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Can you, are you able to see the slides now? Yes, thank you. Private. Okay. Uh um If you want to start now people will keep trickling in. Um Not. Yeah. Would you like to start? Okay. All right, I'll just introduce quickly. Hello, everyone. Um Thank you for coming today. Um Today we're here with us. We have um uh doctor me know who is uh obstetrics and gynecology registrar at Katherine Hospital. Um And she's going to be talking to us about obstetric emergencies and without further a do um over to you. Thanks, Paul. Hi, good evening everybody. Uh I'm Meenu Nanda Kumar and I'm currently an s defy training at the East Midlands Divinity. Uh I'm currently training in catching General Hospital. Uh Prior to this, I'm an international medical graduate and I have trained in ob strict and gynecology in India as well. Um And during that period, I trained in the largest maternity center in South Asia. So let's say I do have a bit of experience in talking about this topic, right? I understand all of you are most uh for the um medical students. So have been to the clinical side of things. So hopefully this uh session will be useful and uh give some insight to this topic. Yeah, next slide please. Right. Every uh specialty be it either medical or surgical. They are faced with an emergent situation. Occasionally in obstetrics and gynecology is no exception. In fact, emergency situations are extremely common in obstetrics and pregnancy poses this unique challenge where a single emergent situation can have an impact on the life of both the mother as well as her foetus. So it is really important that clinicians who are practicing in obstetrics um are up to date, not with just their clinical skills and scientific knowledge, but also they're non technical skills like communication and working as a team, which is really important in managing uh emergency situations and getting good outcomes uh for more than 60 years now, uh the confidential inquiry into metal deaths in the UK has painted a picture of the maternity care in this country and we are able to understand not just our successes uh but also failures. Though emergency obstetric situations are extremely well described and there are clear management protocols and guidelines as to how to manage them. We continuously see from these reports uh of examples of substandard care and women being affected very seriously because of this uh lack of care up to the expected standard. So it's really important that we understand how to uh manage these uh emergency situations. If you look at obstetric complications, there are a number of situations that you can put under this uh blanket term. So I thought in this uh talk, I will concentrate more on the general principles into managing risk so that the uh the chance of occurring of an emergency situation can be reduced. And also general principles of managing an emergency situation, which is going to be same in uh whatever situation that is posed in front of you. All right. Next slide, please. So, like I said, looking at a few general principles to minimizing risk of uh complication occurring in a pregnancy, starting from good antenatal healthcare, which is the crux in getting a good outcome in a pregnancy. And the essence of good antenatal care is risk assessment. Uh starting right from prenatal uh pre conceptual counseling. You need to review the women periodically to assess their risk and also to put in place is uh certain interventions that can prevent a complication from arising. For example, uh the midwife's, he's the woman at booking and measures her B M I and refers her for a glucose tolerance test to diagnose diabetes during pregnancy or just a good history. Taking with relevance to family history can flag up an increased risk of preeclampsia. And thus we start aspirin for these women. So the risk of preeclampsia and its complications can be reduced in such women. Uh and uh the embrace report bought in 2021 2022. Uh focused on the stark inequalities between the outcomes in women of Black and Asian ethnic minorities and they're White British counterparts. It is true that Black and Asian women have a much higher chance of dying during a complication in their pregnancy when compared to their white counterparts. And also the importance of language barrier and socioeconomic inequality. So women come from deprived socioeconomic status or immigrant women, no matter what uh racial background they come from are at increased risk of having a pregnancy complication due to obvious reasons. And so we do need to take some extra precautions with these women to uh ensure that certain protocols are in place to reduce the risk of complications happening. Uh um And the second part is an organized intrapartum care. It's really important that uh the obstetric team and the midwifery team work in coordination so that women in labor are cared for appropriately, especially the most senior obstetric person and the midwife in charge need to have a shared understanding. So as to women getting the care in labor that they deserve. You might have seen during your postings that when some people are on call, no matter how busy the delivery suite is, things seem to be under control and things seem to be done in a very calm manner. Whereas when few other people are on board, no matter how quiet the delivery suite, actually, the numbers may seem everything seems to be chaotic and out of control uh the technique and skills to managing both staff, as well as the workload. They are multiple and they're usually acquired through years of training. But then next time when you have the chance to be on Delery Sweet, and you happen to come across a person who comes in the former category, just take a moment to sort of observe what they're doing differently and try and emulate that into your clinical practice when your chance comes. And the third most important thing is triaging uh risk assessment and prioritizing women based on risk, especially when they are in labor or come in a situation where you have a very high workload. Then it's really important that you prioritize appropriately. So ABC which goes in all other, you know, specialties like airway breathing circulation that stands the same uh in obstetrics as well. But then in obstetrics, you need to factor in the fourth factor, which is the foetus. Sometimes it may not come all in logical order that you secure ABC. Before going to the foetus, you may need to uh act for an emergency situation for the foetus. Uh and then go back to like um optimizing uh not so life threatening condition for a mom. Yeah, next line please, right. Um Soon when you are working in your clinical activity, no matter if it's in delivery suite or say in any, these are a few hints to keep your workload under control. Be aware of the activity happening around you and prioritize your workload. So as to go, you finish off the person with the highest risk. First. Listen to your colleagues, be it midwives or your uh obstetric counterparts, listen to their concerns and address them accordingly. We've already talked about prioritization and it's also important that you allocate patient's are allocated to the person who has the specific skill set to take care of them. If there are a few simple things that can be done very quickly, then get that out of the way, keeping them on just uh keeps adding to your work, Lord and again, do not differ, decision making, unnecessarily. Again, that just adds on to your workload. It's really important that you recognize your limitations and ask for help when you need it. And it's also important to recognize your colleagues limitations and awful help or encourage them to ask for help when needed. And also when you have a high risk patient on your delivery suite or in your triage, keep revisiting them and see if the situation has changed and act accordingly. Don't let the problem to keep mounting and then it comes to you as a huge issue. All right. Next slide, please. Right. I know we all say team workers dream work, but then sometimes working as a team has its own um challenges. You may not know all the people in the team and what they are capable of doing. And sometimes one person doesn't know what the other person is doing. And in the end, all you have is chaos and you know, situation just goes out of hand. So a few aides to good communication and teamwork is that someone needs to assume a lead role. It need not necessarily always be the most senior obstruction on labor board or in that emergency situation. Sometimes your senior registrar, maybe trying to do something like uh securing hemostasis in uh Cesarean section. At that time, it may be the midwife in charge who needs to take on the lead role and coordinating accordingly so that the registrar can do a more important job at hand. Okay. And if you have any unknown staff in your team always clarify, there is and while allocating, make sure that they're happy to do it and also allocate rules to March the skill set that the patient uh that that particular person has okay uh avoid duplication. Have a person a dedicated person described to note down timings and two uh no down, you know what actions is happening at that time. And also please don't forget the patient and the partner while managing an emergency situation. Make sure that there is a person who's speaking to the patient and partner even if very briefly, just so that they feel uh calm and feel well cared for. Yeah, next slide please, right. Uh Like I said before, there, it is important that there is a dedicated person in the team while managing an emergency, whose scribing, but more often than not the most junior person in the team is allocated this role. So they may not have a complete understanding of what is happening and what all is being done. So when you're involved in uh an emergency situation and I mean, you can, you hear us, you've just frozen on us, sorry guys. Um I'll try and we'll try and get this sorted as quickly as we can. I mean, you can you hear me meeting? Sorry about that guys. Um Hopefully um doctor mean you can um get back with us. Uh Yeah, sorry about this. I think she's left the meeting. Um and there's about to join back in. Hopefully it works now. It shouldn't be too long now. Um Sorry guys, let me just email. Mean you quickly. Hi guys, sorry about this. Um I just emailed doctor mean, hopefully she can join as soon as possible. I will let you know once she gets back to me. Sorry about this. Hi Zoe, who just joined. Um I think our speaker's having some technical difficulties. Um Hope you should be re joining soon. Um If she's not able to, well, we'll reschedule the session. Sorry about this guy's okay guys. Uh If our speaker's not back by five to fortunately have to reschedule the talk. I don't really know what's happened. I'm really sorry about this. Um Hold on. I just got back from many adopting Nantha Kuma. Uh, she's just trying again now. Hopefully she can rejoin. Um, but yeah, I'll keep you guys in touch. Sorry about this. Hello? Hi. Are you having issues logging on? Um, hi guys, I'm just on the phone to doctor Nantha Kumar. She um should be joining any second now. Just sorry for your, thank you for your patient. Um I think hello guys, I think doctor nothing is going to try to connect from my phone now. Hopefully that should work. I'll keep you guys posted. All right guys, we're back on track now. Um I think I'm still sharing my screen. Can you guys see my screen? Ok. All right. Sorry about that. No problem, no problem. Um Can you, can everyone see my screen? Yeah. Okay. We'll keep going from where we left. Yeah. Can someone tell me where I stopped? Because I thought I'm in and I think I kept talking for about five minutes. It was about obstetric images. I think just at the start of obstetric hemorrhages have fun. All right. So you got the thing about uh risk management and things? Okay. Fine. Yes. Uh I'm not able to see the screen though. Have you shared the screen as well? Let me try. I'll stop sharing and start again. Okay. Can you see it now? Yeah, again, thanks. Right. So let's get into the individual uh emergencies again. It's going to be more of an overview. Uh and basic principles behind these management because like I said, it's, it's quite a vast topic and talking about each individual uh emergency in detail would be a bit too much. So, obstetric hemorrhage is a major cause of both metal mortality as well as mobility worldwide. Thankfully mortality in the UK because of ob strict hemorrhage is low. But then there's quite significant mobility from all the audits that we have been seeing, uh do two substantive care that these women receive while huh undergoing a major obstruct hemorrhage. Uh Again, the crux of managing these women is identifying women who are at increased risk of a major hemorrhage during the antenatal period, particularly women who've had previous cesarean sections and placenta previa. This is a very dangerous combination and morbidly adherent placenta or placenta accreta where the placenta stuck to the you train myometrium. This needs to be ruled out and these women need to be cared under an M D D team. And clear protocol needs to be put out as to what needs to be done if these women present with hemorrhage or out of us with vaginal bleeding. Okay. So major obstetric hemorrhage is uh defined as a blood loss of more than two liters or ongoing blood loss, more than 1 50 ml per hour, but sometimes two liters, maybe a bit too much, especially for a women who is of low B M I, less than 18 or women with preeclampsia who start off with a contracted uh blood volume uh to start off with. So sometimes a rule of 30 can be used in these women where blood volume of 30% is lost or if their heart rate increases to 30 from their baseline, or if there's a fall in their diastolic BP by 30. It's also important to remember that bleeding can be concealed especially in abruptio placenta where there's a premature separation of the placenta. The then the bleeding may not be revealed. Uh You need to suspect this hemorrhage when uh women present in pregnancy with severe abdominal pain and there is uh funding height is more than the corresponding gestational age with severe uterine tenderness. And also if there is an intra abdominal bleeding, say a pre woman with a previous cesarean section is laboring uh and has had a uterine rupture. Sometimes the vaginal bleeding may not be much, but then they might be having massive intra abdominal bleeding. And also if the uterus is shifted to one side, that may show that there is a broad ligament hematoma in sight. Thank you. Next slide, please. Right. Whatever form of hemorrhage, whether it is antepartum, hemorrhage, or postpartum hemorrhage, the basic principles are the same. Once you come across a woman with a major obstetric hemorrhage, lie her head down, give her left lateral tilt. If she's pregnant, give 100% oxygen too large bowl cannulas and quickly pushing two litters of crystalloids need to give her own negative blood while awaiting specific groups. Specific cross mash blood basic investigations need to go out as urgent, which is a full blood count group and save cross match coagulation studies and use the knees. We can also uh make use of point of care investigations like venous blood gasses. Uh him A Q which both look for uh the hemoglobin and take studies to look at the coagulation factors uh to aid us in what sort of uh blood transfusion products that we need to give the patient. Next slide, please. Specific uh treatment is going to be based on the cause of the bleeding. The two major causes of antepartum hemorrhage is placental abruption and uh placenta previa, placental abruption usually presents as extremely painful, virginal bleeding. Like I said earlier, the bleeding can be concealed in a case of an abruption almost always. This is uh present with women with risk factors like hypertension and pregnancy or premature labor. Placenta. Previa. Usually women present with uh painless unprovoked bleeding and they usually have uh ultrasound finding of a placenta previa, either from the mid Prime Minister scan or from the most recent scan. If you're suspecting a large plus intel abruption and there's also evidence of fatal compromise in in like um fatal heart changes in your C D G monitoring, then the management is very straightforward. You need to deliver the baby under 20 minutes, usually by an emergency cesarean section. Again, if it's a large plus inter previa, then you need to exploit the delivery usually by a cesarean section. In case, uh sometimes women may come in with a large plus until abruption and uh there is already and inter uterine fetal death. Then in that case, if the mother is hemodynamically stable, then there may be placed to exploit the delivery and aimed for a vaginal delivery. However, if there is ongoing hemorrhage or if there is evidence of um coagulopathy in the mother, then you may need to do a cesarean section even uh with the intrauterine fetal death for mother's sake. And almost always, there is usually a postpartum hemorrhage that our company's antepartum hemorrhage. So you need to anticipate this anticipate that and be ready for it. Intrapartum hemorrhage courses can be a you train rupture or a trauma during a cesarean section, both of which is managed by getting surgical Hema stasis. Next. Uh slate please then post partum hemorrhage. The causes of postpartum hemorrhage are the forties. I'm sure all of you must have heard this during your clinical placements. Most common causes stone. Next being trombone and then trauma tone is usually managed by giving cereal you tra tonics, the different you tra tonics that you can use or Oxytocin five units can be given IV bolus followed by a 40 units. IV infusion. You can also give ergometrine contraindications for ergometrine will be uh severe preeclampsia, cardiac disease and peripheral vascular disease is prostate London's for you tra tonics R P G F two alpha and Misoprostal tranexamic acid again can be used to control your postpartum hemorrhage. If your medical management doesn't work, then you need to go onto invasive methods to uh control the hemorrhage. The one thing that you can try is you try and massage. So the picture here shows a by manual uh you train compression where right hand is made into a fist and inserted into the vagina. While the left hand massages the funders of the uterus. This is to give a mechanical compression to uh contract the uterus. You train tampin. It is usually by inserting a hydrostatic balloon. Uh Can you put the next slide, please? So this is a, the first picture is a picture of a hydrostatic balloon. Uh Bakri balloon is commonly used in more centers here in the UK where this balloon is inserted into the uterus through the cervix and the balloon is gently inflated up to 400 mils of uh normal saline. This usually begins to contract the uterus and be bleeding, begins to settled. And if the hydrostatic balloon works, then the balloon can be left in place for about 24 hours and then removed later. And usually this holds the issue for uh atonic postpartum hemorrhage. Uh If this doesn't work, then the other alternative is to do hemostatic sutures on the uterus. For example, the billing sutures where longitudinal brace sutures are taken on the uterus to encourage compression. But if all this doesn't work, then the uh final resort would be to do a peripartum hysterectomy, especially in cases of placenta previa. Along with postpartum hemorrhage, you may need to resort to a hysterectomy sooner rather than later in order to save the mother's life. Thank you. Next slide, please. Uh Right. So a few tips to minimize the mobility due to hemorrhage in cases of an antepartum hemorrhage where you're suspecting a placental abruption with fatal compromise, like I said, deliver within 20 minutes, not only going to save the baby, but also uh minimize the mobility to the mother because of placental abruption. And then when you're a doctor on labor ward, and you hear descriptions like heavy lochia or she is still trickling from your colleagues or the midwives go in person and assess the situation yourself. Sometimes a few trickles in cause when you put them accumulatively can lead to uh quite a large plate and you may be constantly underestimating how much she has lost when you come across a postpartum hemorrhage with a contracted uterus. It's always either due to trauma or retain placental tissue shift, the patient to theater while she's still well for an emergency uh examination under anesthesia and do the needful and usually hypertension is a late sign of hypervolemia in pregnant stage. So don't wait until the BP drops. And if there is a woman who's coming with bleeding and skin peter kit. Then she's usually gone into uh coagulopathy and she needs a very aggressive rezo station with clotting factors and cryoprecipitate. Thank you. Next slide, please. Right. So the next gambit of obstetric complications is maternal collapse. Sometimes this may come to the E D rather than uh you seeing this in the labor ward. Uh And when you face a pregnant patient with the collapse, it can be really uh testing your resilience and your management skills as to how to deal with it. There are a variety of reasons that you can see a maternal collapse in pregnancy, right from an innocent vasovagal episode to the cardiac arrest. But then the approach to any sort of maternal collapses the same, you need to secure airway breathing circulation and then uh cardiopulmonary resuscitation, it is the same as an adult. But then there are a few things next light, please. Next night, please. But then there are particular challenges in doing a CPR in pregnancy uh when compared to a non pregnant patient, because it's not just difficult, sometimes it can be ineffective as well because you need to keep the pregnant patient in a left lateral tilt and doing a CPR on a tilted patient is extremely difficult and also the oxygen requirement and pregnancy is increased by 20%. Um and the uh you try and compression on the inferior vena cava reduces the venous return by 30%. So effectively the cardiac output which is going out is also compromised. And also while diesel stating there is a risk of aspiration because of delayed gastric emptying and poor sphincter tone. So all this makes uh doing a CPR in a pregnant patient very challenging. And in case you don't see any signs of life within the first four minutes of a CPR, then you should be ready to do a perimortem cesarean section in the fifth minute. So almost always, the obstetrician is getting ready for a perimortem Cesarean section as soon as the um collapse has occurred. While the rest of the team is involved in resin stating the patient right next slide, please. Yeah, we've spoken about this difficult intubation risk of aspiration and also because of the splinting of the diaphragm with the pregnant uterus, there is a decreased chest compliant compliance which also makes the CPR ineffective. So even if it's, you're not going to save the baby, you still need to do a perimortem Cesarean section so that you can empty the uterus so that the CPR can be more effective in trying to save the mother's life. Yeah, next slide please. Um music, fluid embolism is rare cause of maternal uh collapse and almost always fatal until recently after uh advances in advanced life support. And h do you care the pathophysiology behind amniotic fluid embolism is not understood very clearly, but then it is thought due to be due to the entry of the amniotic fluid and foetal debris into the maternal circulation. Sometimes you may have pre monetary signs of say restlessness, abnormal behavior, seizure, like activity uh followed by cardiovascular collapse. So, and even if the patient survives from this, there will be D I C and hemorrhage, which is a common secretary following amniotic fluid embolism. So, aggressive treatment and advanced life support is crux in managing such women where amniotic fluid embolism is suspected and even in the smallest suspicion of this situation that women need to be shifted to the ICU as soon as possible and they need to be cared under the MDT involving the obstetrician anesthetists and intensive ist. Uh and usually these women will require quite advanced level of uh supportive management, right from intubation ECMO and because of D I C, they will need um uh transfusion of cryoprecipitates and plotting factors as well. Thank you. Next slide, please. Right. Material sepsis is an important cause for both maternal morbidity and maternal mortality in the UK. Um And almost 8% of all maternal debts uh can be directly or indirectly connected to maternal sepsis as per all the audit reports that come out. One of the main uh problems in diagnosing maternal sepsis is that the physiological changes can often mimic the uh signs of sepsis as well. So sometimes the signs and symptoms of sepsis can be attributed to just normal changes during pregnancy. And uh women are not recognized until they go into septic shock and the physiological changes in pregnancy along with the septic mediators, uh push the women into uh septic shock very quickly while they're pregnant or in their peripartum period. Like for example, there is certain amount of uh cardiac function, my my material uh depression, which puts them at risk of uh cardio vascular collapse very easily. And the increase pommery microvasculature pressure and permeability also put them at risk of pulmonary edema and ARDS. And because of the changes that happen in the renal function, they are at very high risk of having an ischemia will uh kidney disease. The most common core risk factor for uh sepsis in a pregnant woman is either surgery or trauma to the uterus or to the genital tract. Uh pre existing anemia, pre existing diabetes, women with high B M I or all at high risk of having very poor outcomes because of maternal sepsis. The other common causes uh that can cause septic sepsis and septic shock are mastitis, urinary tract infections and uh pneumonia. Thank you. Next slide, please. Next slide, please. Right. Because of the difficulty in identifying women uh with early signs of uh sepsis or infection. Um The R C O G came out with the early warning score but even then they have, they're quite nonspecific and have a sensitivity and specificity of only around 80 to 90%. So, uh the R C O G has now come up with a septic screening chart. This is a flow chart based tool where clinicians are able, which helps the clinicians to identify red flag sepsis. So then they are able to put the sepsis, uh sepsis, care bundle into place. Next slide, please. So the sepsis six pathway involves uh measuring lactate levels. And if the lactate level is more than two, then they need to be re measuring the lactate levels in order to uh decide what sort of resuscitation needs to be given for the patient giving IV fluids at the rate of usually for an adult 30 ml per kg per hour. But then in pregnancy, you need to reduce it to 20 ml per kg per hour. So as to reduce the risk of palm redeemer, uh blood cultures, at least two sets of blood cultures need to be taken in addition to it what channel swaps for culture. And if there is any additional source of infection that is suspected, uh say in mastitis, then uh breast milk culture can be taken or in a urinary tract infection is suspected urinary cultures can be taken. Antibiotics need to be given within one hour of identifying sepsis every hour that uh antibiotics are delayed. Uh the mortality increases by 8%. And the choice of antibiotic needs to be a broad spectrum. One usually which is dictated by the local uh protocol and guideline. Thank you. Next slide, please. Sorry, that was a wrong slate. Next laid. Finally eclampsia. This is uh again, thankfully rare cause of maternal collapse, seen in the UK, but a fairly, quite a common complication seen in rest of the world. This is uh self limiting seizure like activity seen in uh the peripartum period, almost always associated with hypertension in pregnancy. But you also need to rule out uh um intracranial hemorrhage and epilepsy in such women E D emergency management is going to be uh following um uh the ABC pathway, securing airway breathing, getting an IV cannula for circulation and giving magnesium sulfate. Usually magnesium Salfit um terminates the seizure activity. But if there are, there are recurrency shires, then you need to consider disip um or type Penton and of course, the anesthetist need to be involved in care of these women. Um And if the woman is pregnant, then delivery needs to be exploited usually by a Cesarean section. Thank you. Next leg, please. Now let's come to situations where an emergency delivery is required almost always whenever say you have uh a breech delivery or a problem in a twin delivery or problems in C G, you need to do an emergency situation. All of those are emergency situations. But then uh for this talk, I'm just concentrating on these rare occasions where uh and the entire team needs to work in unison to get good outcomes. So shoulder dystocia is every obstetrician and midwives nightmare uh which is failure of the shoulders to come down through the pelvis. Uh after delivery of the head. Uh what we need to remember while managing these uh in this situation is that the problem is at the pelvic brim. Uh So either pulling at the baby's neck or pushing down from the funders is not going to help. And in fact, it's going to cause more complications uh than doing any good. So most of the time the anterior shoulder of the baby babies wished just about the pubic symphysis is the post redia, shoulder may have entered the pelvis and in being the sacrum hollow or it may be about the pelvis as well. Risk factors for shoulder dystocia are big baby person with Postdates, maternal diabetes or high B M I in the mother. When you need to do an operator, vaginal delivery, like a forceps delivery and a prolonged second stage. So, uh this helper is a you uh is a useful pneumonic in uh managing shoulder dystocia. So whenever you come across the situation, call for help, evaluate whether you need to do an episiotomy. So that might give you more space to get the hand in to deliver the shoulders. L is for lex, lay the patient straight and get the patient onto mcroberts. Manual mcroberts, manual uh is uh abduction and elevation. Uh The patient ties, it just opens up the pelvis and increases the anterior posterior diameter of the pelvic inlet so that the shoulder can enter the pelvis. Uh You can ask an assistant to give uh suprapubic pressure. So as to reduce the base acromial diameter of the shoulders and encourage the shoulder to enter the, enter the pelvis. Almost 90% of the time, most of the shoulder dystocia will get uh resolved with these two manuals which is elevating the legs and giving suprapubic pressure. However, if it doesn't resolve with this, then you may need to do the other managers which is basically trying to get the posterior arm out uh or doing rotational manuals, which is easily set them done, which where you're trying to rotate the shoulders to an ob licked diameter. So as to bring them uh to a larger diameter and get them through down the pelvis. Uh And if all this doesn't work, then we can get the patient onto all fours position that has rolled the patient and try the manuals again. Right next slide, please. Court prolapse is another emergency situation where you need to get the baby delivered um in minutes. Uh When the umbilical cord passes through the cervix alongside the present ing part or beyond the present ing part with ruptured membranes, then you call it court prolapse. If the membranes are still intact and if you're able to feel the umbilical cord below the present ing part, uh then it is called a court presentation. Uh Risk factors for having a core prolapses. Um al presentation like a breach or a transverse light poly hydro Mia's when there is excessive like around the baby. So the presenting part is not easily fixed in the pelvis. When you have a high presenting part of the head is very high and it's floating, then there is space for the court to slip through. And also in premature babies, usually the the uh the present in part is not fixed and in case they have a premature rupture of membranes. And there is a chance that uh the umbilical cord uh comes through the cervix. So, the risk in these situations is that uh the umbilical cord when it comes through the cervix can get compressed by the fatal head, uh causing spasm of uh the umbilical vessels or even just exposure to the outside environment can cause the umbilical cord to go into spasm, causing vessel constriction and you can lose the baby within minutes in these situations. Next slide, please. So, the most important thing is to keep calm and to remember not to handle the umbilical cord because just trying, handling the umbilical cord, minute touch can cause the vessels to go into spasm. Instead. What can be done is a gentle vaginal examination and try and elevate the fetal head of the umbilical cord. The another useful thing that can be done is filling up the urinary bladder with uh find a dremel of normal saline. So a full bladder elevates the presenting part, automatically relieving the pressure of the umbilical cord. And uh the other thing that we can ask the women to do is to roll on uh to all fours and to keep her head down with her uh hips high. So this helps in elevating the present ing part and to relieve the pressure of the umbilical cord while you're transferring the woman to theater for an emergency um Cesarean section. But in case the woman is in is at home and needs to be transferred to a hospital setting. Then this is not a very safe position to be in. And then in that situation, you can get the woman to be on an exaggerated left lateral position with a pillow to support her legs. So as to try and elevate the fatal part and to relieve the pressure of the umbilical cord. Uh but in these situations, you need to deliver the baby usually by an emergency cesarean section within a few minutes. And most likely these women will need a general anesthesia for this operation. Next slide please you train rupture again. This is a situation where you need to deliver a baby within minutes or otherwise going to lose the baby with serious uh mobility for the mother as well. It's quite a rare occurrence. Thankfully occurs in about 0.5% of all pregnancies. The risk increases in the presence of a scarred uterus, most commonly a Cesarean section, sometimes when women have undergone surgery to remove the fibroids. So when they have undergone a myomectomy, and while doing a myomectomy. The cavity of the uterus has been entered. These women again are at high risk of uh developing a uterine rupture and their subsequent pregnancies. The risk following one lower segment, Cesarean section is again, pretty small 10.8%. However, when they have a vertical scar in their uterus, a classical Cesarean section, the risk increases by more than 5%. And that's the reason such women are not offered a vaginal birth after Cesarean section. Most commonly, a you train structure occurs at the time of labor. It is very uncommon that the uterus structures during the antenatal period. When there are no, you train contractions. Usually. Uh the main symptoms and signs are the abdominal pain which changes from intermittent while during the contraction to being present almost all the time. Even in between the contractions, you can have a general bleeding and hematuria. The earliest sign is C D G changes when you have repeated decelerations in your C G G or fatal bradycardia in the presence of a woman uh with the scarred uterus who's laboring, it's most likely uh scar rupture when you do over general examination. And if a previously low presenting part feels very high again, you need to suspect you train rupture. Sometimes you can feel the fetal parts on abdominal palpation most of the time, it's too late for the baby. Sometimes a woman may have had a vaginal delivery but following that has quite severe pph and the uterus feels contracted again. You need to think in terms of a uterine rupture and shift the patient to data. So treatment is surgical, the patient needs to go to the data immediately. Usually, if it's a rupture of the previous cesarean section scar, then a straightforward repair should be possible. But then if it's uh if the rupture has extended to the broad ligament or downwards to the bladder, sometimes you may even need to uh do a peripartum hysterectomy in these cases, right? So that in a nutshell is about obstetric uh complications. This is by no means the full uh length or depth of this topic. But then my main aim was to um uh just to briefly highlight the important things in the common complications that you would see probably as uh an F I one or in or as an essential. Yeah, I'm happy to take any questions. Thank you very much, uh Doctor Nantha Kumar, that was really, that was really helpful, really comprehensive. And so I'm sure everyone can agree. Um If anyone has any questions, please do ask and otherwise I'll be sharing my screen with the QR code for feedback. This is really important. Um So that we, you know, can know how are teaching is and how we can improve it and what's gone. Well, what hasn't. Um So if you guys could please just do that, it will take, you know, a minute max, it's really quick honestly. Um So if you guys could do that, I'll leave it on and then I'll keep the call going for a couple of minutes in case anyone wants to ask any questions otherwise. Thank you very much. Thank you. Sorry about the technical hitch in between. Yeah. No, no worries. These things happen. It's okay. Thank you. Okay. We'll keep it a couple minutes. Did if anyone, does anyone have any questions? Uh That's on the chart I think I don't, we don't seem to have any questions. Um I'll keep the feedback form on for people to do it. Um uh Yeah. Uh yeah, I'll close off the call in a minute or so. Um, once everyone, yeah, everyone can see my screen. All right, I'll close it off here. Uh Thank you very much everyone. Thank you. Thank you. Bye. Thanks. Thank you. Bye bye.