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Ok. Um Shall I start from the very beginning? I might be just off from the beginning if uh yeah, if you could quickly just go over um from the, yeah, the stages of labor again, that would be great. Yeah. Yeah, no problem. That's fine. Um Let me go back, let me just make it um full screen and then I'll just check that you guys can see that. Um Can you see my slides and hear me? Ok. Uh Yes. Yeah, we can. Thank you. And can the attendees see the slides as well? I'm guessing. Uh I think they should be able to. Yeah. Ok, perfect. Anyway, II think just let me know if there's any issues. Um ok, so um welcome everyone to the talk. We're gonna cover some delivery problems and um just the normal delivery and some commonly encountered um emergencies and problems during delivery and we'll go through maternal problems as well. So those are just some of the topics that I'm planning on covering in today's session. Um So we'll go through stages of labor. So we've got three stages of labor. Essentially. Your first stage is basically where you've got your replacement of the cervix um and dilatation up until fully dilated, which is 10 centimeters. You've got stage two, which is basically where you um have you go from fully dilated to the delivery of the baby and then stage three is delivery of the placenta itself. So these are just some things that we look at when we do vaginal examinations. So you've got effacement, which is just a fancy way of saying your cervix is basically becoming thinner and shortening of the cervix. And this is really important for this to happen before the cervix begins to dilate. So if you think about it in early labor, your cervix is all the way at the back. So it's posterior, it's long. So at least two centimeters long and it'll be firm as well. And the basement is where it comes forward, it starts to thin and it starts to shorten as well and it becomes much softer before it starts to die. Um And station is basically where the baby's head is in relation to your ischial spine. And the ischial spine, the bony prominences that you can feel when you're doing a vaginal examination and at spine is basically station zero. And the further away it is from the perineum, it goes sort of negative minus 1234 and then uh closer to the perineum is plus one plus two plus three plus four. And, and we've mentioned, yeah, we've mentioned dilatation station and effacement and true labor is basically where you have painful contractions and relaxation of the uterus happening at regular intervals, usually 1 to 2 in 10 um as opposed to Braxton Hicks contraction, which are quite common actually um later on in your third trimester. Ok. So, um going through the three stages of labor in a little bit more detail. So stage one is where the uterus is contracting 2 to 3 every 2 to 3 minutes latent phase is that cervical effacement, which we mentioned already and dilatation up until 3 to 4 centimeters, an active phase is basically four centimeters onwards. And we expect uh women to progress sort of around two centimeters every four hours because we usually examine every four hours or like half a centimeter every hour. Um And stage two is basically from fully dilated to the delivery of the fetus. Passive stage two is in the absence of pushing and active. Second stage is when you start pushing. Um So for example, sometimes if um for Nulla Paris women, so women that have never been pregnant and never uh delivered before, we might allow them two hours for passive descent, which just means that you're from fully dilated, you're allowing two hours until they start pushing. Or if someone has an epidural, you can allow again two hours until they start pushing. But if they are, they've delivered before, if you've had any, if you've got any ecg concerns, you might start that a bit earlier and then stage three is basically delivery of the placenta. So, um there are just three things that you need to think of with regards to labor. So think about power. So power essentially is just your contractions. You need to have good, long lasting regular contractions. So usually when I sort of counsel women, I say we need to have at least 3 to 4 contractions every five minutes. If you're only contracting one, every 3 to 4, every 10 minutes, sorry, if you're only contracting one every 10 minutes, you're not gonna have enough infractions for the cervix to open up for the baby to come down and to actually deliver a baby, you need to think about passage as well. I mean, we don't really kind of uh you, you can kind of sometimes you can have when you're assessing when you're doing a vaginal examination, you can kind of check how much space there is, for example, um passenger as well. So it's about the size of the baby. It's about the position of the baby as well. So for example, if uh babies are bigger, so they're large for gestationally. So if on the ultrasound scan, um the estimated fetal weight is plotting above the 90th or the 97 centile, then that could be a reason why uh there's slow progress in labor. The other thing is position as well. So the optimum position that you want the baby to be is direct oe which basically just means looking straight down. And if baby is in a different position, it could mean that the lab uh labor is maybe progressing a bit slower than you would expect. Those are just some of the things to keep in mind when you um kind of are thinking about why some women are progressing a bit slower than, than you'd expect. And this is just some of the cardinal movements actually that allow delivery of baby's head. So if you think so, at the onset of labor, baby is looking, the baby is looking sideways and baby needs to flex its head and actually turn to face directly down. And that's kind of the optimum position. But obviously, as you might have seen from your shifts, lab order, you might have read up from textbooks and stuff that isn't always the case. Sometimes they can be a little bit kind of um tilted. So it can be um tilted either to mom's right or tilted to mom's left or it can be looking upwards as well, which is or occipital posterior, which just means that the back of the head is at the bottom. Um So yeah, so it basically rotates to face down and then the baby then extends its neck and then restitute, which is basically just so the shoulders and then anterior and then you basically deliver the shoulders and you deliver the baby's body. That's just a useful diagram to kind of think about the mechanism of delivery. Ok. So we'll go through fetal monitoring. So when it comes to fetal monitoring, there are two ways of monitoring babies. So you can either um monitor by intermittent auscultation. And that's not often something that as an obstetrician sort of I come across because that's often done in the but II in the midfield at birthing center, essentially because most of the women that we look after are higher risk. So we would have um you know, continuous C TGI would be doing kind of regular CTG on the women that we look after. But if you, if women are deemed low risk, then they would be offered intermittent auscultation. And essentially all that is is you're basically either listening with a pin out, which to be completely honest, I haven't come across in a very long time or you'd be using a handheld Doppler, which um hopefully you guys would have um been able to use or would have seen people use it. So in first stage of labor, essentially, the way that you auscultate is you um auscultate immediately after a palpable contraction. So you basically feel the mom's tummy and you kind of can feel the uterus tensing. So immediately after that for at least one minute, and you are basically listening to the fetal heart every 15 minutes in the first stage of labor and you'd be recording any accelerations or decelerations and you'd also be checking for the maternal pulse every hour. And the reason why you check for the maternal part is to make sure that you're monitoring, you're definitely monitoring baby and you're not monitoring mom instead of baby. And that's really important um in the second stage of labor, all that's different is you're basically um recording the fetal heart much more frequently. So it's 15 minutes in the first stage and then it's five minutes in the second stage. So just um quickly looking at the basics of um CTG. So CTG stands for cardiotocograph. So cardio just means heart rate. So you're monitoring two heart rates on a trace. So the top one is the fetal heart rate and the next one, which should be where B is, it doesn't actually show it to you on this photo. But at the bottom, you'll usually see maternal heart rate and that's basically to differentiate between baby and mom because you need to be very, very uh confident that you're definitely measuring baby and not mom because sometimes some women during labor can actually their heart rate can go a lot higher up to 1 21 40. So it's very different to very important to differentiate that. And the to of it is basically the uterine activity of uterine contractions. And again, it's very important to monitor uterine contractions because you need to see if baby's hearts, if baby is decelerating. Where is that in relation to the uterine activity? Um Yeah, So you're monitoring baby's heartbeat, mom's heartbeat and then contractions underneath. And if you look at what she is pointing to, uh does anyone know what uh what she is, those kind of those boxes? Does anyone know what um um what that's meas uh what that's pointing to. So she is actually looking at the uh the movement basically. So the mom is usually given a clicker um that she can press uh when baby is moving. So all of the the the the long rectangles are basically loads and loads of fetal movements. And you can see that that's when baby is kind of accelerating and the heart rate is going kind of up and that's kind of um what that line is representing. So when it comes to interpreting CTG S, um a commonly used uh pneumonic that uh people kind of learn is doctor C bravado. So the DR is defining risk. So whenever you look at a CTG, you need to remember what are the risk factors in this case. So does this mom have diabetes? For example, does the mom have preeclampsia? Um is it a small baby? Um Those are some of the things I need to think about because if it's a small baby, you're having loads of CTG concerns. You need to think is this baby going to actually tolerate labor? Right. So risk is very important in obstetrics contraction. So how frequently is the mom contracting? Is she contracting too? Little or contracting too much, you need to look at the baseline rate. So what rate is this baby going on for most of the time? Um So that's basically if um like if you've got the CTG, for example, I would say the baseline rate is sort of 120 or maybe 130 um variability. So that's basically the beat to beat variability. Um So the main thing is that it needs to be over five accelerations are accelerations present. If there are no accelerations that no, that's not necessarily a concerning thing. But if there are accelerations present, especially for example, if I'm, if, if I'm doing a vaginal examination and uh baby's heartbeats going up in response to the examination and that's a good thing, decelerations as well. So not all decelerations are bad and this is a nice um kind of diagram that shows you the different types of decelerations. So when it comes to decelerations, it's very important to see where they are or how they are occurring in relation to the contraction. So an early deceleration is a deceleration that's happening with a contraction or even before, slightly before a contraction. And that's essentially physiological, which just means that it's just basically baby's head being compressed. Um And actually, if you think about it, if you were doing intermittent auscultation, you wouldn't even be picking up on these decelerations because you'd only need to be listening after the contraction had gone. So, actually, early decelerations are not necessarily very concerning same thing with variable decelerations as well. So variable, the on the reason why they call variable is because each deceleration looks different. The the the shape of the decelerations are different essentially. And that's again, that's just compression of the cord. And that's also not as concerning obviously, if it's going for a long period of time, if it's happening with every contraction, there are some concerning features. If it's very slow to recover, it's happening for like if it's becoming very, very wide, those kind of things would be concerning the things that you would definitely be concerned about is a late deceleration. So a deceleration that's happening after a contraction because that means that there are some signs of hypoxia. So la lack of blood flow to baby. So, and if that's been going on for a very long time, then you know that, you know, baby's bh is dropping and that neonatal and the outcome is gonna be poor, baby is gonna be born in a poor uh state essentially. So you need to intervene earlier. Um And the reason why I've put up the traffic lights is essentially whenever you look at a CTG, um it's kind of useful to classify it, especially when you're kind of trying to escalate or when you're trying to communicate to your colleagues, it's useful to kind of think of a CTG as normal. That's why I put the green, the yellow is kind of suspicious. So suspicious just means that, you know, you are not, you don't, you don't think it's red or pathological. It's kind of somewhere in the middle and you sort of want to do things like change position, give the mom fluids, um, stop any, um, stop or reduce the, um, the hormone drip, those kind of things. So that's just a useful way of kind of looking at CTG S and that's the o in this, in the bravado. So the acceleration deceleration, the overall assessment. Do you think this is a normal CTG? Do you think it's suspicious or do you think it's pathological? Ok. So, um this is the first M CQ of the, the teaching session. So you've got a 28 year old pregnant woman who attends A&E with a history of clear vaginal loss. She's 18 weeks pregnant so far has no problems. She's had a large colon biopsy of the cervix. That's her past medical history and she sort of ruptured her membranes. Um What's the most appropriate initial management? And I'll give you guys a minute to um thick. So, in the chart, we've got DD. Yeah. Um Yeah. So the correct answer is D so I'll just go through why um um kind of D is the right answer over some of the other ones just very quickly. So, the reason why, so, um the reason why you did an ultrasound scan is because you basically want to check. Um Essentially how much Lyco there is. You also want to check um kind of uh the, the bleeding, whereas the placenta, those kind of things as well, infection markers. So the main thing, so this is basically um it would, it would count as a miscarriage. Essentially, it's not, it wouldn't really be P PRO because uh preterm, prelabor rupture of memory that you're gonna come on to is from 24 weeks onwards. Um So the main thing actually with rupture of membranes at this gestation is the risk of infection, which is why you would need to admit this patient and you need to do infection markers as well. Um because untreated infection can, you know, can lead to sepsis and women can actually get quite unwell from it. Um So yeah, that's the reason why you would do D and the reason why C is wrong is because at this gestation, sadly, baby is not viable, it's not a viable pregnancy at 18 weeks. So you wouldn't necessarily get steroids. You'd only consider steroids from 24 weeks onwards. Ok. Good. Well done. So we'll quickly go through preterm labor and P prom. So, preterm labor essentially, what causes the main thing we're thinking of is infection. If you've got twins or triplets, you're more likely to go into preterm labor. If you've had an antepartum hemorrhage, if you've got small baby on board. So, intrauterine growth restriction, if you've got polyhydramnios, which is an increase in fluid increase in the amount of amniotic fluid, which we measure on ultrasound scan and previous surgery as well can increase the risk especially of late miscarriage. So, late trimester loss, which is what the previous case was. So, in that case, her risk factor was uh the cone biopsy of cervix. And if that does happen, if you've had a late uh miscarriage, what happens in subsequent pregnancies is we do cervical length scans and we measure the length of the cervix. And if it's shorter or if it's starting to shorten or starting to open up, then we can put a uh elective cervical. So it's basically a stitch going all the way around the cervix to try and keep the pregnancy in. It does fail sometimes, but it can sometimes work and can actually get people all the way up to 37 weeks. Um And that's basically just showing you the cervical cage. Um and the risks of premature that we need to counsel these patients. And often it's actually the neonatal thing that counsel them is problems with um necrotizing enterocolitis or neck neonatal jaundice, failure to thrive cerebral palsy and respiratory distress syndrome as well. So, p prom or preterm prelabor rupture of membranes. It's basically defined as rupture of membranes between 24 and 37 weeks. That's the preterm. The prelabor is in the absence of uterine activity. Why is it a problem because of risk of infection? We've mentioned infection already, especially when you've got rupture of membranes and risk of prematurity as well in the new. And this, we, we investigated by doing FP, CE and C RP. Um to check to just to monitor infection markers, you'll do the urine dip as well to see because often it's a urine infection that's actually triggering preterm labor in these patients. Um And you can confirm the rupture of membranes, either on speculum or you can do tests basically swabs that can um if positive kind of indicate that the woman has actually ruptured her membranes. And how do we treat it so often? These women, if they're well, you can just give them antibiotics for 10 days, consider steroids and essentially you wanna try and take them to at least 37 weeks if possible. Fine. So, next question. So you've got someone who is not. So, para zero, they've been admitted for a post induction at 42 weeks. Um She's received 4 mg of prostaglandin after 72 hours. The cervix is five centimeters dilated. Um um four hours later, she's still five centimeters dilated on abdominal examination. The fetus appears to be a normal size. The position is left occipitotransverse baby is kind of facing sideways. Um The station is minus one. There's no molding which is basically just kind of overlapping of the bones and mild swelling on baby's head. She's contracting two every 10 minutes. She has an epidural in situ. Um You're asked to review and make a management plan. What would be the most appropriate plan? The thing that I should mention that they haven't actually mentioned in this case is that she has uh ruptured her membrane. So she doesn't have any uh membranes during the induction process. She has ruptured her membranes. So yeah, she's five centimeters dilated on two examinations. So essentially you've got failure to progress and she's only contracting two every 10 minutes. So, what should we do in this case? Yeah, exactly. So the answer would be e um and the reason why, so the reason why we would give Oxytocin is because as I mentioned, at the start, you need to be contracting at least at least 3 to 4 and 10. If she's only contracting two every 10 minutes, then there's not enough contractions for the labor to progress. So, what you want to do is you want to give an Oxytocin infusion. And the reason why you would do continuous monitoring as opposed to intermittent monitoring is because obviously with Oxytocin, you would not, you would need to be continuously monitoring the baby because baby can become quite distressed. There's a risk of uterine rupture, the U uu the uterus basically opening up, especially if someone's had a previous Cesarean section. Um And essentially, yes, that that's why you would not be suitable for intermittent auscultation. Um And usually if someone's on an Oxytocin drip, we would either kind of examine them six hours from starting the drip or four hours if they're contracting regularly and we might, we would discuss a Cesarean section, but you would at least try and trial an Oxytocin drip and then, you know, um, go for a Cesarean section if the baby is not tolerating the drip. Yeah. So the answer is e good. So, induction of labor. So why do we induce labor? It's essentially when the risk of continuing on with the pregnancy is greater than the risk of delivery for the mom or the baby. Um And you've got lots of obstetric indications. So things like um IUGR which is basically growth restriction of the baby, prolonged pregnancy. If you've got a non reassuring trace, severe preeclampsia, obstetric cholestasis, medical reasons are, for example, if you've got diabetes either on insulin or poorly controlled, the uh bishop score is basically a scoring system to assess the favorability for induction. And it takes into account lots of different things that we will go through. Um How do we do it? So, essentially there are hormonal and nonhormonal methods of induction. So, nonhormonal methods are, you can just do a membrane sweep, which is basically just separating the membrane from the cervix and that in itself can release prostaglandin to try and naturally induce labor. You can do, you can do things you can put dilapan in which are basically these um they're osmotic dilators and they basically just look at look like matchsticks, essentially and they absorb the water from the cervix and they mechanically dilate the cervix. You can put a cooks balloon in which is a bit similar to a foley catheter. Essentially, you can basically put that inside the cervix and you dilate it with water and it mechanically again, opens up the cervix. You can use prostaglandins, which is a hormonal way. And essentially what it does is it causes the cervical effacement. And all you want is for the cervix to be around two centimeters dilated. And as you can see in the picture, you can put a hook inside and you can break the um water around baby or you can give. And obviously, once, um you know, um you have no membranes around, you've made sure that the, that the woman's ruptured her membranes and if she's dilated, but she's not progressing as much as you'd like, you can then offer an Oxytocin infusion. So usually after we ERM someone which is basically just artificial to rupture of membranes. If someone's um you know, never had a delivery before, then you can kind of give them four hours or if they have delivered before you can give them two hours just to walk around to try and see if their body can naturally start the contractions. But obviously, if it doesn't, then we can give them the hormone dr and I've mentioned the amniotomy, which is just artificially rupturing the membranes that's basically just looking at Bishop's score. So looking at, where is the cervix, what's the length of the cervix, the consistency of the cervix, how dilated it is and the station of the presenting part are all things that I've kind of mentioned already things to consider when you're inducing labor is CTG monitoring, uh monitoring you trying contractions, assessing bishops score um and always kind of checking for the umbilical cord. You want to kind of rule out a cord prolapse and we'll go through what are what are called prolapses in a few slides and checking previous scans. And usually when we start women on the hormone drip, I always talk to them about analgesias because the hormone drip is gonna make your contractions much more painful, can be more regular and it's gonna be longer lasting. So it's very important to kind of offer them things. So with regards to kind of analgesia, you think of it as like the pain ladder. So you start off with tablets, they can have an injection or a pethidine injection, which can be quite useful, especially in the early stages of labor. They can use gas and air as well, which is the entonox. The you can often see women puffing away on, on the labor ward or you can also give an epidural as well, which is a very, very kind of um it's a great form of analgesia and obviously you need to assess progress. So it's if you have put the tampon in, it's 24 hours after. If you put the gel in, then it's six hours after. And some of the complications as well is hyperstimulation. That's basically why the uterus is contracting more than six contractions every 10 minutes. And baby's heart rate is dropping as well. In that case, you might have to slow down the contractions by giving a medication like terbutaline or you might have to reduce the hormone drip or completely stop the drip and give the baby a break. You try and rupture again. It's a complication and failure of induction. Either the induction doesn't work. Uh You can either repeat it or you can offer a Cesarean section in that case. Um Fine. So next question, which of the following are not a risk, I should say a risk factor for a beach presentation. I mean, not one of the commonly documented ones. Yeah, great. So it is previous Cesarean section. That's correct. So quickly going through breech presentation, it's basically where uh either the, the baby's bum or foot or feet are presenting instead of it being cephalic in the longitudinal lie. You've got frank complete or foot language depending on where the legs are basically in relation to the body. And often some a baby can be breached basically at 20 weeks. But then, you know, baby can turn around and stuff. It's basically all that same, some of the risk factors we've gone through already. So you've got the uterine risk factors, the fetal risk factors, um which kind of predispose to breach presentation. How do we manage it? So you can offer an ECB, which is literally when you turn the baby, it does have a 50% success rate. I think I've only ever seen one successful ECB of all the ones I've seen so far. Um And if it's failed, then you offer a Cesarean section around 39 weeks or a vaginal beach delivery as well. So you can turn the baby Cesarean section or vaginal beach. And vagina breach is not very common. Often the the vaginal breaches that I've seen in women that have, that have delivered before and that have just come in spontaneously. But so those are, that's when your bach delivery is most likely going to be successful. So often in most units, you'll probably do the or elective Cesarean section, but you always discuss a vaginal breach with the patient, you know, you want to facilitate patient choice. Um ok. Next question. So you are the junior doctor on labor ward. Um The you've been called by a midwife delivering mitch babies heads delivered, but the shoulders are not delivering with normal shouldn't really be done by axial traction. Which of these is your first step in management of this condition? ABCD? Yeah. Correct. So, um it's asking the mom to hyperflex their legs and applying suprapubic pressure. Um I think Stan has answered correctly. So, do you know what that maneuver is called. Yeah, great. It's mcroberts maneuver. Great. Um Good. So we'll quickly go through shoulder dys Tosia. So obviously it's an emergency. You wanna ring the emergency buzzer and it's something that we counsel, especially, um, diabetic moms that have big babies. That's something that I will tell them about when they've come in for labor. So I will say, you know, there's a risk of the shoulder is getting stuck. It is an emergency. There's loads of people that are gonna come into the room, we're gonna bring, put your legs up and we're gonna try and deliver the baby. So essentially shoulder dystocia is a bony problem. So it's basically where the anterior shoulder gets stuck behind the mom's pubic synthesis. And the biggest risk factor is macrosomia, particularly in women with GDM because just think of the babies as having chunky shoulders, which is why the shoulders get stuck. Uh maternal complications with shoulder dystocia, it increases the risk of DPH and increases the risk of 3rd and 4th degree tears as well. Fetal complications are obviously with when, when it comes to delivery of the baby and some of the maneuvers and stuff, there is a risk of brachial plexus palsy. But actually, in most of the cases, the uh nerve palsy only lasts a few days to a few weeks. And actually after a year, most of the baby, it's very rare to have long lasting neurological complication, which is important when counseling women because you don't want to scare them off of vaginal delivery. Um, flat fracture as well, sadly can happen. And fetal hypoxia and that's the main thing. Um, actually, because if, if it, there's a long time between delivery of the head and delivery of the body, then there's an increased risk of, uh, lo lo loss of blood supply or lack of blood supply to the baby. And that can have long term neurological complications. But the important thing with shoulder dystocia is it's very difficult to predict. And actually shoulder dystocia can happen to babies that are normally grown as well. So it, it is something difficult and it's difficult to kind of anticipate and prevent it. Actually, it's more something it just happens and, you know, you have to just be able to manage it. And um, that's just uh uh palsy. So, um, so the one that, so the one basically shows you mcroberts and the two is a suprapubic pressure essentially. So what, what do you do when you see a shoulder dissociated, you call for help, pull the emergency buzzer, ask the mom to stop pushing, consider a Piot toy. If there is not enough space, it can make some of the maneuvers easier. So mcroberts maneuver, which is what we said, um That's basically where you have knees to chest and that essentially widens the pelvic outlet and actually the success rate is 90% and it's even higher when you combine it with suprapubic pressure. Great. The next one, you've got a 30 year old woman who is 41 weeks pregnant, being induced on labor ward. She has an AM but the midwife notices that the umbilical cord is visibly protruding from the vagina. Um, she's brought for an emergency cesarean section. What's the correct position for her to be in whilst being prepared for surgery? Sorry, that should say ABCD. Let me show you guys. Um Yes. So we've got D which is on her knees and elbows. Do you guys know what that position is called? Um Yes, that's, that's the old four, correct. Uh What's the, do you guys know any other positions that women can be placed in, in case of a co pronase? So it's called an exaggerated Sims. And I've got a photo of that, um, the next page. So court prolapse even though it's, I mean, it's, it's quite, it's quite a, it sounds like quite a scary and emergency, but actually it's not that common in my, in my two years in obstetrics. I actually have never seen a court pull ups. It sounds pretty scary to be honest. Um So it's basically where the cord descends through the cervix on or before the presenting part. Why is it a problem? Because essentially it, because when the cord is exposed to the cold atmosphere, you basically get vasospasm and that's what gives you the fetal hypoxia. And if you can, if you think about baby's head then squishing the cord or any, any part of the baby squishing the cord, you also have occlusion, which again gives you. So you've got the occlusion and you've got the vasospasm, which is what causes the fetal hypoxia. What are some of the risk factors say babies breach unstabilized. So for example, if baby is kind of flitting between cephalic to lying sideways to lying breach, am. So if you're doing a rupture of membranes and baby's head is quite high up, if you think about the mechanism, the cord can then come down or if you've got polyhydramnios because it's just basically a swimming pool in there and then anything can basically come down. So whenever you have a woman with polyhydramnios and you're doing an am you do a stabilizing AM which is basically where you kind of break the waters while someone else is there trying to stabilize the presenting path. So the head can gradually come down without the cord kind of prolapsing. But anyone with polyhydramnios, we always counsel them that this could happen. And the other risk factor is also prematurity as well. So management of cord prolapse. So think about a cord prolapse. So whenever you have a bradycardia or a prolonged deceleration, baby's heart rate is dropping and it's not recovering, that's why we always do a vaginal examination because you want to see is there any cord that could be causing this pathological? CTG uh it's confirmed. Either on vaginal examination, you might be able to feel a pulsing cord pulsating cord. So, or you might just be able to see the cord prolapsing through, um call for help. It's an emergency, avoid handing the cord. And essentially you want to manually. So this is the cord and you've got the presenting part kind of on top of it, occluding it. You basically want to manually elevate the presenting part um off the cord during V. And you've got positions like knees to chest, left lateral to relieve pressure on the cord and consider tocolysis. And unless, and I've spoken to my kind of senior registrars about this. So if you've got a cord prolapse and the woman is fully dilated, then it might actually just be quicker to deliver the baby vaginally. So you might just do an instrumental delivery, but obviously, the woman is not fully dilated and so only two or three centimeters, then you have to take her to theater for an emergency cesarean section. And bladder filling is something that's done in the community. And essentially you fill up the bladder um by kind of squeezing in 500 mils of normal saline. And that basically pushes the baby's head away from the cod because of the enlarged bladder. And the two positions that you can have are basically exaggerated ss or need to elbow position. Um Good. Next question. So you've got a 36 year old Nly Paris woman admitted in neighbor at 37 weeks on examination, the cervix is fully dilated. The head is direct oa which is basically where the baby is facing down and it's straight down, not kind of filtered anywhere. That's why it's direct. The fetation is at plus one. So below spines and you, the head is 0/5 palpable per abdomen. You've got CDG concerns. You have late decelerations, you've got fetal heart rate of 100. So you've got a bradycardia and that's continuing. Um How should the situation be managed? Probably say I wouldn't, wouldn't say 15 minutes because then you actually wait 15 minutes with that CTG. But um, but anyway, let's just say you've got, you've got CTG, you've got a pathological CTG. Yeah, exactly. So you'd essentially want to do an instrumental delivery basically. Um And this question was just me trying to just get you guys to think about what are some of the prerequisites of an instrumental delivery. Um So in this case, you want the cervix to be fully dilated because as you would imagine, you can't do an instrumental delivery if the woman is not fully dilated because you're going to basically damage the cervix. Um the, the position of the head. So in this case, if the baby was direct, oa you know, if it's below spines, if you're, if you're comfortable, if they've got good contractions, a woman is pushing, well, you could try a Kiwi delivery essentially. Um if the baby, if, um, obviously, if the, if it was kind of rotated in any way, then you might not be able to put forceps on. So those are just some of the things that you basically want to think about. Um, if you're very confident that the, that the, you're gonna, if, if the, if the baby was, let's say plus two or like at the perineum and you were just doing a lift up, then you would do it in the room. But obviously, if it, if it was at spines, if it was plus one, and you know, you think that the risk of emergency cesarean section is high and you would take it to theater. Exactly, because you want to do a trial. And the reason why we do trials in theater is because in case you need to convert it to a Cesarean section, then you've got the staff, you've got the facilities, you can very quickly convert it good. So the answer would be at least a trial of instrumental delivery. Good. So just quickly go into the prerequisites. So you need a fully dilated cervix. You obviously need the membranes to have ruptured. You need consent. So usually it's verbal consent. In these cases, you need to make sure the bladder is empty. So whether you can do an in out catheter to just empty the bladder, a lot of them, a lot of time women will have to be catheterized already check your instruments, make sure that the um Kiwi cup, you know, all the um it's actually working before you apply it. Analgesia is very, very important. So they need to have working analgesia, either an epidural or if they don't have an epidural, then you can uh infiltrate local anesthetic into the perineum. You to explain the procedure, examine the vagina check presentation and then place either the forceps or the va too company to check the station as well. And just think you need senior help. So, maternal indications for an instrumental delivery, it either prolonged second stage, maternal exhaustion. So maternal medical conditions like severe hypertension, intracranial pathology. Um So fetal indications as we saw on the M CQ was if you've got any suspected fetal compromise. So Kiwi, so the two main instruments of choice are Kiwi or Vus or forceps. So as a general rule, this isn't always the case forceps kind of have low fetal complications and greater maternal complications because it can be more traumatic for the perineum. So usually we allow kind of three pills. Um and sometimes you can kind of sequential use of instruments, you can do that, but you always need to make sure you've got senior help at hand because if you're not able to deliver the baby with one instrument, you need to check, have you assessed the position wrong? Is there a reason why this instrument is failing? There are lots of things that you need to kind of think about. So you always want senior help at hand if you are thinking about using a second instrument. Um So Kiwi is a handheld device, it can be used for all. So if the baby is kind of ot so looking sideways or if um you know, if it's a little bit tilted, you can use it for all fetal positions and it's rotational essentially. So maternal risks, lower pain and perineal injury. There's a higher risk of swelling on baby's head and phal hematoma just, just shows you what that is in that diagram basically. Um So using forceps, so you've got different types of forceps, the ones that you guys will most likely see because there are very, very few people that are trained in doing rotational forceps. So the ones that you guys will see is called Nevi bars and that's nonrotational. So it's usually used for 08. It can also be used for op as well, which is where baby is looking up. You can use a Wrigley, which is what you might guys might take. So like for example, if I'm doing a Cesarean section, the baby's head is a bit high, then I can, I would use a Wrigley's Forceps. They look very similar to a Neville's bands, but they're slightly different. They're used mainly for Cesarean section basically. Or if baby's head is already there, you're doing like an outlet delivery, you can use that as well. And again, Kins, like I've said, um not very commonly, there's a higher rate of 3rd and 4th degree tests. So it's very important, especially if you're a Paris woman and you're doing a Forceps delivery, you have a very low threshold for giving an episiotomy to kind of reduce the risk of third or fourth degree test. And very, very important to give perineal support whilst you're doing the Forceps delivery, either you do it yourself or you ask an assistant to give that support to try and protect the perineum. Ok. Good. Uh Next question. So you've got a 29 year old multiparous woman contracting strongly. She's four centimeters dilated, having regular painful contractions for six hours, then stop abruptly and then you get, you get you, it's then kind of followed by a sudden onset, severe continuous lower abdominal pain. What's the most appropriate management? Yeah, exactly. And um as you said, stan, the thing that you're concerned about in this case is you try and rupture good. So uterine rupture is basically a full thickness, tear of the uterine muscle typically occurs during labor. Risk factors are anything that makes the uterus weaker. So, previous Cesarean section is the most common. The one that you think of uh myomectomy as well, um indicate induction of labor, multiple pregnancy multiparity. What are some of the signs? So, the thing that we think about is sudden, severe pain that's persisting between contractions. And if you've got scar tenderness as well, which is what we always ask for in, in women that have had previous C sections and that are being induced. Um, shoulder tip, pain, vagina, bleeding, regression of the presenting part, scar tenderness and palpable fetal parts. And obs wise, you'd be quite hypo, you'd be in hypovolemic shock, tachycardia and the baby would be very distressed as well. On the fetal monitor management is basically a to e approach, stabilize the patient and take them straight to theater. Ok. Good. Um Just wary of the time. Um So we've kind of gone through a psy, I've kind of mentioned when you would think about doing an AP um and some of the complications of a PST is kind of the extension of the incision to involve the rectum. You can get a vulval hematoma as well. Postnatally, it's just a collection of blood at the site of the episiotomy. It can, it can become infected or you can, you can get dysuria as well, which is painful, sexual intercourse in the long term. Um And just remember perineal test the ways that we classify them. So first degree, second degree, 3rd and 4th degree. Um and for 3rd and 4th degree test, it's really important to kind of um refer them to physiotherapy to reduce the risk of them getting long term kind of incontinence. Ok. Um I think I'm going to just, I'm just a bit conscious of time. So what I'm going to do is, I'm going to go through the maternal problems in pregnancy. So we'll go through diabetes, high BP and itching in pregnancy and then we'll sort of, if you've got some time we can go through the PPH. But, um, ok, good. So we've got a question on diabetes in pregnancy. So you've got a 32 year old pregnant woman. She's South Asian, she's 10 weeks into her second pregnancy. Um, let's actually, let's, let's let's make that 20 weeks a bit too early. Um She's had one natural delivery at 39 weeks to a healthy child. No other previous pregnancy, she's got a strong family history of type two diabetes. She's offered a fasting glucose test at her booking visit. Um a fasting glucose level is 7.2. So let's, yeah. So let's just make that. Usually we do fasting glucose OGTT between 24 to 28. So let's say she's 24 weeks and she's having her OGTT. So what's the most appropriate initial management for someone who's got a fasting glucose level of 7.2? Yeah. So actually it's insulin and that's correct. Then we'll go through on the next slide. Why we would go straight to insulin. So it's you start off with insulin plus minus Metformin. Um And obviously you would give the diet and exercise, but it's just to say that you would kind of start insulin a bit earlier than you would in other cases, basically. Yeah. That's correct. So, gestational diabetes. Um, so just we'll just quickly go through some of the risk factors and screening questions. So, if you've got high BM I family history of diabetes, ethnicity, a previous macrosomic baby over 54.5 kg and previous GDM. These are all some of the risk factors basically and screening and diagnosis of GD and the way that we do it is by doing an oral glucose tolerance test. That's your OG TT at 24 to 28 weeks. And actually at no, we've got a very, very high population of women from South Asian communities. So we actually screen a little bit earlier. I think we actually screen at 16 weeks. Um So the way that I remember it is 5678, so fasting of 5.62 hour GTT of 7.8 done that already. Um So management of GDM. So essentially, uh GDM is managed in the diabetes. Anti you would counsel the women about complications of diabetes, the importance of monitoring of glucose and the importance of glycemic control and the ways that you manage GDM, very straightforward diet control, Metformin or insulin. Um And yeah, this is just a useful um kind of table you guys will have access to the side, so you don't have to write things down. Um So if you've got less than seven at diagnosis, then it's appropriate to try diet and exercise for 1 to 2 weeks. If it's over seven, then you want to go straight to insulin plus minus Metformin plus diet and exercise. If the, if it's 6 to 6.9 but you already have complications like macrosomia polyhydramnios, those kind of things, then you would again do insulin plus minus Metformin, then diet and exercise always kind of goes alongside it. So some of the complications. So with regards to any kind of maternal medicine problems, so any maternal problems in pregnancy, just think what are the complications to the mom and what are the complications to the baby. So, maternal complications, there's increased risk of preeclampsia, increased risk of infections, higher rates of induction of labor, cesarean section, higher rates of miscarriage, fetal complications are increased risk of malformations, actually, especially if you've got um uncontrolled diabetes. And that's more the case even more. So with type two diabetes, macrosomia, uh shoulder dystocia, which you've mentioned already, polyhydramnios, preterm birth and stillbirth as well. S and also I'm looking at the baby. So hypoglycemia after birth and there's an increased risk of diabetes and obesity later on in the in, in um in the child. So, um just looking at the antenatal care basically, so you essentially have appointments with the diabetic team. So they get seen much more frequently every 1 to 2 weeks, they have a detailed scan and because of the risk of particularly cardiac anomalies, most of these women also have um kind of, they, they do the four chamber, heart view as well. And sometimes they can get referred to a tertiary center for a fetal echo. And that's more so with type one diabetics, they also have growth scans every four weeks because of the risk of macrosomia and polyhydramnios. And you monitor ac which is the abdominal circumference essentially because that's a more sensitive marker of macrosomia. And um essentially, you've got targets for fasting and one hour post meal. And women are asked to kind of um either write it down on, in their diabetic book or they often have apps that they can write it down on delivery or labor. So, obviously, depending on whether they have any complications or the sugar levels are like most women by with GDM. If they've got well controlled GDM, they are advised to give birth by 40 plus six weeks. Um And if there's any complications, obviously consider birth before 40 plus six. So why do we give corticosteroids um in preterm deliveries? And what's the risk if giving steroids to someone with diabetes? Does anyone know? Yes, exactly. So, fetal lung maturation. And actually because of some of the long term data, we used to get steroids way more frequently than we do now. So now we give it from 24 to, I want to say it's 24 to 33 plus six if I'm not mistaken. So the threshold is actually much less. Yes, it can, it can mess with maternal blood sugar levels. Exactly so often. Um so if women are on insulin, you might have to put them on a sliding scale. For example, if you're giving them steroids, perfect. And during labor, you want to do continuous CTG, consider sliding scale insulin requirements often decrease post delivery. That's just something to keep in mind uh and postpartum care. So women that are on, if, if it's gestational diabetes, you stop everything immediately after birth unless they have persistently high levels, which in which case, you would kind of discuss that with the endocrine team, you counsel them about the risk of GDM in future pregnancies. Um Tell them about the risk of actually them developing type two diabetes later on. So you offer them lifestyle advice and often these women, they go to their GP for their six week check and the GP will then check their fasting plasma glucose at six weeks or their HP A1C to kind of risk stratify these patients. So, um just very briefly touching upon women with preexisting diabetes. So it's really important for women with preexisting diabetes to actually have preconception counseling. So you want to aim for A HP one C of less than 48 before they even get pregnant. So it's conception and it's very important to give them high dose folic acid range dietician review and things like, um you know, if they're on SITagliptin or the other oral hypoglycemics need to be stopped except for Metformin and you also stop things like statins ace inhibitors because they're all found to be through to in pregnancy and it's very important to screen their eyes and screen their kidneys as well. Um, and essentially with type one or type two diabetes, you basically want to deliver them usually between 37 to 39 weeks and before 37 weeks, if there are any complications, um, fine. And that's kind of as it says on the slides. Um ok. So we will skip this question and I'm gonna go straight. Oh, ok. I think I might have shown you guys the answer already. But let's go to this question which looks at high BP in pregnancy. So woman in her first pregnancy, 36 weeks pregnant, she's got a mild headache, flashing lights, um BP of 1 58/99. So she's hypertensive, she's got protein urea and she's got platelets of 55 bilirubin of 62 at 359. And that's a urea and creatinine. What's the most likely diagnosis? Yes. B so hellp syndrome, which is um hemolysis, elevated liver enzymes and low platelets, which is a complication of um quite severe preeclampsia. So, um high BP, um you can see we can go through, we can just quickly through that. So, essentially preeclampsia was previously defined as hypertension. So, BP of over 1 40/90 protein urea. But now the definition has changed slightly in the sense that you don't necessarily need to have protein urea. But if you've got high BP with deranged blood tests, if you've got deranged liver function tests, deranged kidney tests, that can also be defined as preeclampsia, you don't need to have the protein urea, um, usually develops after 20 weeks and it resolves within six weeks of uh of delivery and essentially it to do with development of an abnormal placenta and the way that the placenta basically implants and some of the risk factors. So, depending on your risk factors, you might be given aspirin. So if you've got one high risk or two moderate risk factors, you might be given aspirin essentially from 12 weeks, up until 36 weeks. Usually we try not to give it past 36 weeks just because uh you know, the um it's most beneficial during that period. So those are some of your high risk factors. So, obviously in pregnancy, the rule of thumb is having something before in your previous pregnancy increases your risk in your next pregnancy. So, obviously previous severe early onset preeclampsia, chronic hypertension, kidney disease, diabetes, autoimmune disease. So in that uh MCQ, for example, the woman had lupus, which was a risk factor or if you've got moderate risk. So if it's your first pregnancy, age pregnancy interval of over 10 years, BMI family history of preeclampsia or multiple pregnancy as well. And previously, it used to be 75. But now it's 100 and 50 mg. So, clinical presentations, the main things, I mean, that's, that's quite useful. That's a nice diagram because it, the main kind of things are elevated BP, which can give you headaches, flashing lights, nausea, vomiting, you usually get epigastric pain and sudden swelling in your um hands and legs. It's kind of left sent over there already and the signs we've mentioned. So when we examined them, we basically check for reflexes, check for clonus. Obviously, confusion fits placental abruption as well. Something that you can see with uncontrolled severe preeclampsia. And the problem with preeclampsia is that of it means that the placenta is gonna stop. It sort of it indicates placental insufficiency, which means that babies can be growth restricted as a result. So that's a fetal complication and still birth as well. So, um the way that we investigate it, so full blood count, user knees as well, clotting LFT S do APCR which quantifies the amount of protein. And if it's over 30 that's your diagnostic threshold for preeclampsia. When do we admit someone if they've got a sustained systolic of over 160 if you're concerned about their blood test, if they've got pulmonary edema, suspected fetal compromised, those kind of things are signs of severe preeclampsia, that means you need to admit someone and kind of monitor them a bit more closely uh management. So the way that we kind of treat them, the first line is labial unless they have asthma, which in which case, you would give them Nifedipine, um you give them methyldopa as well. The only thing to remember about methyldopa is there's an increased risk of postpartum depression. So you usually stop methyldopa after delivery and you can switch it to something else and you essentially your targets 13 5/85 or less and you want blood test twice a week and BP monitoring. So often these women at period time, so you might see them in the maternity day unit. So they usually come kind of a few times a week to check their blood pressures, do CT GS and do their blood tests as well. And yeah, fetal monitoring is you basically just check growth and check dopplers as well. Um delivery and birth. So if there's no complications, you usually deliver them after 37 weeks. When would you deliver before 37 weeks? If there's any maternal concerns, if there's any fetal concerns. So, maternal concerns, they are difficult in uh difficulty in controlling BP. You're on loads of different medications, you're struggling to control it. There's any deterioration in the bloods, um or if there's any fetal concerns. So if the blood flow to the baby is either there's lack of blood flow or the blood flow is coming back to the mom. So, reversed, end diastolic flow and considerations for preterm delivery is we've mentioned corticosteroids. So it's between 24 and 34 plus six weeks. Uh Does anyone know why you would give magnesium sulfate? And this is just with regards to preterm delivery, not for preeclampsia. Yes. Amazing. So, exactly. So it's for neuroprotection. So it's a fetal brain maturation. Perfect, good. Um So intrapartum just make, just remember, continue antihypertensives, you monitor BP a bit more closely if you've got uncontrolled hypertension. The second stage, second stage is when they're fully dilated. So you might consider operative or assisted delivery with forceps or with um che and postpartum. Essentially day. Just remember day, 3 to 5 is when you often have a spike in your BP. So it's very important to kind of uh monitor these patients. Often they actually stay for a couple of days to kind of stabilize their BP. So, eclampsia. So if that's basically where you essentially have a seizure because of the uncontrolled BP and essentially as you would manage any unwell patient, it's 8 to 8. So airway breathing circulation disability and like everything else. Um and with eclamptic seizures, you give them magnesium sulfate as a bonus and then as an infusion, repeated seizures are then treated with diazePAM. Um it's very important to do regular observations, catheter to monitor urine output, do bloods. And if you're on a magnesium infusion, you want to monitor for signs of magnesium toxicity. So check the respirate, check the tendon reflex, sorry, the reflex is spelled wrong. Um check your urine output as well. Does anyone know what we give for magnesium sulfate um toxicity? What's our antidote, so to speak? Yeah, it's calcium blue. Yes. Um and CTG for fetal heart monitoring and essentially you want to deliver basically once you've stabilized month because eclampsia is an indication for delivery. Um and, but just think outside of um eclampsia, you want to think about other causes of seizures. So, does she have a clot? Is there an intracranial mass? Is it just atypical stroke presentation? Hypoglycemia is very, very important um hyponatremia or infection? Ok. So what do you want to do in this case? This is kind of very straightforward. But um yeah, what, what would you guys do in this, this patient? Ok. Yeah, emergency cesarean section. I mean, you've got uncontrolled BP, you've got CTG concerns. You're just gonna deliver basically. Perfect. Ok. So this is the last bit. Thank you for staying with me for um for so long. I know there's a lot of things that we've covered. Um But what I remember this is the last topic, I promise. So you've got a woman complaining of severe itching at 34 weeks, itching started two weeks previously. It's worse at night, especially on her hands and feet. No other rashes and she, her mom had similar symptoms and she was pregnant with her second child. What's the most appropriate action in this case? Yeah, check bile acids and do you guys know what it is that we need to exclude before we think about anything else. What um condition do we think of immediately when you think of itching in pregnancy? Yes. Satric cholestasis. Exactly good. So I just wanted to go through before we touch on obstetric. So just go through some of the dermatological rashes and stuff that can present in pregnancy. So you can get atopic eruption in pregnancy, which is basically an eczematous itchy red rash. You can get polymorphic eruption in pregnancy, which is associated with the third trimester and the lesions kind of first start in the abdominal stripe. And management is basically emollients and if emollients don't work, um and you can try topical or oral steroids, pemphigoid gestationis is blistering lesions and it's essentially usually periumbilical. So, trunk back buttocks or arms, it can start in the second or the it can present in the second or the third trimester and usually give them oral steroids. And if you think about an uh the polymorphic eruption or I think it's also called pups, those th th that rash is basically, it spares the umbilicus. So you won't have the rash present in the umbilicus, usually all the way around and it's usually in the um in the abdominal stripe. So, obstetric cholestasis, the features of the itch, usually in the third trimester, palms and soles, it's worse at night and it can be quite severe. You can have other features. You can have jaundice, anorexia. So you have dark urine, pale stools, your ob obstructed picture osteo arteria as well. Investigations usually have raised bile acids and you might have abnormal LFT S as well. So essentially the management, so that, that should actually say bile acids. So you don't have to. So you usually kind of monitor the bile acids because uh the diagnosis is basically at the peak of bile acid. So if you've got high bile acids, you need to keep, make you need to make sure you keep repeating it to see if you have reached the peak or not. Um And you consider ursodeoxycholate mainly for symptomatic relief. And when counseling patients, I do tell them that the ursodeoxycholic acid isn't necessarily going to improve the neonatal outcomes. But in some women, if the itch you know, is quite distressing, if it's not helpful with emollients with kind of um chlorphenamine, those kind of things you can give them, they consider ursodeoxycholic acid. And does anyone know why we consider induction of labor if the bile acids are very, very high? What is the main problem with obstetric cholestasis? The thing that you are worried about is stillbirth, basically, which is why we induce them earlier. And sadly, even just doing CT GS and stuff are not a very good predictor of stillbirth. So, if um there's a very good RCO G guideline on um obstetric cholestasis, it's also called intrahepatic cholestasis in pregnancy or ICP. Um and the, if your bile acids are over 100 then you're at a much higher risk of stillbirth, which is why you induce them between 35 to 36 weeks. And it's basically kind of risk stratified, depending on what your bile acids are. So the main thing when we talk to women is about the risk of stillbirth. OK. Good. Um So I think if we have a few more minutes, I guess we could quickly um kind of go through the PPH as well cause that's the only thing that we sort of didn't really cover. Um So let's just go through this last and see you looking at um postpartum hemorrhage, she's got a woman with a background of preeclampsia. She's suffers from a PPH after delivering twins. Um You've got the protocol of PPH is initiated. You've tried bimanually trying compression, which of the following drugs should be avoided in this case to manage her. PPH. Yes. And um Tisha, do you know why we um avoid ergometric? Yeah. Exactly. So it can, it can actually increase BP, which is why you don't want to give it to someone with preeclampsia. Exactly. And the only other thing to think about is carboprost and asthma. Usually you don't give um um hemabate or carbo in someone that's got asthma. So these are the two main things that I'm thinking about, you know, when I'm speaking to my anesthetist and I'm like, I wanna give something for the tone, just think, does she have any BP concerns? If they do, then you can't give ergometrin any asthma, then you don't want to give carbo. So it's just the two things to think about when it comes to PPH. It's very straightforward, thankfully because it's a quite a common thing that we face. So you just want to think about your forties basically. Is it tone tissue trauma or thrombin? And most of the time it's either tone or trauma and less commonly it's tissue or thrombin. So the risk factors for uterine italy is high BM I age of over 40 Asian ethnicity and uterine over distension. So that kind of makes sense that the uterus is, you know, much bigger and it's been distended during pregnancy. It's gonna be a bit floppy after the deliver and it's going to take time for it to contract. So, polyhydramnios multiple pregnancy, big baby if your labor is induced or prolonged and placental problems. So, again, previous PPH having a placenta, pre placental abruption. So management of PPH um so you always start with the conservative thing. So you try and do bimanual compression which stimulate contraction of the uterus and there's a photo there of bimanual compression um which is exact. All you're literally doing is kind of sandwiching the uterus between your hand at the top and the hand and the vagina and you're basically just trying to stimulate the uterine contraction just by doing that um you can give drugs as well as you've mentioned, oxytocin, ergometrine, carboprost mapro are some of the uraton that we give you have surgical measures as well. So the picture on the right hand side basically shows you a Bakri balloon, that's basically a type of intrauterine balloon tamponade. You can put a hemostatic suture in. So, for example, at the time of Cesarean section, you can put a suture on either side of the uterus. If you um if you Google kind of like um a Haman suture, um then those are kind of like some of the hemostatic sutures that you can put or you can do a hysterectomy if those measures are not basically healthy um trauma. So it, or, or a B in as well. Yes, thanks. And that's what I was trying to remember. So you can be in is more commonly used. You can use a, I've seen some, one of my consultants at North used to do a Haman suture as well. So it's kind of just what you're familiar with, but both of them act the same way and it's essentially just hemostatic sutures on the outside to try and control the bleeding to kind of ligate some of the arterial supply uh trauma. So obviously, if you've got a massive episiotomy and that's bleeding, that could be a cause of PPH or if you've done a forceps delivery and you've got lateral vaginal wall tears that again could be a cause of PPH. So the only kind of way to control that is just basically just very quickly repairing it. So the less common things are tissue. So always making sure that the placenta is complete. And if you do find retained placenta, you often have to take into theater, make sure you've got good analgesia, do a manual removal, which is literally just kind of putting your f your hand in and just trying to kind remove the placenta and you give them prophylactic antibiotics because obviously of the risk of infection and thrombin is quite uh quite rare in the forties or to the forties. And you basically just want to discuss with hematology and correct any coagulation abnormalities, red blood products. Um Great. So that was everything that I wanted to cover and that was a lot of stuff. Thank you so much to everyone that has kind of contributed and been quite attractive. I hope that that's been useful. I think that obstetrics sadly is one of the things that isn't taught so well at med school and even on the shop floor, when you guys come in for placements and stuff, we're obviously really busy, really short staffed, quite stressed sometimes on the labor board. So I think we can always give as high quality teaching as we'd like to and it's quite different to the rest of medicine. So I hope that was a useful kind of whistle top stop tour. Um So that these are some of the things that we've covered and these are just some of the useful resources. This is just what I kind of used um during medical school for um for S and Gynae. So I used that, that was a textbook that I used in the top, right. Um Those questions that Question bank. Um Some of the questions that I had to in the slides are from that textbook. I think there's loads of P dfs of that textbook online. Um Nice guidelines. Um Osmosis is really good at explaining some concepts and they really nice youtube videos. Um Past medicine is really good with the um MC Qs. Um Yeah, so that is the end. I hope the top cats what you might have been like before and hopefully after in the session, you guys are happy and you know, a lot of the stuff makes sense. I'm happy to take any questions if you guys have any questions. Um And yeah, I'd love to get feedback on obviously on things that went well, but also on anything that you feel like I could improve any topics that you think I could cover because I'm doing a few sessions for my students in the upcoming weeks. So I'd love to know if there's any kind of particular things in obstetrics and gynecology that you guys would like kind of more teaching on. Yeah. Thank you so much. Thank you for listening and for spending your um Tuesday evening. Thank you very much for the talk. Um Yeah, so please, if you could scan the QR code, that'll take us straight to the feedback form. Um But I've also put a link in the chat as well. Um And if you do have any questions, then please put them into the chat, we'll be here for another minute or so and to answer any that you have. Yeah. So um just regards to what was put in the chat. Um So if you go to the event page, um what helped you the link that helped you join? Um There's an event page on metal and there you'll be able to find the recording of the event. Um The same will be done for this talk, um straight away and that's um able to be accessed for people that filled in the feedback form. Do you have any other questions um particularly about this uh talk? Yes. So the slides get emailed to you, but the recording is on the metal page itself. It should be under the catch up content on the medal page. Um Any other questions?