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Workshop: Safe Forceps, When and How

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Summary

In this on-demand teaching session, medical professionals will be able to gain insight into the various indications for instrumental delivery as well as be provided tips and tools to ensure it is done safely and effectively. Doctor Sherawat, a consultant working at Sandwell and West Birmingham, will be using a mannequin to demonstrate in order to provide a live learning experience. Attendees will learn the importance of getting the woman's consent, proper analgesia and bladder care prior to any delivery. Additionally, a discussion of how to determine when to attempt a trial in the room versus delivery will be included as well as a discussion of how to handle any unsuccessful attempts. This is an interactive session that highlights the importance of trust and communication which every medical professional should attend.

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Learning objectives

Learning Objectives:

  1. Explain the various indications for instrumental delivery.
  2. Demonstrate the proper communication and consent protocols to use prior to an instrumental delivery.
  3. Describe the process of assessing fetal position and station prior to proceeding with an instrumental delivery.
  4. Outline best practices for documentation of an instrumental delivery.
  5. Analyze the decision of when to deliver the baby in the room vs. using a trial of forceps in the theatre.
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Computer generated transcript

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

The police public. Uh huh. Productive negligee. Yeah. Uh huh. Sorry. Right. Why not? Oh, I'm thinking, yeah. Yeah. Let's see. Yeah. So, uh huh. Confirmation of constant sure. That one. You, uh, no. Well, I think, uh, I have, okay. No, it wasn't. Can you stop? That should help or something? What? Okay. Yeah. Uh, okay. So, uh, the west can't use the weather's, yeah, she's here. This is, this is, um, um, Doctor Seward Medicine. Would you be able to turn on your camera? Uh, thank you very much. I thought I was just waiting for the team to be there. Don't worry. Right. All I wanted to know you were here. Yeah. Amazing. So, we're gonna start. Yes, perfectly. And we can see you have people there. Uh, it's just that I was just, you have to, you have 11 people online. Good. Uh, I think I'll start then you have people but they will be coming, they're just coming back from break and then the room will fill up. Oh, yeah, no problem. I know. I know how it works and this is time to catch up, isn't it? You can see me now. Um, so Yeah. So, if you want, uh, I think it's better. I mean, I do be hard to say like it, you like? Oh, yeah. Um, let, uh, we've got rough here sitting next to the, oh. Oh, yeah, she's here. Hello? Yeah, you can find me. Okay. Definitely. Okay. Yeah. Um, this is supposed to be an interactive things, uh, just because I couldn't be there, uh, in the conference. That's why I'm doing it online. So just in with some few slight presentations. Uh and then do you have a, you have like like yesterday, you have a demonstration or something? Yeah, I've got a mannequin with me. OK, lovely. So, I've got a mannequin here, so happy to have any other thing and see that. So what will happen is when you stop screen sharing, you say that your screen, we'll um we'll be able to see the mannequin. Okay. Um So I will go, okay. I will start with my presentation first and then hopefully we'll, we'll let you know. Okay. Can we start now? Uh just, just hold on and then we'll let you know. Yeah. Yeah. So um let me, I'm doing a couple of things. Thank you. Okay. Um I will start with my presentation. Uh So I'm doctor my issue, Sherawat and I'm not the consultants working at Sandwell and West Birmingham. Uh And I just trust and I'm one of the part of the robust faculty that is uh rotational delivery. Uh simulation thing that we do for all our trainees in uh England. Uh So we normally tend to do the training sessions for optics and gynecology trainees. Uh So, so indication for instrumental delivery, I do understand quite a few. Uh people might know this. We do it all the time. We normally tend to do it for their Formentera reason or fetal reason. Maternal reason could be because of inadequate progress uh where a woman has been pushing for more than uh two hours if it's a newly paris and if it's a multi paris, it's more than our, if the regional anesthesia is used it more than two hours or if the mom is uh extremely exhausted or it could be due to fetal distress or the baby got distressed or abnormal trace or uh fetal acidemia. Uh or it could be due to any maternal reasons like severe hypertension or cardiac disease where we don't want the month to push. Those are the times we normally tend to use the instrumentals degree. The thing is uh we did forceps before introducing vendors, vendors came into existence only from 19 sixties, but forces was there in 18 hundreds. And you know, like so one of the oldest uh instruments that's being used, not profession uh is forceps. So before we do any, any instrumentals delivery, always make sure the mother has got good conditional analogies here. I can't stress the importance of getting a good analgesia before attempting an instrumented delivery. Please make sure the mother had good analgesia on board. If not, please do a parental block. Uh make sure the fetal heart rate and things. Uh There, you know, these conference was a good insight into things. In the morning. We heard about uh women who had difficulties who found it traumatic for us. We normally tend to do this every day I/O, but we don't realize that it meant it might be traumatic on the other side. So it's always better. And also if the women is apprehensive that neuro development, you know, like if the patient need to have the trust in yourself, if you don't have the trust, you know, if you have the, the fear and things, you know, like the outcome can be totally different. So it's always better to explain what you're doing before just jumping in or that is a Braddy cardio. Oh, it's been there for quite sometimes, you know, you just need to go a rush and get the baby delivered. You know, please, it's end of the day to her baby need to get the consent, you know, do a proper examination. Uh make sure she's fully dilated, make sure the patient position, everything is fine before you apply the instrument and then try to get to communicate with the patient and get the consent from her before advancing for any uh instrumentals delivery. So next thing is bladder care, make sure the bladder is empty if you have a full bladder, um then, you know, it increases the space and then you will not be, are having adequate space to get the baby out. Um Or if the patient is already on, have a fully catheter, you could just deflate the balloon. That's what we normally tend to do it rather than putting I/O and always please accounts that's the importance of communication and getting a consent. Um It's not sometimes uh uh in our unit, even when you take them to data, we normally get a consent. But even in the room, if you want to do it, it's always better to give a consent. But how can you get a proper informed consent when the woman is in labor, pain, dry, dehydrated. But we have an issue. We have this policy like uh if a woman doesn't speak English, uh if the patient is coming in for induction of labor, the labor is being prolonged. If she needed a communication through a language line or translator, we normally tend to get informed consent or a written consent uh through the telephone interpretation. Uh Even before she gets there before even she becomes fully dilated or abnormal trace. Anything. We go through all the eventualities and get some in consent forms and things signed off just in case we might have to know because those trans patient might have time to go through. Sometimes when patient come for induction, we give them the translation leaflets. Our trainees have done a good project about translating, you know, one of the commonest languages, some 22 languages, they managed to translate Forceps uh sections and fitting it sampling. And we give them the slip for women read when they come in for induction because as we all know prime, when the women come for the first time induction, the chance of her ending up having a section or forceps is much higher. And if it's the first time nulliparous mother, one third of the women in UK delivered by instrumentals deliveries. Um So, and also like, you know, most important thing with all the forces. Yes, we can train uh junior colleagues and every one of us are very good in our uh instrumented delivery. But I can't start the importance of documentation. Please make sure you document very clearly. What was indication you, you did the instrumented Delery, what are the uh what is the position station position? So in we normally to go for the electronic documentation. So it always like a drop down box where we can do it or if it's a performer, just make sure that performers completely filled and uh always go back and talk to the patient and debrief the patient. For us, it might be that we are really busy running around from one room after another room. But sometimes for these patient's who had spent all the time trying for a vaginal delivery and then finally we jump in and do an instrument, got the baby delivered and just we walk off and then sometimes you don't even debrief why we did on what we did. So I just wanted to make, make it more interactive. When do you want to take a lady for a trial versus a delivery in the room? Which ones are the ones you deliver in the room? And which ones are the ones you deliver in? Uh, take data? Any one question, anybody in the audience, please? I mean, just give one reason why do you want to take somebody to, I mean, uh, when we, I got trained in India, we never took anybody for trial either. We deal with them in the room. Uh, I took them to theater for a section. So there is nothing called trial. But here, uh, in UK, sometimes when we think that we are going to fail, we normally tend to take them to theater. Let me see, an online as anybody has it applied, uh, anything, uh, a rotation lower than plus two with the descending on pushing. Yes, if it's an oilier position. And, uh, yes, very good most to, I mean, I'm enjoying the online answers. If it's a pain relieve, the patient hasn't got a good pain leave. Where do you want to attempt an instrumental delivery and make a very uncomfortable? And, um, if it's an oil baby that if the, uh, if it's uh easy to deliver. It's below the spine. Plus too, it's better to go for instrument delivery in the room. If you deliver anybody in the room, it takes less than 15 minutes decision to delivery. But if you want to take for a cat one, it takes at least 30 minutes to deliver anybody in theater. So if that is fetal distress and if it's an oh a baby, and if the head is below better to deliver in the room because you can deliver them quickly. But if it is high head, not an oh a baby, if it's a transfers position where you can't rotate or do anything, it's better to take them to theater where you think there's a possibility that you might fail because we don't want to attempt an instrument in the room, you fail the instrument and then rush to theater to get the baby delivered. Okay. And um and patient with uh cardiac conditions, we normally tend to use uh forceps rather than a ventas mainly because with the forceps, uh you can use a little bit more uh like, you know, help with the delivery. Uh with the vendors, you need a good uh push from the mother to deliver. I think this is an online question that I'm answering. Uh Next failure of instrument delivery is quite high with the patient with a high B M I uh short maternal maternal stature. And when they're, when there is an estimated fetal weight is about the 4 kg. And when the baby's plotting about the 97th is I'll or when the head circumference of the babies, about the 95th disease, I'll uh sent I'll uh O P babies sometimes in the occipital prosteva, their positions. Uh we sometimes may not be able to assist the baby uh correctly in sense. Like we, we want the largest diameter to enter into the pelvis, you know, like in the entire pelvis if the biparietal uh diameter. So what happens in the occipital posterior? I mean oxidative to anterior, I mean, aw sorry oxygen posi position, the head gets deflect and sometimes the by frontal diameter, which is a smaller diameter gets into the pelvis and it looks like it is crossing the spines. So the chances that we fail is completely less and also the longest the diameter that enters into the pelvis uh for occipital posterior position is not the suboccipital pragmatic. It is actually the occipital mental uh occipitofrontal um a diamond of just slightly bigger and the chance that you feel is quite high. And also when the head is quite high about the uh just uh skill spines, it's better to take them to theater. And so there's the three case presentations, Missus ex who had a spontaneous labor at 42 weeks. This young lady is very keen to try for a vaginal delivery. So she had quite a lot of midwifery classes and had uh personal dweller and she comes to us with a slow progress and then she becomes fully die dilated after augmentation with Scinto. And there was a concern in the uh CTG tracing. So this patient was then finally, uh wanted to, to go only for section. She doesn't want any instrumental delivery. I don't know some belief on this patient. And then uh finally uh consented for Cesarean section and this patient then goes to theater, but then the head was quite low. By the time they shift this patient to theater for section, the head was really low. And then the register comes around to talk to the patient. Look, the head is really low. It's be unsafe to do a uh uh section. And then we go ahead and do a full substantively on this patient. And then uh after six years, this patient started developing fecal urgency and incontinence. And then she was referred for by the physiotherapist for endo and in a land ultrasound. Uh And now she has found to have uh that there was a defect in the both external and internal spincter and now some negligent cases going against us. So I mean, I just brought this case not to scare people or do anything. I just wanted to uh look at the importance because now we have to write those things about uh thing to the lawyers and things. One of the things they said suggested to us was uh this patient was consented for section. And in, in theta the decision was changed for an instrument because head was low. This is the right decision. But the the person who conducted the team who conducted didn't go back to document uh um want to debrief the patient. Uh But then later, when this patient had uh Mr degree, there was the the documentation, there was no clear that the external internal spincter was intact and things like that. So it's all come down to documentation. I just brought this case just to show the importance of documentation because sometimes we do change the thing. Sometimes we take a lady for a Bradycardia six centimeters for data and data, they suddenly become fully dilated. Then we go for extra mental delivery to get the baby delivered. In that case, go back and debrief and then clearly documented and write down that external anal speaker is intact. I know you need to really clearly do a thorough examination and then clearly documents your findings. Uh The next case that I want to discuss is Mrs Y. She had a language barrier. Uh So she couldn't understand what the language which she could understand a little bit of uh English but not much. She had a Bradycardia. This is the first time a senior registrar was pulled in. She, the registrar comes in, examines, explained to the patient, the need and does an instrumentals delivery. Uh while after the instrument of delivery, baby comes out fine crying. And then the register goes on to do things to repair of the instrument of delivery. And while I was coming to the skin, there was another emergency buzzer. This register has to leave the room and has to go across and the midwife completes the peace suturing. And then we got a complaint three months later that the patient was not properly debrief, she didn't know what really happened to her. Why did they do what they did? So these are all like managing expectations. Complaint is all about managing expectations. Yes, there are times when we are really literally running around. Uh and for us when things go wrong, we are really good at going back to the room, debriefing the patient coming back and revealing patient's. But sometimes we neglect or ignore and the outcome is not that bad in sense. If the outcome is good, sometimes it's better just go and knock into the room, just the brief, the patient, why you did what you did, especially when there is a language barrier. And so key learning uh things is uh when you want to do any rotation delivery, it's better to go take them to theater and always check the position of your instruments, you know, like sometimes and also when there is never an ego between us and the fourth instrumentals delivery, it's not that you have to get the baby delivered if you applied an instrument and there is not a good descent or it's not progressing, just give up and try to check why he has not been done is because of the Paget's Man hour or is it any anything else that's causing this, uh, baby not to come down? Okay. Do you want me to go through the, uh, four steps, uh, a couple of questions online and then we've got a question in the room as well, which should we do the question the room? Then we'll go through the questions online. Yes, please. So I was just wondering, um, a questionable, thank you very much, which I'm not a very, for a lovely presentation and I was just wondering about this complications and um, these concerns that you try to, um, re brief the patient's. Do you try, um, explaining to them doing their, um, before the surgery or before they come for the labor? Because I'm lazy. So do we do this in internet? It'll clinics prior the, that the different ways of delivering and this could go. It's, the vaginal birth is not appropriate for you. We will do the instrument or family. Is there any, do you initiate such trainings and prepare the women prior to our labor when you start telling them all these new kind of knowledge when they are trying to, um, you know, when they're trying to, actually there are in so much pain with you. I'm trying to listen the expert. I mean, it's a good valid question. That's why I was trying to explain to you. Um uh in our hospital, we try to give the information beforehand like if a patient comes in for induction, but sometimes I totally agree. There are times patient come was planned for a low risk delivery. The low risk unit suddenly get transferred to us at full validation. Uh We normally don't want to, uh we had a lot of uh thing. We don't want to send uh instrumented deliveries and sections to all our patient's mainly because we want to promote normality. But those patients who we think there is increased risk like those who have epidural, those who have uh induction of labor, those patient's who have uh where you think the possibility of an instrumented delivery like a big baby and things like that. Those patient's get the information leaflets beforehand. I totally agree. It's not appropriate when the patient is in labor to come and talk and debrief and they know inventions in so much pain, dehydrated, tired, exhausted, pushing for two hours and then you come and talk to them about all the things. But my, our midwifery colleagues does half the job. They normally, when they're sitting in the room with the patient, they want to won't care, they go through with them or what might happen. What, what is expectations and things like that. So one of the questions Doctrine ration was, is it okay for midwife to do this deep breath midwife can do the debrief. Uh Some of the times we get away with a lot of things because midwifes tend to explain. But it's always better. The person who did the instruments to come back and see the patient advice. Usually half a job is done by the midwife. They tend to debrief them, they always pre empt them that this doctor might come. She might do this, she might do that, you know, like they might decide those things she normally tends to do because she's uh partner with the patient and they know like she's a patient advocate, but especially debriefing. Uh it's always better for a patient to see uh see the same person who delivered the baby. Excellent. Thank you. Uh Some of the questions from online from earlier, would you offer an elective cesarean section behaves? He was great in the 97th due to the high risk of pelvic. This um Yes. But uh you know, I was trained in India. We normally tend to diagnose when there's a mobile head, high head. We normally tend to offer them elective cesarean sections. But here we tend to offer uh patient's uh but careful a pelvic, that's proportions the diagnosis in labor. So sometimes, you know, uh it's better diagnosed. Well, they live because you never know how the primates pelvis move around to get the head into the pelvis. But we normally tend to offer these patient's, we tell them the risk of Cesarean sections. We tell them the risk of shoulder dystocia. Uh We go through with them before they even they reach labor ward and patient's are given options. If they want to have elective sections, they can have it. Excellent. Thank you. Just probably just, um, one more question is a mid hell that can delivery allowed and presuming instrumental. Uh We try to avoid, it's low amid cavity is a better thing to do rather than mid list. But sometimes if it's in the OPI babies and sometimes when you rotate a little bit, the head comes down, we take them only for a trial and theater and uh we attempt when the head is fully engaged or just 1 ft palpable. Uh Those deliveries are done in data only with an experienced uh practitioner in UK. The system is very clear like your basic trainer, intermediate, uh group trainees and senior trainees. So depending upon it's predominantly done by the senior trainees or uh intermediate trainees with the help of a consultant supervision. Excellent. Thank you very much. Uh Quick question. Uh Second question. Has this reduced maternal mortality rates? Uh Cesarean section, of course, I mean, that's, that's the main reason Roberts course was introduced because we wanted to avoid unnecessary second state Cesarean sections. Many don't want it. It's better to deliver more patient's vaginal e uh with an epidural, you have more uh second stage like, you know, uh failure to rotate because of the lax liver to rely. So those sort of patient is better to be, that's where we are training people to do rotational deliveries and instrumentals deliveries. Because if a full validation section, the subsequent risk of preterm delivery is higher and also caesarean section, subsequently, her fertility is compactly less than infection, stay in the hospital. I mean, I there is large data about safety of a second stage of vaginal delivery, dad, an instrument delivery rather than a second state section. Excellent. Thank you very much, Doctor Niacin. And we're gonna have to uh finish that there and rotate. That's okay. Oh, thank you. And then uh one of the questions that be our examination was, I mean, it's not documented. If it's not documented, it's not done. Thank you. Stay online. We're just gonna rotate and then we'll start it again. Yeah. Thanks a lot. Thank you. Mhm. About anybody Invokana? I didn't go through my phone slides. They provide too much. You need to cut it down only for quite one cases that you go the other cases required. Mhm. Mhm. Uh They know what I'm doing so they don't want to know. I think I should just keep it like that, isn't it? Why should I keep doing it? Oh, is it going to be online? Yes. In half weeks. Uh Okay. I see. It's cool. They should be many of us are good. It's a big group specifically. They don't think that. Yeah. Mhm. Uh the talk. Uh I think I will start. Uh Okay. Yeah. Yeah, that's fine. Uh I know there are big prophesies here but I'm not going to teach you how to do forces delivery and when and how, but let me just go through just regarding the documentations and uh the safety of when and how to do an instrument delivery. So we all know the indication for instrumentals delivery when there is inadequate progress When there's somebody has been fully dilated has been pushing profession with the nulliparous woman who's been pushing for more than two hours or three hours when there is a regional anesthesia or multi paris woman who's been pushing for an hour or when there is metal exhaustion or when the fetal distress with suspected fetal compromise uh in the second stage pathological trace or abnormal feel that sampling or sometimes metal severe mental hypertension when the BP is really high or cardiac diseases or maternal and robust in diseases. So assessment uh just make sure that women has got a good pain relief on board. There's no point in attempting an instrumental delivery. Uh the patient is, doesn't have a good pain relief or she's not with that. If, if you can give an epidural, it's fine, if not go give a good parental block and make sure that she has got a good uh perennial pain relief and then make sure the baby's fine. Check how much time do you have to deliver this baby. Make sure most important the safety is their heads fully engaged. Do a vaginal examination. I always ask the trainees when you want to do an instrument degree, you have to assist the Asus and check the position and get the stations right. If you can't check your stations and your position, there's no point in training uh to do an instrument of delivery. Make sure she's fully dilated, make sure she's in the right position, make sure it's not uh it should be away or uh well below the spines and look for a maternal effort. If she has a good maternal effort, you could deliver her in the room if you don't have a good maternal effort. And there is not much dissent. Don't try to attempt an instrument in the room and fail in the room. Better take them to date. Uh and you know, like do a proper assessment and good pain relieve and empty the bladder. Uh Don't just uh I mean, there are times where there so she just wanted, just make sure the bladder is completely empty. If the patient has got an epidural and a foley catheter, just deflate the police catheter. And I can't stress the importance about communication and consent. You have to communicate, it's end of the dates her baby and you are delivering. There are times when we just run, rush in between rooms and you just go and deliver the baby, it's better. You can't, I mean, have uh consent and you know, you need to have the confidence. If the woman has a confidence in you, then how of the time the job is done? So that's the thing, you know, like during ward runs when we start or when you start the induction process and things, you know, make, make sure you have the rapport with the patient and sometimes the half the half a job in UK is done because the midwives already pre empty the women. What is expected for those patients who don't speak the language, who has got difficulty in communicating and things that uh women in the city we normally have um who speaks languages, which we can't even get it in the language lines and things like that like the green in some, some rare languages. So sometimes we tend to in the daytime and the patient come in for induction or when she's in early labor or uh labor, we normally tend to get a consent for what all the eventualities that could happen. Either she might need an instrumentals delivery like a force observed mental or she might need a little bit sampling or she might need a Caesarean section. So we sometimes even get a consent for all these things just to be a pre empty, the patient, everything. And then uh in an emergency doesn't look that bad. If, if you match the patient's expectation and a pre empty the patient, what might happen, then your risk and everything is much less and clearly. Uh And after delivery, please record all the cord uh examples, clearly document it. We have a badge in it, whether it's an online thing. When we document it, it goes to the performer or a performer. Sometimes in a hurry. If you just write forceps, apply baby delivered, uh no problems. Things like very few lines, it's not good enough. So you really need to select uh performer and discuss about uh bladder care and maturation. I think that's one of the things that's coming up in a big, big day because uh patient often go on to develop bladder attention and then go on to have long term uh urological problems like, you know, you're very uh stress and incontinence and please debrief patient's. So for us, instrumentals delivery is such thing which we do it often in England, we tend to do it around 12 to 15%. And a fair analogy, Paris women, one in one third of the patient might deliver an instrumental delivery might need it. So if we are for us, it's such a common thing. But for a patient who has thought about normality and everything, it might be something more, it's always better. You go and pre empt it and talk to these patient's. So which is a better patient to take it for trial or which are the ones to do it in the room. I mean, I was trained in India. We didn't have the facility of taking trial to theater, either you deliver them in the room or go and do a Cesarean section. So we have to get your assessment right. You are not allowed to make an assessment wrong with your positions and stations, you know. So that's sort of, uh, things we had. But here, if we think the stage is high, I mean, uh, plus one and if it's an O D or anything, better take them to theater, so the chances of fail here higher, so we don't want to fail in the room. So it's better to take them to theater. Uh value suspect there's a chance that you might fail the instrumented delivery. Like if you have a high maternal BM I or when the women is shorter or the fetal weight is bigger, uh or the head circumference is larger or occipital posterior positions, occipital posterior positions. Sometimes the by front of diameter looks like a biparietal diameter and it might cross the spine. Many might feel, oh, the diameter is crossing the spine. So probably it's easy then you try to deliver the baby. It might be the deflect O P babies with A D flexed O P babies, the bifrontal diameter because of the, the flex position can look like it's crossing the spines. But originally the biparietal diameter might be about the signs and that's why we term we tend to fail in the room and it is better do through a proper assessment. And if it's an O P baby high, a little bit higher head, better go to data to deliver because if you fail, at least you can go for section straight away. And I just want to discuss a couple of cases that being had recently some of the litigation cases that we had in the force of delivery. Uh We had a lady who was, uh who was very keen for vaginal delivery. She went beyond her 42 weeks awaiting spontaneous labor's. Uh And so she came in quite stark at six centimeters slow progress. Then we have to start her on Oxytocin drip to make her fully dilated because she was 64, almost like 78 hours. So we have to start an Oxytocin trip and she became fully dilated. And then at that stage, there was a concerns in the C D G. So we were planning to take her for, to take uh but patient declined to have an instrument delivery. Uh She preferred to have a Cesarean section. But then in data, when she had the spinal and reassessment, the head was really low. So the register came around and said this is safer to deliver you vaginally. So he went ahead and did a forceps delivery. And then later on six years later, patient was found to have some fecal urgency and incontinence. And then she went for physiotherapy. And after the uh colorectal surgeon feet, uh renal ultrasound. And though they found that there was a tear in the mist um uh externally listening to thing. And then this patient then went on to tell that it was missed. But then the issue was the performer that we had. It was not clearly documented that the external little spincter was intact. Just the routine diagram of episiotomy wound didn't mention about the uh sphincter intact or anything. So it's I just brought this case just for documentation because we don't have any food to stand here because we haven't documented the external sphincter uh was normal. This patient went on to have two normal deliveries uh but it could have happened subsequently, but they blame the forceps because subsequently she did just had a general grazing and the uh subsequent delivery, she had a intact premium made intact. There was no graces. So second case which I want to talk to you, are you all about is one of the patient who had language barrier, couldn't speak much English, but to understand a little uh she had a bradycardia in the second state. So the senior sister comes in examines, finds her to be free dilated explains and quickly does the forceps uh instrumental delivery and then while closing the Parini um uh get another emergency buzzer leaves the room and we got a complaint three months later because the patient's partner was uh psychiatrist. Uh you know, in psychiatry, they tend to debrief and explain patient's better. But here he felt that we neglected his wife. We didn't really uh debrief. Uh We didn't give her the full explanation and everything. So we have to debrief. In spite the outcome was good, the baby was fine. Everything was the same. Sometimes these things happen. So it's always important that we clearly document and sometimes if you have to run, please to say why we had to go. And uh so if it's a rotational instrumented delivery, better take them to theater and well, you're applying for an instrument and delivery forces in theater. Uh If there, there is no dissent or if there is uh you know, like uh if your instrument is not locking or your position, sometimes you're not doing the proper paget's manual budgets manual is when you had really press on the, yeah, it really pressed on the uh instrument and then pull it straight. If you normally tend to go down and pull, sometimes you go and hit against the pubic bone just a second. Oh, yeah. So I'm not going to demonstrate this thing. Yeah. Uh So when you're applying your forceps, can you just stop the screen chair so we can see the video clearer doctor? Uh Oh Sorry. Okay. Can you hear it now? I think it's not. So it, I don't really good. Uh Oh It is a screen. Uh If you just stop the screen share just so we can uh watch the video. What you gonna do now? Oh yeah, sorry I forgot. Stop it. Uh Yeah. So yeah, when you're doing the instrument is delivery, the budgets matter with is you're not really press here and push it down. So when you push it down, it presses on your soft tissues uh there you push the soft tissue down and then you get the baby delivered, you know, you press like this and deliver But sometimes people go down when you go down, you should be straight and pushing it down. But when you go down like this, you could see on the top. Uh here you are cheating against the pubic bone, you know, so uh your your your blades will hit against the pubic bone and so you will not get any progress. So if you want to do a proper budgets, manu er if you want to do a proper budget manual, it has to be locked, pressed harder and then it should be a straight reaction to deliver. You don't go down. If you go down, you can see the blades on the top which is hitting against your pubic bone and you will not get any dissent. So that's one of the reasons sometimes you can fail an instrument. Excellent. Thank you, doctor. Yeah. Thank you. Any questions guys, I'm happy to take any questions, this people, any questions? Thank you very much. Uh Doctor Mukesh January. Yeah, it's not a question I have this is had, is uh it's just to emphasize, you know, we cannot overemphasize the importance of documentation. Unfortunately, um why I come from uh doctors don't document the way they're supposed to do. I think midwives documented and better than us. And uh as you can see, uh you know, due to poor documentation at the end of the giving, you have legal issues, then it becomes real issue for you to be able to defend yourself because there's nothing in the cold and there's nothing in the case route to really define what you have done. You've done everything wonderfully well, but you haven't written it down. So I think as residents and train you very, very important that you talk about every single thing you do. If you have a form, as I think you have, then you can easily feel the form and if there's not a form then ensure that you put every single thing down. Uh communication, communication, your second cases. I mean, he was called for an emergency. Uh probably no dear emergency. So he had to go, you know, to save a life, but there is an issue because he did communicate. Archbishop 20. Thank you and try not uh entry. Hi, Macquarie. It's Andrew easy. Uh Congratulations on that. It's, it's, I love the fact that you're teaching the patch uh maneuver. Um I think that's been under talked in the past and for me, a lot of our trainees run into problems because they end up trying to pull and they're, they're sort of a big angle and their feet are slipping on like or on the floor and it's a very uncontrolled situation. Um, whereas to stand alongside the forceps and you can, you then use your weight down on as a project maneuver and then you've got complete sort of control over the situation and it's always amazed me that it's not been taught more frequently like that. So I'm delighted to, to see that that being taught because I think it's an undervalued uh skill. So thank you very much. Oh, thank you. I mean, I thank all my trainers who trained me uh the proper pageants man. Uh when I was in hull uh Lindo, you know, like Mr Lindo and the other ones. Excellent. Thank you for any other questions. Thank you. Thanks a lot. Thank you guys. Thank you. Thank you. Thank you. Yeah. Uh Oh my goodness. I can't think. Hello, Fatima Heather. Hi. So you are 40 a medical student with us? You talking to me? Sorry. No, no, no. Oh, you're the fourth year medical student with Birmingham, is it? Yes, I'm just going to finally uh Oh, great. So when are you going to come? Which, which hospital are you going to come? For? Option? Tiny. So I'm doing uh at the women's hospital. Okay. But I have my friend who's here as well. She's, she's going to the city she's coming to city. Uh, so you'll see, uh, good professor stood as well. Uh. Oh, good. Yes. So, she's one of my research supervisor and she's lovely. Um, so I've been, I was at city last year for surgery, surgery placement, my surgical placement. Um, really enjoyed it. Honestly, I was so amazed to see you initially. I don't know, your research fellow. You might be, you might be one of our Chinese. But then when the student was really, I just finished my final year and I'm sorry, my fourth year and I'm going into Yeah, that's good. That's really good. What school did you go to with school? Uh As I'm from Telford. So I went to Newport Girls. Huh? Okay. So you're not from Birmingham, is it uh just have you just uh yes. Yes. Uh You have finished way. Uh Yes. Yeah. You had, yes. But the total number. Yeah, it was. Let me look to me. Thank you very much for coming to give the workshops even if you and your down COVID. I don't know. I, I didn't expect it. I escaped COVID but uh thank you very much. I'll come back at the end and we'll close second shortly. Thank you. Thank you. Yeah, I think I just got my Yeah. What you want to say. Mhm Yeah. Mhm Yeah, that's it. Did you doing that? Oh Yeah, it's fine. I never see. Yeah. Uh Okay. Mhm. Uh huh. With this part. But there's more people coming with a Mexican. No. Uh huh. Um Are we okay to start uh people? Uh I'm Dr Mahesh uh amongst uh consultant that sample and Lisbon uh trust and uh the road faculty who trained our training trains in the region regarding instrumented delivery. So we all know what the indication for instrumental delivery. So when there is an inadequate uh maternal progress when she's been fully dilated nulliparous women for more than two hours without an uh regional anesthesia or with three hours with regional anesthesia. Or if there's a multi paris woman, uh we could wait for two hours and if there was a maternal exhaustion, if the mom is exhausted or it could be a fetal distress if there is uh uh any suspicion in the CTG or abnormal uh FBS or sometimes we do, we want to cut short the second stage when there is maternal habitants crisis or cardiac disorders. So assessment uh need to completely assess the women properly, make sure that she has got good analgesia on bold, never try to attempt an instrumental delivery. The allergies as poor try to get an epidural if, if the patient is not uh doesn't want an epidural, if you want to do an instrument to delivery in the room, better go for a parental or a good perennial block before you attempt an instrumented delivery. Um She looked for the fetal heart condition with the, I mean uh CTG traders any need to expedite quicker and make never attempted instrument to delivery. When there's more than 1/5 of the head palpable paradigm. It do eight to A is an assessment. They just no, just uh a full validation alone, you know, like and Kharkiv phallic presentation and oh A or uh you know, it should be, the surgical future should be in the midline. Not never attempt anything on A OH P or other positions and look for the contractions. Look for the dissent. Look for the maternal effort. Most important thing is just have a good wrap over the patient's and never tried to do a uh uh instruments. When the, when the patient has got a lot of fear and apprehension, try to um you know, like down at the rapper and but before attending an instrument delivery, make sure the bladder is emptied. I think we all know the system, it's not something new and I can't stress enough the in communication and consent. We should really get consent from a patient before doing industry. Never tried to do an instrumentals delivery. Uh couldn't get a consent from the patient. Uh in city hospital, we tend to do uh deal with diverse but uh 80 of patients who sometimes don't speak a language and hence, uh when they come in for induction of labor or when they need it and when they're in slow progress, meaning augmentation and things, we normally tend to use the language line and get them consent for all the eventualities. Uh Any uh instrumented delivery FBS or Cesarean sections because there are patient's who uh even can't get uh language line like green in some languages where we sometimes find it really hard to get uh interpreters online. So we normally tend to spend some time get go through all the process. Uh Always have a good explanation. Always try to take a red blood samples after instrumented delivery. Uh And please fully document everything. The main thing that I thought trying women talk to today is about the proper uh documentation and look for the thromboembolic risk factors and number is with the instrument delivery. We are giving one short of antibiotics and it's proper bladder care and offer physiotherapy and debrief and discuss the subsequent birds. Sometimes forces. Delery is such a common thing that we do. 12 to 15% of our women do have forceps delivery. If it's a nulliparous women, one third of the women are delivered by instrumented delivery, but sometimes we don't debrief, we don't explain why we did and what we did. And uh sometimes that those things could be a big issue. So when do you want to take a lady for a trial versus the delivery in the room? Um So we all know whenever the B M I is higher and there's your short maternal stature or when there's a big baby on boat where you expect that might be a difficulty or if it's not an okay position, if it's an or any rotational delivery, it's better to take them to theater and it's no P position because of the OPI position, especially with the cap and morning, sometimes the by frontal diameter can look like the uh biparietal diameter and can look as if it's below the spines and it could be dizzy ving the actually the largest diameter might be still about the spines. And the chance that you failed could be slightly higher and never attempted instrument in delivery in the room if the head is more than a palpable parap Dimmick. Uh So it's always bachir to, you know, like do a thorough assessment before attempting an instrument in the room. So I just want to discuss a couple of cases that recent litigation that we uh in our trust, we are going through uh a patient whose um 42 weeks, she was very keen to try for a vaginal delivery. So she had been to the NTT classes, had a lot of counseling sessions and she was so keen for normal vaginal delivery. There was a slow progress and hence she was shifted to uh delivery sweet. And then we have to go through with her and start her on oxygen sin trip. And finally she manages to be fully dilated. But then at that stage, there are the concerns in the CTG. So we were planning to take her to theatre patient didn't want to have an instrumentals delivery. She wanted only Cesarean section who went through the pros and Cons Peixe uh doesn't want any instrument. And anyway, so we, she consigned a consent for a section. We took her to theater, had a spinal and then reassessed her. At this point, the head was really low and it was in a, a position. So the registrar went back, discussed with the patient and went ahead and did a forceps delivery and uh suturing. But the documentation was uh he has done the documentation regarding the uh um episiotomy, but he didn't mention about the anal sphincter pr examination. So six years later, she uh found to be have fecal urgency and incontinence and then she's beat the physiotherapist. And then uh we had an in uh ultrasound by the colorectal team and found to have a defect in her external sphincter and they blamed everything down to the full substantively that she had. And I mean, the reason I just brought this case is mainly because the documentation, the performer, everything was documented, but they didn't document the pr examination whether the anal sphincter intact on things, those things had not been ticked. So if it's not uh written, it's not done. So another case that I want to discuss about a lady who had uh issue with a language barrier. Um She just recently been to the country and she doesn't speak much English. She had a fetal bradycardia So the registrar comes in, uh examines fully dilated, straightforward instrumental delivery. An episiotomy was scootering and then while he was coming to the skin, there was another emergency buzzer. So he asked to leave this woman and the midwife completed their peace iata me surgery. Uh Then three months later, we get a complaint letter that the husband of the patient felt that we neglected his wife and uh we didn't come and debrief why we did what we did. And all those things, you know, like uh for us, even though for such is such a common thing that we do all the time for women who had uh no expectation of instrument to delivery or anything, it's always better. Sometimes two t uh team up and talk. So most important thing, you need to develop the wrap over the patient or sometimes uh majority of our jobs are done by Midwest. They tend to go around and debrief and some of the times they come back and tell us this patient has got these questions, this patient has got something so then we can go back and talk to them. So, uh one of the key learning points which I want to tase is uh try to uh if you think uh if there's a bradycardia, it's a, a position, the head is really low, but go ahead and do an instrument of delivery in the room because decision to delivery in travel list and then average takes 15 minutes to deliver in the room, but we take them to theater. How were quick? We are, we can take up to 30 minutes and also, uh, just get, keep practicing on the mannequins before applying on the real, uh, patient's and things. And I want to talk about the pageants, man. Our Yes, thanks. Oh, so when you want to apply the, uh, so when you want to apply the force it, Delery, uh I don't want to, I'm just reading it. So when you wanted to apply, you know, that you are to be palate to the inguinal ligament and just apply the forces and uh the proper budgets maneuvering. You need to Ritalin press straight, you know, on this shaft here, you need to press straight and then there's this thing you need to pull, uh, pull it uh horizontally down, never go down like this to uh never, uh never go down. So if you go down and pull, you can see, uh, your, uh, the blades hit against your pubic bowl. And so there is not much different. But if you do a proper paget's matter work, if you go down, you can see it's going in into the pelvis and it can have a good Valerie of the bone. And then can you get me in perfect the millennium. And I'm sorry, I'm happy to take some questions if you have any questions. Thanks. Thank you very much. Doctor in Russian. Does anybody have any questions? Yeah. Um If you have a woman whose uh can you be a little bit louder, please? So ladies fully dilated and pushing. Is it she's pushing? You do decided you're forceps for delayed second stage. Why would you do called pet cord blood gases? Yeah, in medical legal uh implicate better. Any instrumentals delivery, any cesarean section we need to get paired. Uh cord gas is uh just to make sure any emergencies, his parents or any. Um because we sometimes do it for uh uh fetal distress and even um uh failure to progress cesarean sections. We don't really do uh called gas is because many times you think it might be just for delay, second stage. But during instrumented delivery baby can come a little bit shocked. So, or that might be associated shoulder dystocia. It's always a good practice to get core paired uh called gas is because that's the one which is going to help us in the future uh regarding the uh like, you know, the condition of the baby because the new things can come up. The only thing that's going to uh standards in the coat of law is your uh card gas is if the gases were normal. So that tells you maybe it's okay all things, isn't it? Thank you very much. And we've got a question online um in emergency situations, the room with bradycardia and low head uh patient was councilor procedure and idiotically with tell is not mentioned, she was subsequently sustain. Did that with uh the question is in, in emergency situations, are you allowed to do a brief consent or do you still have to go through all the competent? I mean, uh that, I mean, that's one of the reasons we, we got a pre printed consent form in our, in our unit, we start getting pre printed consent form to include, include all the complications centers. But sometimes when there's a bradycardia, we go around quickly tell them about the need to do a full sub delivery and the risk that you may be might have marks in the face. And also there is a risk that, that the tear might go into the back passage. Um I, I think it's better to try to do it quickly and, and I think with repeated practice and you, you will completely uh uh actually this is around each of them, uh particularly wanted to talk about 30 weekend. So we process, we know there's a 7% risk of having a Felicia. Uh and we are duty bound to inform the women anti Netley and therefore part of the O A C K body, we have developed their information need, uh which tells them about respect, ear's for failing. And from uh what we expect if it happens, etcetera, uh we have research that has showed that women are not writing, bring this uh information. So I think the time to tell mothers is not when emergency situation is factoring. But at the time in the anti emetic period where they have time to think about it where they are trying to digestive so that when this happens, they are not terrified. And quite often I've seen them with making have issues with the life. I learn a clinic where I see all the 30 degree test, not only from my institution but from other places as well. The second thing is about that case that you're illustrated in process. Yes, forceps caused the third degree that we know that a 7% interest maybe she needed her process. But the issue there was not really electoral examination, assisted systematic correct members annual examination, which is why the uh industry julie was missed. And I do think that should be part of your frustrating as well. Uh You know how you do electric examination. And again, we have videos on how to do a rectal examination. It's not just putting your finger in the back passage, but it's a systematic examination finger they looking for gotten more test and therefore we'll avoid missing these tests, which has got a significant contract from these when they get your unit, which has to be the worst center in. I totally agree uh with you, I, I think we should have done it. And uh that person who has done it is also quite senior clinician, but I don't know what really happened. Why it was Mr why it's not been documented and we have to do the thorough assessment, you know, like of the inner spincter, I had been to your third degree, four degree coast, long time back, almost 12 years back. And that's when I met you. Um I mean, I totally agree. I take you uh points and uh we also had this issue be in our unit. Some of our trainees got some translation projects. They got around 22 languages. They translated quite a few things that could happen. Labor, make sure dystocia, instrumented delivery feel that sampling Cesarean. So sections, they got this consent and then, I mean, in different languages, uh not the consent, the information leaflets and then they, we tend to give it to patients who come in for induction of labor. We wanted to give it to every patient we want to send it across to everyone. But then we had a lot of opposition from our bit graphically that we are opposing normality. Uh We are trying to show pay, scare, patient's with shoulder dystocia, third daily tests, uh forces do living and things like that. So then we chose patient's who are at increased risk, those who are um like divertics inductions and things we give them those leaflets now in red. Uh uh let's stop that face when I do with this subscription appropriate. Uh huh. Uh It's huge but what can help? Uh uh CVS. Right. Right. Seven that's it okay. But that's sort, and to not kind of defensive, I understand he was backstage to put these programs like that anymore. Uh, secretary economy now actively because everything there is on that. Uh, let's see, that could be something he had the chapters and also that we had not everybody, uh, subtle prison to build your stuff to like. Yeah. Uh, we use it in business education. Is that right? Yeah. Yeah. Uh, I think I don't have, uh, yeah, he's got a mix of right now. So, uh, what, uh, you know, if further facts the little, yeah, it's supposed to be grossed directed and have it to you. It's awesome. Yeah, let's go. They, they don't know what specifics because there is no pain service, you know, they, uh, they got me straight there. Either one is coming through that kind of situation here, uh, because not pregnant. Okay. Okay. Been doing with the fact that you have compared to grow on this requires, you said definitely it was okay making it all the time. So we are condemned to refuse Tara Hollywood. Take this place and time. Um, and, uh, you know, because you have to communicate, uh, do you have a lot of high providing people to having their competition have to be? Mhm. Winds quite big. Second, uh, protective effect. Yeah. Uh, like, uh huh. Thank you so much. I think I wanted to make sure that important. Not just a clean break into complete it. But they say emergency situation. Can you document it? That's amazing. Well, if they had and I have some time to do it too. Delighted. Get my face. I should just get at this. Mhm. So this comes to check it, connections, equitization that after jingle, yes, we do get into a situation like this. Become that's it to me. And I, yeah, I agree. But I think if I can get the content on their insurance for the, especially in the fifties and then the quick, all right, Jim. Okay. Um, so I think these people, some type of business and it was about them. They're not going to say you're quite to be and they have to do this unfortunate doctor that's, that's conservation to you have to kind of thinking that's, uh, and if that book is one of those situations that in your, in your opinion, you're pretty much done and everything was straightforward, but actually document that. Uh, but people like people to do this particular happening actually. And actually excellent position one. You have something, something a nine types just to, uh, just the, it wasn't responsible. Yeah, from what to this, the second case was that she was, I think one of the valet was not. Yeah. Yeah, but I think it's all this. That's right. And that's it. And, but even if it's the next step one and quickly material and nine from, to say, I'm sorry, I got more now, but you still have more control and I think just abandoning, uh, they feel abandoned, you may not even think that you're abandoning it, but that's what she's going to do. So, I think it's absolutely important in your baby. I really feel sick because you were the person meaningful manner. I did go back is it doesn't go away. Yeah. Or focal that failed anyway. Yeah. Yeah. Uh, yeah. Yeah. Uh huh. Averageable dependent. Yeah. Thanks a lot. Uh, Doctor Tucker, you, uh you have fulfilled my space and I would like to be there, you know, like uh it's really missed. Um Well, thank you. Thanks a lot for uh session. Yes. Thank you very much. Thanks. It just head down.