Should we screen for nuchal cord using ultrasound when a woman is planning a vaginal breech birth? and
What should we do with the information if we do identify a nuchal cord on ultrasound?
‘Nuchal cord’ means that one or more loops of umbilical cord are wrapped around the baby’s neck, during pregnancy or birth. Checking for nuchal cord prior to external cephalic version (ECV) or during risk assessment prior to a vaginal breech birth (VBB) is both common and controversial.
cord-leg entanglement, image: Dr Pricilla Ribeiro-Huguet
What is known:
Nuchal cords are common, especially for breech presentation. For example, in this study (Wong & Ludmir, 2006), where someone specifically looked for a nuchal cord prior to an attempt at ECV, 34/75 (45.3%) babies were spotted wearing their cord as a necklace. They attempted the ECVs without this information. More babies with nuchal cords had transient (temporary) heart rate abnormalities, and their ECVs were less likely to be successful. But none of them had an emergency caesarean birth because of the way their heart rate was affected by attempting ECV.
It may cause problems in some pregnancies and/or births, but visual assessment by ultrasound does NOT help us to predict which ones. (… in general. Unless, as in this paper by Hinkson et al 2019, there are 6 loops of nuchal cord visible. Wow!)
double nuchal cord, image: Shawn Walker
What is not known: Does a nuchal cord increase the risk associated with an ECV or vaginal breech birth? We just don’t know if, or by how much, presence of a nuchal cord increases the risk. This is one reason neither of the RCOG guidelines (ECV, Management of Breech) indicate nuchal cord should be identified, or used as an exclusion criteria, for either of these. In fact, they don’t mention ‘nuchal cord’ or ‘cord around the neck’ at all.
When there is clinical uncertainty, we just say … there is clinical uncertainty. We can’t guarantee it won’t be a problem, but we have no clear evidence that it is likely to cause a problem.
Other guidelines often do say something like, “exclude nuchal cord.” This means, “Look for it with ultrasound to make sure it isn’t there.” But it’s not clear what one is supposed to do if you identify it IS there. And if a clinician has not looked for it, or has not spotted it, and it ends up being there and causing a problem during birth, have they been negligent? It’s a slippery slope.
cord-leg entanglement, image: Dr Anke Reitter
In my own clinical experience, breech babies born vaginally quite often have one or sometimes two loops of nuchal cord around their neck at birth. My gut feeling is that these babies more often needed help to flex the head, for example with a shoulder press, but that this was not more difficult than when the cord is not there.
I also checked our video study (Reitter, Halliday & Walker 2020) database of 42 breech births with ‘good’ outcomes. Among these, 8/42 (19%) had a cord wrapped at least once around the neck. Among these 8, 5/8 had help with the arms, and 6/8 had help to flex the head. This was slightly higher than the overall averages in the whole dataset. In the dataset, there were also 2 cases of leg entanglement, 1 case of arm entanglement, and 1 cord prolapse, where the cord comes out first.
It seems plausible that cord entanglement, whether around the neck or another body part, could interfere with the normal mechanisms of a vaginal breech birth. These babies may then require more assistance to be born safely, which is not itself a problem, as long as that assistance is provided in a timely fashion. It also seems plausible that in some case, a tight or short cord entanglement could cause problems that would put the baby at risk. But the kind of potential problems Peesay describes are all very likely to be picked up with the kind of close monitoring (growth scans, fetal heart rate monitoring, etc.) that every known breech baby received antenatally and/or in labour.
I’ve also added a ‘cord’ tag to several videos in our video library. If you’ve taken our Physiological Breech Birth course, you can search the library to watch several videos where cord entanglements feature and are resolved.
In summary, these are my recommendations:
Don’t routinely go looking for a nuchal cord in otherwise uncomplicated pregnancies.
If you do spot a nuchal cord, explain the clinical uncertainty with regard to its implications.
Offer and attempt ECV if the person chooses this.
Offer and support a VBB if the person chooses this.
When attending a VBB with a known/suspected nuchal cord in labour:
interpret fetal heart monitoring in light of this;
interpret descent in light of this;
anticipate the cord could interfere with the mechanisms, which may require your assistance; and
review all of your tools for assisting the head to flex.
I’d love to know others’ thoughts and experiences?
Shawn
This is really interesting. My breechy had the cord x3 round her neck then looped under her arm. Straight forward home birth. When chatting to midwife after we thought if she'd been cephalic the length of cord left may not have allowed her to descend, as bum first fine! Anecdata!
— Ellie Garlick RN MSCN 💙 (@EllieGarlick) June 2, 2021
Another NICE Guideline that mentions care for breech presentation has been put out for comment. This time it is Inducing Labour. Many fine colleagues are collating responses to the guideline in general, but I would like views on the specific section related to induction of labour in breech presentation.
I have prepared a response, based on previous feedback from women and birthing people. Please let us know how you feel about this, and whether you would word anything differently.
Induction of labour is controversial, and even more controversial for breech presentation. I have tried to word the response in such a way that reflects the need for more informed choice, rather than more induction per se.
p.10, line 6 “Induction of labour is not generally recommended if a woman’s baby is in the breech position. [2008, amended 2021]” Cannot locate evidence for this recommendation in evidence review. This statement is vague. Not generally recommended by who? Why? Induction of labour for breech presentation is common outside of the UK.Â
p.10, line 14 “Discuss the possible risks of induction with the woman.” Also vague. What are the risks? A systematic review has been done, so women can be offered evidence-based information rather than general reluctance. https://www.ejog.org/article/S0301-2115(17)30578-X/fulltext
p.10, line 5 Suggest the section on ‘Breech Presentation’ is re-written to reflect the ethos of informed choice and discussion, in a similar manner to the section on ‘Previous caesarean birth.’ Otherwise, the service is inequitable. A guideline on IOL with breech presentation is only applicable to women who have chosen to plan a vaginal breech birth. The guideline should reflect and respect this, using neutral, non-judgemental language.
For example:
1.2.19 Advise women with a baby in the breech position, who have chosen to plan a vaginal breech birth, that:
induction of labour could lead to an increased risk of emergency caesarean birth, compared to spontaneous breech labour
induction of labour could lead to an increased risk of neonatal intensive care unit admission for the baby, compared to spontaneous breech labour
the methods used for induction of labour will be guided by the need to reduce these risks. See the recommendations on Methods for inducing labour.
1.2.20 If delivery is indicated, offer women who have a baby in the breech position a choice of:
an attempt at external cephalic version, immediately followed by induction of labour if successful
caesarean birth or
induction of labour in breech presentation
Take into account the woman’s circumstances and preferences. Advise women that they are entitled to decline the offer of treatment such as external cephalic version, induction of labour or caesarean birth, even when it MAY benefit their or their baby’s heath.
Current wording in Draft Guideline is:
Breech presentation
1.2.19 Induction of labour is not generally recommended if a woman’s baby is in the breech position. [2008, amended 2021]
1.2.20 Consider induction of labour for babies in the breech position if:
delivery is indicated and
external cephalic version is unsuccessful, declined or contraindicated and
the woman chooses not to have an elective caesarean birth.
Discuss the possible risks associated with induction with the woman. [2008, amended 2021]
El servicio de Obstetricia del Hospital Sant Pau se caracteriza por su amplia trayectoria en la asistencia integral al parto de nalgas mediante una atención multidisciplinar.
El objetivo de esta jornada es dar a conocer la asistencia al parto de nalgas y sus alternativas asà como cualificar a los profesionales que lo deseen para atender un parto de nalgas y aprender a resolver posibles complicaciones.
Para ello contaremos con expertas internacionales con amplia experiencia en la asistencia al parto de nalgas.
Plazas limitadas. Se admitirán por orden riguroso de inscripción. Se aceptarán anulaciones hasta el 01/06/2021. Por gastos de anulación, se devolverá el 85% del importe de la inscripción
This week, the NIHR (UK based) announced a PhD Fellowship opportunity. A Fellowship is designed to support a researcher to gain experience and training in doing research, and to support the research itself. It’s a great opportunity. Advertisement pasted below.
If you are reading this after any of these calls have closed, the same organisations may have a more recent call.
NIHR-Wellbeing of Women Doctoral Fellowships (Round 6)
Provide the opportunity to undertake exciting and impactful research that will underpin a researcher’s development as an independent future leader. The Doctoral Fellowship funds researchers to undertake a PhD
Wellbeing of Women is delighted to have partnered with the National Institute for Health Research (NIHR) to jointly fund one Charity Partnership Doctoral Fellowship.
All NIHR Fellowships provide the opportunity to undertake exciting and impactful research that will underpin a researcher’s development as an independent future leader. The Doctoral Fellowship funds researchers to undertake a PhD.
NIHR Charity Partnership Fellowships offer researchers the opportunity to be part of an active and supportive community, drawing on the enormous benefits and opportunities of cross-sector working.
HEE/NIHR ICA Clinical Doctoral Research Fellowship
The Clinical Doctoral Research Fellowship (CDRF) funds health and social care professionals to undertake a PhD and professional development in parallel, alongside continued professional practice.
The scheme is part of the HEE/NIHR Integrated Clinical Academic (ICA) Programme.
CDRFs are available to health and social care professionals (excluding doctors or dentists) who are registered with an ICA eligible regulatory body.
If you are considering training to be a researcher and/or clinical academic who does breech research, we would love to hear from you. There are many challenges in breech research. For example, variations in when the breech is diagnosed make recruitment challenging. Sometimes dramatic variations exist between centres in external cephalic version success rates, vaginal breech birth experience and whether or not breech presentation has a dedicated care pathway. This can make recruiting sites difficult, and it is difficult to reach an adequate sample size within single-centre studies. But we have experience in navigating some of these challenges and are keen to collaborate with others.
For example, in the OptiBreech Project, we are building a database designed to support a large, multi-site observational cohort study with multiple embedded trials along the breech care pathway. Some of the questions women or potential researchers have told us would be useful to answer include:
Does moxibustion work in a UK context, and what does it cost? This could be tested as a trial within the cohort.
Rebozo sifting / positional exercises / homeopathy / hypnosis — do they influence the rate at which babies turn head-down, or the success rate of external cephalic version? This could be tested as a trial within the cohort.
Does provision of an ECV service by a Breech Specialist Midwife change the outcomes of the service? And what does it cost compared to an obstetric service? This could be tested as a trial within the cohort.
Should we offer cervical sweeps to women with breech-presenting babies? Are they helpful? Safe? From when should we offer them? This could be tested as a trial within the cohort.
Does offering induction of labour for women with a breech-presenting baby who desire a vaginal breech birth affect modes of birth and/or outcomes? This could be tested as a trial within the cohort
If you’d like to consider applying for this or another source of funding for breech research, you are welcome to be in touch to discuss!
From 1 May 2021, access to the Physiological Breech Birth video library on Vimeo, hosted by Breech Birth Network, will only be available through our on-line training programme.
Although we’ve always offered a year’s access with training, we’ve never changed the password. But it’s been over a year since we have been able to deliver any in-person study days.
If you have purchased the on-line training, you will have access to the complete training for a year, as well as the Vimeo video library. The password to the library will be posted within the training programme, so you can continue to access the videos you use in training. If you attend an in-person training, you will be given access to the on-line training for one year.
If your organisation uses our videos, someone from your organisation will need to be enrolled onto our on-line course. Institutional rates are available if you would like all of your staff to have access to the course and the video library.
Thank you for making such good use of the training materials we’ve worked hard to create. May the breech babies find you and be safe in your hands.
Emma and I frequently receive requests for elective placements from students keen to experience midwifery practice related to breech birth. We wrote this post to provide some guidance into what you can do if you would like to gain more breech exposure.
Elective placements are tricky for a number of reasons:
At the moment, COVID-19.
A lot of administrative paperwork for a short placement.
We need to prioritise students from our local universities.
Direct work with women with a breech-presenting baby is only a small part of what we do.
No guarantee there would be any breech births during this period and/or that permission would be given for you to attend.
You will not be able to gain hands-on experience on an elective placement.
If you would like to spend your elective placement learning more about working with breech presentation, our on-line course is a great place to start. You will gain more exposure to the way breech births work, in a shorter period of time, than most midwives do in their careers. You will gain insight into how women and birthing people can be counselled to ensure informed decision-making. And you will learn how others have implemented change to the way breech works in their local hospitals.
You could structure your own elective placement, including the following:
Working with your local practice development midwives to attend any local training provided to qualified midwives, doctors or medical students, for example mandatory training activities.
Arranging to observe local counselling for breech presentation in your antenatal clinic. This may require you to liaise with the Antenatal Clinic Matron to find out about the local breech care pathway.
Attending presentation scans. You will need to find out where and by whom these are done in your local unit.
Observing external cephalic versions. Where and by whom are these done in your local unit?
Make a video about some aspect of breech management. If we include it in our training, you get lifetime access for free! Think about what women you encounter need more information about. Or what your fellow students need to learn about breech that you have learned through your placement. Practice finding evidence-based answers to the questions posted to these forums.
Hang out on-line in forums related to breech birth, such as Breech Birth Network’s FaceBook page and Instagram, Breech Birth UK, Breech Birth Australia and New Zealand, and the Coalition for Breech Birth. This will give you insight into women’s and providers’ concerns and experiences.
Writing a commentary article for a midwifery practice journal, such as TPM’s Student Midwife, summarising your self-made elective placement and what you learned.
Finding out the answers to all of these questions and/or completing these activities will give you insight into how the breech care pathway works for the women you care for. In some locations, this care is provided through an organised clinic and the path is clear. In other sites, care is more fragmented, and it may be harder to determine what the pathway is. But this in itself is useful because you will be able to see the work that needs to be done!
Another benefit of crafting your own placement in your local setting is that, when your colleagues know of your interest in breech, you are more likely to be involved in actual breech births. This is called “attracting breeches,” and you can read more about it in this research.
We are very keen to support students but need to be realistic about how we might be able to do that at the moment.
— Shawn and Emma
Image: Danish midwifery student Pernille Ravn on her elective placement, demonstrating the movement of baby to mother’s abdomen when performing the shoulder press manoeuvre
The team at Sygehus Sønderjylland, the University Hospital of Southern Denmark, has created a wonderful new series of training videos for upright breech birth. We are thrilled to be able to share them with you!
The creation of the videos was led by obstetrician Kamilla Gerhard-Nielsen, who also led the implementation of the upright breech concept in the hospital and its introduction in Denmark.
They also host a FaceBook page. Image: Obstetricians Katrin Loeser and Kamilla Gerhard-Nielsen
You are invited to an open discussion about the Draft of the new NICE Antenatal Care Guideline. Breech Birth Network would like to collect the views of families who have experienced a breech presentation at term and care providers on the draft guidance.
Josephine and Thiago talk about their experience of Ulysse’s breech birth at Erasme Hospital in Brussels
The NICE Antenatal Care Guideline covers the detection of breech presentation (how midwives and obstetricians pick up that your baby is breech) and how a known breech presentation at term should be managed by your care providers.
The recommendations are based on outcomes that are considered ‘critical’ and ‘important.’ A discussion of how the committee has prioritised outcomes and decided upon a recommendation is included in the Evidence Reviews.
This is a first meeting. A second will be held in March to review the results of this meeting and any written responses Breech Birth Network has received, before the deadline at the end of March. At the meeting we will:
Help you understand what the guideline and evidence reviews are saying.
Ask you how you feel about the recommendations.
Ask you if you would like to provide any feedback to the committee, which we will include in a collective response.
If you are unable to attend this meeting, you are also welcome to:
engage in this discussion by posting a comment on this blog page;
contact us using the e-mail form below to provide non-public feedback;
or leave a comment on our FaceBook group page, where we will post a link to this invitation.
Note: We have observed that some of the women we work with have experienced distress or sometimes trauma in their breech pregnancies. If your experience makes it uncomfortable to participate in a group event, and you would like to have a 1:1 meeting with someone from the Breech Birth Network, please contact us using the e-mail form below.
Meeting Details
Shawn Walker is inviting you to a scheduled Zoom meeting.
Topic: Consultation on draft NICE Antenatal Guideline Time: Feb 13, 2021 02:00 PM London
‘Physiological breech birth’ is an approach to care informed by evidence about the physiological processes of vaginal breech births, and an approach to clinical education based on evidence about how professionals learn to facilitate breech births.
I spend a lot of time communicating about vaginal breech birth, and equally importantly, a lot of time listening to how other people communicate about vaginal breech birth. Lately, I have become aware that many people misunderstand what ‘physiological breech birth’ is. This causes difficulties in communication and prevents current research evidence from improving the safety of vaginal breech birth as quickly as it could.
Image from Dr Anke Reitter, 2019
It’s my job to help clarify so that research can be used to improve safety and choice, as it is intended. Let’s start with what physiological breech birth is NOT:
Physiological breech birth is NOT ‘upright breech birth,’ ‘standing breech,’ or ‘all fours breech.’ Upright maternal birth positions are a TOOL and not a RULE of physiological breech birth. The reference standard is that, in a normally progressing birth, the woman or birthing person should give birth in the position of their preference. For many women having an unmedicated birth, particularly in midwife-led settings, this will be an upright position. Therefore, the logic goes, a ‘normal breech birth’ is one in which the woman is enabled to give birth in the position of her choice. Requiring supine positioning is an intervention.
How does this fit with the RCOG guideline (2017)? This states: “Either a semi-recumbent or an all-fours position may be adopted for delivery and should depend on maternal preference and the experience of the attendant. If the latter position is used, women should be advised that recourse to the semi-recumbent position may become necessary.”
The RCOG supports the use of upright positioning, but suggests this should be dependent on maternal preference and the experience of the attendant. Our recent analysis of video evidence (2020) showed that conversion to supine maternal position occurs within 10 seconds when use of supine manoeuvres is required. Therefore, the most recent evidence indicates that, while providers should continue to inform women that they may need them to turn over if the birth is very complicated, the experience of the attendant does not need to influence a woman’s initial choice of birthing position. Even if the attendant knows only supine manoeuvres.
Permission to use this video for teaching purposes is granted. Just access this page and click the full screen icon.
Where it is possible and safe to support a woman’s liberty in her birthing process, that’s what we should be doing, right? There is no evidence to indicate that use of supine birthing position improves outcomes for mothers and/or babies compared to enabling upright positioning. There is also no evidence to support the use of some manoeuvres over others; only things, like pulling, we know are dangerous. If a local guideline stipulates that women should be asked to assume a supine position to birth, this is out of line with both current RCOG guidance and the principles of woman-centred care.
Physiological breech birth is NOT, “It’s just hands off the breech. Just breathe, wait for the next contraction.”
The penny dropped for me after hearing two different midwives in two different cities describe to two other people what ‘physiological breech birth is’ using exactly this phrase, word for word. And then participating in risk management reviews following adverse outcomes, where midwives had document that they were practising ‘hands off the breech.’ And then attending multiple births (and videos), where midwives were instructing women to ‘just breathe, wait for the next contraction,’ even when there was concern about fetal condition and the situation was becoming urgent. Because this is what they had been taught.‘Hands off the breech’ has become a dogma with unintended consequences. Instructing someone to avoid pushing when they feel the urge is an INTERVENTION. It has no evidence to back it up, nor any good theoretical basis other than preventing people from pulling when they don’t know what else to do.
It’s not surprising that some senior managers are cautious about enabling ‘physiological breech birth,’ if this is what they understand it to be, especially if they have participated in adverse outcome reviews where this sort of practice has been described.
But, due to science, we know how to do better. Our video analysis showed that in a sample of 42 births, the birth was complete within 2:46 of the birth of the pelvis in 75% of cases. Regarding birth intervals, the RCOG guideline states that breech births should be assisted if there is delay of more than 5 minutes from the buttocks to the head. We are in the same ballpark of the RCOG’s recommendation based on expert opinion. But now we know that if you wait this long to assist, you are already outside the normal reference range.
Physiological breech birth is not contradicting our already strong, evidence-based guideline. Rather, current, living, emerging evidence is refining it.
Permission granted to use for teaching purposes
Historical use of the phrase ‘physiological breech birth’
Midwife Jane Evans used the phrase ‘physiological breech birth’ in her 2012 article, Understanding Physiological Breech Birth. In it, Evans shares her insights and descriptions of the mechanisms based upon her observations in clinical practice. Those of use who use this phrase in our research have continued in this tradition, using systematic, planned observational and other research methods. Many of her observations we have confirmed; some have been modified.
How to let the evidence help you
Let’s say you are a Practice Development Midwife. You teach the breech birth update in a 40-minute slot, using materials commonly used in other obstetric emergencies training programmes. You’d like to ensure the update is as informed by up-to-date evidence* but don’t want to blow people’s minds apart with variations from what they already know, especially now. Good idea.
These are my top 3 tips for making sure the training you deliver evolves with the current evidence base (as of January 2021):
Explain that the RCOG guideline recognises and supports women to adopt an upright position if that is their preference. Explain that the evidence indicates it takes less than 10 seconds to convert from upright to supine position. So even if providers are only experienced in supine complications, women should be supported to adopt the position of their choice. Although ‘lithotomy’ is not necessary, run through what conversion would look like in practice with your team if this helps people envision what is possible. Show them the video above if you are able.
Recommend the use of maternal movement and effort if any delay is identified. Delay is defined as no progress for 90 seconds at any point once the baby begins to emerge. Our video research indicated that maternal movement (#giveitawiggle) and effort (gentle encouragement to “push”) alone is often effective, without the risk of iatrogenic damage from hasty manoeuvres, but it is not always used. Instead, women are often instructed to breathe through a contraction and resist the urge to push. Because time is of the essence, and contractions may be 5 minutes apart in 2nd stage, this is a safety risk. Even in supine births with an epidural in situ, simply asking the woman to push will also work in this situation if there is no obstruction. At this point, the uterus is almost entirely empty; a contraction creates the urge to push, but maternal effort does the job. The use of maternal agency to facilitate the birth is a first principle of physiological breech birth – it’s not all about the position.
Teach shoulder press alongside MSV. Our video research found this simple manoeuvre was used in 57% of the upright breech births in our sample. Start by explaining the principle: elevating the occiput and flexing the fetal head, so that the smallest diameter delivers. When a woman is supine it is done like this … MSV. When a woman is upright, this works too … shoulder press. But the principle is the same. Then invite people to practice the one they are most likely to use. This flexible approach, recognising the variety of practice contexts, also reduces the risk an out-of-hospital midwife will ask a woman to lie down on the floor so she can perform MSV. This is a safety risk as it automatically deflexes the head.
Sure, the physiological breech birth evidence base covers a lot more. Our full training package (study day or on-line) goes into less common complications and their solutions, more about the research, and how to use the Algorithm to guide decision-making. A feasibility study is currently being conducted, hoping to trial a new care pathway based on physiological breech birth. But it is possible RIGHT NOW to use the available evidence to update current practice in a safer direction, without making major changes to what you are already doing.
In Summary
Lastly, if one can point out a single maxim in breech deliveries, take heed of the results of the experienced country midwife and doctor. They are usually very good, and their results are obtained by a policy of non-intervention. Do not interfere unless it is necessary, but when it is necessary interfere quickly and with certainty.
Ian Donald, 1956, Practical Obstetric Problems
The careful, systematic study of vaginal breech births that has taken place in the physiological breech birth tradition reflects this maxim. Do not intervene, not by dictating a birth position, not by instructing someone not to push, not at all, unless it is necessary. Due to a lack of exposure, many health care professionals just do not know how to recognise ‘when it is necessary’ and therefore cannot act quickly and with certainty, through no fault of their own. Due to physiological breech birth research, ‘when it is necessary’ can now be defined and described much more precisely. Therefore, it can be taught. And it can be tested.
But if the available research indicates simply stopping untested but commonly applied interventions may reduce identifiable risks, do we really need to wait for an RCT?
Shawn
P.S. A note on *up-to-date evidence. When preparing to write this blog, I did a brief literature search to find others (e.g. not ‘physiological breech’) who are publishing research related to the clinical practice of vaginal breech birth in the UK. The last I could find were Sloman et al 2016 and Pradhan et al 2005. Many of Sloman’s findings are consistent with those of other physiological breech researchers. I am keen to hear if anyone else in the UK is producing evidence concerning the clinical practice of vaginal breech birth at the moment — breech birth itself, not ECV or decision-making. Because it’s starting to feel surreal when people say, “We don’t teach/do physiological breech birth because it’s not evidence based …”
Here’s some!
Jan, H., Guimicheva, B., Gosh, S., Hamid, R., Penna, L. and Sarris, I. (2014), Evaluation of healthcare professionals’ understanding of eponymous maneuvers and mnemonics in emergency obstetric care provision. International Journal of Gynecology & Obstetrics, 125: 228-231. https://doi.org/10.1016/j.ijgo.2013.12.011 — And one of the co-authors (L Penna) is also a co-author of the RCOG guideline. This is the reason we do not use eponyms when teaching skills on physiological breech birth study days.
The team at Sygehus Sønderjylland, the University Hospital of Southern Denmark, has created a wonderful 
