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Yeah, so, um hi everyone. Thank you for joining us on a Monday evening slash afternoon. So we have um Doctor Paula and SIA here today with us to give us a lecture on labor and CTG. So I'll hand over to you guys and if you have any questions, please pop them into the chat. Thank you very much. Um Give me a minute. Uh Apologies for my very quirky voice. Uh I, I've just got a bit of a cold but it's very nice job all here today. So we just go ahead. Ok. So, yeah, my name is Paula. I'm at the teaching here at Chelsea um Westminster and I'm also an registrar. Uh I just put my four disclosures out that I graduated from Kings and that's probably what they say about me at the moment. Um And my email is at the bottom. Um Living in this session we meet up, I'm a consultant obstetrician here at child so we can get started. So this is session structure. Now, I know that you've had a lot of teaching already. Um That's kind of er does labor and induction and CT doesn't quite lend itself. So I've tried to kind of adapt it, but we're gonna cover quite a lot. Um, normally when this Patel and I deliver this session, it takes somewhere in the reason of 3 to 4 hours. So we're going to try and condense quite a lot in, into the 90 minutes that we have. But, um, please do put your messages in the chat and we'll be, um, going through those as we go along, um, to make sure you've answered them. Hopefully, this is just for vision and not mean I know there's still one rotation there. So again, if there's been, aren't clear, please please do ask the session for the structure. We talk about induction of labor and then about the three stages of labor and the substages, we're gonna go into interventions when there is a delay in labor and how we manage that. And we're gonna go and see which everyone is very excited about. Um has lots of questions about. Um I will just say um that is also on call at the moment. So if she runs out, it's not because um you guys are scared, it's because she's also on call for the lab. So she won't need to excuse herself. Um She just thought that you aware of that um these are some objective objectives which kind reiterate what we just covered. So, induction of labor and s that you use status of labor and also recognition of normality and a and C and that's pretty much all right. So, induction of labor. So it's not quite induction of labor. And I think that's done guidance, probably something I hope you've had a lot about already. And so this is just to give you a snapshot and I say this is something I would definitely try and commit to memory. Um Now it's by no means exhausted. But if you try to bear in mind what we're trying to do with an induction will hopefully help you in. Is this an indication for induction or not? Now, in maternity, we always do great things and fetal, I've also got pregnancy here where things don't fit into a specific box. And I think as it pertains to you can certainly your paces exams, please do try and break things into subcategories in maternity. You're always with at least two patients. And that's the thing that you have to be in mind in terms of induction of labor. One of the things that we're essentially trying to do is to prevent the risk of still either due to unknown fetal concern or due to a maternal condition which may haven't impact on the center and therefore on the fetus. The other thing is we're trying to balance the mother's well being um and the risks of early delivery. So for example, in the case of um pres preeclampsia diagnosis at 30 weeks, we wouldn't want to introduce that one at that time or deliver her at that time because of the risk of prematurity, we have to balance the risks of the mother of continuing the pregnancy. So as the risk of the baby and think about how we get that balance right? And it's a be careful balancing act, but there are some conditions which have quite clear defined plans. So in terms of our maternal conditions, some of the more common conditions that we would recommend induction labor for diabetes, whether that's preexisting, type one or type two diabetes. And those of you who have already done an option. G the nice guidelines stipulate specific time points depending on the medication that woman is on and her control um as well as that there gestational diabetes. And again, that probably makes up quite a large bulk of more common reasons. We offer reduction also includes hypertensive disorders of pregnancy. So hate the initial hypertension and that is when we're thinking about pre existing hypertension and gestational hypertension of pregnancy induced hypertension as well as pre occurrence. And all of these will fall into the R type sensit disorder pregnancy. And depending on what the underlying etiology is, we'd be thinking about inducing between 37 and potentially 38 to 39 weeks, depending on whether it's pre or preexisting or worse than hypertension or chronic hypertension. Other things that we would think about recommending induction for our ICP. So that's intrahepatic cholestasis of pregnancy, also known as obstetric cholestasis. And again, with that, we depends on the degree of disease. So, if women's bilas are well controlled and they're less than 40 she can probably go up to probably quite, quite close to term. Versus if she's got very severe disease byses over 100 and her risk of having a poor outcome. And that would be a stillbirth. It does increase fourf compared to the background risk. And for her, it be recommended in her between 35 and 36 weeks. Now, I try not to give you lots of lists and lots of things to remember, but principles that will be helpful. So I think the key thing to think is what is the condition, what's the impact say on the fetus and on the placenta? And does it warrant induction of labor? So all of these conditions we've discussed so far have an impact either on the baby or on the placenta and and would warrant induction long term line in advanced maternal age, which is a mother over 40 women over 40 are also advised to have um an induction of labor by no 40 weeks because you know, they are at increased risk of other maternal and other ties may take to complications. Since we think our fetal complications, you've got the two extremes of sides. So you can be too big or too small and that presents different concerns. So if you're too small, we think about placental insufficiency. And again, if your placenta doesn't work very well. That means that with increase in gestation that you are at risk, still that and again, there's degrees of similar and I won't go into all of those. But it's just to be aware that if, if there is a small baby, we might think about inducing another time. And if that would be by other factors such as the normality or abnormality or dopplers or any other risk factors, If you're a large baby, the evidence isn't quite as strong as of yet. But generally, most people would recommend some form of either induction or delivery by by. But again, the timing of that might vary and that evidence is not quite as concrete as the evidence of small but would be a potential induction indication. Probably the most common one is reduced fetal movements at time, which I suspect anyone that's been on a maternity assessment suite or triage has probably seen one really reduce or and then I'm sorry. And then uh pre labor rupture of membranes or pre preterm labor rupture of membranes is another reason that we think about inducing. I probably want to say that with preterm or pre labor rupture of membranes. In that indication, we would actually organize that process because actually the process has, by definition started. So I should just put a little caveat by that. And then in terms of the pregnancy specific ones for post maturity. So uh baby that's gone in 41 weeks. And also, if the mother's had one previous Cesarean section, we'll also think about inducing her. If she would like to have a child delivery, there's a few snapshots. Um, I'm going to pause for breath and just check. There's no questions so far. Ok, we'll just continue. So in terms of the induction of labor process, I know that we've made it quite a linear, nice, neat process here, I think there are key things to remember with induction of labor. It's not necessarily, it's not necessarily step wise. So therefore, that means I've seen you as the clinician examine the woman and on vagina examination, she was only three centimeters dilated. The membranes are bulging which got very soft cervix. You don't need to do the membranes and the cycle to go straight to rupture the membranes. So in as much as we discussing it with women and say our maternity assessment suit or an we talk to them about the whole process, we need to count on all of the different things that they might to expect as condition of the future. I want you to understand the principles and what we're doing. So that you know why patient a didn't necessarily go down the same induction as patient. But generally speaking, every induction process is going to start with a vagina examination that might be a doctor in clinic, it might be the midwife. The next thing that we would do is a membrane sweep, which I kind of put, well, which is just outside of kind of the other induction pathway. It's just because a membrane sweep alone wouldn't be a form of induction. It is en route to induction. And that's why you're trying to essentially separate the membranes um off the um the, the internal cycle loss. And that stimulation may be enough to start to stimulate the process of survival for a small group of women that might be enough to get them into labor. But it wouldn't be something that we would be saying is sufficient to start the process of labor. The next thing that.