Women norma transcript — SMP305 lecture transcript

So I'm Carris. I think we might have met, I might have met some of you during anatomy and stuff a couple of years ago. Um, so have you guys, you've not done your placement just yet? No. Anybody coming to the Jessups? Yes, I work here so I'll see you. Um, so today we're learning about antenatal and postnatal care. I think it might just say antenatal screening or something on the timetable, but you don't, I think, have any other dedicated postnatal stuff, so we'll go through a bit of that. Um, and we can take a break in the middle if you want to or we can just go straight through both. Should we aim for both? Yeah? Great. Um, and we're gonna do a bit of quizzing stuff in the middle as well. So, um, the aims of. Today we are to understand some antenatal sort of routine care that we do, understand antenatal risk assessments and how we manage pregnancies that we think might be higher risk. Um think about postnatal care a bit and think about what can go wrong in the postnatal period as well. So all of the routine stuff plus a few complexities because there's no point just knowing about the routine if you don't know what your next steps are, if you're identify any risk factors. So we've said no placement just yet. And when I was a medical student or even when I was an F2 coming onto Obs and Gye there were loads and loads of words that I didn't understand and that probably will be the case for you. Just for a few keywords, there's loads more than this. I just thought we could go through some stuff just to clarify and make sure we're all on the same page for some things. So hopefully antenatal is obvious, hopefully. So antenatal is during pregnancy, so before Before you go into labour, OK? And then intrapartum is the time in labour, OK? And so that's something that we talk about and on the wards, that kind of thing as well and then postnatal on the pparium mean the same thing and it essentially is the 6 weeks following delivery, but it can be a little bit longer if we've got complications that are delayed for whatever reason. If they're related to pregnancy, it still would count as a postnatal complication even if it was 3 months later

or whatever um. Lyca then is the water that surrounds babies, so we talk about amniotic fluid, don't we? But generally in obstetrics we talk about lyca rather than amniotic fluid. We only really talk about amniotic fluid when we're scanning for volume. Um, and then lochia is the bleeding that we get after delivery. So that's normal bleeding that is essentially the shedding of the decidua. Do we understand the difference between endometrium and decidua? Generally no, good. So the endometrium we know is the lining of the uterus, right, and that lining is always there and then the decidua is essentially a specialised layer of the endometrium that proliferates um and then is the layer that allows the placenta to implant basically. um and so when the baby is delivered, it is the decidua that sheds as low here, OK? And then synthesis. fundal height is just something that we measure. So we're thinking about our anatomical landmarks. So the sympus is the symphysis pubis, OK? And then the fundus is the fundus of the uterus. So when we're measuring and palpating, we're really thinking about reaching to the fundus of the uterus and then SFH symphysis fund establishment. OK, I'm sure you will come off across lots of other words that you don't necessarily know, but hopefully a bit of background and always ask what things mean because you might well have Job and an obstetrics is left to or something like that, so it's worth understanding. So antenatal care is really, really important as you can imagine because we want to make sure that people are well in pregnancy and that babies are well during pregnancy as well. So it has to be accessible to everybody and it's really important that it can be accessed easily in a timely manner in an accessible way, be that by language, if somebody needs sign language, raille accessible documents, language accessible

documents. Um, it also is a really important and useful time for health promotion because oftentimes we're looking at a largely healthy population who haven't necessarily had much interaction with, with doctors, with medical care, don't necessarily need to go and see that GP. They might have been for their smears. If they've been otherwise fit and well, they've got no real reason to go and seek medical attention. And so it can be a good time for health promotion in terms of like smoking. Cessation in terms of good diet, in terms of vitamins and things like that and and and just is a is a very useful time for all of those things and it can then impact their close relatives as well. And so it's really important that we're spreading useful messages essentially. It also is the only time in adult life when somebody can get free access to dental care as well and so that from that point of view is a good for health promotion. Um, we also always importantly think about patient led care

and that's key in our communication. It's key in when we're making plans and we essentially want to be able to educate people and give our professional opinion whenever we interact with people to empower them to make their own decisions based on good information essentially. So let's start with this. So it's a bit of a quiz so if you can get your. Phones out or on your it'll work on a map or whatever. So we're just gonna think together a bit about what do we think should be included um in routine antenatal care and please let me know if it doesn't work. I didn't check the QR code this morning, but we can sort it out with that. I don't know. Very good. So the number's different. Apologies. Did the QR code get you anywhere at all? Yeah, OK. Great, so lots of ideas, big ones there obviously being ultrasound, education, screening, that kind of thing, and we're definitely thinking about screening in terms of how we're gonna assess people for greater risk because routine antenatal care is all very well and good and mostly, mostly involves not too much intervention from the obstetric team, but how can we screen people to know whether they. Need a bit more input. um I think someone wrote safety netting as well and that's really important in terms of helping people to know when they need to seek additional help and when they need to access extra support from the obstetric team. OK, vaccinations, education, mental health we'll all talk about in a minute as well, OK?

So. So, um, just as routine, this is the kind of general outline of appointments that I I can't remember why I got this essentially but um it's this is essentially showing us that for a first pregnancy we need some additional appointments and so we get a little bit more input from the midwifery team. Um, at each appointment we want to be risk assessing as a new opportunity for risk assessing basically and checking on well-being as well as doing any routine checks. So it usually would involve a community midwife, sometimes it involves a hospital midwife depending on how the deanery works, um, a health visitor, most commonly in the postnatal period but they sometimes do home checks beforehand as well, um, and a GP. So the GP often is involved with any prescription. Options that the community midwife wants them to start any obviously problems that they have otherwise, um, but also for postnatal checks, really importantly as well. So they always do a 6 week check and at any point, any contact with the midwife health visit to GP things can be uh escalated to the um obstetric team, OK? And so we're kind of a point to be escalated to. Everything's running along smoothly, but then if there's any issues then they'll be referred in to see us.

Now screening programmes, we don't screen for literally everything. There are some things that we check for if people are symptomatic, but regardless of symptoms, regardless of background, everybody gets an HIV, hep B, and syphilis check, and that's all done as part of the booking of blood tests. And that's because of risk both to the, the mother and also to, um, the baby and possible growth defects and possibility of things being passed on um during delivery. We also do blood screening for thalassemia, sickle cell traits, um, and a heel prick test for the newborn for the same because they can have a big impact on a new baby and then growing up, of course. In terms of anomaly screening and ultrasound scan screening, everybody gets a booking ultrasound scan and that has to be or has to be, if it's not they can still have it, but for it to be valid for the. That we measure it needs to be between 11 and 2 and 14 + 1 and that's just because that's where the research is valid in terms of measuring a crown rump rump length for um for dating and also measuring renewal translucency which helps us to risk assess for

things like trisomys. The combined test combines ultrasound scan and a blood test for the mother to again help us to risk assess mostly for. STDs and other abnormalities of that nature, um, and then the foetal anomaly scan, also known as the anatomy scan happens between 18 and 20 + 6 and again those dates are quite strict just because of the evidence for how we can check all of the standardised points which we'll talk about in a minute. So again, little quiz so what risk factors do we want to identify? So we've spoken about. We've spoken about routine stuff and all the routine care that we want to have involved, but what risks are we trying to pick up with our screening, with our questionnaires, with any extra observations or whatever that we might do? What risks are we trying to identify? Or what factors about a patient might increase the risk of pregnancy. Great, so lots of things. Preeclampsia, gestational diabetes, smoking, all very good. So good, good big ones to have. Um, other conditions, social factors, quite a few in there.

um, obesity probably falls under gestational diabetes as well. Because obesity increases the risk of gestational diabetes and pre-existing conditions might well need further input from other specialised teams and all of that stuff, so really good ideas. So um risks generally are things that we can mitigate for so we want to identify them because risk is just. Chance of something bad happening, right? Or a chance of um and so if we identify things that increase risk in pregnancy then we can usually mitigate for them or plan for them or enact something to make the risk less. We identify them through the booking questionnaire, booking with the midwife, and if any problems are escalated there then they'll be asked to have an obstetric booking appointment where they're seen in antenatal clinic. And while you're on your obstetric placements you'll probably go and sit in antenatal clinic and not everybody goes to see an obstetrician at their 12 week scan, but if there are risk factors then they'll come in to see us. Um, and as you said at all meetings.

Some of the main risks that we want to identify and then plan and mitigate for are, um, risk of venous thromboembolism, so risk of DVTs and PEs because that's really, really important in pregnancy. Um, risk of preeclampsia, um, and any pre-existing high blood pressure, because high blood pressure just normally can increase the risk of, um, preeclampsia developing in later pregnancy. Gestational diabetes, foetal growth, etc. we've definitely been said about, um, and then other social factors, etc. so. Um, I've put this slide a bit as a revision tool as well because, because essentially we need to know what, what things do we identify that say that somebody's got an increased risk of something and then how do we act on it. Um, so for smoking we know that that increases the risk of small for gestational age babies and so we need to have growth scans. It increases the risk of placental eruptions and so we need to consider that if we know that somebody comes in. Who is a smoker who's got some PV bleeding or who's got some abdominal pain or who we've got concerns about their baby and it also increases the risk of miscarriage and stillbirth. And so we can, as we say, mitigate for this it's like an opt out uh referral to the smoking cessation team. So some services you have to self-refer yourself because they get lots of do not attend, but smoking cessation is really important and so. People always get referred to the smokers sing team. With preeclampsia and pregnancy induced hypertension, so that's PIH um we always look at personal history of high blood pressure, personal history of preeclampsia and also family history of the same. Um, the risk is also increased with increased maternal age and also first pregnancy. And so we mitigate for that by prescribing aspirin, so if those risk factors are either. then the patient will be prescribed aspirin from booking until 36 weeks and that essentially helps similarly to how like we give aspirin for people who've got coronary heart disease. It helps with the blood flow and blood supply through the placenta and so it helps to mitigate the risk for preeclampsia um and then if preeclampsia is diagnosed then we have to think about delivery planning in terms of timing and risk assessment for both the mum and baby. With gestational diabetes, um we know that a personal or family history of diabetes or gestational diabetes increases the risk and so if somebody has had a previous pregnancy with gestational diabetes, they're far more likely to get it in this pregnancy.

Um we screen everybody with a glucose tolerance test, but only if they have risk factors. So the risk factors would be like a previous gestational diabetes in pregnancy increased BMI so. BMI over 30 would have a glucose tolerance test and and a baby that measures as large for gestational age. We do sometimes do it in small for gestational age babies, but it's more common in foetal macrotonia. Fine. um PPH if somebody's had a previous postpartum haemorrhage or has a raised BMI or is a grand mal tip, so they've had more than 3 babies and that. Greater risk of having a uh postpartum haemorrhage. OK, and so we can mitigate for that and we can make planning and the planning is mostly for delivery, but also making sure that we're optimising the blood count and so we want to not have people who we know are at risk of having a big bleed at delivery who then have an Hb of like 85, 90, that kind of thing because they've not got as much margin for error then and so we want to make sure that we're optimising our patients as well. Existing medical conditions we've got specialised clinics of many varieties at the dress-ups and so we often use other specialists um who can come and help advise us about um how to manage things in pregnancy. And then social factors we've talked a bit about substance misuse, mental health, at young age, so teen pregnancies, etc. um, and anybody who's a victim of domestic. Abuse or like um needs additional safeguarding support will all be given individualised plans so often this kind of thing is a reason to have we've got specialist midwifery teams who can then help us to make a plan that's specific for that patient so there's not one routine screening that we have to do for everybody who's got complex

social factors. So ultrasound scans we have spoken a bit about. Um, the main extra bit with this slide is about the anatomy scan and the anomaly scan. So we, we do these essentially to try and pick up anomalies that we can see on ultrasound scan if that makes sense. So it won't screen for every foetal anomaly ever, but there is a set of 11 structurally visible conditions that are screened for in the anomaly scan, and that happens by taking these very specific pictures at very. Specific anatomical points um like within the abdomen, within the chest of the baby, at the head, looking at the spine, all of those things and so it's a very, very standardised and rigorous test and that's why it has to happen um within a very specific limit of um gestation. And so if we're outside of that gestation or if somebody books late after that we can do a scan and we can have a look at those features, but it wouldn't necessarily, it's not within that kind of rigorously tested um uh gestation. So, yes, and then additional screening, so we know that we have those two scans, so if somebody had a really low risk pregnancy, was otherwise completely fit and well, we would just have the 12 week dating scan and the 20 week anatomy scan, OK? However, additional scans that we can offer include early pregnancy scans, so if somebody had pain or bleeding in early pregnancy or had. Had multiple previous miscarriages or had hyperemesis, then that would all be an indication to do an early pregnancy scan, OK? And so we're talking anything really before that 12 weeks, but often it's around the 6 to 8 week mark, OK? And so the main reason for early pregnancy scans is to confirm viability and also to confirm that a pregnancy is within the uterus, OK, because if somebody comes with pain and bleeding, we need to be. Ruling out ectopic pregnancies, we need to be thinking about and whether there's a molar pregnancy within the uterus.

In terms of hyperemesis, the reason for scanning is because certain types of pregnancy increase the risk of having nausea, vomiting in pregnancy. And so for that our aim really is to look at whether there's a twin pregnancy because twin gestation or multiple pregnancy can increase the risk of high premmesis. Because of the increased level of beta HCG that's released by the multiple or larger placenta, um, or looking again for a molar pregnancy because that again can increase the Beta HCG hormone that's released that they can increase the hypermesis symptoms. Later then we can think about cervical length screening and so this is a picture of a cervix, so it's a, it's a transvaginal ultrasound scan to look at the. Cervix to look at the length of the cervix and the reason for that is that if your cervix is shortening, there's an increased risk of preterm birth or um mid trimester miscarriage unfortunately. The reasons that we would do that is if somebody had had previous preterm delivery, if somebody came in with symptoms of threatened preterm labour, then we, we often do a swab test. That tells us is it maybe yes or is it definitely no. Um, and it can help give us a bit more certainty about risk assessing that. And if somebody has had preterm labour before, so we're talking the full 34 weeks is kind of our cutoff for this extra screening, and then often we'll do multiple cervical length scans to check that the length of the cervix remains OK. Other things that increase the risk of threatened preterm labour include um. Like having a UTI or having an infection, that kind of thing, but also having had a previous caesarean section at full dilatation, so because there's possible risk of the cervix being included a little bit or being disturbed within that caesarean section at full dilatation, so if it's an emergency section in labour, then we know that that risk is slightly increased, um, and then growth scans, so not everybody. Gets growth scans, so our routine growth monitoring would be with the symphysio fundal height, um, but the growth scans that are done additionally, so if somebody had raised BMI, then we can't reliably do SFH um if we've got gestational diabetes, if somebody's had a previous large for gestational age baby or a previous small for gestational age baby, then we want to make sure that we're keeping an eye on the growth of that baby.

Cool. This is the same. Yes, so foetal growth and wellbeing, we've talked just about growth. Um, one of the, one of the kind of difficult things but useful things to monitor is, um, foetal movements. So foetal movements are really really subjective and so that can mean that sometimes people come in with foetal movements or reduced foetal movements essentially quite frequently throughout a pregnancy and sometimes. We find that everything is fine, but sometimes we don't, and foetal monitoring and sorry foetal movements is a really important symptom that allows a patient to say I need to come and see someone just to check in. And so making sure that foetal movements, particularly after 24 weeks are normal, increasing, following the same pattern is important. We should never see foetal movements, never is normal at any gestation after 24 weeks for foetal movement. To drop off and reduce so that would always be a cause for further monitoring, often with a CTG, which is the monitoring on the outside of the tummy that you'll see, looks a bit like an ECG but it's very different, um, and a growth scan as well.

Now, as well as growth scans, whenever we do an ultrasound scan for something like a growth scan or if we're worried about movements, if we're worried about uh placental function, we'll also look at the LA volume and so we're measuring. The amniotic fluid by looking at all of the dark flowly spaces around the baby, so we measure the depth and and and we do a Doppler, so that's measuring the rate of blood flow through the placenta to the baby. So I think we've talked about all those other things as well. So that's all screening and stuff done, oops, um. So maternal death, so these are definitions that definitely can come up in exams, and I have had them in my exam questions in the past as as a medical student. I haven't written these questions. Um, maternal death is the death of a patient while pregnant or within 42 days of termination of a pregnancy from any cause related to or aggravated by the pregnancy or its management, and so that's including. All pregnancies that are carried to term and then that 40 days, 42 days after, or it could be including a miscarriage and the 42 days following a miscarriage because that still is the termination, the end of the pregnancy or a medical termination, surgical termination and that 42 days

after, OK? A late maternal death then would be from 42 days to 1 year, um, the most. Common cause of death and this is really important kind of for your medical knowledge in general as, as well as preparing for exams and whatever but for multiple years we've seen that the most common cause of death of maternal death is venous thromboembolism, so PEs most commonly, um, DVTs obviously that's what what they often would start off as, but PEs are most commonly the cause of death, OK? Um the terms. mortality and morbidity is monitored by EmBRC in the UK, which is an annual audit, an annual national audit that then releases, um, documents with recommendations as well. Um, and so we can see on these ones, I think I probably could, there's one more recent graph than this so I apologise that it ends at 2021, but, um, over recent years we've sadly seen. Increase in maternal mortality in the UK, um, and there's probably multiple reasons within that and it's quite complicated, but it's definitely not what we're aiming for. Um, the blue line here is looking at COVID, which again isn't something that we're looking at anymore. um, but far and away the leading cause of maternal mortality is, uh, BTE. Within the EBRACE audit we also look. At different demographics and so it's really important to note and be aware of and be proactive in our changes to help this but um we know that anybody of any ethnic minority is at greater risk of dying during pregnancy or having a poor health outcome um than white women. We also know that the risk of stillbirth among black babies is higher and. Um, that anybody who's living in a lower socioeconomic group or lower socioeconomic area is up to 2 times more likely to have maternal death as well. And what this means essentially is that we obviously as individuals have to be very proactive about institutional bias and knowing that it's there and acting positively against it, but also about supporting policy change and so there are Policy changes that are coming through and we need to make sure that we're proactive about them essentially.

So here's a little quiz. So that's the antenatal part the racing. So. Yeah, so hopefully that's an easy one because I probably said it 3 times or whatever, but so we want to screen for anomalies in the 20 week scan and we're looking for all of those visibly detectable um foetal anomalies. Great. Which professionals are involved in routine antenatal care Yeah, so largely GPs, midwives and health visitor. If anything needs to be escalated to an obstetric doctor, that's fine. And, and also some maternity units only have a obstetric centre for a birthing centre. So like Barnsley for example, anybody that's got under midwifery led care would also deliver on. The same unit as people who are under consultant led care. So here it's quite separate, but at some trusts it's the same place and so they probably would still see an obstetrician at some point just to say hello. But yeah, routinely GPs, midwives and health visitors. What infectious diseases are routinely screened for in pregnancy? Yeah, good, remember that. So, what factors are used to monitor foetal growth and

wellbeing? I think and I hope that you can select more than one answer. Good. So yeah, foetal movements, SFH growth scans, maternal weight gain we don't really care about, but we do care about maternal weight loss in the context of hyperemesis. And what is the leading cause of maternal death in the OK, important message. If you see a pregnant woman anywhere in hospital, if you admit a pregnant woman anywhere in hospital, you should be thinking about giving prophylaxis for VTE. You don't have to be an obstetric doctor. You don't have to be a gynaecology doctor to do that. If you see someone on the medical ward who's admitted, think about Doctor Kara, intensify and whatever they do, because they probably need it. And it would be embarrassing if you heard me and then they died. Awesome sad. So next bit, I think we can just go onto this. Does anybody want a break? It's not been very long. I'm sure you can all manage. So what can go wrong, we're thinking now about we've had a baby delivered, what can go wrong in the

pool aquarium in the 6 weeks following delivery. I. I. I'm missing another really big one. What do we give aspirin for? No, OK, so anybody want to think about blood pressure in the postnatal period, or do we not care about that after we've delivered? I think we probably do. That's fine, so. So let's think a bit about the physiology first, just as, just as quickly. So we know that in pregnancy and then in the postnatal period there are massive, massive changes in hormone profiles and that largely really is to do with that big temporary organ, the placenta, OK? And so we know that as the placenta grows, the level of. HCG increases, the level of oestrogen and progesterone increases. It's first produced by the corpus luteum that stays until the placenta's big enough, and then from there, the placenta will be producing all of this progesterone oestrogen that helps with both the baby maintenance, the pregnancy, etc. We also see a rise, particularly towards the end of pregnancy of prolactin and that essentially is helping the body to get ready for milk production, milk letdown.

Once the baby is delivered, then, we've got our line of childbirth delivery, whatever you want to call it, we get a big, big, big drop in progesterone and oestrogen. oestrogen drops the quickest and drops back to its normal level the quickest and then progesterone comes down a bit more slowly. At the same time we see again more of a spike in prolactin because the body's gearing up for those it's nearly time to do some breastfeeding and oxytocin as well. And the role of oxytocin is multiple. There's 3 main things that it does. One is that it acts as kind of a bonding hormone, so it's known kind of, uh, in lay terms as a love hormone because it is that just whenever somebody sees their baby, hugs their baby, hugs someone they love, then you get a little spike in oxytocin, so it doesn't have to be to do with the baby. It also is really important for milk letdown and so it's something that helps muscles to contract and so it helps the muscles um in the breast ducts to contract to help milk letdown. So prolactin is important for production of milk, oxytocin is important for letdown of milk, OK?

Third reason is that it's a really important hormone in terms of contraction of the uterus, OK? And so when a baby is delivered, we've got essentially a big floppy. Bag, right? But then it's still got a placenta, OK? We want the placenta to nicely come away, but then the placental bed still has that same vasculature that was there providing the placenta with blood supply. OK? So it's really, really important in the pregnancy, but once the baby is delivered and the placenta is delivered, that's not important anymore and is a risk factor for bleeding postnatally, OK? And to stop that from bleeding, we need it. We need the uterus to contract. OK, and so oxytocin is, is essentially the main hormone that is involved with that and it allows the uterus to contract down thereby occluding the blood vessels that were supplying the placenta, OK? So things that help oxytocin are skin to skin straight after delivery and then breastfeeding as well because breastfeeding also increases the um spike in oxytocin and so all of those things are are are the physiology. Of the poor parent and we can use those as well when we're thinking about managing postpartum haemorrhage. So talking about uterine contraction, once the baby is full term on average, the fundus of the uterus will be pretty much up to the ziphy sternum, OK, so we're really, really high up the standard uterus.

The uterus of course is contracting during labour and so it's becoming smaller as the baby is coming through the birth canal, etc. OK? Because the baby can't just swim out itself unfortunately. Straight after delivery then we expect the uterus to contract down to the level of the umbilicus, OK? And so you might see when you're in labour ward, a midwife palpating the abdomen of somebody who's just had a baby and they're thinking, is the uterus well contracted? And we're feeling for the level of the fundus, so it should be down to about the level of the umbilicus and it can be raised if somebody's got like large fibroids or whatever and so knowing from our ultrasound. Scans, has somebody got fibroids can help us think, is this examination within normal limits? If somebody's got an 8 centimetre fibroid on the fundus of the uterus, you're going to be thinking, oh my goodness, the fundus is so high, it's not well contracted, but they're not bleeding, ah, but actually it might just be that there's a fibroid there and we're all fine. So you might see in the gly palpating the fundus

of the uterus. After that, the height, the fundal height decreases by centimeter-ish per day ish and. Then at about 6 weeks postnatally, we should see the uterus returning to approximately its pre-pregnancy size and so it'll enter the true pelvis, so the, the bony bowl of the pelvis, about 10 days, 2 weeks after delivery, but still be a little bit enlarged until about 6 weeks. OK? It's obviously undergoing a massive transformation that doesn't all just happen by muscle contraction, so we've essentially seen an increase in the amount of tissue that the uterus is. Made of during pregnancy and so as well as contraction of the muscle layer we see um a reduction in thickness of the muscle layer and that's through ischemia, autolysis um and through phagocytosis, so the uterus is kind of getting rid of all that extra tissue that it's made um to come back to normal size and then we said earlier didn't mean the decidua, so that's kind of transient layer of the endometrium is. Shed as lochia and lochia we kind of expect for 2 to 4 weeks probably I'd say 2 weeks is probably the most normal, but 4 weeks is acceptable postnatally and over that period of time we expect the amount of blood to reduce and we expect the loss to get lighter in colour, OK? So it might start off as a dark or fresh red and then it kind of goes pinkier and then creamier and then to normal discharge, OK?

If some. has abnormal lochia, then they might need to come in and be seen. So if they're passing large blood clots, if it's still heavy for a long period of time and then they need to be seen. OK? So routine postnatal care essentially can be by anyone in the hospital, so or anyone in the delivery setting. Most importantly, it's midwives, so if somebody obviously has has delivered in hospital or at home they most commonly have a midwife with them. Um, we are thinking about doing our checks, so we're checking the uterus, we're checking the bleeding, we're giving advice about what's normal, what's to be expected. Support with breastfeeding if they like to breastfeed. Um, and we, we do try to promote breastfeeding because it, it is best in terms of health for baby and it is recommended by the WHO that everybody breastfeeds. Um, and so in all NHS trusts, let me show. Have breastfeeding support workers and we do have some here and they're very useful because sometimes breastfeeding support increases the workload of midwives quite a lot because it can be quite time consuming so having specific experienced people in that area is really, really useful um and they can help support with like using breast pumps and that kind of

thing as well. Health visitors are a big support in the community and we'll go out and visit the patients as well. Sometimes community advice will do home visits or see them in clinic postnatally as well. And then we said about the GP. Checkup and the GP checkup ideally should be like a joint appointment. I don't know if you've seen any of them. Have you done GP placements at all? Yeah, so you might have seen a six week postnatal check and usually it's a kind of double length joint appointment, so we're checking on mom, we're checking on baby, OK? And, and again there's kind of a set of checks and if you are interested in those or interested in general practise, just look at the NICE guidance for 6 week checks and there's loads of stuff. So things that can go wrong. So we did talk about somebody wrote infection. It was an infection in a tiny writing, but we're thinking about infections and sepsis type infections. So infections that can become really severe and so we're we're, we screen for that during labour and then we do routine observations, particularly if anybody is higher risk and postnatally. Postpartum haemorrhage we mentioned a bit preeclampsia, aneclampsia. the big one that everybody missed, unfortunately. So remember that because it's really important. We're monitoring blood pressure. If somebody's had preeclampsia in pregnancy, they're not out of the woods immediately postnatally. Delivery of the baby is a really important treatment for preeclampsia, but we still need to make sure that we've got good blood pressure control because it can develop to eclampsia thrombosis. That's my one message, if you remember, we'll actually do one thing from today, um, uterine prolapse, don't worry about that, hopefully. Um, incontinence, postural puncture headache, if somebody's had an epidural or a spinal for, for pain relief during labour, um, or for a caesarean section, mastitis, breast abscess, and any mental health concerns, OK? So have you, have you done like your sim stuff? Do they do simulation still at what used to be Sand Fox House?