Labour Admission Test: International Journal of Infertility and Fetal Medicine December 2011

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Labour Admission Test

Article  in  International Journal of Infertility and Fetal Medicine · December 2011

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REVIEW ARTICLE Labor Admission Test

Labor Admission Test


1
Vikram Sinai Talaulikar, 2Sabaratnam Arulkumaran
1
Clinical Research Fellow, Department of Obstetrics and Gynecology, St George’s Hospital Medical School, Cranmer Terrace
London, United Kingdom
2
Professor and Head, Department of Obstetrics and Gynecology, St George’s Hospital Medical School, Cranmer Terrace
London, United Kingdom

Correspondence: Vikram Sinai Talaulikar, Clinical Research Fellow, Department of Obstetrics and Gynecology, St George’s
Hospital Medical School, Cranmer Terrace, London SW17 0RE, United Kingdom, e-mail: vtalauli@sgul.ac.uk

ABSTRACT

Labor admission test (LAT) is performed at the onset of labor to establish fetal well-being in low-risk pregnancies and identify those fetuses
who either may be hypoxic, needing delivery or at risk of developing hypoxia during labor so that additional measures of fetal surveillance
can be instituted to prevent adverse outcomes. We searched the literature in Medline, Cochrane Library and PubMed using the words—
cardiotocograph, cardiotocogram, nonstress test, vibroacoustic stimulus (VAS), amniotic fluid index (AFI), Doppler, labor admission test,
labor admission cardiotocography (CTG) and reviewed four randomized controlled trials (RCTs) and three systematic reviews to summarize
the current evidence regarding use of LAT. Although the existing RCTs and systematic reviews do not favor admission testing, we have
critically reviewed the methodology used in some of these major studies. There is a need for robust RCTs with adequate sample size to
evaluate the effectiveness of LAT. In clinical practice, while a normal admission CTG reassures the mother and the clinician about the
health of the baby, an admission CTG with nonreassuring FHR pattern leads to careful review which may reveal a growth restricted or
compromised fetus before onset of active labor when the risk of fetal hypoxia is higher with increasing frequency and duration of uterine
contractions. Like in other obstetric interventions, the woman should be offered the choice of LAT after providing appropriate information
and her informed decision should be respected.
Keywords: Labor admission test, Admission CTG.

WHAT IS LABOR ADMISSION TEST? Since its introduction in 1960s, the intrapartum and the
Labor admission test (LAT) is a test of fetal well-being that is admission use of the electronic fetal monitoring increased
performed when a woman with a low-risk pregnancy is admitted rapidly in well-resourced countries. The effectiveness of
in labor. Its aim is to assess fetal well-being at the onset of continuous CTG in labor was evaluated in a Cochrane systematic
labor and identify those fetuses that may be already hypoxic or review in 2006 which included 12 randomized and quasi-
may not withstand the stress of uterine contractions which can randomized controlled trials (over 37,000 women).1 The study
expose them to hypoxia in labor. Such fetuses may then be found that continuous cardiotocography during labor was
delivered or subjected to additional tests of fetal surveillance associated with a reduction in neonatal seizures, but no
like continuous CTG (cardiotocography) throughout labor in significant differences were noted in cerebral palsy, infant
order to prevent adverse outcomes. An admission CTG and mortality or other standard measures of neonatal well-being.
‘intelligent’ auscultation are the two commonest forms of There was an increase in cesarean sections and instrumental
admission tests carried out in modern obstetrics. We searched vaginal births with the use of CTG. The authors suggested that
the literature in Medline, Cochrane Library and the PubMed the real challenge was how best to convey this uncertainty to
using the words—cardiotocograph, cardiotocogram, nonstress women to enable them to make an informed choice without
test, vibroacoustic stimulus (VAS), amniotic fluid index (AFI), compromising the normality of labor.
Doppler, labor admission test, labor admission CTG and Most clinical guidelines that subsequently emerged
reviewed four randomized controlled trials and three systematic recommended continuous CTG in labor for women at high risk
reviews to summarize current evidence on the use of LAT. and intermittent auscultation for those considered at
low risk.2 The clinician was often faced with the challenge of
HISTORY adequate identification of women at high risk in labor. There is
no such thing as ‘no risk’ in obstetrics. There is ‘low risk’ and
Electronic fetal monitoring/CTG was introduced with the aim ‘high risk’, with a common phenomenon being a change in risk
of reducing perinatal mortality and morbidity like cerebral palsy. with time from the former to the latter.3 Fetal morbidity and
mortality are greater in high-risk women, such as those with
Date of Received: 00-00-00
prolonged pregnancy, intrauterine growth restriction,
Date of Acceptance: 00-00-00 hypertension, diabetes or other risk factors. However, it is
Date of Publication: September 2011 interesting to note that in pregnancies that proceeded to term,

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Vikram Sinai Talaulikar, et al

morbidity and mortality due to intrapartum events occurred with Feeling of fetal movements associated with FHR
similar frequency in those categorized as low risk compared accelerations and no decelerations soon after a contraction
with high risk based on traditional classification4,5 suggesting should reassure the mother and the healthcare professional of
that some of the high-risk cases may have been missed during good fetal health. Subsequent observations should be—
antenatal assessments. auscultation of FHR soon after contraction every 15 minutes
LAT was originally designed as a preliminary assessment for 1 minute in the first stage of labor and every 5 minutes or
of women with low-risk pregnancies at the onset of labor so after every alternate contraction in the second stage.2
that those with nonreassuring fetal heart rate (FHR) pattern could
Admission CTG
be subjected to additional tests of fetal surveillance or delivered
depending on the severity of fetal jeopardy. It often meant that The labor admission CTG comprises of a CTG trace of 20 to
women with abnormal LAT were classified as high risk and 30 minutes duration carried out on admission to the maternity
then monitored with continuous CTG throughout labor. Thus, ward. Most admission tests last 15 to 30 minutes. However, a
LAT could be utilized as a screening tool in early labor to detect normal trace that shows two accelerations and no decelerations
compromised fetuses on admission and select the women who with two contractions within 5 to 10 minutes should not be
may benefit with continuous CTG during labor. monitored unduly. If the test is attempted when the fetus is in
quiescent/sleep phase, it will need to be continued until the
FORMS OF ADMISSION TEST fetus reawakens and a reassuring FHR pattern emerges. In
clinical practice, an admission CTG with nonreassuring fetal
History and Clinical Examination heart rate pattern may often lead to careful review of the case
On admission to the labor ward, detailed history should be which may reveal a growth restricted or compromised fetus
obtained to recognize any known risk factors to detect before onset of active labor when the risk of fetal hypoxia is
pregnancies at highrisk. History of reduced fetal movements is higher with increasing frequency and duration of uterine
important. General examination should include—estimation of contractions.
body mass index (BMI), blood pressure, temperature and signs
Advantages of Admission CTG Overauscultation
of anemia. Thorough abdominal examination needs to be carried
out including symphysial-fundal height (SFH) measurement, A crucial advantage of the admission CTG is the ability to assess
assessment of fetal lie, presentation, station of presenting part all parameters of fetal heart rate including baseline variability.
and nature of contractions. After 20 weeks of pregnancy, SFH Presence of accelerations, normal baseline heart rate, variability
corresponds to gestational age in cm +/– 2 cm up to 36 weeks more than 5 bpm and absence of any decelerations are features
and +/– 3 cm after 36 weeks. A reduced SFH may indicate a of a normal reassuring CTG (Fig. 1). Although auscultation
small fetus who may be suffering from chronic hypoxia and may provide the baseline fetal heart rate and indicate presence
such a fetus is more likely to develop an abnormal heart rate of accelerations/decelerations—baseline variability is not
pattern before and particularly in labor.3 Although clinical audible to the unaided ear and quantification/description of type
estimation of fetal size and liquor volume may be subjective, it of decelerations may be difficult.
may be valuable in cases of significant IUGR or macrosomia The admission CTG being a visual test can make parents as
to undertake additional investigations, such as ultrasonography well as clinicians feel reassured that the fetus is not at risk of
and to anticipate and prepare for complications during labor. hypoxia at the time of admission and is unlikely to develop
Vaginal examination should include assessment of cervical hypoxia in the next few hours.
dilatation, effacement, status of membranes and color of liquor, Interpretation of Admission CTG
station of the presenting part as well as any malpresentation
A normal admission CTG in a mother who on history and
and caput/molding of head if in advanced labor.
examination is low-risk assures a healthy fetus for the next
Auscultation
When performing an admission test with auscultation alone a
Doppler device is preferable to Pinard’s or stethoscope. The
mother should be asked about fetal movements and a baseline
FHR recorded. An attempt should then be made to feel the fetal
movements per abdomen and look for any fetal heart rate
accelerations associated with these movements. If there are
uterine contractions, presence or absence of any obvious
decelerations immediately after the contractions should be noted
and an attempt made to estimate the depth and duration of
Fig. 1: Reactive CTG with normal baseline heart rate (110-160 bpm),
deceleration, and whether it recurs with the next few contractions two accelerations in 15 minutes, normal baseline variability and no
with the mother on her left lateral. decelerations with contractions

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Labor Admission Test

3 to 4 hours unless an acute obstetric event supervenes, such bear in mind that a hypoxic fetus can have a normal baseline
as—placental abruption, cord prolapse, injudicious oxytocic rate and shallow decelerations of less than 15 bpm in a non-
use or incorrect application of instrument.3 If the admission reactive trace when the baseline variability is below 5 bpm
test is normal and reactive, a gradually developing hypoxia will (Fig. 3). Such a fetus may not withstand the stress of uterine
be reflected by no acceleration, repeated decelerations and contractions and runs the risk of death within a few hours of
gradually rising baseline rate. Furthermore, it is known that if a admission. An anemic fetus (due to fetomaternal hemorrhage)
well-grown fetus with clear amniotic fluid and a reactive CTG will manifest with a sinusoidal trace which may not be picked
trace starts to develop an abnormal FHR pattern, it takes some up on auscultation alone as the baseline rate may well be within
time with these FHR changes before acidosis develops. A study normal limits (Fig. 4).
estimated that in situations with abnormal FHR pattern—for
50% of the babies to become acidotic took 115 minutes with EVIDENCE FOR THE USE OF LAT
repeated late decelerations, 145 minutes with repeated variable Prospective Studies
decelerations and 185 minutes with a flat trace.6 Fetuses with a
reactive admission test will show following features prior to or A large blinded prospective study of admission CTG was
becoming hypoxic—all will exhibit decelerations (100%), conducted in 1041 low-risk women where the trace was
almost all will have reduced baseline variability (93%) and analyzed after the delivery of the fetus which was monitored
by intermittent auscultation.8 The test was reactive in 94.3%
baseline tachycardia (93%) (Fig. 2).7 On the other hand, if the
and in this group fetal distress (cesarean section, forceps for
admission test is nonreactive, the development of further
distress, Apgar score less than 7 at 5 minutes) occurred in 1.3%.
abnormal features with progress of labor are variable and
Ten patients (1.0%) had ominous tests; four of these had fetal
subtle; this is difficult to recognize by intermittent auscultation
distress and one of these fetuses died in utero 3 hours after
(Fig. 3).3 This is because there might be preexisting hypoxic
admission, during which time stethoscopic auscultation failed
damage and the fetus is unable to respond. It is important to
to detect the fetal compromise. It was concluded that the
admission test can detect fetal distress already present at
admission and unnecessary delay in intervention could be
avoided in such a case. The test seemed to have some predictive
values for the fetal well-being for the next few hours of labor
following the test.
Another study performed fetal heart tracing on
cardiotocogram for 30 minutes in 500 women on admission in
labor and contraction-mediated responses were recorded.
Subjects were also stratified into high or low-risk groups based
on antenatal factors. Seventy-seven out of 500 labor cases
(36 out of 433 cases with reactive, 16 out of 37 with suspicious
and 25 out of 30 cases with ominous LATs) manifested fetal
distress. Eighty-two percent of antenatal high-risk and 89%
of low-risk pregnancies showed reactive LATs. The LAT
was found to have high specificity (93%) and negative
Fig. 2: CTG trace with fetal tachycardia, markedly reduced baseline predictive value (91%). However, the sensitivity and positive
variability and atypical variable decelerations predictive values were lower (53% and 61% respectively).

Fig. 3: Admission CTG with markedly reduced baseline variability and Fig. 4: CTG with sinusoidal FHR trace
shallow decelerations that may be difficult to identify on auscultation.
These cases do not show the rise in baseline FHR with hypoxia but the
FHR may suddenly collapse with terminal

International Journal of Infertility and Fetal Medicine, Vol. 2, No. 3 91


Vikram Sinai Talaulikar, et al

Patients with no antenatal risk factors did not develop fetal women was managed actively. Among other things, the
distress till 6 hours after reactive LAT.9 amniotomy was performed upon admission (mean cervical
A systematic review in 2005 which included 11 observational dilatation at rupture of membranes was less than 2 cm) and
studies besides three randomized controlled trials (RCTs) found only those with clear amniotic fluid were included in the
that the prognostic value of LAT from the observational studies study. Clear amniotic fluid in itself would have served as
for several major maternal and neonatal outcomes was generally an admission test. Early amniotomy is not a norm in most
poor.10 labor wards and may be associated with a nonsignificant
A Norwegian study was conducted to explore what trend toward increase in the risk of a cesarean section. Third,
information and knowledge the labor admission test is perceived the high rates of continuous CTG and a higher incidence of
to provide and what meaning the test carries in the daily work fetal blood sampling (FBS) may have been because in this
of practicing midwives using in-depth interviews of 12 study 32% of admission CTGs were considered suspicious
practicing midwives.11 The findings suggested that the midwives or abnormal—an unexpectedly high percentage in early
found conflicting interests within themselves, or between labor in women with clear amniotic fluid. This may signify
themselves and others when using the labor admission test. the limitation of 20 minutes for LAT if it was done in the
It was concluded that the labor admission traces could be quiet epoch of the CTG.
difficult to interpret, especially for newly qualified midwives. 2. Mires et al conducted an RCT to compare the effect of
Some midwives thought that a labor admission trace could admission cardiotocography and Doppler auscultation of
protect them in case of litigation. The hierarchy of power in the the fetal heart on neonatal outcome and levels of obstetric
labor ward influenced the use and interpretation of the labor intervention in a low-risk obstetric population.13 A total of
admission test. Some midwives also felt their professional 2367 women were randomized to receive either
identity threatened and that midwives in general were losing cardiotocography or Doppler auscultation of the fetal heart
their traditional skills because of the increasing use of obstetric when they were admitted in spontaneous uncomplicated
technology. labor. The primary outcome measure was umbilical arterial
metabolic acidosis. There were no significant differences
EVIDENCE FOR USE OF ADMISSION CTG FROM in the incidence of metabolic acidosis or any other measure
RANDOMIZED CONTROLLED TRIALS (RCTs) AND of neonatal outcome among women who remained at low
SYSTEMATIC REVIEWS risk when they were admitted in labor. However, compared
Randomized Controlled Trials with women who received Doppler auscultation, women
who had admission cardiotocography were significantly
1. An RCT conducted in Dublin aimed to compare the effect
more likely to have continuous fetal heart rate monitoring
on neonatal outcome of admission cardiotocography vs
in labor (odds ratio 1.49, 95% confidence interval 1.26 to
intermittent auscultation of the fetal heart rate.12 A total of
1.76), augmentation of labor (1.26, 1.02 to 1.56), epidural
8580 women admitted to the delivery ward of a Dublin
analgesia (1.33, 1.10 to 1.61) and operative delivery (1.36,
teaching hospital who were at low risk of fetal distress in
1.12 to 1.65). The conclusion of the trial was compared
labor were randomly assigned admission cardiotocography
with Doppler auscultation of the fetal heart, admission
(20 minutes) or intermittent auscultation only (with
cardiotocography does not benefit neonatal outcome in low-
continuous cardiotocography only if clinically indicated).
risk women.
The authors reported an increase in the use of continuous
3. Another RCT from Glasgow attempted to test the hypothesis
cardiotocography (1.39; 1.33-1.45) and fetal blood sampling
that the use of admission electronic fetal monitoring (EFM)
(1.30; 1.14-1.47) with admission cardiotocography. There
for healthy low-risk pregnant women (n = 312) in
were no significant differences in the rates of cesarean
spontaneous labor would result in an increase in continuous
delivery (1.13; 0.92-1.40), instrumental delivery (1.03; 0.92-
EFM when compared to women who have had no admission
1.16) or episiotomy (1.06; 0.99-1.13). Other indices of
EFM. 14 This trial found no statistically significant
neonatal morbidity also showed no differences. It was
differences between the groups for use of continuous
concluded that routine use of cardiotocography for
monitoring or any of the obstetric interventions studied. The
20 minutes on admission to the delivery ward does not
authors concluded that the use of admission EFM did not
improve neonatal outcome.
There are three significant issues that need to be in itself lead to a cascade of intervention.
considered regarding the conclusions of this study and its
Systematic Reviews
applicability to the general obstetric population. First, the
observation of no significant increase in operative delivery 1. A systematic review was performed to assess the effective-
could have been because of liberal use of fetal blood ness of the labor admission test in preventing adverse
sampling. Second, this study was performed at Dublin outcomes, compared with auscultation only, and to assess
National Maternity Hospital where labor in nulliparous the test’s prognostic value in predicting adverse outcomes.10

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Labor Admission Test

It included the above three randomized controlled trials CARDIOTOCOGRAPHY AND VIBROACOUSTIC
including 11259 women and 11 observational studies STIMULATION (CTG AND VAS)
including 5831 women. It was found that women A study investigated fetal heart rate reactions to the fetal acoustic
randomized to the labor admission test were more likely to stimulation in 952 women in early labor.16 All had cephalic
have minor obstetric interventions like epidural analgesia presentations (greater than 33 weeks of gestation) and were
(RR 1.2, 95% CI 1.1-1.4), continuous electronic fetal screened with a 15 minutes fetal heart rate recording (admission
monitoring (RR 1.3, 95% CI 1.2-1.5) and fetal blood test) before the sound stimulation was applied. Three different
sampling (RR 1.3, 95% CI 1.1-1.5) compared with women types of responses were observed: Type I, an accelerative
randomized to auscultation on admission. There were trends response; type II, a biphasic response with acceleration(s)
toward more operative deliveries, operative deliveries for followed by a deceleration; type III, no response or a prolonged
fetal distress and cesarean sections among the women deceleration (greater than 60 beats/min and greater than
randomized to the labor admission test, although these 60 seconds). A type I response was recorded in 98.0% of the
differences did not reach statistical significance. There were women after a reactive admission test result, in 90.2% after an
no significant differences in augmentation of labor between equivocal admission test result, and in 42.9% after an ominous
the two groups, or in any of the neonatal outcomes. From admission test result. Fetal distress in labor occurred in these
the observational studies, prognostic value for various three groups is 2.0, 22.2 and 35.7% of cases respectively. The
outcomes was found to be generally poor. The authors risk for fetal distress was high after an ominous admission test
concluded that there is no evidence supporting that the labor and a type III response on the fetal acoustic stimulation test
admission test is beneficial in low-risk women. (75.0%). It was suggested that the fetal acoustic stimulation
The high proportion of labor admission tests considered test might be of value in labor and give additional information
abnormal by Impey et al12 and Mires et al13 may be the about fetal well-being in patients previously screened by the
reason that so many women in the intervention group had admission test. Testing time can be shortened after an equivocal
continuous electronic fetal monitoring which then led to admission test.
increased obstetric interventions. The authors pointed out Another prospective study involving 210 women which
that in low-risk women, serious adverse outcomes occur evaluated the efficacy of VAS and modified fetal biophysical
infrequently and that their meta-analysis may be profile (mFBP) for early intrapartum fetal assessment and
underpowered to detect differences in these outcomes. prediction of adverse perinatal outcomes reported a high
2. Another systematic review published in 2007 was performed accuracy of VAS/mFBP for early intrapartum fetal assessment
(diagnostic values for perinatal morbidity—sensitivity 66.7%,
with the aim to determine whether intrapartum admission
specificity 99.0%, positive predictive value 80% and negative
CTG in women at low obstetric risk can improve neonatal
predictive value 98%).17
outcome (in terms of Apgar score) and whether it is
associated with an increase in the incidence of instrumental
DOPPLER STUDIES
delivery and cesarean section.15 The same three RCTs were
included. The pooled relative risk for having an Apgar score The main drawback of use of Doppler studies as a screening
less than 7 points at 5 minutes after delivery was higher in tool in early labor is the need for ultrasound equipment and
the admission CTG group (RR 1.35, 95% CI 0.85-2.13) expertise. Umbilical artery Doppler velocimetry has been used
but it was not statistically significant. The pooled relative as an admission test but shown to be a poor predictor of fetal
risks for having a cesarean section delivery (RR 1.2 95% distress in labor in low-risk population. A large study of 1092
CI 1.00-1.41) and an instrumental delivery (RR 1.1 95% women showed Doppler at admission to be of little value in the
CI 1.00-1.18) were both higher in the admission CTG group. presence of normal CTG. In those cases with a suspicious
Both these were statistically significant. The reviewers admission CTG, normal Doppler velocimetry was associated
with less operative deliveries for fetal distress, better Apgar
concluded that intrapartum admission cardiotocography in
scores and less need for assisted ventilation or admission to
women at low obstetric risk increases the risk of cesarean
neonatal intensive care unit.18
section and instrumental delivery. In addition, there is no
evidence for neonatal benefit in terms of Apgar score at AMNIOTIC FLUID INDEX (AFI)
5 minutes after delivery. However, the authors suggested
that a larger sample size would be needed in order to answer Perinatal mortality and morbidity are increased in the presence
of reduced amniotic fluid volume at delivery. Measurement of
this important question.
amniotic fluid volume in early labor has been considered an
admission CTG to triage a fetus to a high-risk or low-risk status
GUIDELINES
in early labor. In a study of 120 women in early labor,19 it was
NICE guidance (based on the systematic review by Blix et al10) found that ultrasound measurement of the vertical depth of two
presently does not recommend the use of admission amniotic fluid pockets could be easily and rapidly performed
cardiotocography in low-risk pregnancy in any birth setting.2 by medical and midwifery staff and that the results were easily

International Journal of Infertility and Fetal Medicine, Vol. 2, No. 3 93


Vikram Sinai Talaulikar, et al

reproducible. Depth of two pools > 3 cm was highly sensitive Bulk of the evidence regarding use of LAT in low-risk
and predictive when used as a predictor of the absence of women stems from the three RCTs performed to date. NICE
significant fetal distress in the first stage of labor. guidelines do not recommend routine use of admission CTG in
In another study of 1092 singleton pregnancies,20 a four low-risk pregnancies based on the findings of the systematic
quadrant AFI < 5 in early labor was associated with higher review incorporating these three RCTs. However, a critical
operative delivery rates for fetal distress, low Apgar scores and appraisal of the RCTs suggests that the biggest study by case
more infants needing assisted ventilations. numbers that may have influenced the meta-analysis of the
Reduced liquor volume may often be a sign of incipient systematic review had a preselection criteria of clear amniotic
hypoxia. As labor progresses, the stress of uterine contractions fluid at early cervical dilatation (mean <2 cm). Additional
and cord compression may lead to development of hypoxia and advantage was the one to one midwifery care in their unit, that
acidosis. permits FHR auscultation every 15 minutes in the first stage
A Cochrane Database systematic review published in 201121 and every 5 minutes in the second stage of labor. Such facilities
reviewed evidence on the benefits of admission tests other than may not be available in other settings. Hence, appropriate
cardiotocography in preventing adverse perinatal outcomes. The randomized controlled trials of LAT with adequate sample size
objective was to assess the effectiveness of admission tests other are required to obtain definitive answers. Absence of robust
than cardiotocography in preventing adverse perinatal outcomes. evidence does not equate lack of effectiveness.
The reviewers included one study involving 883 women The parents should be given a choice, as in every matter,
[comparison of sonographic assessment of amniotic fluid index after providing them with relevant information about LAT and
(AFI) on admission vs no sonographic assessment of AFI on their final decision should be respected. EFM should be used
admission]. The incidence of cesarean section for fetal distress appropriately to serve best its original purpose for which it was
in the intervention group (29 of 447) was significantly higher introduced—to identify fetuses at risk in labor so as to take
than those of controls (14 of 436) [risk ratio (RR) 2.02; 95% appropriate steps to prevent adverse outcomes.
confidence interval (CI) 1.08 to 3.77]. The incidence of Apgar
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