pain management during labor & second stage of labor

Pain management during labor
&
Second stage of labor

Objectives
At the end of this presentation student will be able
to :
Identify the etiology of pain during labor and birth
Identify types of labor support and advanced
nursing roles in normal labor and delivery care
Define Of Second Stage Of Labor.
Discuss The Mechanism Of Labor
Discuss Cultural and social aspects of labor and
delivery.
Analyze labor and delivery care in Jordan.

Etiology of pain during labor
Basic factors for pain in childbirth: physical and
emotional.
1. physical pain in labor is caused by:
 Muscle cramps/ uterine contraction.
 Stretching of cervix and perineum .
 Medical tests and procedures (pelvic exams,IVs, catheterization,
and so forth)
 Position of the baby and pressure of presenting part on tissue like
bladder,urethra,back,lower colon

Etiology of pain during labor
2. Emotional Factors
Many negative emotions can actually increase your perception of
pain:
 Fear of pain
 Fear of the unknown
 Anxiety
 Self-doubt
 Lack of education
 Exhaustion
 Dehydration
 Hunger

Non pharmacological strategies
Emotional support
Instructional/informational support
Advocacy support
Pharmacological strategies
Labor support

Endorphin
 Natural pain killer produced from pituitary gland released
during stressful events or in moment of grate pain it is
responsible for euphoric feelings known as “runner’s high” and
“adrenaline rush “ .
 It secretion triggered by consumption of certain food
“chochlate,chili peppers” also triggered by massage therapy or
acupuncture .

1. Nonpharmacologic strategies
1. Support from a Doula or coach
 Is a women who experienced in childbirth but without
professional credentials , who guides and assist women in labor .
 Having a doula can increase women self-esteem as well as
decrease rate of oxytocin augmentation ,epidural anesthesia and
cesarean birth .
 Doula can be women husband,mother,father..etc

2. Water therapy(hydrotherapy )
 Standing under warm shower or soaking in tube of warm water ,
the temperature of water used should be between 35-37c .
 Several study have investigated the risk of using hydrotherapy with
rupture membrane findings have shown no increase in
chorioamnionitis , post partum indometraitis,neonatal infection or
antibiotic use
( tournaire & theau-yonneau,2007,zwelling et al ,2006)
 No limit to the time women can stay in bath and often they are
encouraged to stay in it as long as desired

pain management during labor & second stage of labor

 In randomized controlled trial (RCT) to determine the efficacy of warm
showers on parturition pain and the birth experiences of women during the
ﬁrst stage of labor
 participants in the experimental group received warm shower bath
interventions full body or lower back shower, participants could spend 5
minute complete bath 15 minutes directing shower water toward any body
region that felt most comfortable. Facilities allowed participants to stand and
sit as desired. Water was constantly monitored and maintained at a
temperature of 37◦C. Participants in the control group received standard
care.
 women who participated in warm showers reported signiﬁcantly lower VAS
pain scores at 4-cm and 7-cm cervical dilations, and higher birth experiences
than the control group.
 warm showers are a cost-effective, convenient, easy to perform ,non-
pharmacological approach to pain reduction. This intervention helps women
in labor to participate fully in the birthing process, earn continuous caregiver
support, feel cared for and comforted, and have a more positive overall
experience.
(Lee, Liu, Lu, & Gau, 2013)

3. Transcutaneous electrical
nerve (TENS) stimulation
 Two paired of electrodes attached to
women back T10-L1 .
 Low- intensity electrical stimulation
is given continuously or applied by
women herself as a contraction
begin .
 Block afferent fibers and preventing
pain to travel from uterus to spinal
cord synapses , and facilitate release
of endorphin

 Can be effective as epidural
anesthesia
 Not available in our hospital.
 Carries no risk to the mother and
fetus
 Women can refuse to being “tied
down “ to equipment

4.Acupuncture
 Based on concept that illness result from an imbalance of
energy , to correct the imbalance needles are inserted into
the skin at specific body points , activation of these point lead
to release of endorphins .
 Helpful in first stage of labor

A randomized controlled trial was conducted with 607 healthy
women in labor at term who received acupuncture, TENS, or
traditional analgesics
To compare the effect of acupuncture with transcutaneous electric
nerve stimulation (TENS) and traditional analgesics for pain relief
and relaxation during delivery.
 Primary outcomes: were the need for pharmacological and
invasive methods, birth experience and satisfaction with delivery.
 Secondary outcomes : were duration of labor, use of
oxytocin, mode of delivery, postpartum hemorrhage, Apgar
score, and umbilical cord pH value.
(Borup, Wurlitzer, Hedegaard, Kesmodel, & Hvidman, 2009)

Result
 Use of pharmacological and invasive methods was significantly
lower in the acupuncture group (acupuncture vs traditional, p <
0.001; acupuncture vs TENS, p = 0.031).
 Acupuncture did not influence the duration of labor or the use of
oxytocin.
 Mean Apgar score at 5 minutes and umbilical cord pH value were
significantly higher among infants in the acupuncture group
compared with infants in the other groups.
CONCLUSIONS
Acupuncture reduced the need for pharmacological and invasive
methods during delivery. Acupuncture is a good supplement to
existing pain relief methods.
(Borup, Wurlitzer, Hedegaard, Kesmodel, & Hvidman, 2009)

5.Acupressure
Application of pressure or massage to heel of the hand
,fist or pads of the thumb and fingers

6. Therapeutic touch and massage
 Based on concept that body contains energy field when
increased lead to health and when decreased lead to illness
 touch and massage work to relive pain by increase level of
endorphins
 Effleurage is a form of therapeutic touch of gentle abdominal
massage

7.Application of Heat and Cold
Heat Application :
• Effective in relief back pain and raises the pain threshold.
• To increase blood flow and relieves muscle ischemia.
• increases relaxation
Cold application:
• Applied to the back, chest,
and face to increase comfort
• slowing transmission of pain.

9.Aromatherapy
 Their used based on the principle that the sense of smell
plays a significant role in over all health , when essential oil
inhaled it’s molecule transported via olfactory system to
the brain and the brain respond to particular aroma with
emotional responses , when applied externally they
absorbed to the skin and then carried throughout
circulation .
 The oils may be massaged into the skin, in a bath or inhaled
using a steam infusion or burner

A randomized controlled trial was conducted to determine
the effect of lavender
aromatherapy on pain intensity perception and
intrapartum outcome in primiparous women
 The aroma group received 0.1 ml
of lavender essential oil mixed with 1 ml of distilled water via
tissues attached to their gowns close to their nostrils.
Meanwhile, the control group received 2 ml of distilled
water in a similar way.
 Pain intensity perception was measured by Visual Analogue
Scale (VAS) before the intervention and at 30 and 60 minutes
afterwards
(Kaviani, Azima, Alavi, & Tabaei, 2014)

Result
The mean of pain intensity perception in the aroma group was
lower than that of the control group at 30 and 60 minutes after
the intervention (p←0.001).
Conclusion
This study revealed that aromatherapy decreased the labour pain,
but did not affect the duration of labour phases
Kaviani, Azima, Alavi, & Tabaei, 2014

9. Hypnosis
 Hypnosis is an altered state of conscious and awareness
 focus of attention to reduce awareness of the external
environment.
 For childbirth, hypnosis is often used to focus attention on
feelings of comfort or numbness as well as to enhance women's
feelings of relaxation and sense of safety.

10. Sterile water injections (SWI)
Sterile water injections (SWI) are an effective method for the relief
of back pain in labour. The procedure involves a small amount of
sterile water (0.1 ml to 0.2 ml) injected under the skin at four
locations on the lower back (sacrum).

 The injections cause a brief but intense stinging sensation, lasts
for about 30 seconds and then wears off completely.
 To distract from the stinging sensation the injections are done
during a contraction by two midwives.
 SWI provides effective pain relief for up to two hours.
http://www.matermothers.org.au/hospitals/mater-
mothers-private-brisbane/labour-and-
birth/switch/about-sterile-water-injections

Benefits of SWI
 often immediate effect
 no effect on mother’s state of consciousness
 no effect on baby
 does not limit mobility
 does not adversely affect labour progress
 is a simple procedure that can administered by midwife
 can be repeated as needed

case report
• The woman was given sterile water injections and required no
additional pain relief to cope with labor. The pain relief
effect, measured by the VAS, was very powerful and she
described her experience in highly positive terms.
• The method is a good alternative for women who do not want
pharmacological pain relief during childbirth
(Ma°rtensson,2010)
Evidence :Intradermal Water Block

The evidence
concluded that it was effective but it was based only on 4
studies they found suitable for analysis:
Ader et al compared sterile water to saline. Sterile water worked better
but there was no difference in the requirement for pethedin (Demerol)
Trolle et al compared sterile water to saline and found it twice as effective
(89% vs. 45%).
Martensson et al compared 0.1cc of intradermal water, 0.5 cc of
subcutaneous water, and 0.1 cc of subcutaneous saline. The two water
groups were equally effective and superior to the saline.
Labreque et al. compared sterile water injections to TENS and to standard
care (massage, etc.) Water worked better than the other two, but there
was no difference in epidural requests, and fewer women said they
would choose it again.

11.Biofeedback
 use thinking and mental process (focus)to control body
response, to change the response of the stress and pain
 Women who are interesting in using this method must attend
several sessions during pregnancy to condition themselves to
regulate their pain response
 If women response to pain during contraction with frowning
and breath holding her partner use verbal feedback to help her
to relax

12. Double Hip Squeeze
 The double hip squeeze changes the shape of the pelvis and
releases tension on the sacroiliac joints.
 Place hands on each side below iliac crest and over gluteal
muscle with fingers pointing toward midline.

12.Birthball

Definition:
The ability of subject participate and share in the laboring client’s
feelings (Sauls, 2004).
Emotional LSB assist to occupy the client’s mind with positive
thoughts and diminish or block feelings of fear, and anxiety
2. Emotional LSB

1. Nursing Presence
Nursing presence is defined as being with the client rather than
performing tasks on the client and as complete
physical, emotional, psychological, and spiritual engagement
between nurse and client.
Nursing presence includes:
high level of nursing skill.
being open
honest.
nonjudgmental with the client.
listening carefully to her needs and concerns.
2. Emotional LSB

2.partner care
Practice in Jordan
Companionship or social support during labour has been shown to be
one of the most beneficial practices in maternity care( Hodnett E,2007)
None of the public hospitals in Jordan allowed the presence of a birth
companion including the husband during labour and birth.
Evidence show that :
mothers who had received support during labour were significantly
less likely to have pharmacological pain relief.
and significantly more likely report a good birth experience
Shaban et al., 2011

Instruction and information on all aspects of labor and birth
provide clients with an opportunity to be a part of the decision-
making process, which fosters a positive birth experience.
Verbal communication must be culturally sensitive
3. Instructional/Informational LSB

Advocacy includes protecting the client, attending to needs,
and assisting in making choices related to health care; this
requires the establishment of a therapeutic relationship.
Being an advocate for the client, the nurse empowers the
client to give birth with dignity.
4. Advocacy LSB

1. Narcotic analgesic (opioid analgesic)
 Act by decrease sensation of pain .
 Used for their analgesic effect , all drugs in this category cause
CNS depression , respiratory depression .
Narcotic analgesic includes: pethidine (meperidin) , fentanyl
remifentanil, morphine, tramadol
pethedin is the most commonly used analgesic in labor
because it has additional sedative and antispasmodic actions
, these make it effective not only for reliving pain but also for
relaxing cervix and providing feeling of euphoria and well-being
Narcotic antagonist : naloxon (Narcan)
Pharmacological strategies

Advantages and disadvantages of narcotic (opioid )
administration
Advantages
an increased ability for a woman to cope with labor
The medications may be nurse-administered
It has no amnesic effect but create a felling of well-being or
euphoria
Disadvantages
Frequent occurrence of uncomfortable side effects, such as
nausea and vomiting, pruritus, drowsiness, and neonatal
depression
Pain is not eliminated completely
pharmacological strategies

Intrathecally (spinal) narcotic
Refer to injection into spinal cord
Opioid used alone:
 Ex: fentanyle 1.30-3hr with Multipara
 morphine 4-7 hr with Nullipara or women with history of long labor
Excellent pain relief for labor pain they take effect 15-30min and
last 4-7hr
Don’t cause maternal hypotension or affect VS
Women can fell contraction but no pain , her ability to bear down
during second stage of labor is preserved because the bushing
reflex is not lost and her motor power remain intact

2. Anesthesia
The use of medication to partially or totally block all sensation to
an area of the body
• Local anesthesia
 Reduce ability of local nerve fiber to conduct pain
 Used to numb the perineum just before birth to allow for
episiotomy and repair
• Regional anesthesia
injection of local anesthetic agent such as tetracaine or bupivacine
to block specific nerve pathways that supply a particular organ
or area of the body
spinal analgesia
 epidural analgesia
 combined spinal epidural
• General anesthesia
 Intra Venous Analgesia
 Inhalational Analgesia

1.Spinal (subarachnoid)anesthesia
local anesthetic agent such as (bupivacine or ropivacaine) injected
In subarachnoid space through 3dr ,4th or 5th lumber interspaces by
using lumber puncture technique .
Anesthesia mixed with CSF, used on elective and emergent CS birth
not suitable of vaginal birth because it useful for shorter and
simpler procedures.
Anesthesia normally raise to level of T10 , up to umbilicus and
including both legs.

Complication
hypotension from sympathetic blockage lead to impaired
placental perfusion and ineffective breathing pattern may
occur during spinal anesthesia
Turn the women to her left side
I.V fluid administration to increase blood volume
Vasopressin to increase BP
O2 may be used
Check V/S every 5-10min

Complication
spinal headache
Occur because continuous leakage of CSF from the needle insertion
site or by instillation of air into CSF , shift in pressure of CSF cause
strain in vertebral meanings.
Incidence reduced by using of :
 small-gauge needle
 Increase fluid intake to replace spinal fluid

If headache occurred :
 Ask women to lie flat
 Administer analgesic
 Blood patch technique : withdraw 10ml of venous blood and
then immediately injected into the epidural space over spinal
injection site , injected blood clot and seals of any further
leakage of CSF .

2.Epidural anesthesia
 Anesthetic agent placed inside
epidural space at :
L4-5
L3-4
L2-3
 Block not only nerve roots in
the space but also sympathetic
nerve fibers that travel with
them

Patient control epidural analgesia
The newest method is the using PCA that will be programmed specially for the
patient by anesthesiologist indwelling catheter and programmed pump that
allow women to control the dose of analgesic , this method provide optimal
analgesia with higher maternal satisfaction and enhance sense of control during
labor. (saito et al,2005)

IT is more difficult to insert epidural catheter when the women is
obese , morbidly obese patients are more likely to have failed
epidural placement and accidental Dural puncture.
(valleyo,2007)

Advantages of Epidural anesthesia
Women remain alert and more comfortable
Able to participate and achieve good relaxation
Airway reflex remain intact
Gastric empty not delay
Blood loss not excessive
The most effective pain relief.
Fetal complication are rare but may occur

Disadvantages of Epidural anesthesia
• Hypotension
• Urinary retention
• Backache
• soreness where the needle is inserted
• nausea and vomiting
• epidural may prolong second stage of labor ,pushing more difficult and
additional interventions such as Pitocin, forceps, vacuum extraction or
cesarean might become necessary
• baby might experience respiratory depression, fetal malpositioning, and an
increase in fetal heart rate variability

epidural analgesia appears to be effective in reducing pain during
labour.
women who use this form of pain relief are at increased risk of
having an instrumental delivery
having an epidural was also associated with a longer second stage
of labour, more use of augmentation of labour, more frequent very
low blood pressure readings, problems passing urine, fever, and
being unable to move for a period of time after the birth
What evidence say about epidural analgesia
Cochrane Database of Systematic Reviews

 The use of epidural anesthesia is associated with a significant
increase in maternal temperature and in the incidence of
intrapartum maternal fever.
(Passini, Amorim, Almeida, & Barros, 2011)
 Sever hypotension (systolic BP 100mmHg or less or more than
20% decrease from base line blood pressure ) as a result of
sympathetic block can be an outcome of epidural block .
(anim-somuah,smyth,&howell,2008)
What evidence say about epidural analgesia
Cochrane Database of Systematic Reviews

 delay the administration of epidural analgesia in nulliparous
women until cervical dilatation reaches 4 cm to 5 cm and that
other forms of analgesia be used until that time to avoid
suppressing the progress of labor
2002, the American College of Obstetricians and Gynecologists
 It is recommended that the administration of systematic opioid
analgesia be delayed until labor is well established.
(creehan,2008)
 Women in labor most no longer reach a certain level of cervical
dilatation or fetal station before receiving epidural analgesia.
(aab&acog,2007,cunningham et al ,2010)
Time of adminestration of epidural analgesia

3. Combined spinal-epidural analgesia CSE
• Combination of opioid and local anesthesia injected inside spinal cord and in
subarachnoid space , used to block pain transmission without compromising
motor ability
• It is associated with greater incident with FHR abnormalities than epidural
analgesia alone

Inhalational analgesia
during labour involves the self-administered inhalation of
sub-anaesthetic concentrations of agents while the
mother remains awake and her protective laryngeal
reflexes remain intact

inhalational analgesia
• N2O does not interfere with
uterine contractions.
• No effect on fetus too.
• Premixed nitrous oxide
&oxygen.
• N2O 50% and O2 50%
• ENTONOX-cylinders with a
capacity of 500 L are available.
• Inhalation should begin 45
seconds before the onset of
pain.

inhaled analgesia appears to be effective in reducing pain
intensity and in giving pain relief in labour
nitrous oxide appears to result in more side effects compared
with flurane derivatives.
Flurane derivatives result in more drowsiness when
compared with nitrous oxide.
nitrous oxide appears to result in even more side effects such
as nausea, vomiting, dizziness and drowsiness
(Trudy Klomp, Leanne Jones, Di Nisio.2012)
Cochrane Database
What evidence say about inhaled anelgesia

Begins with fully cervical dilation (10 cm) and complete effacement
(100%) and ends with the baby’s birth.
Duration of second stage
Multiparous women 1-2hr
Nulliparous women 2-3hr

Second stage consist of 2phases:
1. latent phase: baby begins its journey through the birth canal, or
vagina, to the outside.
The power for this movement is provided by the contracting
uterus, the diaphragm, and the abdominal and respiratory muscles
of the mother.
With each contraction the baby's head moves down until part of
the baby's head is visible at the entrance of the birth canal .

2. Active phase(delivary
 mother's pushing produces crowning , fetal station +1
 The mother continues to push until the entire head is delivered
 The shoulders emerge next, first one and then the other
 Finally, the medical attendant slowly eases the rest of the body out
of the birth canal and the baby is born.

The mechanisms of labor, also known as the cardinal movements
refer to the changes in position of fetal head during its passage
through the birth canal.
Engagement
Descent
Flexion
Internal Rotation
Extension
External Rotation
Expulsion
Cardinal Movements in Labor

Nursing care during second stage
Sign that suggest onset of second stage
• 1. felling of urge to bush or need for bowel
movement
• 2. sudden appearance of sweat on upper lip
• Episodes of vomiting
• Increase bloody show
• Checking of extremities
• Increase restlessness
• Involuntary bearing down

Perform every 5-30 min v/s
Assess every 5-15min FHR
Assess every 10-15min vaginal show and signs of
fetal descent and maternal appearance
Assess every contraction and bearing down effort

Fundal pressure
Use of fundal pressure is not advised because there is no standard
techniques available for this maneuver also no current legal or
regulatory standard exist for it’s use and no evidence related to it
effectives in facilitating a safe vaginal birth is
available.(simbson,2008)

When the fetal head reaches the pelvic floor most women
experience the urge to bear down or push.
Monitor women’s breathing.
Should not hold breath more than 5 to 7 sec.
Remained her to take deep breathing
Bearing Down (pushing)

THE “OLD WAY”
pushing immediately at 10 cm regardless of whether the
woman has an urge to push.
closed-glottis pushing (Valsalva's Maneuver).
woman lies in the supine Lithotomy position.
These techniques have the potential to cause harm to the
mother and baby.
(AWHONN,2010)
When and how to push

This is when a woman, who in the second stage of labor or the
"pushing stage" has coached to push.
Instructs woman to hold her breath and push for 10
counts/seconds.
But
holding breath for 10 seconds not good during pushing.
Because of:
increase intrathoracic and cardiovascular pressure.
reducing cardiac output.
inhibiting perfusion of the uterus and the placenta.
resulting in fetal hypoxia.
Closed Glottis pushing/Valsalva's
Maneuver

The Best Way
A better approach based on current evidence is to delay pushing
until the woman feels the urge to push.
The latent phase is an ideal time to allow the woman to rest in
preparation for pushing efforts at the appropriate time.
When the time is right for pushing?
the best approach based on current evidence is to encourage the
woman to do whatever comes naturally.
(AWHONN,2010)
When and how to push

• The benefits of delayed pushing include less fetal
heart deceleration , fewer forceps and vacuum
assisted birth , less perenial damage
• The longer length of second stage doesn’t associated
with poor neonatal outcomes , as long as fetal status
during this time is normal.
(berghella et al ,2008 ,brancato,church,&ston,2008)
Reaserch evidence

Reaserch evidence
• More effective bearing down effort conserve maternal energy
and reduce the risk of operational vaginal birth.
(robert,2002,simbson&james,2005)
Based on this evidence it is essential that prenatal nurse
advocate for the practice of delayed and spontaneous
bearing down effort.

Positioning is an important component of safe and effective pushing.
upright position or lateral position works better than supine
positioning.
Forcing women's legs back against their abdomen during pushing
should be avoided because this results in stretching the perineum
and increases the risk of perineal lacerations.
International Journal of Gynecology and Obstetrics (2012)
Position & Pushing

small cut in the vaginal opening to prevent tearing
during delivery.
This is often a routine procedure in primigravidas.
episiotomy is a painless procedure done just before the
baby's head is born.
Episiotomy

Episiotomy is routinely practiced in 67% of the
hospitals in Jordan .
Sweidan et al., (2008)
Perineal (episiotomy) Classified as one of the practices that is
frequently used and should be avoided as a routine.
Khresheh et al., (2009)
Practice in Jordan for Episiotomy

There should be a policy of restricted episiotomy (episiotomy only
when necessary).
There is no evidence that a policy of routine
episiotomy resulted in significant:
Reductions in laceration severity.
pain.
pelvic organ prolapse.
better maternal outcomes.
Episiotomy

Episiotomy at first vaginal delivery significantly and independently
increased the risk of repeated episiotomy and spontaneous
perennial tears in subsequent delivery. (Lurie,2012)
Avoiding routine episiotomy in unnecessary condition would
increase the rate of intact perineal and minor perineal trauma and
reduce postpartum delivery pain with no adverse affect nether on
maternal nor neonatal morbidities .(shahraki,2011)
Evidence show that

Episiotomy and laceration repair should always be
performed under adequate perineal anesthesia.
such as:
epidural.
local infiltration.
Episiotomy

A comparison of labor and birth outcomes in Jordan
with WHO guidelines
Pain relief (pethedin) 44% one of the practices that is
frequently used inappropriately.
 Low Apgar Score
 Admission to NICU
 Interrupts mother–baby bonding and disrupts breast
feeding initiation.
 Respiratory depression for both mother and infant.
Perineal (episiotomy) 53% Classified as one of the practices
that is frequently used and should be avoided as a routine.
Khresheh et al., (2009)

Cultural Differences Among Birthing
Women
The Russian Culture
 Russian women prefer to be alone during labor and
birth.
 They view labor and birth as a private experience.
 They prefer not to have their partners present because
they were afraid for their husbands!

Women

Women
The Russian Culture
 Using female relatives at the birth instead of the
husband is a common practice.
 This is popular among many women in Arabic cultures
as well as traditions of Pacific
Islanders, Cambodians, Chinese, Filipinos, Indonesians,
and Koreans

Women
The Chinese culture
 Chinese women are encouraged to avoid heavy manual
,encourage rest.
 Infant boys are considered more valuable than infant girls.
 The Chinese avoid “cold” foods such as bean sprouts and
bananas because they believe it increases the risk of
miscarriage.

Women
 In the Chinese culture, eating during labor is the norm.
 When asking for water, they prefer warm water. If given ice chips
they are not eaten for fear of upsetting the hot-cold balance.
 They may not choose to use ice on episiotomies for this reason
 Upsetting the hot-cold balance is thought to cause arthritis in old
age. The “Sitting Month” is the month after delivery where
women are encouraged to rest and recover.

Cultural Differences Among Birthing Women
African Culture
 It is typical for the woman to deliver while squatting on the
ground surrounded by female relatives. Squatting is
representative of the mother’s connection with the earth.
 Midwives only get paid if delivery is successful. Some relatives
act as midwives.
 In the Yoruba tribe, in Nigeria, the name given to the child must
reflect circumstances around the birth.

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