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Hello, everyone and welcome to this week's session um for SA, I think it's just gone up. Hello, everyone and welcome to this week's session for SA. My name is he and I'm the chair of this um program this year and I'm joined by et who's also our social media liaison and lead, who you may have seen on our social media today. She is um going to talk to you about the anatomy of the uterus as well as Cesarean sections and just to give you a bit of background on, she is a second year at the University of Buckingham and she is interested in pediatrics as well as Syne and hopefully a potential of a doctor. So without further ado, I'd like to hand you over to and I really hope you enjoy a brilliant presentation. Um at the end, we will give the feedback form. Um And if you answer this, you'll get your certificate for the session if you have any questions throughout pop a chat um in the box and we'll answer it as soon as possible. So I'll hand over now to you and um I'm looking forward to your session. Thank you, Hanna. So thank you all for joining us today. And as Hannah mentioned, I'm gonna be going over anatomy of the uterus and C sections. The close part is going to be the anatomy. So let's start with the uterus. So the uterus is a secondary sex organ which means that it develops and matures during puberty under the influence of hormones. It has a variety of functions. So it maintains and transports c needs. It is the site of embryonic and fetal development. And it also facilitates with expulsion of the fetus. So, during uh while delivery, the uterus contracts and allows the expulsion of the fetus anatomically, the uterus can be divided into three parts. You have the fundus which is right on top and then the body in the middle and the cervix at the bottom, the fallopian tubes join into the uterus at the fungus. And then in most normal pregnancies, you'll have the blastocyst implanting itself into the body of the uterus. And then the cervix links the uterus to the vagina structurally and functionally, the cervix is different from the rest of the uterus, but I will get into that in a little more detail. So the layers of the uterus are, there are three main layers of the uterus. You have the perimetrium which is the outermost layer. And then in the middle, you have the myometrium, which is the muscle that contracts during childbirth. And then the innermost layer is the endometrium. And that can be further divided into the superficial stratum functionalis and the deep stratum basalis. So, if you take a look at this diagram here, you have the myometrium here, the deep stratum basalis here and the superficial layer inside. And that's the innermost layer of the uterus during menstruation. The superficial stratum functionalis is the layer that sheds off and the deep stratum basalis is the one that has regenerated throughout the cycle. Now, if there are issues with the deep stratum basalis such as um fibrosis or any sort of damage to it, it can cause something called Asherman syndrome. And this essentially the superficial stratum conchal is not going to develop properly. And hence, the endometrium is going to be quite thin and it can cause uh issues with being able to conceive the ligaments of the uterus. So you have too many ligaments that support the fundus and the body of the uterus, you have the broad ligament which is a double layer of the peritoneum, which essentially just drips over the uterus and it attaches it to the pelvic walls. So that can be divided into three parts. You have the mesosalpinx which uh which drapes over the fallopian tubes and then the mesometrium which drapes over the fundus and the body of the uterus. And then you have the meso, which you can see in the sagittal view of the uterus. And that's what the ovaries. You also have something called the round ligament, which is a remnant of the distal gubernaculum. And that runs from the uterine cornua or the uterine horn, which is right here and then it passes through the deep inguinal ring and then the superficial inguinal ring and then finally attaches itself to the labium matura. As far as the cervix goes, you have three main ligaments. You have the pubic cervical ligament which runs from the cervix to the pubic bones. And then the cardinal or the trans cervical ligament which runs from the cervix to the lateral walls and then the tersac oral ligament which runs from the cervix to the sacrum. If there is any weakness in the pubic cervical ligament, it can cause a vaginal prolapse. However, if there is any sort of weakness in the cardinal ligament or the uter sacral ligament, it can cause a uterine prolapse. Finally, you have the ovarian ligament. It is uh it is a structure that links the ovary to the uterus. So if you can see it in this section here, there's a little structure that connects the ovary to the uterus. And that's the ovarian ligament positioning of the uterus. So the position of the uterus can be described according to the position of the uterine body and the cervix. So um if you describe it according to the position of the body, you have, you can describe it as antiflex and that's when the body is pointing anteriorly or it can be retroflexed and that's when the body is pointing posteriorly. And then if you look at the cervix, it can be antiverted. And that's when the cervix is pointing anteriorly and retroverted. If it is, if the cervix is pointing posteriorly, so how are you going to determine that? So you're gonna try to figure out the vaginal axis, which is right here and then the cervical axis and the uterine body axis to describe the position of the cervix, you're going to compare the cervical axis with the vaginal axis. So if you, if you look at this, for example, you can see that the cervical axis is pointing anteriorly compared to the vaginal axis. So that would be described as antiid. And then if you move on to the position of the body, you'll compare that to the cervical axis. And you can see again here that the uterine body is pointing anteriorly compared to the cervical axis. And hence, that's antle. So I know it can be a little difficult to identify that in scans and stuff. But I think it would be helpful for you guys to practice these four. So we're gonna start releasing a both. And if you guys could identify the first structure, identify the position of the first diagram here and then I'll explain it. I know what's the final response. I'm just having a look at this and um 100% of you answered Antiverted and Antiflex. Yeah. So that's right. So we just discussed that. So you have cervical access point anteriorly and the same thing goes for the uterine body as well. Let's try the second one. Now, do we have a new response? Uh Yes, we do. So, 11 of you have responded, um, if anyone wants to put in their last minute responses, now, now would be your final time to do that. All right. So to you have now responded, it's actually been quite mixed. 41% of you said it was anti antiverted and retroflexed. And a quarter of you said it was um antiverted and anterior flex and a quarter said retroverted and retroflexed. OK. So this is antibotic and retroflexed. So if you look at the vaginal axis and the cervical axis, it can be a little difficult to identify it. But um the cervical axis is still pointing slightly anteriorly compared to the vaginal axis. And that is why it's antiverted. And then hopefully, you guys can also see that the uterine body axis is pointing posteriorly compared to the cervical axis. I hope that makes sense. Um Can we go on to the third diagram? Ok. So as of now, no one's responded. If you guys could get your responses in, in the next few minutes, that would be very useful. Oh, brilliant. They've started coming in now. So we'll just um give you a couple more seconds to answer that. Ok. I'll be stopping it soon. So if anybody wants to get their last minute answers in. That'll be the time. Brilliant. So for that poll, 40% said it was antiverted and Antiflex and 40% said it was retroverted and Antiflex. Yeah. So those who said retroverted and an are right. So if you look at this, now, the cervical axis is pointing slightly posteriorly. I've drawn it here for you guys. But yeah, it's pointing slightly posteriorly. So that's why it's retroverted and then the uterine body is flopping forward. So that would be antiflex last one. OK. So two of you have replied, um, if anybody else wants to get their responses in brilliant and we'll just keep that up for a few more seconds. So, all right, I'm going to stop the pole now. And for the fourth diagram, uh, 83% of you said it was retroverted and retroflexed. Yeah. So you're right. I think this is a lot more obvious now. So the cervical axis is pointing posteriorly and so is the uterine body axis. So it's retroverted and retroflexed. I hope I understand that this can be a little difficult to grasp onto in the beginning. But if anyone wants me to reexplain that I can definitely do it, just put that in the chart, otherwise we can move on. So I have another question for you guys. Can someone tell me why an individual with a retroverted? Cervix is at a high risk of developing a uterine prolapse. Is it because of the position and the gravity um and the organs kind of in communication with it. Yeah, it is so similar to that. So if you look at the retroverted positioning, you can see that the uterus is directly above the vagina. So if there is an increased intraabdominal pressure, there is an increased chance of having a uterine prolapse. But that is not to say that just because you have a retroverted cervix, you will have one. It's, there are a lot of other factors that go into it. But it this is just one of them, right vascular supply of the uterus. So you mainly have the uterine artery that supplies the uterus. So that comes from the abdominal aorta and the abdominal aorta splits off into the right and left common iliac artery and then that further splits off into the external iliac artery and internal iliac artery, the external iliac artery will go on to supply the lower limbs. Whereas the internal iliac artery will supply the urogenital organs. So the internal iliac arteries will further divide into the anterior branch and the posterior branch, the uterine artery arises from the anterior branch of the internal iliac artery. I hope the partly made sense. So once the uterine artery comes off, it becomes a plexus and then supplies the uterus. You also have the ovarian artery that directly arises from the abdominal aorta and it is slightly below the renal artery. So it comes off and then it goes through the suspensory ligament here and then it becomes a plexus and supplies the ovary. Can anyone in the chart? Tell me what is the relationship between the uterine artery and the ovarian artery? No. Ok. So basically what happens is the uterine artery and the ovarian artery form an anastomotic network and then provides collateral circulation to the uterus. So what that means is if feasible is the uterine artery is compromised. For whatever reason, you still have the ovarian artery that provides some sort of circulation to the uterus. But the main artery that supplies the uterus is the uterine artery. As far as venous drainage. It's quite straightforward. So you have a plexus present in the broad ligament and the plexus drains into the uterine vein which drains into the internal iliac vein. And that brings me to the end of the anatomy section just gonna pause up for a second. Does anyone have any questions on what I've got so far? All right, if there are any questions, just put them in the chart and I will get to them at the end. Ok. So now I'm gonna be talking about c sections and a little bit about the pudendal nerve. So, the pudendal nerve provides sensory and somatic innervation to the external genitalia and the vagina. It, you have s 23 and four which give off the pudendal nerve. They're all from the sacral plexus gives off the pudendal nerve and then it passes through the create sciatic foramen and it goes near to the atrial spine and the sacrospinous ligament and then it comes out of the lesser sciatic foramen and then it goes on to go give off its branches. Now, how might this be clinically relevant? A pin nerve block is generally given as analgesics or um the 2nd and 3rd stage of labor and you might use it for normal or instrumental delivery. Instrumental delivery is when you use literally any instruments to facilitate with the delivery of the baby. And you may also use it before you do anesthesia. So, an hyst toy is when you make a slight incision into the brand name to prevent any further damage and to administer a tendon nerve block, you are going to do a vaginal exam and then you're going to feel for the atrial spine. So, like I mentioned this bit here is the atrial spine and about a centimeter medial to that, you're going to inject the pretend nerve block into the sacrospinous ligament and then you're gonna keep advancing the needle until you feel no resistance. And after that, you're going to aspirate to make sure you haven't hit any blood vessels. And if that's clear, you'll go to inject nerve block. However, before you do carry out any procedure. So before you do an EES toy, for example, you need to make sure that the predental nerve block has actually taken into effect before you carry on with anything C sections. So you can have an emergency C section or an elective C section. An electric one is something that is planned prior for whatever reason and an emergency C section is done. That is something that needs to be done immediately. So you have maternal indications, anatomical indications and fetal indications. I've made a little table for you guys to help sort of uh organize all of that. And I'm just gonna touch up on a couple of these, the first one being a previous C section. So after having ac section, it is recommended that a mother goes through with have with continuing to have C sections with any subsequent pregnancies because they're at an increased risk of having a uterine rupture. If however, a mother decides not to do ac section and decides to deliver vaginally, then it's really, really important that the mo that there is constant fetal monitoring by something called a cardiology, which is going, which is going to assess and monitor the fetal heart rate. And if there are any changes in the fetal heart rate, that can be the first sign of an impending skull rupture. A primary genital herpes case during the third trimester of pregnancy can be dangerous. And it is recommended to continue to do ac section if someone has been diagnosed with it mainly because there hasn't really been enough time for the development of HSV antibodies and for it to pass through the placenta to protect the baby. So to reduce the risk of any sort of transmission to the baby, what they may recommend doing ac section, placenta tria is when you have a low lying placenta. So it either narrows or blocks off the birthing canal. And as you can imagine, it can, the baby will not be able to fit through the birthing canal. So at that point, they'd have to do ac section, mild presentations. So I DD, you want a baby to be in a position, which means that the baby's head is facing the building and canal as you can see in this diagram here. But then sometimes the baby just doesn't decide to turn around and decides to come in a breach position. And that is when the baby's bottom is based on the bottom canal. So as you can see in these top three, so um a breech presentation can still be delivered vaginally, but some teams may recommend doing ac section instead and um may recommend doing ac section, but sometimes they may even try something called an electro an external cephalic version, which is when they literally try to turn the baby around to make it be present in a cephalic position. So if you can see in these four and three pictures, they are applying external presenting uh external force to turn the baby around and this comes with its own risks as well. So the baby may have the baby might undergo any fetal distress and it may not always work. So it's always beside the Macky's pieces. At what gestational age are elective c-sections usually plant, we have a pool going out for that. Ok. So five people have replied so far, I'll just give you a few more seconds to answer that. Ok. That's good. Most of you have replied, but I'll just keep it open for just a couple more seconds and I'm gonna close the pole now. So, um 73% of you said after 37 weeks. Ok. So you'd ideally do it after 39 weeks of gestation. So that's mainly done to reduce the risk of a risk of respiratory distress. The most common type of neonatal respiratory distress is transient tea of a newborn and that is when the baby isn't able to clear the amniotic fluid from the lungs. So normally, if you look at a vaginal board, the mother is uh when the baby is coming out, there is external pressure on the baby's chest to push the amniotic fluid out and clear it from its lungs. But as you can imagine with an elective C section that really that, that pressure on the chest isn't going to be there. Now, by having it at 39 weeks, the baby's lungs are much more well-developed and they start to produce something called surfactant, which is going to help prevent its alveoli from collapsing on itself. So, if there is amniotic fluid which is present in your lungs, then uh the baby is still able to better cope with TTN compared to a much younger baby. Um II also forgot to mention that amniotic fluid, if it is present in the lungs, it can stick to the alveoli and cause it to collapse. So by having separin, it's going to help prevent any worse side effects of it. If the C section needs to happen prior to 39 weeks, what might be given to prevent the respiratory distress? Um you can give corticosteroids. Yeah. So you get corticosteroids and that's literally to just stimulate the production of surfactant. So if you can, this is just, this is just a bit of embryology. So you start producing cefactam from week 24 but then you don't produce enough up until week 32 to prevent any atelectasis or lung collapse and things like that. So, in such cases, you'd want to promote the, develop the production of surfactant and hence you give corticosteroids to stimulate that emergency c sections. So you might do one if there is failure to progress in labor or if there is any uh fetal compromise and it can be, it can be categorized into four different categories. The fourth category being category one and that is when there is an immediate threat to the life of the woman or the fetus. And an example of one might be a placental abruption, placental abruption is when the placenta prematurely detaches from the uterus. And that can have its negative side effects on the baby and the mother. And um in such situations, it's really important that the baby is delivered within 30 minutes. Category two is when there is fetal and fetal or maternal compromise, but it is not immediately lifethreatening. So it's still a problem and the baby still needs to come out, but it's not as threatening to life as it was for a category one. He's actually so an example would be a non reassuring fetal heart rate. So again, it is a problem but the baby can still stay for a little longer. But in a category two situa in a category two C section, you'd want the baby to be delivered within 75 minutes. And then category three is when there is no maternal or fetal compromise. But there needs to be an early delivery. And an example of a situation like that would be something like chorioamnionitis. And that's when you have an infection of the amniotic sac. So if the baby stays in for too long, they could have negative side effects like cerebral palsy. And the mother also could have infections of the lower genital tract and it could just have a lot of problems for the mother. And the baby. Category four is just an elective C section. So you might do it if you had, if a mother had a previous C section we request or we just discussed like a bunch of other reasons for is for an electro C section, preoperative management. So the first thing you wanna do is gain informed consent. You're going to explain to the mother what why she needs the, why she needs surgery, what is going to happen during it and any sort of complications or risks that come along with it, you need to make sure she's fully understood that. And once you've gotten consent from then from that, you can move on. If you're doing an elective C section, you want to optimize any major comorbidities. So something like anemia, gestational diabetes or hypertension, you wanna make sure that you've gotten that under control as much as possible before the surgery to prevent any sort of complications, then you're gonna do an FBC just to get baseline levels and then a group and save. So group and save is gonna help determine the blood group of the mother and will screen for any atypical antibodies. In case the mother needs blood during the surgery, you'll also give the mother PPI S and H two receptor antagonists and that is to reduce gastric acid secretion. So there is a risk of developing something called aspiration pneumonitis and that's when you inhale gastric contents into your lungs. And by reducing the gastric acid secretion, it's going to reduce the negative effect of aspiration pneumonitis, vte prophylaxis. Um as with any surgery, people are at risk of developing a venous thrombo embolism. So you'd want to calculate the risk of every mother before going to surgery and come up with a proper plan to prevent, to prevent obe leave. So some others might get something like an anti thromboembolytic stocking, something like what you can see up here. And if some others are at a higher risk of developing O BD E, they might be given low molecular weight heparin as well. But that should also be used cautiously considering any other factors that might be, that might be relevant. Can anyone in the chart tell me what complications does severe anemia increase the risk of during pregnancy and birth? No. Ok. So you can increase the risk of developing preeclampsia, placental abruption and cardiac failure in pregnancy. And as for birth, you can have an increased risk of preterm labor, low birth weight and iron deficiency in babies. Now, why would this happen? If a mother is severely anemic, it can um it can impact oxygen distribution throughout the body and cause all these complications. So, if you look at preeclampsia, for example, it's when you have the arteries that support the placenta and the pregnancy, it's when they haven't developed properly. So if you don't have enough oxygen distribution to the uterus to support the development of these arteries, then you might be at an increased risk of developing preeclampsia. And then for as for preterm label, when you have low oxygen going to the fetus that can trigger stress signals and hence, it can trigger preterm labor as well. Iron deficiency in babies is because when a mother is fairly anemic, it can cause reduced iron storage in babies as well. And they, they can go on to develop iron deficiency later on in life anesthesia. So you have too many types of anesthesia. You have regional anesthetic and general anesthetic. Um regional anesthetic, you can have a spinal anesthetic or an epidural, a spinal anesthetic is when the medication is directly injected into the cerebrospinal fluid. And because it's directly injected, you would require lower doses of the medication. And also, uh because you're having low medic doses, you also lessen the complications from the medications, epidurals are, are injected into the epidural space and that diffuses through the dura into the cerebrospinal fluid. There are a lot of factors that go into deciding between a spinal anesthetic or an epidural and some might be something like patient preference or even something like anatomy. So if for example, the patient has uh scoliosis, they might prefer doing a spinal anesthetic or an epidural because with an epidural, the distribution of the medication into the cerebrospinal fluid may be uneven. So to prevent that they might just directly inject the medication into the cerebrospinal fluid, then you have general anesthetic and that's when the patient is completely unconscious during surgery and that might be for a variety of reasons. So, if there are any contraindications to the regional anesthetics, something like allergies or failure of regional anesthesia. And even if there's a need to expedite delivery. So in a category one C section, for example, they might uh give a general anesthetic because it's much quicker once the anesthetic is put in, it is really important to put in a foley catheter as well to drain the bladder so that it's not distended and then that reduces any sort of risk of bladder injury during the procedure. Can anyone in the chart tell me at what spinal level is an epidural administered? No. Ok. So we have, it can either be administered at L2 or L3. So up here or between L3 and L4. And that's literally just because that's where the spinal cord ends. Obviously, there are differences between from person to person, but that's generally when the spinal cord ends and that's just to prevent any chance of neurological damage the procedure. So the patient is going to be at a left lateral tilt of 15 degrees. So she's gonna be uh turning on her left side at around 15 degrees and that's to prevent, that's to reduce the risk of supine hypertension. Why might a mother experience supine hypertension? Is there anything in the chart? Um No, but also my chat seemed to be loading a bit later. Oh, so someone's just said presents um pressure of uterus on great vessels. Yes. So that's right. So it's aortocaval compression. And that happens because when the pregnant uterus is putting pressure on the aorta and the inferior vena cava, there is reduced venous return to the heart. So there is reduced cardiac output. And hence, that causes hypertension. It can also be dangerous because there isn't enough blood going to the uterus and the baby. One more question for you guys. What might be administered to, to aid with delivery of the placenta bonus points for anyone who tells me why. Ok, I'm assuming we don't have a response in the chart. So I'm just gonna tell you guys, it's Oxytocin and Oxytocin is a uro to. So what that means is when the uterus, the uterus is going to contract and that's gonna help with the delivery of the placenta. Now, if you're doing ac section, you might be wondering why you need to give Oxytocin, but it may at least to me one if you administer it and the uterus starts to contract. It's going to be easy for the surgeon to detach the placenta from the uterus. And also by contracting the uterus, it's going to clamp down on the arteries which otherwise would bleed heavily. So once the uterus contracts, it's going to clamp down the arteries, reduce any bleeding and also prevent postpartum hemorrhage, then we come on to the different incisions. So you have two main types of skin incisions. You have a transverse skin incision, which are also of two types, you have tunnel steel incision, which is a curvilinear incision and that's about two centime i above the pubic synthesis. And all the subsequent layers, surgeon comes across after that is accessed through a sharp incision. And that's when they use tools like a scalpel to access the other to cut through the other um layers of the abdomen. Then you have a gin incision and that's three centimeters above the pelvic synthesis. All the subsequent layers are axis bluntly. So what that means is the surgeon is going to use the fingers to stretch out each layer and access the baby. Eventually, there is an exception to this when the midline of the fascia is incised. And then after that, the surgeon bluntly stretches out the other layers. Then you have a vertical skin incision, which is right here and that is mainly used in in emergencies. And it also provides better exposure to all the organs and structures that are present there. Then you come to the abdominal incisions. So they can either be sharp or blunt like I just mentioned. And then finally, you have a uterine incision. So the uterine incision can be of three types. You have a vertical incision which is up here in the midline of the upper segment of the uterus. And that again is used mainly in emergencies and it's there is an increased risk of developing a uterine rupture after that. But then you may use it if you need to access the baby quickly or if there's placenta previa as well. So again, if the placenta is low lying, it can be difficult to access the baby. If you do a low lower incision, then you have a low vertical incision. And that's generally done if there isn't enough space to access the lower segment of the uterus, and it's not really that common, but it might be preferred over a vertical incision because they have a relatively lower risk of developing a uterine rupture. And then you have the most common type which is a low transverse incision. And that is a horizontal incision happening in the lower uterine segment. And that is also associated with a lower risk of uterine rupture, then the layers of the abdomen. So you could start off with the skin, you cut through the skin and then you come across the subcutaneous tissue or the fat. And then you have fascia, the fascia is made up of two layers. So you have campus fascia which is more superficial and then scalp fascia. After that, you come across the rectus sheath, which is again made up of two layers. And the first layer is made up of the aponeurosis from the external oblique. And the second layer is a first layer that is made up of the aponeurosis from the transverse abdominis and the internal oblique. After that, you cut through the rectus abdominis and then the parietal and the visceral peritoneum once the visceral peritoneum is incised, you're gonna push it down to access the bladder and then you're going to use a joint retractor to retract it. Now, by retracting the bladder and by putting a catheter in to prevent it from being distended, you're going to protect the bladder and reduce the risk for, uh, reduce the risk of its damage during surgery. After you cut through the visceral peritoneal, you find, you'll find the uterus and you'll cut through all three layers of the uterus. And if the amniotic sac is still intact, then that's also cut through and then you have the baby complications. So you can classify the complications into three stages. The first one being immediate complications and these are generally complications that occur within the 1st 24 hours of surgery. So, one hematoma is when there are blood clots developing around the wound or the surgical scar. And there's an increased risk of that happening with individuals who have a higher BM I or are diabetic as well. And it's a problem because it can slow down the healing of the surgical scar. Um, bladder and bowel trauma, I just spoke about it. So, bladder trauma, you will try to reduce the risk by using a joint retractor and by placing a catheter in. But, uh, if someone has had previous abdominal surgeries, they may be at an increased risk of developing a bladder or bowel trauma in neonates. Um, you have an increased risk of TDN and fetal lacerations. So, if the amniotic sac is not intact before the C section, they have a higher risk of fetal lacerations, but it's still a relatively small risk of develop, of having one, then you have an intermediate complication. And that happens from 24 hours after a week after the surgery. And two main of two main complications are infections and APD. So you can have a uti and endometrial endometritis and a respiratory infection. And for that, some others might be offered prophylactic antibiotics. And um there is a strict guideline against the use of coloxyl again for prophylactic antibiotics for endometritis especially. But yeah, most mothers are still offered prophylactic antibiotics. It's also recommended to take out the catheter as soon as possible to reduce the risk of infections. And for A BTE, as I mentioned earlier, patients should ideally have some sort of prophylactic plan in place. And it's also really important to promote early immobilization after the surgery to reduce the risk of O BTE. Uh late complications are ones that happen much later. So for example, a rupture adjacent of the scar after at the next level. So be back of China both after C section. And um yeah. So it's generally recommended that they continue with ac section, placenta previa and placenta accreta, placenta accreta is when the placenta embeds itself a bit too deep into the uterus. And it can be a little difficult for the uterus to, for the placenta, to, to touch itself from the uterus. So, after having ac section, a woman is at a higher risk of developing either of these two conditions. And finally, a cesarean scar of an ectopic pregnancy. And that's literally when a fertilized egg implants itself into the cesarean scar, postpartum hemorrhage. So, postpartum hemorrhage is one of the i immediate complications of the C section. And it can be classified into a minor and major postpartum hemorrhage minor is when the mother bleeds about 500 to ha 1000 mils of blood. And then major is if they bleed more than 1000 MS. And that can also be subclassify as moderate when they bleed about 1000 to 2000 miles and then severe is if they bleed more than 2000 miles, there is a very detailed chart about the management of a postpartum hemorrhage, which is given by the nice guidelines. And I think it's worth going through after this, but I just wanted to highlight a couple of things for you. So you're gonna start off with the ABCD E approach. And again, the chart goes through it all in detail. But here are some of the main points. So you're going to want to aim for a range, an oxygen saturation of 94 to 98%. And if a mother isn't within that range, you'll want to give them 15 L per minute of oxygen. You're also going to want to check for the mother's temperature every 15 minutes. And then you're going to set up two points of IV axis. One point is to give things to the mother and the other point is to take things from the mother. So you're going to drop that to run FBC SA clotting screen and also cross March. So cross March is when you physically mix the recipient's blood with the donor's blood and you make sure that there isn't a sort of uh there isn't any reaction that occurs while mixing it. And then you're also going to run serial arterial blood gasses and venous blood acid every 15 to 30 minutes as well. You're going to give the mother blood products or blood because she's losing a lot of blood and you're also gonna give her warm IV fluids and terro tos. So, as I mentioned earlier, terro tos are medications that help stimulate the contraction of the uterus. And by doing that, it's going to clamp down on the arteries and reduce any bleeding. That is she skiing and then you're going to examine for something called the forties. So you have tone and again, if you have uterine artery, the uterus is not going to be able to contract and clamp down on those arteries and to, to facilitate with the uterine contractions, you might do something called rubber contractions and bimanual compressions. So, rubber contractions is when you apply external pressure and essentially massage the uterus to trigger it to contract on its own. And bimanual compression is when you apply external pressure, as well as internal pressure to stimulate the uterus, to compress, to contract, then you're going to look at tissue. So you're going to check if there is any remnant tissue inside the uterus cause, that can also be something that is in the way to prevent, which is preventing the uterus from contracting. And if the placenta hasn't been delivered, so that is something that could be, that could be a remnant tissue in the uterus. And if it hasn't been delivered, the surgeon might do something called a controlled traction. That's when they essentially gently pull out the uterus, the placenta from the uterus, then trauma, you're going to check the genital, the uh genital tract and the entire birth canal to make sure that there isn't any other trauma that might have occurred and anything else that needs to be addressed and then you're gonna check for thrombin. So just to check if the mother has any sort of bleeding disorders that might be making this worse. And yeah, and again, just go through these uh go through this chart when you have time. And yeah, that brings me to the end of the session. I just have a couple of questions for you guys to practice and then you guys are free to ask your questions. So we have the post questionnaire if you can release the call and I'll give you guys two minutes to read through it and answer it. OK. Yeah. All right. Uh Do we have any responses? Um So 70% of people have answered the broad ligament. Yeah. So it is the broad ligament. So the question is asking us what uh ligament is attaching the uterus to the lateral pelvic wall. And that is the broad ligament. The pubic cervical ligament, carpal ligament and uterus sacral ligament are ones that support the cervix. Next question, any responses. So yes. Um So 70% again have um answered round ligament. Yeah. So it is the round ligament. It runs from the uterine cornu to the labial matura. And yeah, that's right. Answer question three. I don't think I went over this but just have a guess at this how the responses are. Um So slightly mixed responses on this one actually. Um Should we give them maybe a couple more minutes, a couple more seconds to answer it. Yeah. All right. So um 54% of people said antiverted and Antiflex. OK. So it is antiverted and Antiflex. It is the most common kind of positioning in women. But uh that isn't to say that the other positionings are not normal. It's just that antiverted and antiflex uterus is the most common in women. Next question, just for anyone who may not know G two means that she has had two pregnancies and P one means that she's given birth after 24 weeks of gestation once. Ok. So 63% of people for that said category two. Yeah. So it is category two, there is no immediate threat to the mother or the baby. So you can, we can see that there are decreased fetal movements which is concerning but there isn't an immediate threat to the mother or the baby. So that's why it would fall under category two. under category two C section and the baby needs to be delivered within 75 minutes. Last question. OK. So for this question, um 50% have said transverse vical or cardinal ligaments. Yeah, that's right. So the transverse is the, the cardinal ligament is the one that attaches the cervix to the lateral pelvis. And the pubic cervical bone is the one that comes from the cervix to the pubic bones. And then the uteral one is the one that comes from the cervix to the sacrum and brought in the long round ligament are the ones that support the upper parts of the uterus. So hopefully that makes sense. And that's all I have for you guys. I just wanna point out the uh point you guys to the nice guidelines as well. So it just talks about how you take care of a woman from pre op POSTOP and things like that. While the, while they're undergoing ac section, it's worth having a read if that's something you guys are interested in. And yeah, also we will be posting more S pa s on our social media as well. So give that a follow. I've already put up five questions so far and we will be putting up five more tomorrow. So keep an eye out for that and follow us on that as well. Thank you. If you have any questions, I have been answering the questions as they've gone along. But if anybody has any uh new questions, please hold them in the chat though certificate. So once you finish doing the, once you finish filling in the feedback form, you will be able to get your certificates immediately. And I've just posted the feedback form onto the chat for all of you. No, you also get um, you get discount codes to teach surgery and BO the MRC S as well in your certificates. Brilliant. So, whilst I have all of you here, thank you so much for all attending and thank you so much for that brilliant lecture. That was abso absolutely amazing. I definitely recapped a lot of anatomy there and learned a lot too. Um, for all of you interested in obs and G our next session is tomorrow at half 7 p.m. So we would really like to see you there and it would be brilliant if you could join us again for the second session of this week's series. Yeah. Thank you guys. Mhm If nobody has any questions, um I might stop the session here. Does that sound all right. Yeah, that's fine.