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um so you're going to start? Okay, Uh, you, uh I'm Dr My patients, um the the consultant that the sample and just trust and the throw back and see who train train be changed the region regarding instrumented generally. So we all know what the indication finds him into delivery. So when that is an inadequate maternal progress and she's been fully dilated Paris women for more than two hours without a regional, the CT or three hours with regional anesthesia. Oh, our. If there's a multiple, it's women. We could wait for two hours on if there's a metal exhaustion of the moments exhausted or it could be a fetal distress. If there is any suspicion in the CT G or abnormal, it appears well, sometimes we do. We want to short the second stage when there is maternal hepatitis, A crisis or cardiac are disorders. So assessment need to completely assess the women properly. Make sure that she has got good energy on bold. Never tried to attempt to instrument and elevate their allergies as poor. Tried to get an epidural. If the patients know, uh, doesn't want any urine. If you want to instrument to live in the room. Better go for a little or a good panel block before you. I am done. Instrument of delivery. She looked for the fetal heart condition, whether I mean city to try, there's any need to expedite quicker on make never attempted instrumented delivery men that it's more than 1/5 of the head palpable. Better priming do our Ain't doing is assessment. Just no, just a food allergy, tension alone and character phallic presentation on a boy or a It should be the sagittal future should be in the midline. Not never attempt anything on the okay are the positions. Look for the contractions. Look forward to sent for the maternal effort. Most important thing is just have a good drop over the patients on. Never tried to do it in, um, instruments when the baby when the patient has got a lot of fear and pretension trying to, you know, like the apple on Before coming instrument delivery. Make sure they bladder is emptied. I think the all annoyed system It's not something new, and I can't stress enough in communication and consent. We should really get the consent from a patient before the injury. Never tried to do an instrument of delivery. Uh, I couldn't get a consent from the patient. In City Hospital, we tend to be, oh, being with diverse. But if your patients who sometimes don't speak language onda hence they come in for induction off labor or when they needed in a very small progress, meaning augmentation, things we normally tend to use the language line on, get them consent for all the eventuality. Any instrument of delivery FBs all cesarean sections because there are patients because you can get the language line next green in some languages where we sometimes find it really hard to get the interpreters online, so we know I'm going to spend some time get go through all the process. Ah, always have a good explanation, but let's try to take the samples after instrumented delivery on please document everything. The main thing that I doctor trying women talk to today's about the proper documentation on to look for the trauma Bolic. This factors number Is it instant little baby and getting one shot of antibiotics and proper bladder care and office your therapy in deep breath and discuss the subsequent rare but sometimes for substance such a common thing that we do 12 to 15% off. Our women do have four substantially from the Paris women. One third of the women are really what instrument Adela be, but sometimes we don't debrief. We don't explain why I needed on what we did on. Sometimes that's those things could be a big issue. So when do you want to take a lady for trial? But it's a delivery in the room, Um, so we all know about never be, um, iced higher and that you're short metal, a stage er or and that's a big baby on board that you expect that might be a difficulty. Or if it's not an over a position since then, or any rotation of the new, it's better to take them later on a be position because of the oh people. Session is specially with the capital morning, sometimes the by front diameter. Tran looked like the of by parents diameter and can look as if it's below the spines, and it could be dizziness. They're actually the largest diameter might be still about the spine and the child that you failed. It would be like a higher on never attempted instrumented every in the room if the head is more than a palpable abdomen. So it's always a bachelor to, you know, like do a thorough assessment before attempting an instrument in the So I just wondered this this couple of cases that recently occasion that we are not just we're going through that That's a patient who so 42 weeks she was very keen to try for vaginal delivery. So she had been to the city classes, had a lot of conflict sessions, and she was so keen for normal vaginal delivery there was a slow progress, and hence was 52 daily sweet. And then we have to go through with her and started on oxygen syndrome. And finally she manages to be fully dilated. But then that that stays there. The concerns of the CT. So we were planning to attain control. Tighter patient didn't want to have an instrument to delivery. She wanted only says add In section we went through the pros and cons. Patient here doesn't wanted any instrumented. It'll be so be she consigned a consent for a section. Been to court today they're had a spinal and then reassessed her at this point that it was really low and it was no a position. So they're registered and back, discussed with the patient on, went ahead and did the force of still a very on But, uh, did the surgery, but the documentation was he had done the documentation of guarding for, um it is your to me. But he didn't mention about the anus. Victor be on examination. So 60 years later, she followed to be have fecal urgency and incontinence. And then she's been to the physical therapist. And then we had it in indoor in the ultrasound by the Colorectal 13 and found to have a defect in our external sphincter, and they blamed everything down to the full substantively that she had. And when the reason I just brought in this case it's mainly because the documentation of performance everything was documented. But they didn't document the PR examination whether the anus think they're intact and things those things have not seen picked. So if it's not written, it's not done. So another case that will discuss about a lady who had the issue with the language about here, um, she just recently mean to the country, and she doesn't speak much English. She had a figured riding cardio, so the Register comes in examines fully dilated, straightforward instrumental delivery, and MPC Artemis is we'll suture ing on. Then, when he was coming to the skin, there was another emergency buzzer, so he has to leave this women. Onda, the midwife, completed a PCR to me surgery. Then three months later, we get a complaint letter that the husband off the patient felt that we neglect and his wife on a didn't come on, be brief. Why we did what we They're on all those things in order for us, even though forceps is such a common thing that we do all the time. For women who had a no expectation off instrument delivery anything, it's always better sometimes to be a team member. Talk. So most important thing you need to develop the drop over the patients or sometimes over the majority for jobs are done by mid fascinating. To go on a normal day, live on some of the times they come back and tell us this patient has got this question's this patient's and start something, so then we can go back and talk to them. So one of the key learning points which 100 days is try to, uh, if you think if there's a lot of cardio, it's a weird position, the head is really no. We'll go ahead and do an instrument of delivering the room because decision should definitely in trouble is and then average takes 15 minutes to Denver in the room, but we take them to take her how quick we are. We can take up to 30 minutes on also just get keep practicing on the manikins before applying on the really patients and things. And I want to talk about the pageants matter. What? So you want to play the so when you want to play the force? It generally I don't want you. This many wanted apply, You know that we are to be pounding to the inguinal ligament. And just like the forceps on the proper Paget matter of hours, you need to really rest straight. You know this shaft here, you get frustrated, and then this thing beautiful, uh, pull it horizontally down. Never go down like this, never never go down. So if you go down and pull you can see it the place hit against your pubic bone and so that it's not mustard sense. But if you do a proper protest matter, if you go down, you can see it going in into the pelvis and it can have a good day. Perfect. And I'm happy to take some questions to be having impressions accident. Thank you very much. Traction questions. You have a woman who's progressing? Yeah. Case can be little bit louder, please. So, letting fully dilated and pushing, is it motion? Do decided for some delayed second. See, Why would you do head? Yeah, um, in medical implicated better. Any instrument of delivery, Anything Caesareans that we need to get paired Car gas x is, uh, uh just to make sure any emergencies is Adam's any because sometimes do it for, ah, fetal distress on even failure to progress so that in sections we don't need to do, uh, cord gases because many chance you think it might be just for delay. Second stage, but during instrument, a delivery baby can't come. Uh, okay, but shocked. So that might be associated shortness. Tosha. It's always a good practice to get compared, uh, cord gases because that's the one which is going to help us in the future. Uh, regarding the, you know, the condition of the baby because the new things can come up. The only thing that's going to go stand up on the court of law is your car pair. Uh, car gas, is it? The gases were normal. So that tells you maybe he's a scale things, isn't it? And I have a question on line in vision situations. Bradycardia. Had a patient mentioned sustained distractions. I mean, um, that I mean, that's one of the reasons we've got a big printer consent form, you know? You know, even it. We started getting frequent and consent form thing called include all the complications. Centrist. But sometimes when there's a broader cardio, we go around quickly. Tell them about the me to do a force, absolutely, and the risk that you may be might have parts in the face and also that it's just that that term, it's going to the back passage. Um, I think it's better to try to do it quickly, and and I think with repeated practice, you were completely, uh oh, Okay, so we use it we know that I we have information which they're about this from what I expect, it happens. We have research that so that the time their mother is not really a little depression. But I think I'm the when this happens Verify Quite open. I seen I mean it. The second big piece of the street. Yes, well, since school's, maybe he needed. But the issue, they will not really. Which is why he and I do think that what you you do it exactly should be on. There will be a one c which which has to be the worst. I totally agree with you. I think we should have done it on, but that person who has done it, it's also quite seeing a remission. But I don't know what really happened. Why it was Mr Weight's not being documented. And we have to do the thorough assessment. You're like off the sphincter. I had been to your thirties early forties because long time back almost in Georgia years back. And that's when I met you. I mean, I don't really agree and take your, uh, your points on, but we also have this thing should be. You know, I you know, and some of our trainees got some translation projects. They got around 22 languages. They translated quite a few things that could happen. Labor. Make sure this tosha instrumented that repeated that some planes, they're in sections, they got this consent and then in different languages, not the consent of information. If let's on, then they reject to give it to patients who come in for induction off labor. We wanted to give it to every patient. We want to send it across to everyone. But then we have heard of a position for a moment perfectly that we are opposing normality. We are trying to show his care patients with Children's Tosha 30 test for substituting things like that. So then we chose patients who are increased risk. Those who were like divertics inductions and things. We give them those, you know, in it. But no, this that's no. So you Yeah. No. Okay. Yeah, yeah, but you know, I okay up. It's okay, I think. Hum. Yeah, right. Thank you. Yeah, I uh huh okay. Yeah, it was no Okay. Yes. Yes, yeah. And but, um, just But thanks, but oh, yeah, that Yeah. No. Yeah, I Thanks a lot, doctor. You you have to fill my space, and I'm going to be there. Uh, it's really miss. Well, thank you. That's a lot for, uh, deficient, like, literally just helps them.