INTRAPARTUM FETAL

SURVEILLANCE

by

Dr A. P. Soibi-Harry
Ultrasound and Fetal Medicine
Unit
23/09/2015
1
 Outline
 Introduction
 Brief History
 Etiology of Fetal Death
 Etiology of Reduced Fetal Oxygenation in
Labour
 Goal of Intrapartum Surveillance
 Intrapartum Monitoring Parameters,
Interpretations and Management
 Conclusion

2
 Introduction
 Intrapartum fetal surveillance are techniques and
procedures used to assess the wellbeing of the fetus
during labour.
 The goal is to identify fetuses in whom early and
adequate intervention will prevent fetal distress and its
attendant sequelae.
 Fetal heart rate patterns are indirect markers of the
fetal cardiac and central nervous system response to
blood volume changes, acidemia, and hypoxemia.
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 Brief History
 1893: Von Winckel suggested that a FHR greater than
160bpm or less than 100 bpm is indicative of fetal distress.

 20th century: Evolution of intrapartum fetal surveillance by

intermittent auscultation of the FHR

 Early 1970s: Continuous intrapartum electronic fetal

monitoring was introduced into clinical practice in the
United States.

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 Etiology of Fetal Death
Fetal
Death

Intrapartum
Antepartum 10 – 30%
70 – 90%

Placental Reduced Fetal Oxygenation-

Others 50%
Insufficiency
1/3
2/3
Idiopathic– about 50%

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Etiology of Reduced Fetal Oxygenation
in Labour

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 Goal of intrapartum fetal
monitoring

 Intra-partum FHR monitoring is a screening test that

provides information to alert the clinician that a true test
for fetal welfare assessment needs to be performed.

 The timely identification and rescue of the fetus at risk of

neonatal and long term morbidity from intrapartum
hypoxic insult.

 Reduce perinatal morbidity and mortality.

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Intrapartum Monitoring Parameters
 Clinical
 Amniotic Fluid Assessment

 Biophysical
 Fetal Heart Rate monitoring
 Intermittent auscultation
 Electronic fetal monitoring Doppler

 ST waveform analysis

 Biochemical
 Fetal Scalp pH
 Fetal Pulse oximetry
 Fetal scalp lactate testing
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 Amniotic Fluid Assessment---
Meconium
 The presence of meconium in the amniotic fluid may be a
sign of fetal distress

 Classification
----Early passage
 Occurs any time prior to rupture of the membranes and is
classified as light or heavy, based on its color and
viscosity

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 Meconium
 Light meconium: Light meconium is lightly stained
yellow or greenish amniotic fluid. It is not associated
with poor outcome

 Heavy meconium: Heavy meconium is dark green or

black and usually thick and tenacious. It is
associated with lower 1- and 5- minute Apgar
scores the risk of meconium aspiration

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 Meconium
 Late passage
 usually occurs during the second stage of labor, after
clear amniotic fluid has been noted earlier
Late passage, which is most often heavy, is usually
associated with
----umbilical cord compression
----uterine hypertonia
----fetal distress.
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 Meconium ----Management
 Amnioinfusion: can decrease meconium-related respiratory
complications perhaps as a result of the dilutional effect of
the infused fluid .
◦ Infuse a bolus of up of up to 800 ml of normal saline at a rate of 10-15
ml/minute over a period of 50 to 80 minutes. This is followed by a
maintenance dose of 3 ml/minutes until delivery.

◦ Maintain baseline uterine tone below 20mmHg to prevent uterine over

distension

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 Intermittent Auscultation-
Monitors

Pinard
Stethoscope

Hand-held Doppler Fetoscope

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 Intermittent Auscultation-
Indications
 Normal labor occurring after 37 weeks.

 Abnormal labor occurring after 37 weeks, where

continuous electronic fetal monitoring is not
available.

 Labor or contractions occurring prior to 37 weeks,

where continuous electronic fetal monitoring is
not available.

 As an adjunct to tocolysis, where continuous

electronic fetal monitoring is not available.
 Elements of Fetal Heart Rate
Assessment

a. Baseline fetal heart

b. Rhythm

c. Accelerations

d. Decelerations: impossible to differentiate type with

intermittent auscultation.

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 Procedure

•
Timing.
• In the active first stage
of labour - after a
contraction, for a
minimum of 60secs
every 15 minutes

• Second stage: Assess

the fetal heart every
5minutes.

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Management of Abnormal Fetal Heart
Rate by Intermittent Auscultation
• Reposition patient
• Rule out fever, dehydration, drug effect
Tachycardia • Correct maternal hypovolemia if present
• Check maternal pulse and blood pressure
• Reposition patient
• Assess for cord prolapse or relieve cord compression
• Administer oxygen @ 8- 10L/min
Bradycardia • Correct maternal hypovolemia if present
• Check maternal blood pressure and pulse
• Reposition patient
• Assess for passage of meconium
Decelerations
• Correct hypotension if present
• Administer oxygen @ 8-10L/min
• Continue auscultation of fetal heart rate
Additional
• Consider initiation of electronic fetal monitoring
Measures • If abnormal findings persist despite corrective
measures consider expedition of delivery
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 INTERMITTENT AUSCULTATION
BENEFITS LIMITATIONS

Evidence based practice Frequency of auscultation is lacking in

evidence but agreed on
Lower rates of CS, operative deliveries Could miss an acute but sustained
& maternal and fetal morbidities & bradycardia
mortalities
Increased mobility for mother Difficult to assess variability
Decrease use of analgesia/anaesthesia Periodicity of decelerations can not be
determined
Fosters more continuous labor support Requires more staff and proper
documentation
Focus on mother not machine Requires unit education, commitment
and support for sustained use
Facilitates alternative birth positions No permanent record of fetal heart rate
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 Electronic Fetal Monitoring
 Involves the use of a cardiotocograph
to record changes in the fetal heart
rate and their temporal relationship to
myometrial activity and uterine
contractions.

 The aim is to identify babies who may

be hypoxic so additional assessments
of fetal well-being may be made, or the
baby delivered by caesarean section
or instrumental vaginal birth.

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 Cardiotocography
Internal Fetal Heart Monitoring

 Noninvasive method
Internal Fetal Monitoring
 Utilizes an ultrasonic transducer to
 Invasive
monitor the fetal heart
 FHR is monitored via a fetal scalp electrode (IFSE)
 Utilizes the tocodynamometer to
 Uterine activity is monitored by an intrauterine pressure
catheter (IUPC) monitor uterine contraction pattern
 Application directly impacts results of20
data received
 Indications for Electronic fetal
monitoring
Maternal Fetal

Pre-existing antepartum indications Pre-existing antepartum indications

Vaginal bleeding Meconium stained liquor
Chorioamnionitis Abnormal fetal heart rate on auscultation
Previous caesarean section
Prolonged rupture of membrane
Induction / Augmentation of labour
Preterm labour
Post term pregnancy

Hypertonic Uterus

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 Electronic Fetal monitoring- a
look at evidence
 Central hypotheses of Electronic fetal monitoring has
never been tested”

 Controversy about the efficacy of EFM, interobserver and

intraobserver variability, nomenclature, systems for
interpretation, and management algorithms.

 There is evidence that the use of EFM increases the rate

of cesarean deliveries and operative vaginal deliveries.”
(ACOG July 2009)

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 Limitations of Electronic Fetal
Monitoring(EFM)
 Differences in recording techniques

 Primarily qualitative information (pattern recognition)

 Lack of uniform classification systems

 Confusion due to the many influences on the fetal heart

rhythm

 Substantial intra- and inter-observer variation regarding

the interpretation

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 Parameters Assessed
◦ Base line Fetal Heart Rate

◦ Baseline variability

◦ Accelerations

◦ Decelerations

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 Baseline Fetal heart Rate
 The mean of the FHR when this is stable,
excluding accelerations and decelerations.

 The baseline FHR should be determined over 5 to

10 minutes and expressed in bpm

 Normal 110 – 160 bpm

 Bradycardia <110 bpm

 Tachycardia >160 bpm

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Baseline Fetal Heart Rate

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 Tachycardia

Hypoxia Chorioamnionitis
Maternal fever B-Mimetic drugs
Fetal anaemia, sepsis, heart failure, arrhythmias
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 Bradycardia

Prolonged cord compression, Cord prolapse,

Epidural or Spinal analgesia, tetanic uterine contractions etc. 28
 Baseline Variability

 The minor fluctuations in baseline

FHR occurring at three to five
cycles per minute.

 It is measured by estimating the

difference in beats per minute
between the highest peak and
lowest trough of fluctuation in a
one-minute segment of the trace

 Normal 5 – 25 bpm
 Increased > 25 bpm
 Reduced 3 – 5 bpm
 Absent < 3 bpm

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 Short-term variability /beat-to-beat variability: is the
interval between successive mechanical events of the
cardiac cycle
◦ Normal short-term variability fluctuates between 5 and 25
bpm
◦ Variability below 5 bpm is considered to be potentially
abnormal
◦ When associated with decelerations a variability of less than
5 beats/minutes usually indicates severe fetal distress

 Long-term variability : reflects the frequency and

amplitude of change in the baseline rate
◦ The normal long-term variability is 3 to 10 cycles per minute.
◦ Variability is physiologically decreased during the state of
quiet sleep of the fetus, which usually lasts for about 25
minutes until transition occurs to another state.
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 Reduced Variability

Hypoxia, Drugs, Extreme prematurity, Sleep, CNS abnormality

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 Accelerations
 Transient increases in FHR
of 15 bpm or more above
the baseline and lasting
15seconds or more

Adequate accelerations
 <32 weeks' : >10 bpm
above baseline for >10
seconds
 >32 weeks' : >15 bpm
above baseline for > 15
seconds

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 Decelerations
 Transient episodes of slowing of FHR below the baseline
of more than 15 bpm lasting at least 15 seconds.

 Early Decelerations -uniform, repetitive decrease of FHR

with slow onset early in the contraction and slow return to
baseline by the end of the contraction.

 Late Decelerations -uniform, repetitive decreasing of

FHR with, usually, slow onset mid to end of the
contraction and nadir more than 20 seconds after the
peak of the contraction and ending after the contraction.
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Early Decelerations
 Significance: This pattern
is seen when engagement
of the fetal head has
occurred.
 Early decelerations are not
thought to be associated
with fetal distress.
 Mechanism: The pressure
on the fetal head leads to
increased intracranial
pressure that elicits a vagal
response

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LATE DECELERATIONS
Significance: The severity
is graded by the magnitude
of the decrease and the
nadir of the deceleration .
 Fetal hypoxia and
acidosis are more
pronounced with severe
decelerations.
 Generally associated
with low scalp blood pH
values and high base
deficits.

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 Variable decelerations

 Intermittent periodic
slowing of FHR with rapid
onset and recovery.

 The time relationship with

contractions is variable
but they most commonly
occur in association with
contractions

 Vagal in origin, medical

experts suggest variable
decelerations result from
stimuli such as cord
compression
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37
 Prolonged decelerations
 Decrease of FHR
below the baseline
of more than 15
bpm for longer than
90 seconds but less
than 5 minutes.

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Sinusoidal Pattern
 A regular oscillation of the
baseline long-term variability
resembling a sine wave.
 This smooth, undulating
pattern, lasting at least 10
minutes, has a relatively fixed
period of 3–5 cycles per
minute and an amplitude of
5–15 bpm above and below
the baseline. Baseline
variability is absent

 Associated with -
Severe chronic fetal anaemia
Severe hypoxia & acidosis
Fetal Death

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Categorization of Fetal Heart traces
Rate
BASELINE Features
VARIABILITY DECELERATION ACCELERATION

REASSURING 110-160 ≥ 5 bpm None present

NON 100-109 < 5 for ≥40 min Early decel;

REASSURING 161-180 but <90 min typical variable;
single prolonged ≤
3min
ABNORMAL <100 < 5 for ≥90 min Late decel;
>180 atypical variable;
sinusoidal ≥ 10 single prolonged >
min 3min

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Interpretation of CTG Results
Category Definition

Normal All four reassuring

Suspicious 1 non-reassuring
Rest reassuring
Pathological 2 or more non-
reassuring
1 or more abnormal

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Possible Interventions

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 FETAL SCALP BLOOD
SAMPLING
 Useful in the presence of
a non reassuring CTG
 A scalp blood sample for
pH or lactate
determination
 Specificity is high ( A
normal value rules out
asphyxia)
 The sensitivity and
positive predictive value
of a low scalp pH in
identifying a newborn
with Hypoxic-ischaemic
encephalopathy is low
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 Fetal scalp blood sampling
Indications Absolute contraindications Relative
contraindications
Suspected fetal Clear evidence on Gestational age 34
compromise continuous EFM of serious weeks to 36 weeks 6
suggested by sustained fetal days
pathological CTG compromise
Heavy meconium Fetal bleeding disorders Maternal pyrexia >380 C
Face presentation or
uncertain presenting part
Maternal infection( HIV,
herpes, HBV)
Severe intrauterine sepsis
Gestational age < 34
weeks
Active second stage of labour 44
 FBS- Procedure
 Membranes must be ruptured and cervix 3cm dilated.
 Consider effacement, station, application of vertex to
cervix, AFV and amount of baby hair.
 Explain procedure and obtain informed consent
 Assemble equipment on trolley
 Position patient in left lateral or lithotomy with wedge
applied to prevent supine hypotension
 Sampling under direct vision with amnioscope to prevent
amniotic fluid contamination
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 FBS- PROCEDURE
 Clean incision site and apply petroleum jelly.
 Avoid fontanelles.
 Use a disposable blade on plastic mount with blade not
protruding more than 2mm.
 Make a 2mm scalp incision and collect blood into
preheparinised glass capillary tubes.
 Apply pressure with dry swab till bleeding stops.
 Document procedure and plan and examine sampling site
postnatally
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 Fetal Scalp Ph
 First introduced by Saling in 1967.

 First technique to assess intrapartum fetal condition.

 The use of pH as a trigger for intervention to prevent poor

long-term neurological outcome, using current thresholds,
will fail to prevent most adverse outcomes and at the cost
of high rates of intervention (recent observational studies)

 Obtaining a fetal scalp sample for pH has been shown to

take a significant amount of time and to be prone to failure.

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 Fetal Scalp Lactate
 Lactate is a metabolite produced during glucose
anaerobic metabolism as a result of tissue hypoxia.

 The advantage claimed for lactate over pH is that

sampling is easier to perform, yields results more often,
can be performed at the bedside and is a better

predictor of long-term neonatal condition.

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 Interpretation of Results
Fetal Blood Sample Fetal Scalp Lactate Fetal Scalp pH

Normal ≤ 4.1 ≥ 7.25

Pre- Acidotic 4.2 - 4.8 7.21 - 7.24

Acidotic > 4.8 ≤ 7.20

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FBS -Lactate Result- Management
 Normal range
◦ if CTG returns to normal there is no need to repeat
◦ if abnormalities continue - repeated in 1hr
◦ if abnormalities worsen then repeat sooner than 1hr

 Pre-acidotic range
◦ repeat within 30 mins
◦ deliver if there is significant deterioration from the previous
result

 Acidotic range
◦ delivered immediately by either instrumental delivery or
urgent CS
◦ stop oxytocin infusion if in progress
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FBS- pH Results- Management

 If the pH >7.25 --- observe.

 If the pH 7.2 and 7.25---repeat in 30

mins.

 If the pH <7.2----repeat immediately

 If pH still low -- Prompt delivery

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FETAL PULSE OXIMETRY
 Measures fetal oxygenation during
labor

 It is performed using a sensor placed

transcervically against the fetal cheek,
forehead or temple.

 Normal values range between 35%

and 65%

 When the fetal oxygen saturation

remains less than 30% or the signal is
unobtainable for more than 10
minutes, there is need for intervention
***However, some conditions may alter readings
including fetal scalp edema, caput succedaneum,
dark/thick/curly hair, or vernix
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FETAL PULSE OXIMETRY
Contraindications include:

 Placenta previa,

 FHR pattern that clearly indicates immediate delivery,

 Abruptio placentae

 Antepartum hemorrhage

 Maternal genital infections

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Fetal Pulse Oximetry- The Evidence
 Fetal pulse oximetry has not been shown to improve
the accuracy of fetal evaluation in the presence of
non-reassuring CTG and does not contribute to a
reduction in caesarean section rates in this situation.

 However, the use of computerized auto-analysis of

fetal pulse oximetry in combination with CTG data has
also been investigated with some evidence of
usefulness

54
Vibro-acoustic stimulation

 Also known as fetal acoustic stimulation test (FAST), is

the application of a vibratory sound stimulus to
the abdomen of a pregnant woman to induce FHR
accelerations. The presence of FHR accelerations reliably
predicts the absence of fetal metabolic acidemia
 Proposed to be used as a substitute for scalp sampling when
CTG –is Non Reassuring. (However, a Cochrane systematic review has,
to date, found insufficient evidence assessing its safety and efficacy to
recommend its use)

 Normal ----------if FHR acceleration > 15 bpm for 15

seconds within 15 seconds after the stimulation with
prolonged fetal movements.

 Abnormal ----Only 50% have acidotic pH. 55

 Fetal Electrocardiography
 This involves an electrode being passed through the
woman's cervix and attached to the baby's head. It
measures the heart's electrical activity and the pattern
of the heart beats.

 The fetal ECG, like the adult ECG, displays P, QRS,

and T waves corresponding to electrical events in the
heart during each beat..

 Two parts of the fetal ECG waveform have attracted

attention from researchers: PR/RR relations and the
ST waveform
56
 ST Analysis Monitor
 How?

 One fetal scalp electrode and one skin electrode placed on the mother’s thigh record the fetal ECG (FECG)
signal.

 Each fetal heart beat provides one fetal ECG (FECG) complex, which STAN automatically records, processes
and analyses.

 The results are displayed on screen and any potential causes for concern are flagged up as “ST Events”.

 Why?

 Non-reassuring CTG trace in labour

 The combination of ST Analysis and CTG provides more accurate information about the fetus than CTG alone.

 The combination helps identify fetuses at risk of oxygen deficiency.

 ST Analysis has been proven to help identify fetuses at risk, improve decision making, and ultimately result in
delivering healthier babies.
 * Cochrane Review: Fetal electrocardiogram (ECG) for fetal monitoring during labour. Neilson JP. The Cochrane Library 2006:3

57
ST Analysis Result-
Management
 Normal CTG ignore ST changes

 An abnormal CTG with a normal ST during

the second stage of labour, should only be
allowed to exist for a maximum of 90
minutes, as the fetus may not cope with
acute hypoxia during this time.

58
 Conclusion
 Continuous electronic fetal monitoring is a useful
intrapartum tool in experienced hands, if used
selectively and according to evidence-based guidelines

 It should not be used routinely, as this is one of the

factors that has pushed up the instrumental and
caesarean delivery rates in the developed world.

 Its use should continue to be investigated by carefully

designed randomized controlled trials to optimize its
utility and compare outcomes with newer, potentially
more accurate ways of evaluating fetal well-being in
labour. 59
 Reference
1. Tollanes MC, Wilcox AJ, Lie RT, et al; Familial risk of cerebral palsy: population based
cohort study. BMJ. 2014 Jul 15;349:g4294. doi: 10.1136/bmj.g4294.
2. McIntyre S, Taitz D, Keogh J, et al; A systematic review of risk factors for cerebral palsy in
children born at term in developed countries. Dev Med Child Neurol. 2013
Jun;55(6):499-508. doi: 10.1111/dmcn.12017. Epub 2012 Nov 26.
3. Vincer MJ, Allen AC, Joseph KS, et al; Increasing prevalence of cerebral palsy among very
preterm infants: a population-based study. Pediatrics. 2006 Dec;118(6):e1621-6. Epub
2006 Oct 30.
4. Parer JT, King T, Flanders S, et al; Fetal acidemia and electronic fetal heart rate patterns: Is
there evidence of an association? J Matern Fetal Neonatal Med. 2006 May;19(5):289-94.
5. Intrapartum care: care of healthy women and their babies during childbirth; NICE Clinical
Guideline (Dec 2014)
6. Kitzinger S, Green JM, Chalmers B, et al, Why do women go along with this stuff? Birth.
2006 Jun;33(2):154-8. etal electrocardiogram (ECG) for fetal monitoring during
labour
7. James P Neilson*
8. Editorial Group: Cochrane Pregnancy and Childbirth Group ,Published Online: 31 MAY
2013 Assessed as up-to-date: 12 FEB 2013, DOI: 10.1002/14651858.CD000116.pub4
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Thanks for Your Attention!

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