normal spontaneous delivery procedure

Most women with a low transverse uterine incision are candidates for a trial of labor after cesarean delivery and should be counseled accordingly. Childbirth classes: Get ready for labor and delivery. N Engl J Med 341 (23):17091714, 1999. doi: 10.1056/NEJM199912023412301, 4. A. Use OR to account for alternate terms Mayo Clinic Staff. In the delivery room, the perineum is washed and draped, and the neonate is delivered. When epidural analgesia is used, drugs can be titrated as needed during the course of labor. Uterotonic drugs help the uterus contract firmly and decrease bleeding due to uterine atony, the most common cause of postpartum hemorrhage. This pregnancy-friendly spin on traditional chili is packed with the nutrients your body needs when you're expecting. The Global ALSO manual (https://www.aafp.org/globalalso) provides additional training for normal delivery in low-resource settings. Complications of pudendal block include intravascular injection of anesthetics, hematoma, and infection. Explain the procedure and seek consent according to the . A tight nuchal cord can be clamped twice and cut before delivery of the shoulders, although this may be associated with increased neonatal complications, including hypovolemia, anemia, shock, hypoxic-ischemic encephalopathy, cerebral palsy, and death according to case reports. The 2023 edition of ICD-10-CM Z37.0 became effective on October 1, 2022. Oxytocin can be given as 10 units IM or as an infusion of 20 units/1000 mL saline at 125 mL/hour. In these classes, you can ask questions about the labor and delivery process. In the first stage of labor, normal birth outcomes can be improved by encouraging the patient to walk and stay in upright positions, waiting until at least 6 cm dilation to diagnose active stage arrest, providing continuous labor support, using intermittent auscultation in low-risk deliveries, and following the Centers for Disease Control and Prevention guidelines for group B streptococcus prophylaxis. A local anesthetic can be infiltrated if epidural analgesia is inadequate. Mother, infant, and father or partner should remain together in a warm, private area for an hour or more to enhance parent-infant bonding. Labor opens, or dilates, her cervix to at least 10 centimeters. Fetal risks with vacuum extraction include scalp laceration, cephalohematoma formation, and subgaleal or intracranial hemorrhage; retinal hemorrhages and increased rates of hyperbilirubinemia have been reported. What are the documentation requirements for vaginal deliveries? Emergency medical technicians, medical students, and others with limited maternity care experience may benefit from the AAFP Basic Life Support in Obstetrics course (https://www.aafp.org/blso), which offers a module on normal labor and delivery. Obstet Gynecol 75 (5):765770, 1990. Physicians must also ensure that CPT code description elements for the code (s) reported are documented as applicable. Remove loose objects (e.g. Stretch marks are easier to prevent than erase. Because of the perceived health, economic, and societal benefits derived from vaginal deliveries . However, exploration is uncomfortable and is not routinely recommended. The 2023 edition of ICD-10-CM O80 became effective on October 1, 2022. 1. Healthline Media does not provide medical advice, diagnosis, or treatment. (2014). The link you have selected will take you to a third-party website. Spinal injection (into the paraspinal subarachnoid space) may be used for cesarean delivery, but it is used less often for vaginal deliveries because it is short-lasting (preventing its use during labor) and has a small risk of spinal headache afterward. A. Indications for forceps delivery read more is often used for vaginal delivery when. However, traditional associative theories cannot comprehensively explain many findings. Complications of pudendal block include intravascular injection of anesthetics, hematoma, and infection. Most of the nearly 4 million births in the United States annually are normal spontaneous vaginal deliveries. An episiotomy is not routinely done for most normal deliveries; it is done only if the perineum does not stretch adequately and is obstructing delivery. Walsh CA, Robson M, McAuliffe FM: Mode of delivery at term and adverse neonatal outcomes. Spinal injection (into the paraspinal subarachnoid space) may be used for cesarean delivery, but it is used less often for vaginal deliveries because it is short-lasting (preventing its use during labor) and has a small risk of spinal headache afterward. The average length of the third stage of labor is eight to nine minutes.38, The greatest risk in the third stage is postpartum hemorrhage, which was recently redefined as 1,000 mL or more of blood loss or signs and symptoms of hypovolemia.39 The median blood loss with vaginal delivery is 574 mL.40 Blood loss is often underestimated by as much as 30%, and underestimation increases with increasing blood loss.41 The risk of hemorrhage increases after 18 minutes and is six times greater after 30 minutes.38 Postpartum hemorrhage is most commonly caused by atony (70% of cases).42 Other causes include vaginal or cervical lacerations, uterine inversion, retained products of conception, and coagulopathy.42 Table 5 lists risk factors for postpartum hemorrhage.42, Active management of the third stage of labor (AMTSL), which is recommended by the World Health Organization,43 is associated with a reduction in the risk of hemorrhage, both greater than 500 mL and greater than 1,000 mL, maternal hemoglobin level of less than 9 g per dL (90 g per L) after delivery, need for maternal blood transfusion, and need for more uterotonics in labor or in the first 24 hours after delivery.44 However, AMTSL is also associated with an increase in postpartum maternal diastolic blood pressure, emesis, and use of analgesia and a decrease in neonatal birth weight.44 Although AMTSL has traditionally consisted of oxytocin (10 IU intramuscularly or 20 IU per L intravenously at 250 mL per hour) and early cord clamping, the most important component now appears to be the administration of oxytocin.43,44 Early cord clamping is no longer a component because it does not decrease postpartum hemorrhage and may be associated with neonatal harm.35,44 Delayed cord clamping may avoid interfering with early transplacental transfusion and avoid the increase in maternal blood pressure and decrease in fetal weight associated with traditional AMTSL.44 More research is needed regarding the effects of individual components of AMTSL.44, Cervical, vaginal, and perineal lacerations should be repaired if there is bleeding. If anesthesia is local (pudendal block or infiltration of the perineum), forceps or a vacuum extractor is usually not needed unless complications develop; local anesthesia may not interfere with bearing down. Normal Spontaneous Vaginal Delivery; Vacuum Assisted Delivery; Forceps Assisted Delivery; Repeat History Line above noting. Cord clamping, cutting, and cord drainage o Clamp cord 1 inch above umbilicus and 2nd clamp placed above Cord is cut in between 2 clamps o Collect umbilical blood if needed for pH, Rh typing, or mother-baby studies Physicians must follow facility documentation guidelines, if any, when documenting delivery notes for vaginal deliveries. The following types of vaginal delivery have been noted; (a) Spontaneous vaginal delivery (SVD) (b) Assisted vaginal delivery (AVD), also called instrumental vaginal delivery (c) Induced vaginal delivery and (d) Normal vaginal delivery (NVD), usually . Third- and 4th-degree perineal tears (1 Delivery of the fetus references Many obstetric units now use a combined labor, delivery, recovery, and postpartum (LDRP) room, so that the woman, support person, and neonate remain in the same room throughout their stay. Learn more about the Merck Manuals and our commitment to Global Medical Knowledge. For manual removal, the clinician inserts an entire hand into the uterine cavity, separating the placenta from its attachment, then extracts the placenta. 7. Diagnosis is by examination, ultrasonography, or response to augmentation of labor. LEE T. DRESANG, MD, AND NICOLE YONKE, MD, MPH. The length of the labor process varies from woman to woman. The normal spontaneous vaginal delivery is a fundamental skill in the intrapartum care of women. This frittata is high in protein and rich in essential nutrients your body needs to support a growing baby. Don't automatically initiate continuous electronic fetal heart rate monitoring during labor for women without risk factors; consider intermittent auscultation first. With thiopental, induction is rapid and recovery is prompt. Shiono P, Klebanoff MA, Carey JC: Midline episiotomies: More harm than good? There's conflicting information out there so we look, Healthline has strict sourcing guidelines and relies on peer-reviewed studies, academic research institutions, and medical associations. It is also known as a vaginal birth. There are two main types of delivery: vaginal and cesarean section (C-section). About 35% of women have dyspareunia after episiotomy (7 Delivery of the fetus references Many obstetric units now use a combined labor, delivery, recovery, and postpartum (LDRP) room, so that the woman, support person, and neonate remain in the same room throughout their stay. Opioids used alone do not provide adequate analgesia and so are most often used with anesthetics. Delaying clamping of the umbilical cord for 30 to 60 seconds is recommended to increase iron stores, which provides the following: For all infants: Possible developmental benefits, For premature infants: Improved transitional circulation and decreased risk of necrotizing enterocolitis Necrotizing Enterocolitis Necrotizing enterocolitis is an acquired disease, primarily of preterm or sick neonates, characterized by mucosal or even deeper intestinal necrosis. Tears or extensions into the rectum can usually be prevented by keeping the infants head well flexed until the occipital prominence passes under the symphysis pubis. Pushing can begin once the cervix is fully dilated. Bedside ultrasonography is helpful when position is unclear by examination findings. A local anesthetic can be infiltrated if epidural analgesia is inadequate. As labor progresses, strong contractions help push the baby into the birth canal. Tears or extensions into the rectum can usually be prevented by keeping the infants head well flexed until the occipital prominence passes under the symphysis pubis. After delivery of the infant and administration of oxytocin, the clinician gently pulls on the cord and places a hand gently on the abdomen over the uterine fundus to detect contractions; placental separation usually occurs during the 1st or 2nd contraction, often with a gush of blood from behind the separating placenta. Complications of pudendal block include intravascular injection of anesthetics, hematoma, and infection. Some read more ). This content is owned by the AAFP. Women without an epidural who deliver in upright positions have a significantly reduced risk of assisted vaginal delivery and abnormal fetal heart rate pattern, but an increased risk of second-degree perineal laceration and an estimated blood loss of more than 500 mL. The time from delivery of the placenta to 4 hours postpartum has been called the 4th stage of labor; most complications, especially hemorrhage Postpartum Hemorrhage Postpartum hemorrhage is blood loss of > 1000 mL or blood loss accompanied by symptoms or signs of hypovolemia within 24 hours of birth. 1. version of breech presentation successfully converted to cephalic presentation, with normal spontaneous delivery. Maternal age with Gravida and Parity; Gestational age, weight, and Sex; Fetal Vertex Position; APGAR Score; Time and date of delivery; Episiotomy or Perineal Laceration. prostate. Episiotomy, An episiotomy is a surgical cut made in the perineum during childbirth. These problems usually improve within weeks but might persist long term. Use to remove results with certain terms 59320. what is the one procedure code located in the Reproductive system procedures subsection. Learn more about the MSD Manuals and our commitment to Global Medical Knowledge. Extension into the rectal sphincter or rectum is a risk with midline episiotomy, but if recognized promptly, the extension can be repaired successfully and heals well. However, evidence for or against umbilical cord milking is inadequate. A C-section is a surgical procedure where your provider makes an incision (cut) in your abdomen and delivers the baby in an operating room. Copyright 2023 American Academy of Family Physicians. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Sequence of events in delivery for vertex presentations, Brought to you by Merck & Co, Inc., Rahway, NJ, USA (known as MSD outside the US and Canada) dedicated to using leading-edge science to save and improve lives around the world. Episiotomy is associated with more severe perineal trauma, increased need for suturing, and more healing complications.31. This is a clot of mucous that protects the uterus from bacteria during pregnancy. False A Which procedure is coded to the Medical and Surgical section? Treatment depends on etiology read more , occur at this time, and frequent observation is mandatory. Some read more ), but it causes greater postoperative pain, is more difficult to repair, has increased blood loss, and takes longer to heal than midline episiotomy (6 Delivery of the fetus references Many obstetric units now use a combined labor, delivery, recovery, and postpartum (LDRP) room, so that the woman, support person, and neonate remain in the same room throughout their stay. This teaching approach may lead to poor or incomplete skill . The tight nuchal cord itself may contribute to some of these outcomes, however.32 Another option for a tight nuchal cord is the somersault maneuver (carefully delivering the anterior and posterior shoulder, and then delivering the body by somersault while the head is kept next to the maternal thigh). The uterus is most commonly inverted when too much traction read more . Pudendal block is a safe, simple method for uncomplicated spontaneous vaginal deliveries if women wish to bear down and push or if labor is advanced and there is no time for epidural injection. Compared with interrupted sutures, continuous repair of second-degree perineal lacerations is associated with less analgesia use, less short-term pain, and less need for suture removal.45 Compared with catgut (chromic) sutures, synthetic sutures (polyglactin 910 [Vicryl], polyglycolic acid [Dexon]) are associated with less pain, less analgesia use, and less need for resuturing. With thiopental, induction is rapid and recovery is prompt. Some read more ) and anal sphincter injuries (2 Delivery of the fetus references Many obstetric units now use a combined labor, delivery, recovery, and postpartum (LDRP) room, so that the woman, support person, and neonate remain in the same room throughout their stay. Use to remove results with certain terms Thus, the clinician controls the progress of the head to effect a slow, safe delivery. Outcomes in the second stage of labor can be improved by using warm perineal compresses, allowing women more time to push before intervening, and offering labor support. However, exploration is uncomfortable and is not routinely recommended. Please confirm that you are a health care professional. An episiotomy incision that extends only through skin and perineal body without disruption of the anal sphincter muscles (2nd-degree episiotomy) is usually easier to repair than a perineal tear. Brought to you by Merck & Co, Inc., Rahway, NJ, USA (known as MSD outside the US and Canada) dedicated to using leading-edge science to save and improve lives around the world. Episiotomy prevents excessive stretching and possible irregular tearing of the perineal tissues, including anterior tears. The diagonal conjugate refers to the distance from the inferior border of the pubic symphysis to the sacral promontory (Figure 162-1A).The normal diagonal conjugate measures approximately 12.5 cm, with the critical distance being 10 cm. Eye antimicrobial (1% silver nitrate or 2.5% povidone iodine) . This 5-minute video demonstrates a normal, spontaneous vaginal delivery. When effacement is complete and the cervix is fully dilated, the woman is told to bear down and strain with each contraction to move the head through the pelvis and progressively dilate the vaginal introitus so that more and more of the head appears. So easy and delicious. The cord should be double-clamped and cut between the clamps, and a plastic cord clip should be applied about 2 to 3 cm distal from the cord insertion on the infant. Spontaneous vaginal delivery: A vaginal delivery that happens on its own and without labor-inducing drugs. Many obstetric units now use a combined labor, delivery, recovery, and postpartum (LDRP) room, so that the woman, support person, and neonate remain in the same room throughout their stay. If the nuchal cord is loose, it can be gently pulled over the head if possible or left in place if it does not interfere with delivery. Wait 1-3 minutes after delivery to clamp cord or until cord stops pulsating. Should you have a spontaneous vaginal delivery? In particular, it is difficult to explain the . Placental function is normal, but trophoblastic invasion extends beyond the normal boundary read more ) should be suspected. Ask the mother to change position (to lie on her side), and check the baby's heartbeat again. In the later, this assistance can vary from use of medicines to emergency delivery procedures. Feelings of fear, nervousness, and tension can cause the release of adrenaline and slow the labor process. The mechanism of this intervention has been the extinction procedure in Pavlovian conditioning, and this application has provided many successful instances for the prevention of relapse. Exposure therapy is an effective intervention for anxiety-related problems. If it is, the clinician should try to unwrap the cord; if the cord cannot be rapidly removed this way, the cord may be clamped and cut. To advance the head, the clinician can wrap a hand in a towel and, with curved fingers, apply pressure against the underside of the brow or chin (modified Ritgen maneuver). LeFevre ML: Fetal heart rate pattern and postparacervical fetal bradycardia. Second stage warm perineal compresses have been associated with a reduction in third- and fourth-degree perineal lacerations.28 Studies have not shown benefit to keeping hands on vs. hands off the fetal head and maternal perineum during delivery.29 Although not well studied, shorter pushes as the head is crowning are encouraged by many clinicians in an attempt to decrease perineal lacerations. 00 Comments Please sign inor registerto post comments. A vaginal examination is done to determine position and station of the fetal head; the head is usually the presenting part (see figure Sequence of events in delivery for vertex presentations Sequence of events in delivery for vertex presentations ). https://www.youtube.com/watch?v=WaJ6sZ4nfnQ. Pudendal block, rarely used because epidural injections are typically used instead, involves injecting a local anesthetic through the vaginal wall so that the anesthetic bathes the pudendal nerve as it crosses the ischial spine. o [ abdominal pain pediatric ] o [teenager OR adolescent ], , MD, Saint Louis University School of Medicine. Latent labor lasting many hours is normal and is not an indication for cesarean delivery.68 Active labor with more rapid dilation may not occur until 6 cm is achieved. more than one or two previous cesarean deliveries or uterine surgeries, your options for pain management (from relaxation and visualization methods to medications like epidural blocks), about possible complications that can happen during labor and delivery, how to work with your partner or labor coach. Childbirth classes can give you more confidence before it comes time to go into labor and deliver your baby. Provide continuous support during labor and delivery. If it is, the clinician should try to unwrap the cord; if the cord cannot be rapidly removed this way, the cord may be clamped and cut. Between 120 and 160 beats per minute. You can learn more about how we ensure our content is accurate and current by reading our. Some read more ). Pudendal block, rarely used because epidural injections are typically used instead, involves injecting a local anesthetic through the vaginal wall so that the anesthetic bathes the pudendal nerve as it crosses the ischial spine. Women without epidurals who deliver in upright positions (kneeling, squatting, or standing) have a significantly reduced risk of assisted vaginal delivery and abnormal fetal heart rate pattern, but an increased risk of second-degree perineal laceration and an estimated blood loss of more than 500 mL.27 Flexing the hips and legs increases the pelvic inlet diameter, allowing more room for delivery. Use for phrases If fetal or neonatal compromise is suspected, a segment of umbilical cord is doubly clamped so that arterial blood gas analysis can be done. Call your birth center, hospital, or midwife if you have questions while you are in labor. Professional Training. and change to operation attire 3. Offer warm perineal compresses during labor. Some obstetricians routinely explore the uterus after each delivery. Use OR to account for alternate terms Search dates: September 4, 2014, and April 23, 2015. We do not control or have responsibility for the content of any third-party site. Allow women to deliver in the position they prefer. Obstet Gynecol 64 (3):3436, 1984. Rarely, nitrous oxide 40% with oxygen may be used for analgesia during vaginal delivery as long as verbal contact with the woman is maintained. Simultaneously, the clinician places the curved fingers of the right hand against the dilating perineum, through which the infants brow or chin is felt. Compared to other methods of childbirth, such as a cesarean delivery and induced labor, its the simplest kind of delivery process. Mother, infant, and father or partner should remain together in a warm, private area for an hour or more to enhance parent-infant bonding. Second-degree laceration repairs are best performed in a continuous manner with absorbable synthetic suture. Youll learn: When labor begins you should try to rest, stay hydrated, eat lightly, and start to gather friends and family members to help you with the birth process. Learn about the types of episiotomy and what to expect during and after the. Identical twins are the same in so many ways, but does that include having the same fingerprints? This occurs after a pregnant woman goes through. After delivery of the infant and administration of oxytocin, the clinician gently pulls on the cord and places a hand gently on the abdomen over the uterine fundus to detect contractions; placental separation usually occurs during the 1st or 2nd contraction, often with a gush of blood from behind the separating placenta. Diagnosis is clinical. See permissionsforcopyrightquestions and/or permission requests. The 2nd stage of labor is likely to be prolonged (eg, because the mother is too exhausted to bear down adequately or because regional epidural anesthesia inhibits vigorous bearing down). An arterial pH > 7.15 to 7.20 is considered normal. Allow the client to assume a birthing position of her choice as long as it is not contraindicated. Management of spontaneous vaginal delivery. Fetal risks with vacuum extraction include scalp laceration, cephalohematoma formation, and subgaleal or intracranial hemorrhage; retinal hemorrhages and increased rates of hyperbilirubinemia have been reported. Soon after, a womans water may break. Its important to stay calm, relaxed, and positive. This is the American ICD-10-CM version of Z37.0 - other international versions of ICD-10 Z37.0 may differ. (2014). Because of possible health risks for the mother, child, or both, experts recommend that women with the following conditions avoid spontaneous vaginal deliveries: Cesarean delivery is the desired alternative for women who have these conditions. Then if the mother and infant are recovering normally, they can begin bonding. In the 2nd stage, women should be attended constantly, and fetal heart sounds should be checked continuously or after every contraction. Author disclosure: No relevant financial affiliations. Consider delayed cord clamping in all deliveries not requiring emergent Resuscitation. In such cases, an abnormally adherent placenta (placenta accreta Placenta Accreta Placenta accreta is an abnormally adherent placenta, resulting in delayed delivery of the placenta. 7. Treatment depends on etiology read more , occur at this time, and frequent observation is mandatory. Obstet Gynecol 121(1):122128, 2013. doi: 10.1097/AOG.0b013e3182749ac9. Z37.0 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. Then if the mother and infant are recovering normally, they can begin bonding. Indications for forceps and vacuum extractor are essentially the same. (See also Postpartum Care and Associated Disorders Postpartum Care Clinical manifestations during the puerperium (6-week period after delivery) generally reflect reversal of the physiologic changes that occurred during pregnancy (see table Normal Postpartum read more .). Once the infant's head is delivered, the clinician can check for a nuchal cord. The 2nd stage of labor is likely to be prolonged (eg, because the mother is too exhausted to bear down adequately or because regional epidural anesthesia inhibits vigorous bearing down). This can occur a few weeks to a few hours from the onset of labor. Opioids used alone do not provide adequate analgesia and so are most often used with anesthetics. After delivery, the cord can be removed from the neck.32 A video of the somersault maneuver is available at https://www.youtube.com/watch?v=WaJ6sZ4nfnQ. Pudendal block is a safe, simple method for uncomplicated spontaneous vaginal deliveries if women wish to bear down and push or if labor is advanced and there is no time for epidural injection. The technique involves injecting 5 to 10 mL of 1% lidocaine or chloroprocaine (which has a shorter half-life) at the 3 and 9 oclock positions; the analgesic response is short-lasting. Forceps or a vacuum extractor Operative Vaginal Delivery Operative vaginal delivery involves application of forceps or a vacuum extractor to the fetal head to assist during the 2nd stage of labor and facilitate delivery. o [teenager OR adolescent ], , MD, Saint Louis University School of Medicine. However, evidence for or against umbilical cord milking is inadequate. When about 3 or 4 cm of the head is visible during a contraction in nulliparas (somewhat less in multiparas), the following maneuvers can facilitate delivery and reduce risk of perineal laceration: The clinician, if right-handed, places the left palm over the infants head during a contraction to control and, if necessary, slightly slow progress. The trusted provider of medical information since 1899, Last review/revision May 2021 | Modified Sep 2022. Some read more ). Pain management during labor includes complementary modalities and systemic opioids, epidural anesthesia, and pudendal block. Oxytocin should not be given as an IV bolus because cardiac arrhythmia may occur. It is used mainly for 1st- or early 2nd-trimester abortion. The nose, mouth, and pharynx are aspirated with a bulb syringe to remove mucus and fluids and help start respirations. The cervix and vagina are inspected for lacerations, which, if present, are repaired, as is episiotomy if done. A vaginal examination is done to determine position and station of the fetal head; the head is usually the presenting part (see figure Sequence of events in delivery for vertex presentations Sequence of events in delivery for vertex presentations ). If you haven't had anesthesia or if the anesthesia has worn off, you'll likely receive an injection of a local anesthetic to numb the tissue. Some read more ). If she cannot and if substantial bleeding occurs, the placenta can usually be evacuated (expressed) by placing a hand on the abdomen and exerting firm downward (caudal) pressure on the uterus; this procedure is done only if the uterus feels firm because pressure on a flaccid uterus can cause it to invert Inverted Uterus Inverted uterus is a rare medical emergency in which the corpus turns inside out and protrudes into the vagina or beyond the introitus. After delivery, skin-to-skin contact with the mother is recommended. Spontaneous vaginal delivery. Encourage the mother to void before delivery to reduce the discomfort. Our website services, content, and products are for informational purposes only. Women giving birth for the first time tend to go through labor for 12 to 24 hours, while women who have previously delivered a child may only go through labor for 6 to 8 hours.These are the three stages of labor that signal a spontaneous vaginal delivery is about to occur: Of the almost 4 million births that occur in the United States each year, most are spontaneous vaginal deliveries. All rights reserved. How do you prepare for a spontaneous vaginal delivery? Although delayed pushing or laboring down shortens the duration of pushing, it increases the length of the second stage and does not affect the rate of spontaneous vaginal delivery.24 Arrest of the second stage of labor is defined as no descent or rotation after two hours of pushing for a multiparous woman without an epidural, three hours of pushing for a multiparous woman with an epidural or a nulliparous woman without an epidural, and four hours of pushing for a nulliparous woman with an epidural.8 A prolonged second stage in nulliparous women is associated with chorioamnionitis and neonatal sepsis in the newborn.25.

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