashamed, saying what we need to do is to be absolutely sure of the position of the baby, and we have some discussion with the last group. What if you're not sure? So we can talk about that later? But generally we should just be making sure we are sure. And even though it's uncomfortable for the woman, usually if we explain why it's really important for her safety that we actually find the flexion point. So so if you just want to demonstrate where that is, so the affection point is a present to me, it's along the It's such a two seater from the posterior fronton L S O. Ensuring that you have this point is really important for successful Want to use delivery so you have the posterior ones now here and then you follow along three centimeters down to find inflection point on the satchel suture. So, um, I think there's less use. I think of it like that. So if you imagine putting an egg into neck up on, know, having smallest diameter, then that I'm going to fit on. That sounds really simplistic, but I think it's a really good rule of thumb because if the baby's head is not flex correctly, then it won't be the smallest I am until it to come through the birth canal on. But I think for men who has probably got a very bad name because some of us, we're not using it properly. And if you don't use it properly and don't get the election point, the complication rate goes from about full to 17 and above. I don't know whether any seeing, but this is what a form to use about name, I think by people you're not using it, probably not using it right where you know and inflection point. Sorry for the glory pictures, but I think it's important just to make that point that if we do it properly, we can avoid those. And we have to. Especially as we're talking about introducing on Tuesday in areas where perhaps the uses less, we have to make sure that we're all skilled and probably trained to do it. So it's really important when we're looking at the cops election that we use a cup that's maneuverable on. But just ask. So feedings, though, had to show us Miami those real cold and especially, for example, if the position was paid. You want to just yeah, so in a known Lee position, then often the flexion point is quite a long way back. And so it's really important that we use a cup, either. Manson court, all this cup that's able to get really far back and then get on the actual election point. So but so I just some of these five steps, I think it's worth spending a bit of time on these. This is described by I'll go back, and this is the way that we should all be using some twos. So, first of all, ready to locate the flexion point. So so field of study? Well, it's so in three centimeters from the posterior from now. He used to be so Holden insert, cut. And then we knew that cop towards the flexion point, which is what Sofia is, just a. The next thing we need to do is to create a vacuum, which is so hell demonstrate now so related that vacuum. We also need to make sure that there's no tissue so occasionally that could be vaginal to use. Also mixed, trapped as you can imagine on that back in. So it's really vital that we do whatever we come to make sure that there's no issues there on my number five, obviously, which is the easiest one. Probably build up the vacuum pump, which so how is doing on? But I was saying to the last group, I have talked midwives to do 12. I actually think that they're much better than we are and because they always down to normal physiology there. Patient, they went with baby to come down, and they look at the way that the pelvic curve naturally works. Where is some of us? Sometimes move it in patients who have a pool, not unnecessary the right direction. So I was in my junior go march Mid wives doing that's watch her Exactly how the baby comes through because that's what we need to emulate. Are so hurt just don't know. So the axis a traction is really important that we follow the pelvic curb promptly on that we maneuver have to use as we go. They're not calling home, and you just want to demonstrate what we do with that number you have. So it's important that we just guide and ourselves was doing keeping a fun there on the bottom, too, so that were guiding it through, and it provides count fresher. Now someone was saying this morning, all that happened was one of these not coming through, which is for the dilated or second state, is that the normal mechanism is stored for whatever reason, you know the woman's scan. She's not analgesia all the baby's not in the last session. There are lots of reasons, but basically the normal mechanism is stalled on. We just need to encourage it by flexing the baby's head simple as that. And then it will also rotate. Okay, so one of the one of the biggest things that island is the first one point is always in the midline. And that's you know, if you are in your instance, I was when you're learning to do you want to use probably you will think it must be somewhere electoral. But it isn't. It's always in the midline, so that's really important. So we're just going to finish off before anyone has to go. If you like to have a good ongoing use so similar to four steps delivery for a long second stage, generally a little compromise as you know which one's being increasingly careful with our language. So we try not to use terms like fairly to progressed anymore. We're talking about progressively with about we try and avoid using those negative terms. But basically these are the reasons why so prolonged second stage we try and use rather than fairly to progress when not to use. So we have some discussion in the seaside meeting yesterday about whether um, HIV is a visa and which I'm speaking to some colleagues in South Africa, actually, because they do use from twos on. I think it depends in terms of HIV prevalence when people have access to viral load estimations, which was obviously quite crucial with that scenario, I think useful for us to discuss further on whether the cervix is dilated, we say it should be, I think, with experience. If it's absolutely a multiple, I think it's reasonable to do without, but that needs to be with caution. I think the last one is the most important. If you don't know the position that people had, we should not be putting on Tuesday. So finally, manual protection was really important. As with any delivery, we need to be protecting the peroneal if we possibly can. If you got a system do it or otherwise. We need to do that at the time and just allow Arsu down. Told us today sometimes you just can't allow it to turn. Left it to do in the last week. That which is really nice. Okay, so will be a lot of questions. Um, maybe one or two people want to have go. We won't. I'll stare at you. We will have discussion. Anybody wants to go and have a girl. Well, we're doing some talking. Okay, I five minutes. So, God is that people don't have ago. So that was an opportunity from the back way. Won't help. What? You know, it just let's bring the corner. If anyone else wants to do is well, yes, I think you I was just wondering. Um, Yeah, definitely. Yeah. No reason at all. Why not? So if all the conditions from general after that I really know sets up and safe, then you can do not to use delivery. Just a You could do, uh, allow things to happen spontaneously on. In fact, sometimes it is a way that we do to limit the second stage in. Somebody has seen the previous surgery on you. might be slightly worried about a scar. If they're in the second stage for a long time, it might be a good idea to use on to. So yes, we are commonly is a cesarean. Yeah. Absolutely. Absolutely. So any compressions? A vaginal birth, esteem to be reasonable after cesarean, then a bunch of use? Definitely. Also reasonable. So if a vaginal birth was contraindicated So yes, what did they advice or really, Aydin's your experience. How many times can I can I try? A few fails one time just pops up, but it's a good question. Um, they asked you to kind of change quite recently. We still say three calls. So three pulls is what the current house here to you guys didn't send us. They also now have it on. But if the heart is on the parent here, you can give another three gentle pools. I'm any contradiction or anything that would make you change the third time you put it, you know, compare with the first. Yeah, right across the. So they also have also added now, just recently, a closet says if after two pools you're not seeing progress, you shall be reassessing so previous college students was three pulls yes or no, which was actually quite frustrating if you knew that you were nearly there. And similarly, when each pill you don't get any more of that school, we should not be continuing. So yes, I think that's really pertinent of those of the reasons why the osteo GI guidance changed recently. T flex that that if I clinical opinion, is that the woman is my progress. We're making progress. We should be continuing. If we're not, we should seek a senior personal. Is that opinion? Uh, this's But I think it's a medical part of it is something that we are trying to encourage all fixed stuff to be involved in. So, you know, there was some difficult cases. Worse, somebody might be calling on pulling because they're in the one at the baby and and sometimes it needs someone else to say, actually, shall we? Someone else to help. Shall we consider an today etcetera? So I think it's speak of culture in That's well, it's really important. Yeah, well, I I wouldn't caution again. He's putting them on Tuesday. I don't know the position. I would say you shouldn't do it. I mean, there might be exceptional. So himself. This house I have had if someone's been in labor with such a long time, the tissues are so swollen. Sometimes if the baby's had very low way, just have to try so the right things. But I think generally we should not be putting on a bunch of these awful zaps or anything if we don't know the position. Yeah. Sorry. Yeah, much. There is the minstrel evidence out a year now the rate of success of the box on. But it may not just apply it, uh, vaginal birth on. But it's not about you Try and look through it for about success of a John over. So yeah, so we would we would, um, support women. Happy that anytime you end, I think what? It was much sometimes people think that way past If it's been 10 years ago, therefore, the reason to risk. And I would say there was always a risk that what we search says there was always a risk there. Thank you very much. Not from online know. Toe will move on. Lucy will take this group on to your next workshop on online people, please log out of this session and then log into the one that you haven't attended yet, But I e o e okay. Uh huh.