 First thing I like to do is I put the probe down, cutting the abdomen transversely, the mother's abdomen transversely. Then I angle the probe to the maternal right, and then I angle it to the maternal left. So you see how the screen is moving the wrong way, so I'm going to turn the probe around. Now I angle to the maternal right, and to the maternal left, and now I know I'm holding the probe correctly. Now I don't bother to look at this PF here or anything on the probe. I just want to see how the baby's lying. So now we know this is the mother's right, mother's left. Now we need to figure out fetal left and right. So first we need to find out the spine is down here. So if the spine is there, I look to see if the head is down here. So now we know the spine is here, and the head is towards me, and the feet are towards the back, the front of the room. So that means now I figured out that the baby's head is down here, this is maternal right, so this is going to be fetal left. Just by thinking how the baby is lying on the mother, that's the way I like to do it. So here's the spine post here, now we know that this is fetal left. Here's the stomach on the left, and the heart's on the left. Before I zoom in, you can see the left, the axis is normal. It's about 45 degrees, not left axis deviation, and not mesocardia. Naxidexacardia looks perfect, and the heart size qualitatively looks normal. But you could do quantitative measurements of the heart size and shape and function, which I'll talk about later this afternoon. But just grossly, it looks normal in terms of size and the axis, and we know that the stomach is on the left and the heart's on the left. And we can also see the desineurida to the left of the spine and the inferior vacana here, rightward and anterior. So that's visceral sinus, but visceral sinus goes along with atrial sinus. So that's visceral atrial sinus, solitis, or normal. Now we can zoom in and start to look at the heart. So what I'm going to do is talk about some of the techniques we talked about earlier. I'm going to narrow the sector so we don't waste all the resolution and narrow it. Now I'm going to zoom up, maybe, or the depth. Make sure that the focal zone is where we want it, not up here, not down there. That's just right. Now we can see it's not perfect because the placenta is here and we've got some appendage here, but that's where two hands helps. I have someone helping me so I can use two hands to push a little harder. I'm looking structure by structure. For instance, right now I'm seeing a very important structure we talked about, this lower part of the atrial septum. I'm showing that that's intact. Sometimes you do things as you get them, see the baby's moving, so it may not be as easy now to see that as it just was a second ago. So now I'm still using two hands. I'm finding a different place on the maternal abdomen, but if you look with your eye, you could see the lower part of the atrial septum. So I'm going to walk back. Sometimes I start here. See, this is the lower part of the atrial septum. Always important to see that relatively perpendicular. It's not as perpendicular as I like, but good enough. Now the baby is not so perpendicular. If you look carefully, you'll see it looks like it dropped out here because this is not a good angle to look at the inlet septum. Not a good angle. It looks like a big BSD, but that's artifactual right here. In this position, we might as well look at the mitral valve. I hold the probe and I want to look very carefully at the mitral valve. It looks like it's opening up well. And then I'll look at the tricuspid valve. So you can see the mitral tricuspid valve up here. And then, of course, you should put color on here because it's a good angle. So I'm optimizing the color. So you can see now that there's no tricuspid regurgitation. There's the inflow up here. And you can see there's no regurgitation during systolate. So the color, if I had increased the gain too much, it looks like this. If I lower the gain too much, then you don't see much. So you have to put just the right amount of gain. The right amount of gain at one point in the exam may differ the next minute. And the other aspect is the scale up here. This usually you like to be very high up so you don't get artifactual TR. If you lower it too much, then it's hard to interpret. So it's a combination of working with the color gain and the scale to make sure you have enough sensitivity but you're not bleeding into the septum. And now we're backing out a little bit. We looked at the mitral valve and tricuspid valve. What about a pulmonary vein? Let's say we want to look at the pulmonary vein and I'm going in terms of structures rather than views. Again, as I mentioned earlier, it's not a single four chamber view. This would be a four chamber view. But you want to, of course, put color on. So this is very important to look at the inlet septum. You can see that the inlet septum, there's no dropout. The mitral valve inserts up here. The tricuspid valve a little further towards the apex. But here we're relatively perpendicular. So here you can put on color to look for VSD. You put color on. If you lower the scale, it bleeds too much. So you have to do it just right. But not too low that you miss. Same thing for the gain. If you put the gain too high, it bleeds in. You have to be careful not to miss. And I'm going to talk about this later. The apex. Right now you can see the angle is not very good. I might be missing something at the apex. So I'm going back to two hands. You can see the lower part of the atrial septum. I hope everyone sees that. Now let's do a pulmonary vein. With the pulmonary vein you want to optimize the 2D picture first. And make it so that when you put color on, you know where you'll see it. Like here I know this should be a vein. It should be coming up and it should be. What color should it be? Should be red. Coming into left atrium. So now let's see if we can get that. So now we know it should be coming right at the probe. Red. There it is. So you could lower the scale a little bit. So that's a pulmonary vein coming in. Even if you do, I think one pulmonary vein is enough to rule out total anomalous pulmonary venous return. You could see the atrial septum within the left atrium. I mean the flap of the frame and within the left atrium right here. So now what about the atrial tracts? We haven't even looked at the atrial tracts, but we've looked at the four chamber view, the mitra check-up valves, the crux of the heart, the inlet septum, the muscular septum, the pulmonary vein, the flap of the frame and ovale, and we look for mitra and check-up valve regurgitation. And to look at the valves, you could see how they open. You could see how the mitra valve comes towards the, away from the septum and opens up here where the check-up valve comes straight towards the apex for the attachments on the septum. So now we want to start to look at the outflow tract. And I'm using two hands because I need to push a little bit. The baby's not the easiest. So now it's just gradually going from the inlet to the outlet. It's this baby's, I'm pushing a little hard. You could see the uric valve. Does everyone see that? So this is my favorite view, although it's tough to see, but here's the septum. And here's the ureta. And we're going to look at the uric valve opening and closing. See? Opens and close. Open. And it disappears. So see? And then it closes. It's tough because the baby's forcent is right here and there's no fluid right where I want it. So that's the uric valve. And see the ureta going all the way up. All the way up. And then the crossing. Here's the pulmonary valve and PA. So this is the sweep I was talking about earlier. We go watch the ureta go up, come down into the three vessel view, and then watch the PA come down and make the V. So the ureta going up and down. See how the V. So this is the one sweep that I think that is important to do from floor chamber, LVOT, RVOT, and then the V. You can see that the ureta comes down here to the left of the trachea. Ideally, we can also look saggily. So you just turn a little bit to get saggily imaging. There's the ureta carc. So here's the ureta with the head and neck vessels. And then if you go from fetal left, well, here's going from fetal left to right. So here's the short axis of ventricles, which is actually a nice place to color. But you can see I haven't optimized the image yet. So what do we want to do? We want to narrow this. So we're doing all these adjustments, which are key. And now I'm holding with two hands. The first arch is the ductile arch, which you really want to see trifricating. There's the ureta carc, and there's the trachea. And then as you go from the left, you go the ureta carc, ductile arch. So the ductile arch has the PA bifricates or trifricates RPA, LPA ductus. Let's see if we can make that nicer. So you could see the ductus right here, the ductus. So the order always should be ductus, LPA, RPA. Sometimes it's hard to open up all three like right now. This is the trifrication. PA goes to RPA, then LPA, then ductus. Do that. RPA and LPA, ductus, ureta carc, trachea. So this is going from the left to the right. Here's the left. We start off again with RPA, LPA, and then the ductus. And as we go towards the fetal right, then we get the ureta carc, and then we get the trachea. Here. So that's another way to show arch-sidedness. And you can put color on as well, but you can see, look for ductile constriction with the color. So I like, after I'm done zooming in, I like to go back to 30,000 feet just to look at everything again really quickly. You can see the ureta, stomach, IVC. You can see the heart, apex to left, 45 degrees. From above you can see the lower part of the atrial septum, the flap of the framen, the in-bed septum, the ureta valve, the pulmonary valve and how they cross. The pulmonary vein, again, you want to angle it, and then you can repeat it and see the pulmonary vein coming in here. Outflow, crossing, and you can turn sagittally. There's the trifrification, but you see the trifrification. I like sagittal imaging in addition to the transverse imaging. It just complements it. So the bottom line though is, even after you finish going in, I like to zoom back out, make sure that I haven't missed the cytus. I don't want to miss cytus and versus totalus. I want to make sure I have the cytus correct. I want to make sure all the ailments are there, and you can see the lower part of the atrial septum there. You can see the atrial septum, the ureta valve, pulmonary valve, the crossing. So this is a nice normal heart. But I've been using two hands almost the entire time to get these. If I didn't, then it would be much harder to get, particularly with an anterior placenta, and the baby hasn't been in the best position. I like sepia, but that's just my style. But this looks beautiful, and I think we showed that there's no VSD. We showed there's no significant valve or recurrence. Down here, I like, on the 3-velse of you, I usually lower the scale to make sure, I'm not saying an aberrant rights of clavian, which, as was mentioned, no, we need to go further. It would be coming just about here, heading towards the right, behind the trachea. So I always like to look that I'm not seeing that lowering the scale all the way down. Okay, I think we're good. Thank you. Thank you so much.