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Undergraduate Surgical Teaching Series: Obstetrics & Gynaecology

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Summary

Today's medical teaching session for medical professionals, hosted by Dr. Herod Campbell will cover intrapartum surgical care, including indications and techniques for assisted vaginal deliveries, pelvis repairs and Caesarean sections. Dr. Campbell will also provide an explanation of the 3 stages of labor and delivery and the changes necessary in the cervix, in addition to case studies at the end. This is a great opportunity to learn essential surgical and obstetrics principles from a specialist in pediatric and gynecology. Don't miss out!

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Description

The ESSS Undergraduate Surgical Teaching Series covers surgical topics at the level expected of clinical year students. The content is relevant to the Edinburgh Medical School curriculum and extremely useful for exams! Sessions run throughout the year. Each session consists of a presentation followed by case discussions in small groups.

Our fifth session is entitled ‘Obstetrics & Gynaecology’. This will be delivered by Dr Angharad Campbell on Monday 6th February 2023 at 7pm.

Learning objectives

Learning Objectives:

  1. Understand the stages of labor and delivery
  2. Identify indications for surgical intervention during labor
  3. Describe methods of assisted vaginal delivery
  4. Explain the anatomy of a pevic floor repair
  5. Demonstrate knowledge of a typical caesarean section procedure.
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Computer generated transcript

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The following transcript was generated automatically from the content and has not been checked or corrected manually.

Should be live now, hello, everyone welcome to the undergraduate surgical teaching series today. We're extremely fortunate to have dr and herod Campbell here with us to deliver a session on obstetrics and gynaecology. Doctor Campbell is in st to not pediatrics and gynecology at the More infirmary edinburgh A special interests include global health, sexual and reproductive of, and psycho sexual medicine. She's commencing a role with the forensic service, providing care to perpetrators and victims of sexual assault. She describes herself as a nonsurgical surgeon and has used her experiences of learning surgical techniques despite a diagnosis of dyspraxia, to teach medical students the skills without further do, I would like to invite inherit to deliver her presentation all right thank you so much for having me everybody. I know, it's a cold evening. I'm certainly armed with tea, so we'll go through a couple of bits of intrapartum surgical care, um talk through a couple of the procedures and I've got a few cases. At the end. I can see the chat box as well, So if you've got any questions, please don't hesitate to ask me okay, so I thought this evening obs in guinea was far too big A topic for me to tell you everything, but I thought I'd zone in on something that hopefully will maybe come up in future exams or will appeal to those interested in obscene guinea, but also those interested in things like general surgery or other types of surgical specialties, so the things I'm going to cover this evening, I'm going to talk about the stages of labor and delivery just as a nice baseline, especially for those who haven't done Obs and gynie indications for surgical intervention. I'm keen to highlight that obstetrics is in principle not surgical, in that we try and intervene as little as possible. It is a natural process, but sometimes nature isn't able to deliver the outcome that we want and we have to step in and then going to cover three particular things assisted vaginal delivery using non rotational methods, perennial repair, and caesarean section, which I'm hoping most of you will have heard of. There are multiple variations on a caesarean section, but I'm just gonna cover sort of simple vertex E. Head presenting uh cesarean section this evening. I was going to cover management of postpartum hemorrhage, but I thought that maybe a little bit bulky for this evening, but I'm happy to take questions on that and if we have time at the end, I'm more than happy to open some discussion on that and at the end, we'll have some case studies with some sort of questions that go along with those so the stages of labor. Now, this is a really commonly misunderstood concept, um when you go into the labor ward and you hear all the screaming and there's all axion going on that. We think that that that is labor, but actually it's a multi step process and the key to all of this is the cervix, so, I've included a diagram on the right hand side to try and explain this to you, so the cervix itself is a sort of tunnel that connects the uterus and the vagina. In most women, it's about 2 to 3 centimeters long so you can see from the baby's head to the vagina. There, that's what I mean by the length of the cervix and it's closed so there should be a pinhole is what we would describe it, or if a woman's had a baby in the past, they may have up to one centimeter of dilatation as a normal variant and that's just because that has been stretched in the past. Once a woman approaches the point of going into labor in order to be able to labor, there has to be effectively know cervix, so the cervix has to disappear and the way that it does that is that it let strengthens it dilates those people have heard of and it faces which less people are familiar with and what that basically means is that it it goes from being three centimeters thick and thins right down to being paper thin. We call that effacement and without going into too much detail, it's enzymes called metella protein is, is that that cause that process to happen, it effectively digests the cervix too thin, it out so there are three stages of labor. The first stage is divided into two stages that are quite different. The first is the latent stage so that's where a woman might experience some mild irregular uterine tightenings and she will be aware of those, but what she won't be aware of is the feeling of the cervix beginning to change, so it starts to soften, It starts to thin out and they may start to, they may lose their mucus plug, they may start to produce something called show, which is sort of mucusy blood stain mucus, which is from that process of it thinning out, and then over a period of hours today so this can go on for several days, these contractions will start to form into a pattern regular, lasting up to 60 seconds, and they become quite strong. In this period, the cervix dilates up to 10 centimeters, so this active first stage is those are the women that you'll see in the labor ward, so once you kind of get above three centimeters, you're in pretty good going labor. This is the point when we would be looking at citing an epidural starting intrapartum care having a care of a single midwife that sort of thing, and at this point the descent of the foetal presenting part so it might be a head, but it could also be a bomb, it could be feet, in some unusual cases, it could be the cord. Whatever it is that's touching the cervix is what we call the presenting part, and it is the pressure of that presenting part which causes this change in the cervix, as well as these enzymatic changes, but equally that allows the head or the bomb, or whatever to come low into the birth canal to prepare for delivery point where the cervix is dilated up to, to send 10 centimeters, which is the maximum dilation we call it fully. Um that would be the beginning of the second stage and the second stage is from that point of full dilatation until the foetus has been delivered. Now the length of that stage, we actually control that reasonably carefully and that's for a number of reasons, um but principally it basically prevents the mom and the baby from becoming tired from the exertion of flavor and prevents things like sepsis, obstruction are some hemorrhage, So we control that to about 1234 hours depending on the woman, but generally in no woman would we let that go longer than four hours unless we were told that they didn't want us to do anything, and then the third and final stage would be once the baby has delivered delivery of the placenta and that is a much quicker process on the whole, and usually takes between 30 minutes to an hour and then if that doesn't deliver, then, we would look at doing another surgical procedure, which I'm not covering this evening, but which would be a manual removal of placenta, which is much like what it sounds like you effectively put your hand into the uterus and pull the placenta out being very careful not to invert the uterus and then the post partum period is up to about six weeks post delivery, so women up to six weeks post delivery are still considered to be obstetric patient's the stages of delivery. This is uh I like this diagram, I think it's a really helpful diagram for showing the the changes in the baby's position. This is like obviously, I'm this is all with the caveat. This is a catholic i. E. Head, first baby, so the head is coming down into the birth canal. It does something called restitution, which is where it turns, so it twists in the birth canal and all being well, it should internally rotate so that it's looking down at the bottom, to the boards, the floor, and then as it comes around the pubic bone, which you can see just the sort of top right part of the diagram that pubic bone that's where a lot of people struggle to get the baby's head around and that's where sometimes we need to help. Um Once it's passed the pubic bone, the baby's head comes out of the vagina and then we'll again restituted to one or other side and then the placenta follows that so this is the process of the intrapartum period, so that during delivery period and that's where these surgical procedures I'm going to explain to you tend to, will will occur. I'm going to cover assisted vaginal delivery, first, so it's all it is, is in the name, so we are going to do a vaginal delivery. This woman is going to deliver her baby herself by vagina just with some assistance from us and the key thing is that we are guiding the baby passed that pubic bone where that baby's head may have just not quite come around that corner. This procedure can be done with a number of instruments and I've put a picture there to try and hopefully explain that there's lots of different ones, you don't have to remember these. I think it's unlikely you'll be asked, but just for your reference. This is what they look like this procedure can be done either in theater or in the delivery room. There are lots of of reasons why we do one or the other. Effectively, If the baby is close to being delivered, If it's very close to the outside, If the woman is low risk. If the woman hasn't been delivered for a very hasn't been in labor, excuse me for a very long time, then she may be suitable for delivery in the room, But if, if those things are not the case, we would want to go to the theater equally, If pain management, we think is going to be a problem theater, again, so, from the left to the right and the diagram that you can see. Um The names are different, depending on where you're training, on the basis that different places use different names because of the people that named them, but from left to right, you've got Killen's forceps, which are rotational forceps, I'm not good, this is not covering those, then you've got what we would call haig ferguson's or neville barnes forceps, Wrigley's forceps, and then you've got two types of von twos is to the right, and we don't use these in edinburgh, so you won't see them, but it's just that you're aware that they exist and then underneath those, you have a kiwi cup and a kiwi cup is a suction cups, of where that yellow padding is that that goes on baby's head just in front of the posterior front, now so to fontanel's one at the front on it back, this one goes just in front of the posterior front now and suction is applied and then that pressure is used to help guide baby around the corner. There's some prerequisites for this type of delivery. Um The woman has to be in the second stage of labor, I E fully dilated, which a lot of people think is obvious, but actually, I think it's not always obvious, especially when you're learning that that would be the case, so if there is a cervix there, this cannot be done that baby cannot come out of the vagina, know how no way they are coming out of by a cesarean section or you have to wait until that cervix is dilated. The fetal head has to be at spines or below, and when I say spines, what I mean is the issue of spines, so there's a part on the issue um bones of the pelvis, which you can feel on a vaginal examination, and that's how we basically explain how high up in the vagina um sort of birth canal that baby is so if you're at the issue of spines or closer to the vagina that baby is suitable for delivery using forceps or kiwi cup kiwi, particularly that baby should be as low as possible, so it may be that a kiwi would not be suitable, but a forceps would be maternal effort is really important so with all of these, we are not pulling the baby. The mom is pushing the baby and we are guiding with some traction, but if there's no maternal effort, it's going to be really hard to deliver that baby. So if if um um is completely completely exhausted or she's not going to push, you would really think twice about using any of these methods, particularly the kiwi um concerns about bleeding disorders in the baby, so uh you know for things like a kiwi cup, where you're applying suction to a baby's head. If they've got potential bleeding disorder and platelet disorder, hemophilia, you can cause serious bleeding using one of these implements, so in those cases, these would not be suitable why would you use these you would use these. Basically you want to deliver a baby quickly so why would you want to deliver a baby more quickly um delay in the second stage, so we talked about the second stage, that's once you're fully dilated until the baby is born. If that is progressing longer than it should then we might use these fetal distress so that's for obvious reasons, you want to get the baby out as soon as possible and maternal illness, so things like sepsis, exhaustion. If we're not getting anywhere, then we might want to give the mama hand to live that baby. Throughout this presentation, I've included some videos. I'm not going to show these this evening just because some of them are a little bit long, but I would really encourage you to check this website out and I've posted the link in the chat. The Toronto video atlas of Surgery have a number of really excellent videos where they show you lots of procedures in lots of surgical specialties, not just obstetrics, and they show it to you in a cartoon and then in a live format so that you can appreciate what you're looking at and also if you are someone like me who really struggle with things like anatomy and visualizing abstract concepts it's really good, so I would highly recommend you watch these videos on your surgical rotations, so when you've done you're doing uh an assisted delivery, like the ones, we just described, you may wish to do something called an episiotomy, not episiotomy, is what you can see in the top right picture on my slides here and what that is is where you're basically making a cut in the perennial skin so that red thing believe it or not is meant to be a vaginal orifice and basically what you're doing is putting the scissors in and making a cut at what we call a medial lateral position so off center and to sort of lateral direction and that is to basically reduce the force going through that skin to reduce tearing and also to provide additional space for the fetal head. Because as you can imagine if you're putting those metal forceps or a kiwi cup as well as the head, you've not got a lot of space to play with, so we do that, just as the head is what we call crowning or just emerging from the vagina. Also, we might do this for a vaginal delivery. If we don't think the head is going to come without one and that would that would also required episiotomy, so that's one type of perennial trauma, the other type would be tearing. You may have heard of that and it is an unfortunate consequence we do try and prevent that and we have lots of programs that we need to try and prevent that, and that's basically where, when the baby's head or body or whatever comes out, and there can be some force put down through the weakest part of the skin, which is at the bottom towards the anal sphincters and you can get tearing as I described and and this unfortunately, if that test to the anus, you can tear the internal or extinct, er, or even into the mucosa of the anus, this be called a third or fourth degree not going to cover that today that that is an additional procedure repairing that the second diagram at the bottom, I've just put the muscles in questions, so when you're doing your medial lateral episiotomy, you have to be aware of what muscles you're gonna be cutting and that would be the bulbocavernosus and the transverse perennial muscles that's the green and the blue uh. There, so when you're doing a perennial repair, what you're trying to do is bring all the tissues back together and to restore function and the way that we do that is you identify the apex of the tear. Now it's very hard for me to explain this to you without a diagram, but effectively what you do is you want to part the labia and look into the vagina and find the tear and the tear will will be in a sort of triangular shape facing away from you, so you'll be looking into the vagina and you will see eventually that there's a kind of upper triangular bit and what you want to do is bring that together, so we start by structuring the vaginal mucosa and I've explained that they're that that's using two oh vicryl and you use continuous suture, so what we don't do is, you don't do a stitch and then tie in a stitch and then tie in a stitch, anti you stitch and tie, and then you keep looping your sutures around around and bringing that together when you do your triangle you pop first which is the vaginal mucosa, then you would tie a knot, then looking straight on. So if you look at that that red line that says midline episiotomy ignore that, but looking at that line, That's imagine that's looking at you that would be a part, you then suture the perennial muscles which you'll see right in front of you, and that's again using continuous suture and using to like roll, and then you would want to bring your suture out at the edge of the skin at the bottom edge of the tear, and then you would go back up using sub particular future, which for those of you don't know what that is, it's just layer that's just need the skin itself, It's not in the muscles, it's not in the skin, it's just that in between layer and you do a nice little continuous suture and it kind of purse strings together and brings everything together. Then you tie the knot inside the vagina. It's really important to do a p. R. S. A. Rectal examination both before and after this procedure. The reason you do it before the procedure is to check for that anal sphincter injury that we describe because it may not be obvious just from looking, you may have to feel it may be deeper than you think it may be in some places and not others that's really important and then we also repeat that after the examination at the procedure, excuse me that is to ensure that you have an accidentally suit into the rectum, sounds difficult, but it would be really easy cause. These structures are very close together, so you put your finger in and feel if you can feel any sutures in the rectum and if you do you all you need to do is take them out and start again. This is another video from this from from uh the University of british columbia, so I don't know why I've got such a canadian thing, but clearly they're doing good videos, so this is a model and so you can kind of see at the top there, that is the vaginal you, those that that's been sutured towards the outside ideas currently structuring the perennial muscles together and once she gets to the bottom, she'll then suture that back up together and then you'll have this lovely tight super futures. There. This is a good thing for any of you that about to do labs and guinea or doing it, you know have done it or wish to do it. This is a really good um type of suturing that we can teach you really we can teach you the sutures, we can the procedure on a um so it's a really good one for practicing practicing and featuring skills and just get getting an eye for how these things so you can do that and then I put a grapefruit there and that is for a good reason. So if you want to learn how to do an episiotomy, tell me you want to try at home just with the grapefruit and then you just peel hole in the grapefruit skin, so you've still got the flesh of the grapefruit and most of the skin, but just with a whole, so this is a grapefruit you got a hole here, you can then take your finger and put it inside the skin as you would in the vagina and then you could take season practice cutting. It believe me you think it sounds easy, but Gangel is really really tricky and that is also a good thing to practice mint, so if you bring a grapefruit in last and it'll happen, show you how to do a midline lateral episiotomy, so under the cesarean section now. Obviously, I could talk all night and all day about cesarean sections and we do them constantly. They are many and varied aid and interesting and every time but what I'm going to talk to you today is just about a simple vertex presentation and again, I've got a video for this as well for you to watch at your leisure, So the point of a cesarean section is that you're doing a trans abdominal delivery of a foetus. Why would you want to do that. There are so many reasons it's almost impossible to count them all but I've listed some here. It's also important to distinguish between an emergency cesarean and an elective cesarean, so an emergency. This is erin, if one that you maybe weren't expecting to have to do an elective on that, you've decided planned procedure, uh and they'll use slightly different and they're usually done for different reasons, so it's just important to bear that in my mind, reasons why you bit mild presentation, so breach, presenting baby to a bottom presenting baby or a transverse baby, which is as it sounds transverse, two or more previous cesarean sections, so we would not do a cesarean section on someone who had two or more previous sections. The reason being that the scar tissue is friable and if that woman were to um sorry we would do it in someone and would insist on doing a cesarean section in someone with two or more previous sections because if they were to labor, the scar tissue is friable and the is likely to rupture and you could have a uterine rupture, which is a big emergency maternal request in the United Kingdom. We will do cesarean sections at maternal request, so if a mom wants a section, then that is what she shall have um maternal factors, so if got preeclampsia, she's got the that's not well controlled and primary genital herpes sepsis. All these, that's the reason why the mum basically wouldn't be able to labor. We would do section fetal factors if the baby's not going to cope with labor, so multiple pregnancy is more bit of a gray area just because you've got twins, doesn't mean you have to have a section, but that that is often the case intrauterine growth restriction, so small babies don't cope well stress of labor, so we may deliver them by section, or if the this continuous monitoring of the baby's heart rate is not normal, that is a sign of fetal distress and we would deliver that baby by section, failure to progress in the first stage two, going back to our stages. Again before the this, the patient is 10 centimeters dilated. That baby is not coming out of the vagina and if that woman just isn't dilating and were in labor for hours and hours and hours, we're not getting anywhere that would be an indication for cesarean delivery invasive placental conditions, so you've got your placenta accreta That was um you may have heard of placenta previa basically placental site problems, produces a cesarean and psychological issues as well. Some women have had previous trauma including sexual trauma uh or toca phobia, which is a phobia of labor itself and we will section ladies on that basis. Um If required things to bear in mind, women with a high b. M. I. That is a big risk factor for complications in cesarean, we will generally avoid doing a cesarean in someone with a really raised Bm ibm over 40 we do it, but we try to avoid it if we can previous abdomen surgery, so people who've got very complex um very complex abdominal surgery, so for example, people who've got stoma as um Crohn's disease, people who've had cancers all sorts of things like that we may try and avoid a vaginal delivery or we might try and avoid a cesarean. It depends what they've had done and then finally bleeding and clotting disorders, so people with no platelets. People with you know previous things like p. S. Or DVTS, we may wish to avoid surgery, so that's the kind of background the actual procedure, so the diagram at the top right is describing the incision, so what's happened there is, we've, we've don't know what's got a fan inch deal, which is german for panhandle, so it's a kind of slightly curved lengthy incision at the lower uterine segment, so it's two fingerbreadths above the pubic synthesis um is where you make your incision, it's about 10 centimeter plus incision through the skin. You then dissect the subcutaneous fat, then the rectus sheath than the rectus muscles, So when you see your kind of six pack, imagine your six pack in your brain, you don't cut those muscles. We separate them manually, so we just separate them using our hands, and then we use this device that you can see at the bottom. That's called a joins retractor that basically retract the lower layers and the bladder down to prevent them from being injured and then you can see in the bottom diagram that someone then delivering the baby so what you do is you put your hand in underneath the baby's head flex the head and deliver the baby that is an o. P. Baby so that is a baby that is malposition in that picture, so that baby should be facing down, not up, doesn't matter that's the reason why we deliver babies by section, but you have to you know. It's really difficult actually to deliver the head of the baby because often they're not facing the right way you need to work out what's going on when you go in, so the the layers of delivery in a section are quite important and are often questions that come up in exams and also certainly questions that you'll get asked when you come on placement, So if you had to learn some anatomy, my advice would be the abdominal wall would be my top top tip so Pfannenstiel incision, which I've already described to you and then we do the blunt and sharp or you can use diathermy dissection of those tissues that we mentioned including separating the rectus muscles reflecting the bladder using the joins, the point that is in that top right diagram that is a curve that will be the curvilinear incision at the lower uterine segment, so the uterus is then sat in front of you, you make a small kind of smiley face looking incision that is then manually extended enough to insert a hand. You then deliver the head and the body while your assistant presses at the fundoscopic is the top of the uterus. Um To give you pressure to help bring that baby out. You deliver the body as well, then you delay the cord camping, so in the past we used to kind of what we call clamp and cut, but we don't do that anymore, so we try and let the baby of as much good blood from that placenta before we cut the cord. Then we deliver the placenta using controlled cord traction that basically means that we put mayo forceps, which are kind of big clamps on the cord, and we use that to gently withdraw the placenta. If we have to, we manually do that, if we have to put your hand into the cavity and deliver it, but hopefully not check that the cavity is empty, then we close the uterus into continuous layers using one oh vicryl. Now Obstetrics is quite an individual specialty people do things differently in every place in every hospital, in consultant consultant consultant, they'll do things slightly differently, different types of sutures, etcetera, but these are the broad things that everyone will do in some countries in the world. They will use one layer to close the uterus and there are arguments for and against that, but in this country, we do two layers, so you'll close end to end using I use locked continuous suture suture. Some people use unlocked and then you tie and then you go back over again and do a second layer using mattress sutures and you can use horizontal or vertical mattress sutures for that. You close the rectus sheath, then using continuous sutures again again using one oh vicryl and then you close the skin using your continuous subcuticularly sutures and again this varies a lot place to place, but in edinburgh, they tend to use proline, which is a non dissolvable suture, so sub particular praline and then securing that with beads. Potential complications are there are many but these are the important ones, so this is what I would put on a consent form if I was consenting anybody for a section, so pain infection, bleeding those are your three surgical go twos for consent, um but you know we do good anesthesia for the pain infection. We give a dose of antibiotics at incision and we will give after. If we need to bleeding. Wise, we have to consent women for major hemorrhage and hysterectomy, so I can I can send any woman no matter low risk for those two things and consent them for blood fusion. Obstetrics is a know, touristy specialty. Unfortunately, I've seen blood loss is upwards of 30 liters and so you know it's important to make sure that you've consented women for that in advance, damage to other structures. Obviously, we're operating close to the bladder and the bowels were handling the bladder, We're handling the bowels, and so we have to consent women for that too, VTE so that's venous thromboembolism, so clots in the legs, clots in the lungs. We have to council woman about that your risk of a clot is significantly higher in pregnancy than it is out with pregnancy, so we have to be very careful to council woman about that and we generally give VTE prophylaxis after a section cut to the baby's head. I have done it once and it's very upsetting when you do it, but you're obviously making your cut pretty directly over the baby's head, so there is a small risk of that, but it generally requires absolutely no treatment. It's nothing really more than a paper cut, but it's something I like to tell women about that. If it does happen, it's not distressing to them and then finally return to theater, so we council woman about a return to theater because any of those things only come to light following up, they may not have expected the need to have to go back to the operating theater at a later stage. Once again, I've got this video. This is probably my favorite of all the videos. It's such a good way to describe how to do a section, and I would strongly encourage you all to watch it when you have some time okay, so I've got some cases now now, I'm under the impression from lucas that I won't be able to sort of hear you guys. If you have questions, not questions, but your answers to these, so if you could just type in the chat, your thoughts, I'd be very grateful. I know nobody ever wants to answer, but it makes my job a lot easier and I don't have to answer my own questions. So fine case number one, So this is a 28 year old female. She is primigravid and what that means is she's never been pregnant, so no babies know, terminations, no miscarriages. She's 38 weeks and five days pregnant, so she's nearly at term which would be at 40 weeks. She's a low risk pregnancy. She comes into obstetric triage with some abdominal tightening, so she's feeling some some contraction starting up their occurring about one in every 10 minutes and they're lasting about 10 to 15 seconds at a time. After she consents for a vaginal examination, the cervix is found to be two centimeters dilated by three centimeters thick with intact membranes, so my question for you guys is what stage of labor is this lady in and what would your management plan B. And you do not have to know the answers. I haven't necessarily covered all of this just to get you thinking about these things, so a lot of obstetrics is about decision making and and then after I've got some answers, I'll chat you through what I think, I'll give you a minute or so and then I'll oh jumping, so we've already said someone said, stage one, which is right and latent phase, which is right as well, so the, as we said before, stage one divided into two stages and this is the latent phase of labor, so this lady is beginning to establish that is not yet established in labor and does anyone have any thoughts about what what your management be um. And in terms of management, I'm talking you know do, we should admit her should we send her home should we induce her do, we deliver her what should we do with her, what should we do this lady come on okay great, so we've got a couple of answers, so it's not easy this job is not easy. I have to say but your yeah a mixture of these things, so analgesia is, is right yep. So you know these women are like miserable and tired and sore and they're just like please god, can this be over already and you have to say I'm really sorry, but it's not so she could be like this for a couple of days and there's nothing wrong at the moment. There's no nothing much that we're going to add in hospital, so I would send this lady home, but I would give her a good advice about when she should return and yes I'd probably be nice and offer some analgesia as well, although she may have her own at home um brilliant, so let's move on to the next case, So this is our second lady. She is a 42 year old lady. She is a power of three, para zero plus three excuse me, so she's had no deliveries over 24 weeks and she's had three deliveries under 24 weeks, so for the purposes of this, I'll say that they were miscarried pregnancies, she was 39 5 weeks pregnant, so at term, this is an IVF pregnancy and she's a type two diabetic on metformin and insulin, and she is not in labor, so the patient has come because she wants to discuss mode of delivery, so what other information do you need to know about this lady to help decide about that mode of delivery and what would your advice be about delivery for this lady. I want to say mode of delivery, it means how would she deliver vaginal induction cesarean, what do we think yep. Absolutely you want to know how big how big this baby is. She's diabetic that's what I'm alluding to so great, yeah anything else, so, I want to know what her BM is. I'd want to know that she had previous abdominal surgery. I'd want to know what her wishes were. Um you know, I want to know all of that kind of stuff before we make a decision um On the basis of the information, you have, let's say, she's a normal BM, I, let's say she's not had any abdominal surgery any thoughts on mode of delivery. Mhm, yeah, yeah you want to know what her Bms like absolutely, let's say she's got good control, So the question is, do you need to deliver her now or deliver her later, let's do it with that question first okay anyone else mhm, so she is at term, so yes, you're right, but yeah she's at term, so yeah we would induce this lady um well, we would we would lay that we would deliver this lady so she's a high risk pregnancy because she's 42 she's high risk cause. She's IBf, she's high risk cause. She's a diabetic um We wouldn't want someone who is diabetic to go over there due date because that baby could be massive and make delivery really difficult, so we'd want to know how big her baby was and in some units, they will advise induction or delivery by cesarean Based on the size of the baby. We generally don't in Edinburgh, but we wouldn't want this lady to get any more pregnant, if anything she probably should have been delivered already, so we would deliver this lady, I would unless she wanted a section. I would give her the option of induction and aim for a vaginal delivery unless there was a reason not to, so, we generally would opt for a vaginal delivery unless there's a reason not to do so cool. So this is our third case we got a 23 year old power one previous vaginal delivery at 40 weeks, so she's at term she has been she's in the labor ward for induction of labor with syntocinon. She is a gestational diabetic on metformin. The estimated fetal weight is 3.8 kg on her last ultrasound, which was two weeks ago. You are asked to review the patient after she has been fully dilated and pushing for 1.5 hours and she has an epidural and there is no vertex visible, So basically nothing is visible by vagina, so what are the available options for delivery for this lady okay. So basically this lady has all the options because she's fully and assisted vaginal birth as possible. Cesarean section is always possible and and nazi now, we're all replying great and I mean technically a vaginal delivery is also possible like a spontaneous vaginal delivery, so with this lady, you could let her keep pushing for a bit longer, um but at this point, we'd probably be encouraging this baby to be coming out, but someone will decline so that is possible we could do an assisted delivery we could do a. C section, so um rinko, you said cs trial assessing theater, I you know descent with pushing, so as in you would take her to theatre and see what she was like with her pushes and then decide whether or not to do a cesarean is that what you're trying to say right, sorry, ok, yes that makes sense I was going to say, yeah, so well we dysesthesia lady in the room, So the next question is what are the relevant factors in making a decision, so um is there anything else that what do you need to know so say I'm in the room I've done and I'm going in to assess this lady life is like this is the situation what we doctor. I'm probably going to examine her so what what would be what would what would my decision making be like. What am I looking for in that examination. Yeah absolutely so by station what we were saying is about that issue or spines as the baby low in the canal are high in the canal cap it and molding yeah That gives you an idea of how obstructed the baby is so cap, it is swelling on the top of baby's head molding, is why the bones start to overlap on top of one another. It's not harmful to the baby, but it does give you an indication that baby is starting to get pretty stuck. The reason why that's important is it basically tells you whether or not that baby is gonna come the giant like is gonna come on its own. You can deliver a stuck baby using forceps, so it doesn't tell you that you're not going to deliver a baby with forceps. What it means is you're not going to deliver a baby on your own and in terms of the station, so the o. A. R. O. P, or OT, which is transverse, so what you mean by that is occipet, which is the back of the head anterior back of the head posture basically is what way is the baby looking babies looking the wrong way, then you wouldn't do that delivery in the room. You'd have to go to theater, you'd be thinking about forceps where you can turn the baby, um for example, or you may just have to go for a section. If the baby is facing the right way, you may be able to deliver the baby by forceps in the room yes exactly, and station is how high up the baby is. If that baby is above the spines, you are not delivering that baby with forceps, it's going to be a section. So yes you'd assess the baby. You just excuse me the lady in the room. You would then take the lady either you either do a forceps delivery in the room or you would go to theater and you would reassess her under a make sure anesthetic was working well and then you can make a decision about how to proceed um either with forceps or to a section. If you do a four set, you always have to consent for a section because if the four sets don't work, we only do what we call three pools, So you do three pools with three contractions, and if that is not working, we do a section, so you always have to consent them for section as well what specific complications is this lady at risk of, so, there's one in particular that I'm looking for and that is on the basis that she is a diabetic with a big baby, so what do people with big baby what risk do people with big babies have in a vaginal delivery. Uh. Yeah absolutely thanks monica, so shoulder dystocia, so big babies have a risk that the head will come will deliver, but then the upper shoulder will be stuck behind, so yet you would use it, so the mangan case exactly so the montgomery case was a very famous case in Whishaw, where a lady was counseled against having a cesarean section and, and the risk of shoulder dystocia was not explained to her. Uh She felt in in sufficient detail and then she had a shoulder social, her baby was born with cerebral palsy, so yeah it's really important to to consider that as as a factor in making your decision a forceps okay number four we've probably got time, so number 4 34 year old para two plus one at 39 plus three. She's had two previous vaginal deliveries. She has just had a spontaneous vaginal delivery with a compound presentations, So the baby has come out with its head, It's a hand like this on top of its face, so it's a big, a much bigger area to deliver and unfortunately she sustained a tear, so she's got second degree tears. There's no injury to the external anal sphincter's, so in what order would you be suturing the tissue layers, muscles, skin and mucosa are your options, mhm, yeah, that's perfect ok well done, so, yeah your vaginal mucosa, then the perennial muscles and then the vagina, the perennial skin. After that yet you could use vehicle repeat um to, and you can use that for the entire thing some people, so I often do two over the mucosa and the muscles and then three over the skin that just means that it's uh finer, but it depends how much future you have, so you wouldn't waste sutures just to change the type and what type of a, sorry, that should say what type of examination should you perform following the procedure and why yet so you do a p. R. Examination both before the procedure and after the procedure, and why would you do a p. R. Before and why would you do a p. R. Afterwards. Yeah that's right, so you want to exclude a third degree tear at the beginning and then you want to make sure you haven't accidentally sutured the rectum um at the end okay, so we got one final case yep shereen absolutely, just like you said I think that the chat box is slightly delayed, so your responses are coming through a little bit late, so I apologize if I'm jumping ahead of you guys and they're they're sort of coming through after a while, okay last case and then you are free to enjoy your evening. So last cases, a 26 year old lady. She is a primigravid at 39 plus five weeks. She has a normal BM. I, she's a spontaneous laborer, and fetal distress is identified on the continuous monitoring at six centimeters dilation. What would your management plan B how are you going to are you going to do about this lady. I'll let you all respond and then I'll come in. I'll come in after you've had a chance to right yeah fine. There's some good answer, nice different answers as well, so yeah as rink you said I mean you'd always want to assess the picture, call for help, so fetal distress is quite a stressful sounding thing you can have real fetal distress like a big bradycardia and that's you've got nine minutes basically that baby should be out in nine minutes. If that hasn't resolved, but fetal distress can take lots of forms, so you can get a c. T. G. Like a heart tracing. That's not that nice but it's not terrible and that's fetal distress, but it's not an emergency, it's just okay. This baby is not happy We're going to have to move ahead with this idea In terms of what you're saying about induction of labor, so the reason why we wouldn't start that said, prn lull, and I was like that sounds like a funny TV show or something so in terms of induction of labor, so you would not induce somebody with fetal distress for two reasons, so if the fetus is distressed, we're now in a time limited situation and this baby needs to be delivered sooner rather than later and also um sorry, give me one second, I'm just gonna mess it um um So induction of labor you need to deliver the baby sooner rather than later. An induction of labor is a, is a long process, it can take up to four or five days, so unfortunately uh induction of labor wouldn't be appropriate. Also the induction methods that we have can cause distress to the baby, so one of the risks of induction of labor is that the hormones that we use can cause the baby to be under stress, and so we wouldn't use an induction of labor, so if a lady is already an established, also you wouldn't be able to induce her labor because she's already in labor. If that makes sense, if you're at six centimeters dilated, you're already established, well established into labor, so induction of labor is to basically prepare the cervix to start labor happening. If that makes sense very complicated, it took me a while to get my head around it, so at six tend to be just dilated, we're not anywhere near fully dilated, we're going to be waiting a while for that. We're still having ongoing contractions and the baby's not coping, so our option here, there is only one option and that is a caesarean section, So caveat to that is, I'm saying that there's fetal distress, I mean it's possible that that could be it could be a period of um distress that very quickly resolves and then you would be able to carry on it, will be fine, but whenever written fetal distress, I kind of mean that this is sort of the point of no return like with distressed and we're not going to be coming back from that we need to deliver this baby, so the basis that we're going to do an emergency cesarean section. What risks do we need to put on the consent form and yet you've mentioned anesthetic risks as well. We anesthetist are obliged to come and speak to every patient before they go to theater, so you don't go into detail but yes and we will often say you'll be getting you know this anesthetic. There are risks someone will come and speak to you. Yep bleeding absolutely the number one big big big one, and I said earlier that there was two specific aspects of bleeding that we have to consent for, does anyone remember what those were. I, e, if I said in the event of significant bleeding, we may have to do one of two things does anyone remember what those two things could be, Yeah one is a blood transfusion absolutely and there's a surgical management option. It's quite extreme option. I have done it once unfortunately and that's a hysterectomy okay, so that's removal of the womb altogether. Unfortunately and yes, call for help absolutely always, I will not be performing that on my own. We often end up calling our and gynecology oncology colleagues actually to help us with those, but if you've got to do it, we've all got to be trained to perform an emergency hysterectomy uh like I said I have seen that done uh once on one of my patient's quite recently, so it does happen okay everybody, so that's all the slides that I have we're just about sometime. I'll maybe, I don't know if lucas wants to come back in and sort of coordinate things, but I'm very happy to take a couple of questions, I will need to get away by a I'm afraid to another meeting, but very very happy to answer any questions. People have you're very welcome my absolute pleasure and please come and see us and have stat tricks to be very welcome anytime love to have you thank you and heard for the amazing talk and thank you for everyone for joining. Um Today's session. Please don't forget to fill out the feedback form before you leave, You will get a certificate of attendance as well as access to the slides. If you do, um so, make sure to fill that out apart from that, I think we won't hold you on for any longer and narrowed, They love much thank you so much, have a nice evening everybody you later