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you know, now there's no number. Just zone section. Just continue on the movement is first is an infection. That's fine. 15 skin set. So I go back, I'm seeing this room, you know, 567 Cesarean section of six for our mothers and boobies. Got that as well? Because, really, I feel probably have a memory of mortality associated with a peak. It's in sections. Um, I think performs open for us to discuss before we get She's there. Okay, good, Rich. So we'll have to wait. I was like, Yes, I can hear you. Excellent. So you're from Sandwell and West abandoned him, and he just trust you. Okay, Uh, I think that's all I have for you as a buyer. So maybe you can just introduce yourself for a second and then just stick the flow. Yeah, and my history. I'm sorry I was supposed to be down in person, but unfortunately, because of my life, long have to stay for bone and do it. You know, that's a few miles away from there. I'm the collar stupid buying hospital. And then after national failure of the year because of the Chinese who ordered for me I'm really passionate about teaching and training. So that's one of the reasons I normally getting bored with progress training. And that's why we thought we will talk about this. Complexes that in sections. So just some few slides on, then you'll have a discussion. You know, we know that Cesarean Sections rate is just on the rice on his shooting. A PSA level would leave. We have to submit a little section. They went about 30 miles in the schools. We have to, uh, make the Norden find the reason I do the Robson's classification and present in the quality improvement have things. Um, so the golden examine section has gone up. It might be a religious reasons. It could be because of metal core mobilities that is rising to their instructions. There with the metal obesity mission, your metal of the city off be, um, I about 50 was something just quite rare, and it was noted, But now we have quite a few women that the amount of sixties coming into labor, we have quite a few medical core mobilities like I have a potential problem with the ability to expect such a few cardiac on most important thing is some samples of something and we capture to die. I was biting patients and we do have patients who have got multiple large fibroids on who had multiple surgeries, girls disease, who had, uh, sections of the bottle, who had multiple surgeries in the tummy, multiple perforations and things that because her baby and also be be often encounter difficult fetal extractions in the form of mobile head. Oh, are you going back to head or now with tax toe? Everybody comes Now. We have to give equal importance for babies even from 22 weeks over. So we have to think about delivering these preterm babies with treating ruptured membranes in a safe environment. Go avoiding. And this is the extensions on laceration organ damage. In a normal presentation, I don't each topic. It's a bear thing by itself. So we will just talk about few things. So the city's on the rice, you know, on most important things to get into the lower segment, get into the place safely to deliver the baby and avoiding um uh, unnecessary organ damage. So no, we have introduced a taxi, I think problem. You can't quite a few people off you might be a flare up of normal traction device is, and also the Lexus protectors on the fibers that it's no mention about difficulties. Women, maybe experience when women have multiple $5 a little segment on not just on the examination is key before undertaking a Caesarean sections is better, too. Uh, do it on examination Trader, uh, localized A safe place where you couldn't enter on decently. This is one of the case that we have a lady who had a fibroid uterus. This one was a portion 15 brothers. This is the 91 fiber on this because you trust she had a second trimester miscarriage every 10 plus under, we have to take a potato for rule of this lesson of tissue on it was I only one we couldn't reach from the generally the thing. So we have to do both from the top and the bottom to remove the test until tissue So but this is the things about the fiber. So with the think nowadays, we have to do a month, and it's really approach. We have to do a peak planning mapping off the five points on some cases, we might have to use MRI on some. Nowadays, we have more and more used ultrasound. That's why I think, um, the college has introduced is turning as a part of the I've gone straining a little wart on the difficult extractions I've got happy to go through with you. The party weapons are there was rechecks traction for deliveries if needed. Any question. So yeah, they just don't want to take your time. Just please. I have got the manic in here, so if anybody wants a them off or anything, I'm happy to go through with you guys. Okay. So thank you very much, Doc, over that both, uh, intension. I just wanted to add that you see, for my my experience, one of the most difficult there in section abdomen. It's a fibroid in pregnancy. Ah. Fortunately, I had this patient that was transferred from another state, and she came all the way from a budget to Canada for a cesarean section. And she came to me like a walk toe her toe hard date off Cesarean section on, but she don't know she had a fibroid in pregnancy on DA. She came with a scan Now, the mistake I made was not to have repeat at that scan. So I just saw this scan on the scan. Said, you know, she had full fiber. It's and clinically off course I could feel all the fibroids, but men when I got in. I don't know where to come together, baby. In fact, the uterus was turned upside down. So the baby was behind the the you know, the fibroid. I couldn't access the bumpy on bridges had a turned. I was just just be, uh, luckily side. I could see I don't I've never had a cesarean section like that. It was only go back on. It was saved us to be able to do it with a baby. I cut, cut, cut, cut, cut, cut, cut. I couldn't get to the baby. And by the time I didn't have a good with good Abdallah school, I don't understand the anatomy anymore. And I was just for few years, but I was very lucky. I was a great time with also it's can't obstetrician, because I was like, What is this on? Because the other movie was that obstetrician was you know, she wasn't the med so should have seen crosstable really on. She knows. Said Okay. Okay. Populace less less during this. And that's how we're able to enter the liver. She had, like, five points of blood. Uh, you know, so very difficult. So not is you come in this. Can I miss it? Do a scan myself to identify, right? The fibrosis. I walk and put my knife How My going to deliver this baby. And I keep on stress and back, You know, for all the training, so is really difficult. So really, Doctor Uh, Doc, I I think fibroid in pregnancies and major Ah ah difficult their section But I This is a section that is also difficult. You mentioned repeated surgeries but I think we put it very in section specifically not even other public surgeries because they you have placenta increase by crater because that lower segment where you're going to going That's why the placenta is going to be so. You are present a pretty ear as well as incredibly critter you're deliver. You cannot stop bleeding, you know. So that's another difficulties. A a section so open for discussion. We have about them 10 minutes. Any questions any experience to share, you know? Yes. Please. Uh, can we have the mic? Uh huh. Thank you so much, Professor. Probably performing a C section is out of my scope of practice on my midwife on the probably of assistant. Will this stuff called City in Sections That being done? But my concern is the like. I don't understand. That's what she That's association between the creator Press enter on the ah cesarean section scar. Because once the there was a scar, I expect fibrotic tissue Toblarone that area and I run the whole the president again can in bed around that earlier, after the extent of invading deep a little deeper, Probably maybe some explanation around that association between the present, our creator and then the scar tissues our own. Yeah, Doc. Okay. My grandma to party, you're increased risk. Or plus and, uh, Previa on diffuse have north of Aryan sections. We have one plus entropy, like a blood and a pina. Your risk of a creator is 1% on if they have to sit there in once they're in section and a glass and a pina. The reason that the class and they're getting on here and your your previous cesarean sections card. It's never present when you have to sit there and section under placenta previa. Your your risk of having an Akita is there are 33% and then after three becomes 44 then after four because 55 so it exponentially increase is so. That is one of the reasons multiple cesarean sections you're invariably had. One day you will have a placenta previa on. Then the list cough dies much fire on. Then, when you open, it's almost impossible to come through and get the baby delivered. So it's better to completely avoid the blood center and go high up, make a vertical skin incision, make a classical incision, get the baby delivered and probably consider for hysterectomy. Feed it so Yes. Yeah, yes. Um, so he didn't want to add to that. Okay. Uh, no, I have another question. I had a call from Kenya. Ah. Whereas we have Ah, a knish. You with a very deeply impacted head. We also sometimes have a pre term baby with a head really floating very high. So maybe if you have any comments or suggestions on what you know If it's a breach, it's find easier, probably. But when it's Catholic and really floating up there, that also can be challenges there. And I better to get the baby delivered as a breach floating there on sometimes when you deliver, it's a breach. Okay, so sometimes been making incision eso when you make an incision and the baby is floating high up, the baby's going floating half on. The heart keeps coming up sometime. Just keep the hands, go find the legs. I'm trying to get the baby delivered at the beach, you know, like try Teo get the baby, then rid of the beach with preterm. So it is not a Peter baby. But if you have a return baby or something floating head rather than going and finding a floating head to get trying to find the legs and try to track the legs and try to deliver them both together. And, uh, if I have a hand coming out first rather than pushing the time keeping up with keep the hand, try to fax back that back, trying to find the legs and then try to get the whole for the impacted head. We all know the system. If it is an opiate baby with the babies in the open position, it's better to go on the liver. Allegra Ah, breach extraction. But when the head is deeply impacted away on especially if you're trying attributed Lee on when really deep impact it unable to deliver vaginally then you could do about the weapons. Take me But you could deliver the arms well, your your arms and then go in. Ask your assistant a formal pressure while our system is giving funnel pressure, you extract the baby on, you know, like try to just gently flex the baby. I'm get the baby delivered like it was reached A little stick Me? What do you call that technique? Because I haven't used that technique. I I can't imagine living in the hands. I've got a little of the body. Oh, yeah. I mean, that's what I was planning to do. The manic in across there It is something that we do it in. Uh, I I got trained when I was in India. So where sometimes when the a baby's o p. Babies it easy because o p r o b, it's easy because after you go in. You can easily go and get the babies legs. But when it's a cold air, really, when the head is deeply impacted, it's almost very hard to go in on get the baby delivered. So that's a big you. First. Get the arms out on, then gently flex the baby. You put your hands under me. Uh, he's okay. Oh, yeah. You put your hands on learning the oh, So you put your hand I mean, ask you to give for my pressure on ask, You're pressing. You're getting the back dilemma so frustrated with the arms. Then the back bought them and then we'll be comes out. Can I ask a question? It's under weeks. It I've never done the reach first for a name packed it head. My concern would be I appreciate it so well described technique, but I've never understood why. Surely you still need somehow decompression cause you still get that suction of the head. Yeah, Do do you find that you first need to of either somebody vaginal lifted up the head or somehow put your hand along side the head to toe Release this the suction. What? We'll use what they call it the snorkel which somebody has invented which allows air into that space. You need that? Or does it? Does it just come? No, no, you could use the mineral in and sample we normally don't use is a little below. We have the luxury of using it. But normally been any fragrant military We know we're going to push it ourselves. But sometimes when we make an incision on that incision line, we get the shoulders. If you're you know the shoulders, if you're in the face or in the in the years, then you can actually go in on get the baby delivered. But there are times when we make an incision on the reshoot when you see the shoulders, especially those patients with the Androgel pelvis and things like deep pelvis is where the head is deeply impacted. Sometimes I find the shoulder the the advantage of this particular that's technique is the angle never gets were extended. Because when you're delivering, you're delivering the baby in the flex position. Rather going keep inside the pelvis on this, impacting the head and bringing it up on extending your angles. You are a delivering the baby in the flex position off. Um, in the thing. Sorry, I couldn't come there to show you them things. Yeah, we've just got one question. Um, online s So what is your recommendation on foreign myomectomy doing the same sicknesses there in section, uh, we normally don't perform. I meant to me is, But there are times we have to. I remember we now unit. We once had a lady with a large fibroid uterus who came in the court prolapse. So my register went ahead and made a question on the fibroid Andrea wise that she had made a decision. Then we went up on the baby, then call the consultant leagues at that point because it has been cut through. We had done it, but we try to avoid, uh, my rectum me during cesarean sections, if possible. But if he had to, then you have to and then get all the team. We have the luxury of the gun oncology unit with us. But there are times when the blood loss goes more than a few leaders, like 57 liters. Then we call them and they come in with their hand. Uh, I have tea. Comment One is um, So he did, just to add that for floating head. We can also use the forceps for me. You know, off time delivery I use of forceps on deliver the baby for floating head. Okay. And then in terms of fibroid in a cesarean section at times, you know, in African women, we have a lot of fibroids. So at times, if the fiber is in front of you in the new a segment, you know that it's a metal that you can really quickly. And your fasts agent, you can quickly, you know, do, um, rules that that not a laughter on that cut in, deliver the baby and then repair your your your trying Ah, you know, scan. So we don't Do you know my make to me if we have to, or if it is a p. Don't collect that fibroid and easily tied a fibroid. I mean, tie the pedicle did live Mean cut it off, and then do your cesarean section and then repair the, uh you know, the pedicle. All right. But otherwise we also don't touch fibroids in a cesarean section. So, ladies and gentlemen, thank you very much. Doctor Thinking for Asian. I think it's the end of our own workshop. So where do you go to A A round of a plus. I think we need to follow you. Djamila. You stay here. You know, I stay here. They have people stay here. I don't want to miss. Oh. Uh, okay. Yeah. Oh, you could come back. You come back, right? Right. Yeah, yeah, yeah. Okay. Yeah, right. Yeah, Yeah. You Yeah. Yeah. Okay. Yeah. Thank you. Yeah. Yeah. Okay. Yes. Hello. We're just waiting for her. Decide to come back and we'll start the next workshop. Okay. Thank you. Yeah, thanks. It's brains. Yeah. You know why? Okay, Um my ladies and gentlemen, you're welcome to on this workshop, so we're going to be discussing managing difficulties there in sections. So, um, we have with us, um, Doctor, my visually I was joining us from Sandwell and Wester Birmingham and hs Trust. She's going to take some few minutes to give us a presentation on. Then we will be discussing, you know, I'm exam cell. So, Doc, can you go ahead? OK, a profit can stay on stay. So, uh, it's just a quick background, guys, you know that it's there in sections is the one of the commonest procedures that we do on down. The rate of cesarean section is slowly been increasing. Uh, thanks to Oakland and report after that. No, you're not so much bothered about the number of sections that we do on. You're not bothered about the rate, but the rates are going up on if you start doing more more section the subsequent there in sections also will be going up on. This leads to more Procrit us on da, uh, complex there in sections complexes that in sections could be due to various reasons. It could be due to medical core mobilities like obesity. Slowly, obesity's on the rice on. So be on my 50 and about, um, come with a lot of comorbidities and medical complications like patients with severe asthma, cardiac of problems. Sometimes we have difficulty in accessing the lower segment. It could be because of fibroids, or could be because off multiple surgeries, including multiple cesarean sections with key lights. Sometimes we can't even access the know segment. Uh, almost after the level of fund assist, then sensations between those floor segments on be know sometimes come across patients with Chron's disease or patients who have multiple bowel surgeries. A bubble, the sections coming back with pregnancies on. Sometimes we have difficulty with a fetal extraction sometimes, UM, move ahead polyhydramnios mobile head or deeply impacted head during second states or a failure instrumental delivery. Sometimes preterm ruptured membranes with the transfers are legal. I where we have difficulty because you just has literally, uh, planning on to the baby and sometimes, well, you're doing and surgery when you have gone in well, entering your damaged bladder or bowel. We want had a lady with a severe constipation when the incision was made in the lower segment. Actually, the cervix was pushing off. Vagina was stretched, the rectum was loaded. So when the operative kept going in, they had gone to the 100 vaginal wall motion vaginal wall into the bowel into the rectum. So things like that on off course now, with increasing cesarean sections, you have abnormal class and patients like under a creatures and creatures I didn't see. This is, I mean, one of the things that that would be a moderately all these women, but we have difficulty in accessing, and also it's not just a Caesarean sections. And also the recovery The postoperative, uh, wound infection, uh, increase morbidity and mortality. And so that's why we started using appropriate abdominal retractors like the tracks. See, it is in a probable a tractor that tends to retract anti double ball. Or it could use a Lexus to retract to help you, uh, things. And sometimes if you have multiple fibroids, especially red fibers complicating pregnancy, especially in the lower segment with animal different flavors the lower segment, uh, where do you make the decision to go and get the baby delivered? So one of the things is always trying to scan. Never make an incision until you have scanned yourself on. Better to know we had we started using intrapartum scanning. We have got, can't rolls can covers. We tend to scan them with before we make an incision. Sometimes when you have multiple fibers, because sometimes the head and the sub, uh, mucus fibers can Sometimes it looks similar s it's better. Do, uh, have ah be planning. So this is one of the recent cases that he had Where, uh, this, um, ramp leases should all the normal ignorant on this is the portion of all fiber and that is a large one is an ideal fiber. Is the lady what miscarried and who have reading glasses until tissue in couldn't even access from a china to go and take that is written as an issue. She was really Paris, and so we had to literally open up, reposition the uterus to access there. You just to get the lead in bed. So pleasant of this year. Um, and so for any cases of the multiple fibers, it's better to have MDT approach like you don't really have a Monday disappearing meetings. We tend to have a meeting. We tend to map, and we tend to plan the sections Uh uh, the ultrasounds. And here Ah, we'll talk about the deep impactions, like in the head is deeply impacted inside. After failing to instrument a daily or a prolong sex, I can stay. You're obstructed labor with the baby is an old people's issue in. Sometimes it's easier to just go on deliver the baby. I said it was breeched, but if the baby is in a hallway position so the head is keeping back in, okay, it's back to to deliver in the party. Weapons thickening where you deliver the shoulders first on the body. I'm happy to take the questions. If you have any questions, we can discuss it. Thank you very much. Um uh, doctor may swear. Yeah. Yeah. Any money, Maggie? Okay, So I just in the last session, I mentioned that one of the most difficult there in section I had is ah, fibroid in pregnancy. Unfortunately, I didn't do a a repeat ultrasound at term through know where the fibrates are. And I took her in, and I just couldn't get the baby because the baby was completely behind the fibrates. The fibroids were covering the whole lot of the, you know. Ah, uterus. And I just kept on cutting and cutting and cutting. I would say, What is the baby, for goodness sake? Before I finally got the baby on, it was so difficult to control him. You know, bleeding. Because, of course, is that my meter? Um, I was cutting on the on the fibroid nodules. So the most difficult cesarean section I've had, um, so I think her suggestion off, You need to have, like, a meeting. You really need to know where the fibroids are You really need to know where you're going to make your decision. And, you know, in Africans we don't have, you know, a 16 weeks fibroid and 20 weeks fiber glasses, minor fibroids. You have, like, 30 weeks, 36 weeks. They get pregnant with 36 weeks size fibroid, and they still get pregnant. So you the fibroid is bigger than the baby. That's the usual thing. So really, it's a difficult as they're in section. So any questions for Doc? Any question? We had a question in the last session regarding, you know, deeply impacted, you know, head, because that's another difficult delivery on do. Um, So can you just You mentioned it. Um, but can you just describe the procedure you described in the last walk? Yeah. You know, I don't. Okay, I think I was talking to them about the part of weapons technique. Hlinka, if the head is deeply impacted just a second. So when the head is Deek impacted, if it is an old be baby, so that's always better than you. Examine. Assess yourself before you make a decision so that any second state section the surgeon is better to examine so that you are mentally prepared. Which direction you're going to go and get the baby delivered. If the head is deeply impacted. Yes, you can do all other things. You can help us, somebody to push, but more than the pushes. Better to deliver by the port technique. One of the things is if it's a reverse reach or B, you can go up on, get the babies legs, try to get both the legs and then ask your assistant in the form of pressure on getting a B. S. C was reached. But if it is an all a baby, if the head is deeply, in fact I mean engaged and then you couldn't deliver the baby with Jonah. Be then better to make a decision on but the incision site. If you have your limbs, get the hands out for the hands out on. Then put your hands underneath the short shoulders baby baby assistant to give Russia as they give the front of pressure on the bottom of the back. It's a little as any good general baby, so it's going back to what it is that your first liver, the arms. So this is the busy. So first you go there they have the ounce less the baby and then the baby out. So this is the time when you condiment put your hands in the head Is dpt so on drawing and thank you. Thank you. I'm just from there were discussing so deeply impacted heads. I've got a question on line. What is your experience with the fetal pillow? We have been using frequent lows, and we have presented We have found that the, uh, angle extension is, uh, less on. Um, the recovery is quicker. So that's one of the reasons we, uh, continue to use the two pillows. A sample in this bombing is Ever know what for? Your pillow is No. Okay, So fetal pillow is, um, something that we use in? Well, we use it in a little something. So sections now, the women's essentially sucker, uh, like a inflatable bag that you can fill up with fluid to insert it. Vaginal e is instead of a hand to avoid skull fractures. Okay. Inserted vaginally inflated. Okay. It's meant to sort of bring the head up, disimpact the head, and then you can deliver a section. Okay, so just leave with Increase it. That's I mean, here, this impacts around four centimeters, and that makes a lot of difference. Oh, so we haven't seen that. So what you do, you still drink it here? I brought it to the monster. Yeah, there's a There's a link actually, in the chat. Somebody's just posted links. If anybody wants to just check how they can. Okay, now, be interesting, because what we do is that an assistant will have to disimpact the head for you on the question. Do you disimpact the head before you make us incision? Or do you do it after the incision? That's the question, You know, uh, Robert drink. You okay? I think that we tell them you are the surgeon. You want the one who are making the decision. You make your life easy for yourself. One you make go up. You disimpact yourself on. Well, it is improving. Is not just gently pushing, isn't it? You're literally start off doing a little of screw movement up. So that makes life easier for you to go up. Because when we are some off the colleague, sometimes they use two fingers or sometimes, um uh can cause more problems, isn't it? So it's better that you put the whole hands when you can't deliver your failings to be going for sections. Better too distant back to yourself. Make your life easier. Push the head as high as possible and then go home. Scrabble make an incision. That's what we normally tend to tell a trainees. Okay, um, I think we have, like, three minutes. I think the other difficulties there in section is reports is there's sections, especially those that have. You know, I'm to patent marriage at centipede the most. They're in sections you do, the more likely that you're going to have a pleasant to previa on. You can have a creature and Procrit ER, because the sky is there and therefore the center will get, you know, implanted there. And it's not going to my great because there's a scar tissue on. At the end of the day, it gets back rate and a crate, and then you have difficulty in room trying to control him a ridge once you get into the placenta. So that's another, you know, cesarean section. So we want to think about you know, the polluted cesarean section. I was saying that know when? When I was training, it was five first cesarean section, and that was it. But now a days you do 56780 section and they claim, you know it's safe. But then there is a problem. The most science section, the more you have a person to be unpleasant A creek timber critter. So we need to think about that for cesarean section a safest, you know, Cesarean section. Any more comments before we call it a day? Uh, well, thank you very much. But my, uh, Q. So we're going to have one more group. So please stay back for the next group and thank you. Uh, group See a round of a plus. So good. Last one. Okay. Okay. I sure thank you so much for joining us. Get you through that. Thank you. God, I don't have any food. Only family. No, no, no. You haven't let anything down a tall thank you for our hope. You're okay. Yeah. Yeah, Catch up sometime and then I'm sorry. No problem. Yeah, they really do appreciate it. Thank you. Thank you. I had a view behind it. Okay. Okay. Okay. Okay. And, you know, came to you. Get lazy. Came later. Many, many is on you. Ended up all in Birmingham. Yeah. Hospital in Birmingham. Wow. Wow. Great. I can see it with I don't know the technique, you know? Okay. In India. Okay. It's Yeah. Okay. Oh, yeah. Okay. All right. Um, ladies and gentlemen are going to start. Okay, so, um, I walked up. It's in managing difficulty sections, and we have a doctor. Maheshwari was from Sandwell and West. Women have any chest dressed. She's going to make a shot presentation on difficults. How we can manage difficulties. I in sections on. Then we'll open the floor for for discussion. Uh, so, Doctor Okay, Thank you. Prop s. So we all know that Cesarean section is one of the commonest surgery that's being done worldwide. On slowly, our section rate in the country has been slowly increasing on. We have a cross more than her. The percentage, uh, for patients are a little bit of their injections because of the multiple cesarean sections, that complexity of sections also going up complexes. That city could be just because of the medical core. Morbidities like obesity. Slowly the uh, rice beer. My be, um, able 50 medical core mobilities like asthma. Um, uh, kind of problems are. Sometimes you have difficulty in accessing the lower segment. Either It could be due to fibroids. Are you multiple surgeries, Not multiple subject. Could be even about the pulses there in sections on scarring and killer information's patients with the phones disease who had a bottle of the sections. Uh, patients who had a normal blasting is there's quite a few patients who come and have difficulty the lower segment on. Sometimes you can have complications. You have difficulty with the fetal extraction. It could be because of the mobile head floating head, or could be a deeply impacted head or a pre term baby with a ruptured membranes with the Oakland A report and also the savings with his life. We have to know, uh, start delivering really preterm babies. Uh, on we need to make a safe condition and save delivery on a laceration or organ damage before delivering the baby's on. We have sometimes abnormal presentations like placenta previous, afraid Earth. So with obesity, the morbidly obese women we have difficulty in accessing on you have the issue about the traction on. But the thing is a plate safe place to make an addition and safe place to go and get the baby delivered. Eso. Now we have to use a pro, uh, appropriate abdominal tractors, I think May office and you gave you tend to use the tractor abdominal fraction, which tends to help with the traction of that your normal wall or Lexus. Uh, sometimes we have women with the multiple fibers complicating pregnancy way Have a medicated, then lock clinics where these patients are seeing earlier in the 5% ma muscle more than 2030 centimeters, we normally tend to organize them. Have, um, MRI minimal $5 in the little segment or, uh, under Nice to have some lunch or crones on. He had a seat in case bad. We kind of think internist. A miscarriage on this was the post here Fibrin stand here. Hydro on the uterus was sandwiched between the two fibroids on grant access, the pleasant of issues. When the patient miscarry, going to remove the blocking tissue, we have taken the day the reposition the uterus to access the uterine cavity and do the the evacuation. So anyhow, multiple fibers move to find a safe place to make a statement to get the baby delivered, so it's always a month dyspenea po approach any harm in doing cyber? It's better to have a few people in bold have a pre planning mapping of the fibroids. Sometimes you might need an MRI, or it's better to have a pre operative ultrasound whenever you have. Fibroids are plus. And, uh, Accredo chance was like anything that you're doing better to do. Uh, I'll just sound just before I mean after the A final not before this part, just to make sure you're you are mentally prepared. The van You want me to make an incision? Sometimes we can use other town with the probe covers intraoperative you also to make a safe place where we can go in and get the baby delivered, because as props set number of large, my first, the sports, and that it pushes the one side and you will. You don't know very on entering into the uterus to get the baby delivered. Um, sometimes with the head is deeply. In fact, you might need a liver recipient extraction or are ah, particle turns taking to the baby, but I'm happy to go through, uh, any questions if you need it. Yeah. Thanks. Problem? Uh, very much. Ah. Doctor Maheshwari. Uh, What she said, You know, there are some very difficult cesarean sections. If you practice us an obstetrician, you're bound to, you know, meet them along the way. So, um, a discussion now? Yes, she did. Yes. So shaky and minimester Birmingham eso my history. Thank you for the nice presentation. You know, if you're working in a setting where you don't have access to ultrasound, you don't know it's ah present previously because the mom had never had bleeding. And then you open up and you realize, actually, a low lying, pleasant up present anteriorly on you are only obstetrician. What do you think should be the steps that have need to be done to continue safely from that point on words to minimize the complications for the mom? Uh, yes. You are made an incision on the uterus on. Then where you're entering, you see the blood issue. Yeah, any other one when you get reports that the class and I scare of us, but when we make an incision, sometimes you go through the placenta when the placenta might be there on your incision line. But there are white cutting through the placenta. Try to separate, um, the blood center. If you know it's definitely anterior. And if you can go on the meat and trying to find a plane, well, you can reach the membranes on reach the baby. And usually sometimes at this stage, it might be a floating head, so we might have to use the instrument or something to get the baby delivery. One of the things which I would suggest is what cutting through into the breast center. But, uh, if we have gotten through, then call for help with your compartment on, you're on the way. And so thank you, Doctor May. Actually, I think you need to call for help. I will say that if if you just find First of all, that's why once you make one through a polyp, you can see the lowest segment. Um, if it's a pleasant of previa and you have the vessels looking at you, try and see. As she said, If you can go a little bit above so that you can get today, you know members with that cuts in the percentile s. So that's one way so that you don't need that call for help. You know, uh, you know, I was so fast. But if for any reason you cut before you realize that this is really a present a behavior, then cut straight go straight. Because the most important thing is straight to deliver the baby. Because as soon as you deliver the baby, then you're you're going to tell them. Give oxytosis give this Give that you can is legal of, uh, the the placenta after that and then, you know, have 200 you know, bleeding from the lower segment. So I think speed is It's it's Ah, it's something that is needed. A best age. Yes. Um, yes. You have a question? Yeah. One minute. One minute. Yeah, I was just wondering. Thank you, Mara. Sure you for a very nice presentation. And I was just wondering, if you have all the resource settings are like the question I'm from doctor here. You You know that there is fibers. Would you still go on with the Caesarean section despite off knowing the complications that arise from it? I can't I mean, if you wake from what? The general delivery. If the head of the baby has crossed the person fibroid, be promote, really to do with the majority. But if there are multiple reverse of the lower segment about the vagina released, not possible, that's when we go four sections. Yes, so you might have some, you know, five. Pregnancy body you. It's only cesarean section, you know, the fibers can even make the baby to toe have a mile presentation. The baby can be a transfer's on topic because there's a huge fibrate days occupying the lower segment, so they had doesn't go in, and therefore you cannot deliver vaginal. So in that case, you have to do a cesarean section on. My second question is, I'm not really sure if it's rather than but as to ask, I'm not very sure if we can prevent fibroids. No way. I don't know what that that but I since I brides almost 60% of the you know, black women have fibroids, so fibroids are extremely common in the black race, and we don't see fibroids off trust. Intimidators three centimeters with the image fibroids 16 weeks, 20 weeks 30 weeks. Some fibrates are bigger than the baby's. You you see a fibrate as big as 36 weeks on. The woman will not come until she's gotten pregnant. Then she comes with the pregnancy. So you have a huge fibrate and you have a small baby on one side. So really complications throughout the pregnancy. Red degeneration on on on on on on. Uh, so really preventing fibrate is something. If we can find a reason, I mean, we want to prevent fibroid. I think it will be a noble price. Yes. Could you give us examples of when we should be going for a classical cesarean section and how to do it on what people should be aware off? Because there's not something that obstetricians routinely do. Um, so just want to if you could sort of help help us when you will go for a classical section and how you would go about it. I mean, it's a little border inverted t shape incision, which that worst thing is to get the inverted t because something to interrupt your uterus and things. How much higher? I'm also the be back in in the trust. So that's one of the reasons they keep promoting. When you have preterm babies with ruptured membranes on transfers, lies and things, it's better to go sometimes with, um, a classical section or something to get the baby delivered safely. But we try to room majority of if it's longitudinal on not any problems. We can go the the low segment. But if you have a pleasant our creator expected to go plastic, a look at the baby delivered on, then try to be with the placenta previa. Yeah, I think for us we we train our residents that the only indication for classical cesarean section is one postmortem cesarean section. You have a mother dead, a big. It's a life. If she dies immediately, you can easily do a classical and deliver the baby. Secondly, when you can't access the lower segment, for example, you have spicoli cancer, cervical cancer. That's okay by whole lower segment. If I'm not even fibrates because you can cut fibroids and deliver, but when you have when you have a cervical cancer. A. Sometimes the only classical have seen that have assisted is actually a patient with cervical cancer, and we don't the classical cesarean section on at the end of the day, you know, did weapons hysterectomy for her after s. So that's, uh, the only indication, because even, you know, before they used to say, major plants and a Prevnar do classical normal. You have to get your way to deliver the baby. You don't need to do a classical. Oh, um, you know, a transfer. It's like, now it's transverse lot. Unless it's a transfers, like with an impacted shoulder, then you might need to do a classical. But if it's just normal, transfers lie. You can actually get the legs off the paper, even if it's one leg. By the time you turn the baby, the rest of the body will follow. Yes. Ah, questions. The other thing is a creator, a creator. If you're doing things in sections, replaces and sections many your bank to come in contact with Procrit and a crater because placenta previa will be there on then because they said scar, it just gets into the my meter. Um, and then you have a lot of problems. So repeat cesarean section. I think we need to think twice now. Is that forces and sexual really the safest. Or do we go 567 as we're doing now? Because we now say no end to Susanne section where really, By the time you crossed our four, the morbidity and mortality is very, very high. In the last two months of saying to cases off, you know, Ah, five professors there in section I'm, then a center here on on a crater. And one of them had, like, 10 points of blood to save her life on a hysterectomy on the other one. We lost her. This was just last week. We actually lost her. So So I think we need to think about, you know, cesarean section. I don't believe it. The person, the first person that we saved her life. I was telling her that when we enter, we're going to do a beauty up. I mean, she was still telling me that she doesn't want to be a t 06. Previous is a little section, and when she came out, I said, Now you can see where I said you needed a big deal. Now the trustees haven't gone because we had to do any strict to me to see if our life had to get, say, gents to come in because we didn't know whether we had injured the bow were confused with, you know, brand of blood. Um, did not stop. So for cesarean, section six is a A section. Know what after fall. So but that man sherry any less Any last thoughts? Oh, that's a lot prophecy. It was really a great meeting. And I was nice talking to you. And do you? All right, so we're done, so thank you very much.