If the cause cannot be identified and corrected, immediate delivery is recommended. The FHR is under constant variation from the baseline (Figure 1). Copyright 2023 American Academy of Family Physicians. Electronic Fetal Heart Monitoring Trivia Quiz Questions! -Fetal Doppler: transmits small, high frequency sound waves that are reflected off of the fetal heart - measures heart rate -Normal fetal heart rate = 110-160 BPM Electronic Fetal Monitoring Electronic fetal monitoring is performed in a hospital or doctors office. 04 November 2020 c. Reassure the family the finding is normal. What should the nurse do in this situation? The nurse will chart the variability as which of the following? Early decelerations are caused by fetal head compression during uterine contraction, resulting in vagal stimulation and slowing of the heart rate. 4 It is. Continuous monitoring of your babys heart rate is conducted during labor and delivery as well. Intrapartum Fetal Monitoring | AAFP Initiate oxygen at 6 to 10 L per minute, 5. Variable and inconsistent interpretation of tracings by clinicians may affect management of patients. The electronic fetal monitor uses an external pressure transducer or an intrauterine pressure catheter (IUPC) to measure amplitude and frequency of contractions. According to AWHONN, the normal baseline Fetal Heart Rate (FHR) is A. If any problems arise, reviews are done more frequently. The normal FHR range is between 120 and 160 beats per minute (bpm). Health care professionals play the game to hone and test their EFM knowledge and skills. -Positive Contraction Stress Test: Hasten fetal delivery. Typically performed in the later stages of pregnancy and during labor, fetal heart tracing results can say a lot about the health of your baby. This web game uses NICHD terminology to identify tracing elements and categorize EFM tracings. A change in baseline FHR is said to occur when the change persists for 10 minutes or longer. In 1991, the National Center for Health Statistics reported that EFM was used in 755 cases per 1,000 live births in the United States.2 In many hospitals, it is routinely used during labor, especially in high-risk patients. It indicates severe fetal anemia, as occurs in cases of Rh disease or severe hypoxia.24 It should be differentiated from the pseudosinusoidal pattern (Figure 11a), which is a benign, uniform long-term variability pattern. Quizzes 6-10. The Value of EFM Certification (One Team One Language), showcases the national PSA campaign Your Baby Communicates along with peer-to-peer video discussions on the value of EFM Board Certification. What should the nurse do before appropriate clinical interventions are initiated? Auscultation of the fetal heart rate (FHR) is performed by external or internal means. A. Category I is defined by an FHR baseline of 110 to 160 beats per minute (bpm), moderate variability (six- to 25-bpm fluctuation in FHR from baseline), with no late decelerations (onset and nadir after peak of contraction, decrease of more than 15 bpm from baseline, likely uteroplacental insufficiency) and no variable decelerations (onset variable to contraction and slow [i.e., more than 15 seconds and less than two minutes] return to baseline, likely from cord compression) present5 (Figure 27). Treat placental fetal perfusion through intrauterine resuscitation before proceeding to immediate delivery for all Category II or III tracings with concern for fetal acidosis. A gradual decrease is defined as at least 30 seconds from the onset of the deceleration to the FHR nadir, whereas an abrupt decrease is defined as less than 30 seconds from the onset of the deceleration to the beginning of the FHR nadir.11, Early decelerations (Online Figure H) are transient, gradual decreases in FHR that are visually apparent and usually symmetric.11 They occur with and mirror the uterine contraction and seldom go below 100 bpm.11 The nadir of the deceleration occurs at the same time as the peak of the contraction. Test your EFM skills using NCC's FREE tracing game! (f) Comment on the agreement between the answers to parts (a) and (e). Any type of abnormality spotted in a fetal heart tracing could indicate an inadequate supply of oxygen or other medical issues. They are usually associated with fetal movement, vaginal examinations, uterine contractions, umbilical vein compression, fetal scalp stimulation or even external acoustic stimulation.15 The presence of accelerations is considered a reassuring sign of fetal well-being. You scored 6 out of 6 correct. Assess fetal pH (fetal scalp stimulation, scalp pH, or acoustic stimulation), 8. Late decelerations (Online Figure J) are visually apparent, usually symmetric, and have the characteristic feature of onset of the deceleration after the onset of the uterine contraction.11 The timing of the deceleration is delayed, with the nadir of the deceleration occurring after the peak of the contraction.11 The onset, nadir, and recovery of the deceleration usually occur after the beginning, peak, and ending of the contraction, respectively. How an individual's senses are elevated by arousing the central nervous system? FHR Quiz Flashcards | Quizlet Continuous electronic fetal monitoring, compared with structured intermittent auscultation, has been shown to increase the need for cesarean delivery (number needed to harm = 56; RR = 1.63; 95% CI, 1.29 to 2.07; n = 18,861) and operative vaginal delivery (number needed to harm = 41; RR = 1.15; 95% CI, 1.01 to 1.33; n = 18,615), with no statistical decrease in fetal death or cerebral palsy.1 Continuous electronic fetal monitoring has also led to a 50% reduction in the incidence of neonatal seizure vs. structured intermittent auscultation, but this has no effect on long-term outcomes.1, Several adjuncts have been studied to overcome the high false-positive rate of continuous electronic fetal monitoring. INTRODUCTION. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Tachycardia is certainly not always indicative of fetal distress or hypoxia, but this fetal tracing is ominous. The first-order bright fringe is at a position ybright=4.52mmy_{\text {bright }}=4.52 \mathrm{~mm}ybright=4.52mm measured from the center of the central maximum. This type of deceleration has a uniform shape, with a slow onset that coincides with the start of the contraction and a slow return to the baseline that coincides with the end of the contraction. One hour later, the nurse notices that the FHR baseline is 145 bpm with minimal variability. comprehensive exam fetal tracing index references the maternal fetal triage index frequently asked questions web each of the ve levels has key questions with . Which of the following heart rate patterns would the nurse interpret as normal during the transitional phase of stage one? 1. Table 1 lists examples of the criteria that have been used to categorize patients as high risk. Fetal Heart Tracing Quiz 1 - 3/10/2017 - Course Hero Another area of interest is the use of computer analysis for key components of the fetal tracing,29 or decision analysis for the interpretation of the EFM tracing.30 These have not been demonstrated to improve clinical outcomes.29,30 Fetal pulse oximetry was developed to continuously monitor fetal oxygenation during labor by using an internal monitor, requiring rupture of membranes.31 Trials have not demonstrated a reduction in cesarean delivery rates or interventions with the use of fetal pulse oximetry.31. Perform amnioinfusion for recurrent variable decelerations to reduce the risk of cesarean delivery. Data Sources: PubMed searches were completed using the key terms intrapartum fetal heart monitoring, cardiotocography, structured fetal heart monitoring, National Institute of Child Health and Human Development classifications, amnioinfusion, and advanced life support in obstetrics. Increased variability in the baseline FHR is present when the oscillations exceed 25 bpm (Figure 2). The fetal heart rate undergoes constant and minute adjustments in response to the fetal environment and stimuli. Long-term variability is a somewhat slower oscillation in heart rate and has a frequency of three to 10 cycles per minute and an amplitude of 10 to 25 bpm. The American College of Obstetricians and Gynecologists (ACOG) states that with specific intervals, intermittent auscultation of the FHR is equivalent to continuous EFM in detecting fetal compromise.4 ACOG has recommended a 1:1 nurse-patient ratio if intermittent auscultation is used as the primary technique of FHR surveillance.4 The recommended intermittent auscultation protocol calls for auscultation every 30 minutes for low-risk patients in the active phase of labor and every 15 minutes in the second stage of labor.4 Continuous EFM is indicated when abnormalities occur with intermittent auscultation and for use in high-risk patients. Almost any stressful situation in the fetus evokes the baroreceptor reflex, which elicits selective peripheral vasoconstriction and hypertension with a resultant bradycardia. Fetal Tracing Quiz Please answer each question. -Stress = uterine contractions 140 145 150 155 160 2. Decelerations represent a decrease in FHR of more than 15 bpm in bandwidth amplitude. Fetal heart tracing is also useful for eliminating unnecessary treatments. All Rights Reserved. https://www.acog.org/~/media/For%20Patients/faq015.pdf, Current version ( Continuous electronic fetal monitoring was developed in the 1960s to assist in the diagnosis of fetal hypoxia during labor. PDF Review of Category I, II, and III Fetal Heart Rate Classifications Any written information on the tracing (e.g., emergent situations during labor) should coincide with these automated processes to minimize litigation risk.21, Table 5 lists intrauterine resuscitation interventions for abnormal EFM tracings.9 Management will depend on assessment of the risk of hypoxia and the ability to effect a rapid delivery, when necessary. Non-stress test PLUS Place the Doppler over the area of maximal intensity of fetal heart tones, 3. Your doctor can confirm the likelihood of hypoxic injury using fetal heart tracing. Fetal Assessment in Non-Obstetric Settings 9. Uterine tachysystole is defined as more than five contractions in any 10-minute period, averaged over 30 minutes.2 Each normal uterine contraction causes a temporary decrease in uterine blood flow and fetal oxygenation, which is generally well tolerated.26,27 However, tachysystole increases the risk of acidosis.26,27 To correct tachysystole, physicians must reduce or stop uterine stimulants or add tocolytics.2,2729, Goals of intrapartum fetal monitoring include rapid identification and intervention for suspected fetal acidosis as well as reassurance and avoidance of unnecessary interventions in cases of adequate fetal oxygenation.4,26 Figure 1 provides an algorithm for suggested management.2,7,16,21,27,3033. Accelerations are transient increases in the FHR (Figure 1). The nurse understands that the primary intervention is to: The nurse notes that the fetal heart rate baseline is 120-130 with an increase in FHR to 145 bpm lasting 15 seconds. The number of migratory animals (in hundreds) counted at a certain checkpoint is given by. Baseline of 140 - 150 with decelerations to 120 noted beginning with the contraction and returning to baseline by the end of the contraction. Select the answer that doesn't belong with the others: -How? -0-2: Deliver promptly, -Assesses fetal tolerance of stress Are contractions present? d. Places the tocotransducer over the uterine fundus, An NST in which two or more fetal heart rate (FHR) accelerations of 15 beats per minute (bpm) or more occur with fetal movement in a 20-minute period is termed. It involves using an electronic fetal monitor that records the fetal heart rate and the frequency and duration of uterine contractions. Assess maternal vital signs (temperature, blood pressure, pulse), 3. Faculty, Students, State Boards & Volunteers. Nonreassuring variable decelerations associated with the loss of beat-to-beat variability correlate substantially with fetal acidosis4 and therefore represent an ominous pattern. This web game uses NICHD terminology to identify tracing elements and categorize EFM tracings. Contractions are occurring every 3 minutes and lasting 60 seconds, and are of moderate intensity with a soft resting tone. -4: Suspect lack of adequate oxygen, If >36 wks: deliver, If < 36 wks: Lung Maturity Test Document in detail interpretation of FHR, clinical conclusion and plan of management. Recurrent deep variable decelerations can be corrected with amnioinfusion. Instruct the woman to drink 1 to 2 quarts of water. VEAL CHOP Nursing Mnemonic: Complete Guide - Nurseslabs https://www.mayoclinic.org/tests-procedures/nonstress-test/about/pac-20384577 Describe a hypothesis that explains these results. Fetal Tracing Index. Home. The baseline rate is interpreted as changed if the alteration persists for more than 15 minutes. Management of late decelerations includes intrauterine resuscitation and identifying and treating reversible causes, with immediate delivery recommended if they do not resolve2,5,7 (Figure 67). Foremost, the entire fetal heart rate tracing requires evaluation, which includes assessing the uterine activity for tachysystole, presence or absence of variability, and accelerations. FHR baseline of 120-130 with V shaped decelerations to 100 noted before and after contractions. -Fetal body movements https://obgyn.onlinelibrary.wiley.com/doi/pdf/10.1016/j.ijgo.2015.06.020 Non-reactive: Management includes correction of identified reversible causes. Practice Quizzes 1-5 - Electronic Fetal Monitoring This content is owned by the AAFP. Copyright 2020 by the American Academy of Family Physicians. About. Gene amplification in cancer cells has been shown to lead to resistance to cancer-killing medications when the dose of medication is increased gradually. Health care professionals play the game to hone and test their EFM knowledge and skills. None. -NST Continuous EFM reduced neonatal seizures (NNT = 661), but not the occurrence of cerebral palsy. is part of the free online EFM toolkit at. The nurse is caring for a low-risk primipara at 40 weeks' gestation and in active labor. Therefore, it is a vital clue in determining the overall fetal condition. 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. The patient is now 7 cm dilated, 100% effaced, and at +1 station. to access the EFM tracing game and to take full advantage of all the resources available. Beta-adrenergic agonists used to inhibit labor, such as ritodrine (Yutopar) and terbutaline (Bricanyl), may cause a decrease in variability only if given at dosage levels sufficient to raise the fetal heart rate above 160 bpm.19 Uncomplicated loss of variability usually signifies no risk or a minimally increased risk of acidosis19,20 or low Apgar scores.21 Decreased FHR variability in combination with late or variable deceleration patterns indicates an increased risk of fetal preacidosis (pH 7.20 to 7.25) or acidosis (pH less than 7.20)19,20,22 and signifies that the infant will be depressed at birth.21 The combination of late or severe variable decelerations with loss of variability is particularly ominous.19 The occurrence of a late or worsening variable deceleration pattern in the presence of normal variability generally means that the fetal stress is either of a mild degree or of recent origin19; however, this pattern is considered nonreassuring. -Neither period yields adequate accelerations Category II tracing abnormalities can be addressed by treating reversible causes and providing intrauterine resuscitation, which includes stopping uterine-stimulating agents, fetal scalp stimulation and/or maternal repositioning, intravenous fluids, or oxygen. A key causal event in the release of neurotransmitter molecules from vesicles into the synaptic cleft is the________. When continuous EFM tracing is indeterminate, fetal scalp pH sampling or fetal stimulation may be used to assess for the possible presence of fetal acidemia.5 Fetal scalp pH testing is no longer commonly performed in the United States and has been replaced with fetal stimulation or immediate delivery (by operative vaginal delivery or cesarean delivery). Intrapartum Fetal Heart Rate Monitoring - Perinatology.com If decelerations are not reversed by intrauterine resuscitation measures, immediate delivery is recommended.2,43, This article updates previous articles on this topic by Bailey44 and by Sweha, et al.45. fetal heart tracing quiz 12. fetal heart tracing quiz 12. where are siegfried and roy buried; badlion client for cracked minecraft; florida man november 6, 2000; bulk tanker owner operator jobs; casselman river hatch chart; who makes carquest batteries; sacred heart southern missions mass cards; Membranes have to be rupture in order to establish direct contact. Category III tracings are highly concerning for fetal acidosis, and delivery should be expedited if immediate interventions do not improve the tracing. Copyright 2023 American Academy of Family Physicians. What is the peak current supplied by the emf This alone is not predictive of fetal acidosis unless accompanied by decreased variability and/or absent spontaneous or stimulated accelerations.2,5. The five components of the biophysical profile are as follows: (1) nonstress test; (2) fetal breathing movements (one or more episodes of rhythmic fetal breathing movements of 30 seconds or. A nurse is teaching a woman how to do "kick counts." 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. A pattern of persistent late decelerations is nonreassuring, and further evaluation of the fetal pH is indicated.16 Persistent late decelerations associated with decreased beat-to-beat variability is an ominous pattern19 (Figure 7). distribution of tributaries influences This is followed by occlusion of the umbilical artery, which results in the sharp downslope. 3. Practice Quizzes 6-10 - Electronic Fetal Monitoring Professionals using Electronic Fetal Monitoring in their practice should also take advantage of: The EFM Resources page with linked papers and articles including the NCC monograph Fetal Assessment and Safe Labor Management authored by Kathleen Rice Simpson, PhD, RNC-OB, CNS-BC, FAAN. External monitoring is performed using a hand-held Doppler ultrasound probe to auscultate and count the. a) lapilli For example, fetuses with intrauterine growth restriction are unusually susceptible to the effect of hypoxemia, which tends to progress rapidly.4, A growing body of evidence suggests that, when properly interpreted, FHR assessment may be equal or superior to measurement of fetal blood pH in the prediction of both good and bad fetal outcomes.13 Fetuses with a normal pH, i.e., greater than 7.25, respond with an acceleration of the fetal heart rate following fetal scalp stimulation. A. While admitting a patient who is at 40 weeks' gestation, the nurse observes an FHR of 165 bpm with recurrent decelerations. The patient is being monitored by external electronic monitoring. Every 15 to 30 minutes in active phase of first stage of labor; every 5 minutes in second stage of labor with pushing, Assess FHR before: initiation of labor-enhancing procedure; ambulation of patient; administration of medications; or initiation of analgesia or anesthesia, Assess FHR after: admission of patient; artificial or spontaneous rupture of membranes; vaginal examination; abnormal uterine activity; or evaluation of analgesia or anesthesia, 1. Strongly Predictive of normal acid-base status at the time of observation. Most patients who undergo internal fetal monitoring during labor accept monitoring as a positive experience.6. Use a definite integral to find the number of animals passing the checkpoint in a year. Compared with EFM alone, the addition of fetal electrocardiography analysis results in a reduction in operative vaginal deliveries (NNT = 50) and fetal scalp sampling (NNT = 33). Finally, the recovery phase is due to the relief of the compression and the sharp return to the baseline, which may be followed by another healthy brief acceleration or shoulder (Figure 8). Try your hand at the following quizzes. No. The NCC EFM Tracing Game is part of the free online EFM toolkit at NCC-EFM.org. -2+Fetal Heart Rate increases in 20 minutes She asks the nurse to explain the results. Self Guided Tutorial. Your doctor will explain the steps of the procedure. : Powered by. Continuous electronic fetal monitoring was developed to screen for signs of hypoxic-ischemic encephalopathy, cerebral palsy, and impending fetal death during labor. Pressure on the cord initially occludes the umbilical vein, which results in an acceleration (the shoulder of the deceleration) and indicates a healthy response. Mucus plug: What is it and how do you know you've lost it during pregnancy? Persistent tachycardia greater than 180 bpm, especially when it occurs in conjunction with maternal fever, suggests chorioamnionitis. To assess 5 areas of fetal health: Usually done after 32 weeks, Assesses 5 areas of fetal well-being: Determine whether accelerations or decelerations from the baseline occur. Regardless of the depth of the deceleration, all late decelerations are considered potentially ominous. On a drawing of the body locate the major body regions containing lymph nodes. 150 155 160 4. What action by the student indicates to the registered nurse that the student understands the procedure? Ultrasound assessment x 30 minutes Palpate for uterine contraction during period of FHR auscultation to determine relationship, 5. Patient information: See related handout on electronic fetal monitoring, written by the author of this article. A more recent article on intrapartum fetal monitoring is available. Remember , the baseline is the average heart rate rounded to the nearest five bpm . -Contraction Stress Test (CST), How? b) Recalculate the primary current, IpI _{ p }Ip. This pattern is most often seen during the second stage of labor. D. Determine the onset and end of each deceleration in relation to the onset and end of the contraction. References. The searches included systematic reviews, meta-analyses, randomized controlled trials, and review articles. the presence of moderate variability and/or accelerations offers reassurance in Category II tracings because the presence is predictive of a lack of fetal acidosis, Category II management should focus on first correcting reversible causes, including stopping uterotonic agents and placental fetal perfusion, through intrauterine resuscitation, Amnioinfusion has been shown to reduce cord compression, leading to resolution of FHR decelerations (RR = 0.53; 95% CI, 0.38 to 0.74; n = 1,000) and lowering the likelihood of cesarean delivery. Health care professionals play the game to hone and test their EFM knowledge and skills. A scalp pH of less than 7.20 is considered abnormal and generally is an indication for intervention, immediate delivery, or both.12 A pH less than 7.20 should also be assumed in the absence of an acceleration following fetal scalp stimulation when fetal scalp pH sampling is not available. Theyll wrap a pair of belts around your belly. Your doctor evaluates the situation by reviewing fetal heart tracing patterns. Mosby's Pocket Guide to Fetal Monitoring: A Multidisciplinary - eBay What characteristic of this fetal heart rate tracing is indicative of fetal well-being? A.True B.False According to the 2008 NICHD consensus report, the normal frequency of uterine contractions is which of the following? Category 1. What should be the nurse's next action? 3/10/2017 Fetal Heart Tracing Quiz 1 Correct. The baseline FHR is 135 bpm with moderate variability. The patient received an epidural bolus approximately 10 minutes ago. The practitioner has ordered continuous electronic monitoring, but the patient requests IA for the early part of labor. Variable decelerations may be classified according to their depth and duration as mild, when the depth is above 80 bpm and the duration is less than 30 seconds; moderate, when the depth is between 70 and 80 bpm and the duration is between 30 and 60 seconds; and severe, when the depth is below 70 bpm and the duration is longer than 60 seconds.4,11,24 Variable decelerations are generally associated with a favorable outcome.25 However, a persistent variable deceleration pattern, if not corrected, may lead to acidosis and fetal distress24 and therefore is nonreassuring. A normal fetal heart tracing would reassure both you and your obstetrician that its safe to proceed with labor and delivery. Notify your provider if the baby's movement slows down, The nurse explains to the student that increasing the infusion rate of non-additive intravenous fluids can increase fetal oxygenation primarily by, A pregnant woman's biophysical profile score is 8. Management depends on the clinical picture and presence of other FHR characteristics.18, Overall Assessment (O). Fetal hypoxemia results in biphasic changes in the ST segment of the fetal electrocardiography (FECG) waveform and an increase in the T:QRS ratio.15 The ST-segment automated analysis (STAN) software from Noventa Medical can record the frequency of ST events and, combined with changes in continuous EFM, can be used to determine if intervention during the labor process is indicated.15 Several studies have evaluated FECG analysis, documenting its effectiveness at reducing operative vaginal deliveries, fetal scalp sampling, neonatal encephalopathy, and fetal acidosis (pH < 7.05).2528 One drawback to this technology is that it requires rupture of the membranes and internal fetal scalp monitoring. Together with Flo, learn how fetal heart tracing actually works. Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a patient in labor when repetitive late decelerations are noted on the external fetal monitor. Maternal hypotension and uterine hyperstimulation may decrease uterine blood flow. The workshop introduced a new classification scheme for decision making with regard to tracings. Influence of Gestational Age on Fetal Heart Rate 8. The true sinusoidal pattern is rare but ominous and is associated with high rates of fetal morbidity and mortality.24 It is a regular, smooth, undulating form typical of a sine wave that occurs with a frequency of two to five cycles per minute and an amplitude range of five to 15 bpm. Amnioinfusion for umbilical cord compression in the presence of decelerations reduced: fetal heart rate decelerations (NNT = 3); cesarean delivery overall (NNT = 8); Apgar score < 7 at five minutes (NNT = 33); low cord arterial pH (< 7.20; NNT = 8); neonatal hospital stay > three days (NNT = 5); and maternal hospital stay > three days (NNT = 7). Detection is most accurate with a direct fetal scalp electrode, although newer external transducers have improved the ability to detect variability. -Daily Fetal Kick Counts While caring for a patient in active labor at 39 weeks' gestation, the nurse interprets the FHR tracing as a Category III. For the letters on this figure, choose the likely cause of melting for Site B. An acceleration pattern preceding or following a variable deceleration (the shoulders of the deceleration) is seen only when the fetus is not hypoxic.15 Accelerations are the basis for the nonstress test (NST). The EFM toolkit also offers EFM CE opportunities and C-EFM(R) certification information. Initiate scalp stimulation to provoke fetal heart rate acceleration, which is a sign that the fetus is not acidotic. Fetal Heart Tracing Quiz 8 - Utilis a) Recalculate the branch current in the 22 \Omega2 resistor, I2I _2I2. Fetal heart tracing is also useful for eliminating unnecessary treatments. Nonreassuring patterns such as fetal tachycardia, bradycardia and late decelerations with good short-term variability require intervention to rule out fetal acidosis. Increase mainline IV Interpretation of the FHR variability from an external tracing appears to be more reliable when a second-generation fetal monitor is used than when a first-generation monitor is used.3 Loss of variability may be uncomplicated and may be the result of fetal quiescence (rest-activity cycle or behavior state), in which case the variability usually increases spontaneously within 30 to 40 minutes.19 Uncomplicated loss of variability may also be caused by central nervous system depressants such as morphine, diazepam (Valium) and magnesium sulfate; parasympatholytic agents such as atropine and hydroxyzine (Atarax); and centrally acting adrenergic agents such as methyldopa (Aldomet), in clinical dosages.19.
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