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Hi. Um, I'm Louise. I'm an F two. I work in Manchester right now, but I studied Edinburgh. Um, so first we're gonna do, um, obstetrics. Um, for, for finals, I feel like compared to fifth year exams, obstetrics is quite like, just mostly more ba like the basic stuff. It's not like the really um nitty go to difficult stuff that comes up in um fifth year as far as I can remember. So I tried to just kind of cast a wide out of things that it's quite easy to forget. Um, and like the basics so that you kind of know, like sort of a little bit about everything. Um, full disclosure. I didn't make most of the MC CSI made some of them, but a lot of them were from my M sra question banks. Um So, yeah, I'll turn off my camera while I'm presenting. Um, but yeah, um we'll go from there. Ok. So kind of going in the timeline um of like Antenatal care first. So, um also I'll let you guys read the questions unless you can put in the chart if you want me to read them out. But sometimes it's easier for you just to read them yourself. You can let me know what you prefer. Um, but I'll let you go ahead and answer that one and we'll go and talk it through. Mm. Mhm. Mhm. Am I, am, am I starting to pull or how's it working? Yeah. Yeah. Thank you. Uh OK, we will stop it there. So, quite a mixed bag there. So the correct answer was a which wasn't many people. Um So it's G four P two plus one. So I've put all of the, the gravidity is in red here. So she's currently pregnant, has a daughter, a six, was pregnant with twins, which counts as like one total pregnancy and then had a miscarriage that's G four and P two. Um The X for the two is in blue. So she's had a daughter and um twin pregnancy which is also one, um one each and then the Y is for the number of pregnancies which um were before 24 weeks. So like miscarriage, termination and ectopic. So that's in the yellow there and that's one because she had an early miscarriage. Um So yeah, it's quite, it's quite tricky to get your head around in terms of like the number of pregnancies, all that sort of stuff. Um But it is quite easy mark if you remember them to like pick up the party and that's probably the most complex type that you'll get, you know, like in terms of having twins and um miscarriages and stuff. So the next question is how many weeks gestation would a pregnancy be considered postterm? Ok, nice. Um Most people have got that right. So yeah, it's 42. So let's have a little look at kind of the trimesters and anal timeline. So first trimester is the start of pregnancy to 12 weeks. Second is 13 to 26 and then third is 27 until birth. Um Term is defined as 37 weeks but less than 42. Um And what so 42 would be postterm and then the estimated delivery date is calculated at 40 weeks, which is 280 days from the last menstrual period. So sometimes these can be quite useful to remember. I remember, I'm pretty sure we got a similar question of like, what's of this one and like what's described as term in, in one of my exams somewhere. So it can be useful to remember those and other key points in the antenatal timeline. Um I'm sure you guys have been passed when a ton of them come up. Um I think the key ones to remember are these ones. Um the booking visit 10 weeks, the dating scan at 10 to 13 plus six. And then the anomaly scan is um 18, sorry, that's not an equal sign 18 to 20 plus six weeks. Um So yeah, I think if you're gonna try and remember anything. Um I would try to remember these ones. Um First cool. So which of the following physiological changes are normal during pregnancy? Ok. Quite an even split between B and E your answer was B. So the red blood cell volume increases by about 20 to 30% plain volume, cardiac output and stroke volume, they all increase rather than decrease. Um So that's why that one is um the right answer in terms of other physiological changes. Like, you know, this diagram has a ton of them. Um And it can be quite like overwhelming to remember. I would say um I've put the red circles around the ones that I think are the most important to know like the what happens in the lungs and what happens in the heart. Other things that you can be aware of, I wouldn't memorize this as your top priority. But, you know, um remember about the hemoglobin, we're gonna go into that in a second. Um A little bit about the LFT S knowing the AP has increased. Um And a little bit about how TSH goes um in the different trimesters. Um I wouldn't get really bogged down in this, but it could be a question that comes up. So, next one. OK. Um So most people are going from b which is the correct answer. So let's go a bit into anemia. So the screening is a booking visit um 8, 10 weeks or 8, 12 weeks and at 28 weeks. Um There's different cutoffs for each gestation. So the first trimester, um the cut off for it being called anemia would be 100 and 10, then 100 and five and then 100. So that's quite easy that they go like, you know, down each time. Um The management is just kind of the same like f fever or sulfate. Um And you want to continue this for three months after, um the iron deficiency is corrected. Um They can also use um IV iron um in the from the second trimester if there's no response or um the patients not tolerating oral um probably cause of like the gi side effect. Um And then in terms of blood transfusion, it's mostly given for like bleeding um and kind of like high risk situations rather than kind of anemia. They'd rather I think sort of wait and safe. Um and, and try and like correct it with um oral iron or IV iron. Um So that's gonna make you to want to remember and yeah, just if you get someone with um bloods in pregnancy and how and what the cutoffs are for. So the next one that, what about the aspirin and not too long ago ago, weren't you? Uh the under nasal care? Nice. So most people are on the right track. So the right answer is b um so majority of people got that. So asthma uh uh asthma aspirin is used to reduce the risk of hypertensive disorders during pregnancy, which will go on to um a bit later. So nice advised to take 75 to 100 and 50 mg of aspirin from 12 weeks until birth. And if someone has one high risk risk factor or more than one or like, so two moderate risk factors. So you can see, um, here there's a table of the high risk ones, um and a table of the moderate risk ones. Um So depending on what the um what their background is. So for the example, on this one, the patient had sl E so that would be high risk immediately. They would be taking um aspirin from 12 weeks uh until birth. And so it's really popular, like when I was Moss and Gyne, they really liked aspirin. That's really meant to be good for um the prevention of high chance of disorders. So there we go. Um And last one, I think for antenatal care, close stop there, most people have answered that and most people got it right. That was fairly straightforward. Once you remember kind of similar to asthma, just the like thing, the sort of um indications four or 5 mg or um 400 mcg. So they were, it's recommended that um anyone pregnant takes 400 mcg of folic acid from 12 weeks um until week, 12 of pregnancy. So I guess if you think about it folic acid before then from 12, it's which is um and that's when you take aspirin and a lot not that they not that the indications are the same. But um that's when the cutoff of timings are. Um So any and it's for anyone who has a higher risk um of neural tube defects should take 5 mg. So you with epilepsy, diabetes, cem rate BM I of over 30. So this patient has BM I 31. Um And then this is just to reduce the risk of neural tube defects. Cool. Um um oh sorry, last one. So what would be the expected um sy basal fundal height um for a patient who is 24 weeks pregnant. Nice. Most people have got this right. So, really easy. So it's measured. So the um S FH is measured from the top of the pubic bone to the top of the uterus. Um And after 20 weeks, um it kind of matches as a gestational age plus or minus two centimeters. So for 24 it's gonna be 22 to 26. Um Anything else? Um you'd want to refer to um for further investigation. Um So yeah, perfect. So we've moved on from antenatal care to kind of like different conditions that can occur in pregnancy. The two top ones, if you're gonna not do any obstetrics, apart from two things, do these two pregnancy induced hypertension and preeclampsia and diabetes, I would say. Um So we have a patient who's currently got hypertension. What would you do with the management? Nice. So most people have got this one. I think the other person's put be, it wouldn't technically be wrong. But labetalol is still first line when I checked yesterday um on the guidelines. So anyone who, although, although it's, it's first line for a pregnancy induced hypertension, which will go into the size in a second. Anyone who has a past medical history of hypertension and is on something different like Ramipril, um A RB or anything, they have to be switched um to labetalol or Nifedipine as well, depending on their risks. So, we've got a few more questions for hypertension, hypertensive disorders and then we'll go on to the revision explanations. OK? We're quite a mixed split there between ABC and D. So the correct answer is D. Um So I guess it's kind of two partial. You first need to remember what the first line management is um for um preeclampsia and then uh preeclampsia and then you have to understand what you need to monitor. And the last one before we go on to some quick explanations. OK. Quite a mixed from there between ABC and DRE. Um So the correct answer here is reflex is difficult to elicit and in preeclampsia, um patients are actually hyperreflexive. So they'd be really easy to elicit. So that's gone to a bit of explanation. Um So gestational hypertension is the cutoff is BP 100 and 40/90. So anything above that would be gestational hypertension. And the key thing to remember is 20 weeks of onset. So, if someone is hypertensive before 20 weeks, it's not gestational, it's essential hypertension. And then the next one along is preeclampsia, which is gestational hypertension plus. Um It's most of the time it's proteinuria, but they can have thrombocytopenia. Um LFT S are off pulmonary edema and they can have headache, visual symptoms. Um The answer was reflex, reflex is difficult to elicit. Um and then eclampsia is when you have preeclampsia and then you have a seizure. There's also hellp syndrome um where you have sort of th thrombocytopenia and elevated A LT and AST. Um and hemolysis, that's kind of like a subset of preeclampsia. So risk factors that we've got are in the, like the in the previous um aspirin size. I haven't repeated them there. But like the, the ones that you want to go on for um for prophylaxis of hypertensive disorders are kind of the same risk factors. Aspirin use for prophylaxis. Um Every patient um is monitored for um hypertension at every nasal appointments. They get the BP, they discuss symptoms and they get a urine dip sick. Um If a person has gestational hypertension, the target BP is below 100 and 35/85. Um and they should be admitted if it goes over 1 60/1 10. Um if they're known to have gestational hypertension, they'll get weekly urine dipstick monitoring for um progression to preeclampsia, um weekly um bloods to monitor for Hellp syndrome. Um And they'll also get more often, they'll get growth scans. Um And then management of preeclampsia is kind of the same thing as above, but they get their BP monitored even more often. You don't need to do a dipstick cause they've already got preeclampsia. So you're not looking for anything new. Um And they'll get ultrasounds every two weeks in terms of the management, there's a lot of management, you know, a lot of different things to, to know. But I think for the key things to remember are first line is labetalol. Second line is Nifedipine. Um Unless they're, they've got asthma, that's the key thing. Make sure they don't have asthma in the um questions them and then that otherwise that would be first line, third line is methyldopa. They can use like IV hydrALAZINE and stuff. Um But that's probably not gonna be a question that comes up in finals. And then the management of preeclampsia is with IV mass soft to manage seizures and you want to monitor um the respirator as we found out in that question. So next, we're gonna go on to gestational hyper hyper uh gestational diabetes that was quite a quick stop for um hypertensive disorders. But I think those are the main things that are likely to come up. Um Obviously, if you've got time and you want to do more. But in terms of the amount of questions that are coming up gonna come up for abs, I think that's probably enough. Ok. Ok. We've got some mixed answers here. So the correct answer is e um, and then we've got one other question to do and then we'll go into some explanations. Ok. We've got kind of a mixed response again. There. The correct answer for this one is insulin, which we'll go on to in a second. So gestational diabetes, um so the risks that the risk factors for having it are um high BM I previous um big baby over 4.5 K EKG um previous gestation, gestational diabetes, family history, um and an ethnicity group with a high prevalence of diabetes. The oral glucose tolerance test is what you use for um screening. Um If they have had previous gestational diabetes, it's done as soon as possible. Um And then again, if it's not, if it's negative, then they do it again at 24 to 28 weeks. If or if they have any of the risk factors that you see above, then it's done at 24 to 28 weeks. Um Diagnosis is from a fasting plasma glucose of 5.6 or above and a fasting uh a two hour plasma glucose. So that's after the oral glucose tolerance test of 7.8 or above in terms of management. Um They need to have a joint diabetes antenatal clinic appointment. Um If they have a fasting plasma glucose below seven at diagnosis, you can do trial of um diet and lifestyle, then you see them again in one or two weeks. And if the glucose uh the glucose um results aren't on target, then you need to add Metformin. If anyone has a fasting plasma glucose of over seven as was in our question um seven or above. Sorry, as was our question there and then they need to be immediately treated with insulin. Um You can use Metformin or not, but you would need to sort of know whether to use insulin and Metformin. Just know that they do need treatment with insulin at seven or above. Um And as well, obviously give them um diet and lifestyle advice, um, other notes for diabetes um as well. This is just gestational there. Obviously people have diabetes um prior to pregnancy. Um So if they've got preexisting diabetes, you want to advise them like prenatally um to aim for an HBA1C of 48. Um And if they have an HBA1C of O of 86 then um, pregnancy wouldn't be recommended just for the risks that are associated with um gestational diabetes. The main one being um, macromia and shoulder dystocia. Um So that, that's kind of again like a whistle stop tour, but I think those are the main things that you, um should remember for gestational diabetes. Um And knowing you're kind of for one, your, um, your diagnosis, um, 5.6 and 7.85678. Um, and also your, um, sort of treatment targets. Unlike when you treat with what? Cool. So, next month nausea and vomiting in pregnancy. Yeah. Cool. So, a bit of a mix between D and E, but the correct answer is e so a little bit of nausea and vomiting, it's really common. Um, most cases don't require treatment. It's not associated with like bad outcomes either. Um for, you know, like for the pregnancy, um most cases resolve within 16 to 20 weeks. Um and the non pharmacological managements are ginger and risk acupuncture and pharmacological antihistamine. I think it's promethazine is the top one, or phenothiazine, which would be like chlorproMAZINE. So that's kind of most of what you need to know for nausea and vomiting. Um And then the next one about hyperemesis. So nice. So most people got that one. So it's more common in um multiple pregnancies. So, hyperemesis is kind of like severe nausea and vomiting in pregnancy and the patients get dehydrated electro imbalances, ketones in the urine. Um and they have um weight loss. Um It's more, more common in pregnancies associated with higher levels of beta HCG. So things like multiple pregnancies down syndrome and um molar pregnancies. Um So in, in terms of investigation, you want to do a physical exam for the fluid status, do bloods, um check the thyroid as well. Um You want to do an ultrasound to exclude molar pregnancy or multiple pregnancy. The pharmacological and non pharmacological managements are the same as in um just, yeah, general nausea and vomiting. But the key thing here to remember is if they, if they're dehydrated clinically or they have ketones in the urine, then they need to be admitted onto the antenatal board for um IV fluids. Um and probably IV antiemetics as well. Um Just until just because of the risk of like the dehydration and the electrolyte imbalance. So that's one of the key uh aspects there. Cool. So the next one is to be honest, kind of a mean one. Yeah, one that I found very difficult to remember personally. OK. So a bit of a split one, it was actually varicella zoster virus. Um I find torch infections, one of the most difficult things to remember, you know, the different syndromes that come with them. One of the diff most difficult things to remember, you're only gonna get one question of it. So um so torch stands for the like the common infections um that can occur during pregnancy and have um sort of like impacts for the mother and the and the child. So toxoplasmosis o always other. So you've got syphilis, um Varicella zoster parvovirus HIV and tons more rubella CMV and HSV. So they can be transmitted via the placenta during birth or through breastfeeding. They kind of common general risks are like stillbirth, miscarriage, intrauterine growth restriction. Um And then each sort of um infection has specific manifestations. So, in the question, we saw varicella zoster virus, I would say if you have time and you want to, you know, make sure that you've got everything covered, then go ahead and remember them um and try and revise like um congenital rubella syndrome, et cetera if you don't, I wouldn't say it's your top priority. Um And just try, you know, some of the management of um HSP like with a Ciclovia. Um And I'm sure you've guys have done tons of personal questions with the chickenpox in pregnancy um as well. So the next one is on ad Yeah, sorry, I realized after I made these uh um they don't do the negative questions anymore, but I'm sorry, still, it could be hard. OK. So quite a split between A BD and E. So the correct answer is a, so following spontaneous miscarriage at 10 weeks. So we'll just go on to a little bit about rhesus. So it's the recent antigen like in blood. So like o positive O negative, et cetera. So if a patient is um rhesus positive, then you don't need to get any treatment. If the patient's rhesus negative, the aim of the treatment is to prevent sensitization. So if a mother who's rhesus negative has a baby who's positive, then she can become sensitized. And then the risk is that in the next pregnancy, the sort of anti d antibodies will cross the center and attack the next baby. Um And that can um have a risk of hemolytic anemia of the newborn. Um So rhesus, if a, if a mum is found to be um negative, it's routinely given at 28 weeks. Um and then at birth after the baby has a blood test to find out its blood type. Um and then these are the other times that nice recommends um rhesus to be given. So, in the surgical and medical termination or miscarriage, a spontaneous miscarriage over 10 weeks, the one in our question was uh over 12. The one in our question was 10 or a threatened miscarriage over 12 weeks. Um And times when there could be a plan transposal hemorrhage. So, in amniocentesis or chorion sampling and also in ectopic pregnancies. So just be aware of those times that you would give it um and be aware of kind of the reasons and the indications that um rhesus negative um patients would need to have um an TD. OK. I'd say that's kind of all you need to know. So next we have, do you know what? I'm gonna skip this question just for the interest of time. Uti pregnancy, treat asymptomatic bacteria to avoid progression to pyelonephritis. Use nitrofurantoin except in the third trimester. Um and use or otherwise use penicillins and cephalosporins and avoid trimethoprim, especially in the first trimester because it's teratogenic. That's all you need to know. I'd say just cos I'm kind of running out of time. I've got a lot of questions to go and same with this one. Sorry, obstetric cholestasis. It's diagnosed by really intense itching, but with normal skin and a raised bilirubin management, um kind of says like 37 to 38 weeks should be when patients are inducted. But the guidelines kind of save us depend on how high the bile assets are. So it's not gonna be something that an F one is gonna have to make a decision about. And the aim is just to reduce the risk of sbir. That's why they do the early induction. Cool. So we'll go on to this question about cool. OK. So most people are saying c which is the correct answer. Um So molar pregnancy, um you can either have a complete mole, which is why an empty egg is fertilized by one sperm or a partial mole, which is when you have a normal egg that's fertilized by two sperms. So that would create like a triploid um like um ok. Um And then you can sort of tell by if they have nausea and vomiting. So it's one of the causes of hyperemesis, um vaginal bleeding. They have a large for date uterus um And they can be hypertensive as well. They need to be um they need to have a specialist referral um cause they need evacuation of the pregnancy because it's um, not viable. Um, and they also need to, um, have this or special care just because of the risk. There's a small percent of chance that it can progress to choriocarcinoma. Um, and they should be told to avoid pregnancy for 12 to 12 months as well because of this risk. Um And the picture here shows um, a complete mole which is a bunch of grapes. Um, picture on the ultrasound. Nice. So I'm also gonna skip this question about GBS. Um So group B strep is quite a common worry for people. Um during pregnancy, it's a common commensal. Um The guidelines recommend not testing everyone and even maternal request is not an indication for testing someone and um who should have antibiotics are people who've had previous GBS. They've got, if they've got positive swabs, if they were swabbed for some reason, anyone pre going into preterm labor if they're parial during labor. Um And the management is with um intrapartum IV benzylpenicillin. Um I'll let you have the slides after if you want to do the questions, but I'm just kind of running out of time and there's still quite a lot to go because there's just so much to cover. So I'm skipping some of the different questions. So we'll go on to this one about O VT E so, so slightly mixed, but most people have got the right idea. So it would be to immediately start low molecular weight heparin. So VT E in pregnancy, these are the guidelines. So everyone gets their VT E risk calculated at booking and at birth and you give low molecular weight heparin as prophylaxis depending on their risk assessment. Um if it's needed. So classical would be like people um with antiphospholipid and stuff. Um If a patient has suspected VT E because pregnancy and they just because of like the physiological changes that we discussed earlier, they do become um, in an increased risk of having a BTE. Um, you need to immediately start treatment with low molecular weight heparin and then stop it depending on the results. Um, in terms of investigations. Um, if you think they've got a DVT, they need to do Doppler ultrasound. If you think they've got a pe, then they need um, a C TPA or a VQ scan. These, uh, like it's kind of a bit up and down like what the best one is because there's risks with both to either like um, mother or baby. And so a discussion with radiology and the patients decide the best one is the best option here. Um And then another note definitely don't do ddimer and don't use the well score in pregnancy because it's not useful. So those are the kind of key things you want to start prophylaxis. Um Sorry, you want to start treatment um, with low electric heparins like betapar and oxy, depending on whatever trust you're in. Um, you want to start that immediately. Um And then, you know, pull it back if, if it's not, but it's better to treat first and then find out afterwards. Cool. So a little bit back, fetal movements, one of course, most people are on the right back. So you'd want to refer at 24 weeks. Sorry, you can't really see that, but it's d 24 weeks. So a little bit about reduced fetal movement. Um When I was on down, it was a really common um presentation to emergency triage. Um So they usually come on about between 18 to 20 weeks. You need to refer to secondary care if they're not there by 24 weeks. Um And then make sure that like at every appointment you're safety netting about coming in if they have reduced fetal movements. Um because they do need investigation for that. Um If they come in with reduced fetal movements, if they're over 20 weeks, you wanna do a handheld Doppler if there's no heartbeat, her, then an ultrasound and if there is a heartbeat, then they can get a CTG and then if they're below 28 weeks, um you use a Doppler um and see what happens. They don't, they don't like CTG S in kind of um earlier pregnancies just because they can't use the dog Redman criteria as well. Um And then the concern like for people having reduced fetal movements is because a lot of people with stillbirth say that they had reduced movements before that. Um But you can kind of co people and say that like one single episode of reduced movements um in mo in like a lot of cases isn't a big risk. So people get really worried about them, but it's still really important to safety net them for, to come in for urgent investigation. Ok. So we'll go to this one, remember, skip a little bit of it. Ok. Most people have gone for the right one. So the answer is b so placental abruption is a premature separation of the placenta from the uterus. You have a triad of vaginal bleeding, abdominal pain and uterine rigidity. I find in MC QS it's pretty easy to tell. Um, when someone's got an abruption, they'll have like a tense woody uterus. That's kind of the classic ones. Um One of the risk factors that everyone likes to remember is cocaine, but there are a lot of other ones like previous abruption, smoking, multiple pregnancy, high age, high parity, et cetera. And in terms of management, as long as you know that it's an emergency, you don't really, you know, and they'll, they'll probably get a quick section like you don't need to know much else of that. Um As an F one, which is what they're testing for in vinyls. So I'd say may be able to recognize it, be able to know the risk factors and be able to understand it's an emergency and that's most of what you're gonna need. Um Got a little, little table of other causes of bleeding in pregnancy depending on the trimester. So you can have miscarriage interme one and two and ectopics intra one while they pregnancies as well as a cause of bleeding. Um And yeah, you can read it on the slides after, but these are the kind of different causes of bleeding presenting in pregnancy and then a little bit about placenta previa as well. So this picture shows a different grade. So they, it goes in grade 1 to 4, um depending on the severity. Um, grades three and four require ac section just because of the risk of bleeding. Um If you had a vaginal birth, um and in terms of the surveillance for it, um you'd have a scan at your scan at 20 weeks, shows where the placenta is lying, depending on where it is, you can get rescanned at 32 weeks to check if it's still there. Um And they'll come and go on for this as well. If someone who's pregnant presents with pain, painless bleeding and then you'd be suspecting placenta Praevia. Um And you want to admit them, use an at E approach and then consider an emergency c section depending on sort of um the gestational age, um and stuff like that. But again, as long as you know that it's an emergency and what to do, you're not gonna be making a decision on what of when to do a section of realistically. So we've got about five minutes left. We're gonna move on to labor and delivery. Um I'm gonna skip this one. Um I didn't even put the answer anyway. So, um, so chorioamnionitis can come on um in labor. So there, it's a leading cause, leading cause of maternal sepsis. There's no kind of single, most likely bacterial cause like there is for pneumonia or anything. One of the biggest risk factors is um premature rupture of membranes. Um in terms of how they're going to present, they're going to have signs of sepsis, which I'm sure you already all know the sort of specifics would be abdominal tenderness and a foul smelling discharge. You want to manage them using sepsis six. and then they might need an early delivery and ac section and then use antibiotics dependent on the trust guidelines. But again, as long as you know, as long as you're able to recognize it and manage it in the basic ways, you're not gonna be making a decision of when to deliver realistically. So we'll do this question. Ok. Well done. Everyone's got this one right so far. So the answer is d so admit for these 40 hours antibiotics and steroids. So this is a patient presenting with um P prom. So in terms of diagnosing it, you want to do a sterile speculum with like sterile um surgical gloves, um you would look for pooling of the fluid and then you can also use an amnesia, which if you've not seen it before, it kind of looks like a pregnancy test, like you just put dip it in. Um, and that can tell you if it's amniotic fluid or not. Management is with regular abs because they've got a big risk of developing chorioamnionitis. You want to do 10 days of erythromycin. Um, you want to give antenatal steroids um which reduces the risk of respiratory distress syndrome and they'll probably likely have early delivery. Um And then other complications um are to the baby is um R DS because the lungs aren't properly developed infection, prematurity and then the mother has a risk of developing chorioamnionitis. Ok. This one as well. I'm gonna skip um a little bit about induction of labor. Um So it should be off people with pregnancy of over 41 weeks. Um rupture of premature rupture of membranes. Um Other maternal medical problems like preeclampsia, diabetes, et cetera cholestasis as we kind of discussed earlier and anyone with um intra intrauterine fetal death. So, the methods that they do is they can do a membrane sweep and they as assess the bishop score, which is on the next slide, depending on the bishop score, then they can get sort of like um a suppository um or they'll get um sort of um an amniotomy which is when they break the waters. Um and, and IV Oxytocin drip. Um and one important complication to remember that comes up in a lot of MC HS is the risk of uterine uterine hyperstimulation with um IV Oxytocin. Um So what you want to do is you want to stop the um infusion. Um and then they use tocolysis to kind of reduce the amount um that the, the uterus is contracting because it kind of, if the uterus is contracting too much, then that's a risk. There's a risk of fetal hypoxia. So sorry, that's a bit of a quick one. But yeah, I'll, you can have the slides afterwards. I'm sure you guys have seen the bishops score before. So I'm also gonna skip this one cause it's a really easy question. Um So, Cesarean sections, the most common is the lower uterine. I'm sure a lot of you guys have been into ac section. They're categorized by urgency. Um So I would also remember the layers if you can of the uh that you go through during ac section um cause it can come up in exam sometimes um beware of the indications and the risks. Um And then beware of the contraindications to um vaginal birth after C section, which is here, a vertical C section scar or previous uterine rupture. Those are the two main ones. So sorry, that's really quick. Um We'll go for this question next and then probably be the last question. OK. Most people have gone for the right answer there. So the answer is a which is compress the uterus um and catheterize the patient. So, postpartum hemorrhage, um it classed as a blood loss over 500 mils. Primary PPH is within 24 hours and then secondary is within um 24 hours to 12 weeks. Um for primary um PPH, the causes are the forties. So, tone is the most common due to an atonic uterus, um tissue, um and tear and thrombin are the other causes. So the management is an a to a approach. Um and there's sort of additions that you do for specifically for PPH. So rubbing up the uterus to kind of because the most likely causes tone is to try and like get the tone back into the uterus, catheterize the bladder as well. Um You want to give um IV Oxytocin, um it's like a um an injection and then IV ergometrine, um unless they're hypertensive, you don't give ergometrin, you can give I am carboprost, um which is contraindicated in as uh um in asthma and that's kind of the medical management. And then, um in terms of surgical management, the first line is um a balloon tamponade which um helps to kind of like it goes in, it goes into the uterus and it kind of um they blow it up and it helps to kind of with the, with the tone of the uterus. Um And then it goes, there's other options going along to emergency hysterectomy um and then secondary PPH um is caused by mostly by retained products of conception or um endometritis. Cool. So we'll skip this one as well for a shoulder to associate the risk factors. I'm sure you guys know macrosomia diabetes, high BMI labor and previous shoulders of. So the risk um to mum is um postpartum hemorrhage and tears and also the psychological risk and the baby can have risk of brachial plexus injury, brain injury and, and death. Um The management here is written down in this diagram to be honest, the the most that you guys are gonna, I would think that would be coming up as call for help and mcroberts maneuver on suprapubic pressure. Like after that, it get, it's getting quite specialized with the AIOT and stuff. So I think as long as you know that there is a uh like a way that shoulders associate is managed, I think you can probably um just re re revise the first part of it. Cool. Um So I guess it's kind of probably time to stop. I can give you these slides after I've gone. There's a bit of umbilical cord prolapse and perineal tears and then there's some postnatal sort of mental health stuff and also um some postnatal endometritis. Um These are also topics that I didn't cover, sorry that it was really fast. Um There's just so much to cover and I was trying to kind of cast a wide net to um, remind, sort of not teach you anything new but just remind you of what was out there in terms of the topic. Um, so I hope it was somewhat useful. Um, and yeah, we can have a little break if that's ok with everyone.