Trying to make sense of uterine rupture fear... - Mothering Forums

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#1 of 37 Old 07-31-2007, 03:03 PM - Thread Starter
 
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I just picked up a copy of the new book "Pushed" by Jennifer Block; its awesome! Anyway, I'm up to the section about VBACs and the more I understand about uterine rupture, the more puzzled I am: I simply cannot make sense of why the obstetrics community (and women in general) take a c-section (and all of its' potential risks) so lightly...but quiver in fear at the extremely rare chance of uterine rupture???? When you get right down to it, isn't a c-section essentially a planned uterine rupture? Even my new midwife, while acknowledging how rare rupture is, says that its "something they worry about" with this ominous look on her face. Isn't normally the patient who has the irrational fear and the provider who reassures the patient with the facts? Something is just inherently backward about this whole thing: is there any other area of the medical community (plastic surgeons aside) where people are encouraged to undergo unnecessary surgery for something that will remedy itself with time?
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#2 of 37 Old 07-31-2007, 03:32 PM
 
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For me, personally, before i had my vbac, it was the randomness factor. Yes, i had a 99.5% chance of being fine. But there are those 1 in 200 women that do have a UR. And there is very little reliable, consistent way to know who it will happen to and who it won't. And who will catch it in time have a healthy baby and who won't.

But i choose to vbac because i had two other little ones at home who needed me to be able to take care of them. And because surgery is terrifying to me.

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#3 of 37 Old 07-31-2007, 03:36 PM
 
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Something is just inherently backward about this whole thing: is there any other area of the medical community (plastic surgeons aside) where people are encouraged to undergo unnecessary surgery for something that will remedy itself with time?
I am a little confused what you mean by this? I know that the majority of ruptures are asymptomatic dehiscences, is that what you are talking about?

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#4 of 37 Old 07-31-2007, 04:38 PM - Thread Starter
 
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I am a little confused what you mean by this? I know that the majority of ruptures are asymptomatic dehiscences, is that what you are talking about?
Sorry, I meant that birth would likely remedy itself with time; specifically referring to giving a woman time to VBAC vs. planned elective c-section.
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#5 of 37 Old 07-31-2007, 04:40 PM
 
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Sorry, I meant that birth would likely remedy itself with time; specifically referring to giving a woman time to VBAC vs. planned elective c-section.

Gotcha

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#6 of 37 Old 07-31-2007, 06:25 PM
 
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I reasoned that there are so many things that can go wrong in birth with or without a scar and that I was sick of worrying and needed to just trust my body. I never understood the scared mentality of the medical pros either. I had already had a section and knew I might not slide by so easily with very few side affects the next time.
The word "rupture" is a scary word anyways it makes me think of a damn breaking or something. I always refered to "uterine instability" instead of rupture when talking about my scar and the risk I was taking. I used this wording in my birth plan. (example, If I experience uterine instability, this is what I would like to happen in regards to baby care, people in OR ect) I know that "instability' is one of those terms that could be interpreted many ways but rupture is also and I couldnt come up with a better word!!
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#7 of 37 Old 07-31-2007, 06:55 PM
 
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I reasoned that there are so many things that can go wrong in birth with or without a scar and that I was sick of worrying and needed to just trust my body. I never understood the scared mentality of the medical pros either. I had already had a section and knew I might not slide by so easily with very few side affects the next time.
The word "rupture" is a scary word anyways it makes me think of a damn breaking or something. I always refered to "uterine instability" instead of rupture when talking about my scar and the risk I was taking. I used this wording in my birth plan. (example, If I experience uterine instability, this is what I would like to happen in regards to baby care, people in OR ect) I know that "instability' is one of those terms that could be interpreted many ways but rupture is also and I couldnt come up with a better word!!
Angela
This is interesting. Since a lot of "rupture" isn't the uterus actually rupturing (just windows) i think the term uterine instability is probably more appropriate. It also brings up different connotations than "rupture" Mind if i use your word?

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#8 of 37 Old 07-31-2007, 06:59 PM
 
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I just picked up a copy of the new book "Pushed" by Jennifer Block; its awesome! Anyway, I'm up to the section about VBACs and the more I understand about uterine rupture, the more puzzled I am: I simply cannot make sense of why the obstetrics community (and women in general) take a c-section (and all of its' potential risks) so lightly...but quiver in fear at the extremely rare chance of uterine rupture???? When you get right down to it, isn't a c-section essentially a planned uterine rupture? Even my new midwife, while acknowledging how rare rupture is, says that its "something they worry about" with this ominous look on her face. Isn't normally the patient who has the irrational fear and the provider who reassures the patient with the facts? Something is just inherently backward about this whole thing: is there any other area of the medical community (plastic surgeons aside) where people are encouraged to undergo unnecessary surgery for something that will remedy itself with time?
Some honestly believe that the c/s they think they can control is a lot more safer than the possibility of a rupture that is a scary out of control thing for them ( of course, the sense of control is illusory).

Many though admit that it's due to the legal climate. Very rarely is a doctor sued for doing a c/s, only for not doing one. Rupture cases have brought in huge jury awards. That's pretty much it.
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#9 of 37 Old 07-31-2007, 09:30 PM
 
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I think we should also consider the roles of insurance companies, hospitals and doctors alike when it comes to this anti-VBAC problem. Malpractice insurance urges physicians to take what they consider the easy route with a c-section since, as doctors, they are first highly trained as surgeons and not as natural birth attendants. Hospitals rely on the revenue of c-sections -upwards of $15-20,000 instead of the meager $2-4,000 they charge for a vaginal delivery. Insurance companies don't take time to question why they are paying for so many c-sections, they just pay up. Most don't cover homebirths either, which is strange because they'd save a bundle on c-sections.
As for doctors, and this is my opinion (everyone's free to disagree), while I respect many of them, do not belong in the delivery room at all unless the pregnancy is genuinely high-risk or a c-section is really called-for. To them, everything is a potential emergency with childbirth, that is how they are trained to look at it, so it's no surprise that they too are more supportive of repeat c-sections. They don't trust that women's bodies are beautifully designed for childbirth, scarred or not. That's one reason why there are so many primary sections.
You just have to find your own faith in your body and realize that while the risk of UR is there, it is very small. You have to decide if it's worth that risk for you. I had to separate my thoughts about the risks from what I heard from my (ex) OB and all the other naysayers I encountered and come to a place where I don't care what their preconceived notions are, they're overreacting, I'm not.
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#10 of 37 Old 07-31-2007, 09:37 PM
 
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isn't a c-section essentially a planned uterine rupture?
There ya go! We should start saying "with a section you have a 100% chance of uterine rupture!"

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#11 of 37 Old 08-01-2007, 01:03 AM
 
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Oh, to be a fly on the wall to see a pregnant mama tell that to a VBAC-resistant OB.
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#12 of 37 Old 08-01-2007, 01:07 AM
 
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Oh, to be a fly on the wall to see a pregnant mama tell that to a VBAC-resistant OB.

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#13 of 37 Old 08-01-2007, 03:06 AM
 
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Honestly, I think there's another factor, although I'm not sure that any OB would admit it - maybe not even to themselves. I think the fear of rupture, on the part of practitioners is partly driven by...ego, I guess. Many of these doctors really do seem to have some kind of god-complex - a belief that they can make everything right, and fix whatever problems may exist. Rupture scares them, because they did it. They put the scar there in the first place, and they can't pretend that they've made everything perfect for mom and baby when mom has a catastrophic rupture in her second pregnancy. Despite their impressive ability to ignore statistics, they can't ignore numbers like a 1 in 17,000 chance (last I saw cited for an unscarred uterus) vs. a 1 in 200 chance (most frequent number I see cited for a scarred uterus). So, instead of acknowledging that this is potential complication they created - often unnecessarily - they simply focus on trying to prevent it from happening...by cutting again.

Maybe I'm off my nut, but I've felt this way about it for a long time...fits into my confusion about how they reconcile "VBAC is SO dangerous" with "c-section is safe"...conveniently (once again) overlooking the fact that the c-section they performed is what created the increased risk of rupture in the first place. The obstetrical community is playing mind games with itself.

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#14 of 37 Old 08-01-2007, 08:45 AM
 
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I think that that 1 in 200 mark is based on hospital VBAC--and reflects inductions as well as all the other normal interference that takes place in hosptials--women lying on their backs for constant monitoring, not being allowed to eat/drink enough, IV's etc. I would have to say from informal surveys I've done w/HBAC midwives, that the rate of rupture at home, with a healthy mom and no interference, is much much lower than that. Much lower!
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I think that that 1 in 200 mark is based on hospital VBAC--and reflects inductions as well as all the other normal interference that takes place in hosptials--women lying on their backs for constant monitoring, not being allowed to eat/drink enough, IV's etc. I would have to say from informal surveys I've done w/HBAC midwives, that the rate of rupture at home, with a healthy mom and no interference, is much much lower than that. Much lower!
Oh, I agree, but I was talking about the stats the OBs use (although the OB I was seeing last time cited a 3.7% risk for me, because I'd had two sections...fear-mongering, anybody?). I really think they're paranoid about UR, because they feel responsible to some degree...and won't admit it to themselves.

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#16 of 37 Old 08-01-2007, 03:18 PM
 
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The 1 in 200 number is based on hospital births but it does not include inductions. The rate of rupture with induction is a bit higher than 1 in 200. The other hospital interferences, while they may sabotage a VBAC attempt, are not linked to rupture risk.

I did all the "right" things and still had a rupture. Sometimes terrible things just happen.

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I did all the "right" things and still had a rupture. Sometimes terrible things just happen.
I don't know that there are any "right" things you can do; like you said, it just happens. It is the randomness that scares the bejesus out of most of us.
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#18 of 37 Old 08-03-2007, 02:56 AM
 
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The midwife I met with today was telling me that the insurance companies who insure birth centers, hospitals, etc, often place strict restrictions on who can and can't VBAC in their setting.

I personally can't blame doctors for being protective of their livelihood. Yes, it would be great if every doctor did the "right" thing by every patient and didn't think of possible litigation, but the reality is that even if parents have been through true informed consent and the doctor is doing what they want, if something happens to the baby, they can be successfully sued. My OB was telling me that the average OB on the East Coast has been sued 1.3 times. Sometimes no one is doing something wrong and terrible things happen to babies. There are risks to having children.

I personally take the risk of uterine rupture seriously. Yes, it's only .5% and if it were a .5% chance that my baby could end up brain damaged. I will VBAC this baby because I think it's less risky than a C-section for me and the baby, but I do take uterine rupture seriously.

About home birth having fewer instances of uterine rupture, that may be true. But it may take a home birth midwife a long time to rack up 200 VBAC mamas, so just talking to one and asking if she's seen it, the answer is probably not.

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There ya go! We should start saying "with a section you have a 100% chance of uterine rupture!"
Hmmm. One more thought, if it's ok.

99.6% chance I won't rupture vs. 100% chance you will rupture.

:
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#20 of 37 Old 08-03-2007, 11:11 AM
 
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Hmmm. One more thought, if it's ok.

99.6% chance I won't rupture vs. 100% chance you will rupture.

:
Gee, whatever will I choose? :

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#21 of 37 Old 08-03-2007, 03:36 PM - Thread Starter
 
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I personally take the risk of uterine rupture seriously. Yes, it's only .5% and if it were a .5% chance that my baby could end up brain damaged. I will VBAC this baby because I think it's less risky than a C-section for me and the baby, but I do take uterine rupture seriously.
I don't think anyone is saying they don't take the risk of UR seriously, just saying that it doesn't make sense that the more risky of the two options is being promoted as the "better" option. I could walk into any random OB right now and ask for a repeat c-section and could have one scheduled, no questions asked...but have to fight tooth and nail to find VBAC support, even though it is statistically the safer option for mother and baby.
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#22 of 37 Old 08-03-2007, 04:20 PM
 
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I personally can't blame doctors for being protective of their livelihood. Yes, it would be great if every doctor did the "right" thing by every patient and didn't think of possible litigation, but the reality is that even if parents have been through true informed consent and the doctor is doing what they want, if something happens to the baby, they can be successfully sued. My OB was telling me that the average OB on the East Coast has been sued 1.3 times. Sometimes no one is doing something wrong and terrible things happen to babies. There are risks to having children.
I think that this is the problem-- in a lot of those cases, those primary c-sections were not for a valid medical reasons. So this is largely an OB- made problem. Honestly, if i died from having a repeat c-section or my baby died in a vbac, the responsibility would mainly lay in the fact that i couldn't find a doctor to be there to catch my frank breech first baby. Yes, it is risky to have a c-section. Yes, it is risky to have a vbac. Sometimes woman have a catastrophic rupture and sometimes they die during a RCS. If there weren't so many doctors doing frivolous primary c-sections in the first place, there wouldn't be the problem of having to choose between two risky things, kwim?

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#23 of 37 Old 08-03-2007, 08:39 PM
 
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If there weren't so many doctors doing frivolous primary c-sections in the first place, there wouldn't be the problem of having to choose between two risky things, kwim?


Amen to that!
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#24 of 37 Old 08-03-2007, 08:46 PM
 
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I don't think anyone is saying they don't take the risk of UR seriously, just saying that it doesn't make sense that the more risky of the two options is being promoted as the "better" option. I could walk into any random OB right now and ask for a repeat c-section and could have one scheduled, no questions asked...but have to fight tooth and nail to find VBAC support, even though it is statistically the safer option for mother and baby.
I didn't mean to imply that anyone wasn't taking it seriously -- just that for me personally, it does scare me. I agree -- it seems *most* people choose repeat C-section because they think it's safer, and it clearly is not in most cases. In my experience I am not having to fight for a VBAC, but I will have to fight for how I want to VBAC and it is very discouraging and irritating. : It sucks that in many parts of the country people have to fight just to VBAC. Someone on another board I'm on said in her area, they call it a "trial of labor" after a C-section. What a terrible way to word it -- it's like setting you up for failure before you even start. Even where I am where it's, in theory, pretty VBAC friendly, the only choices I am finding are home birth or hospital birth with restrictions -- no middle ground. More :

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I think that this is the problem-- in a lot of those cases, those primary c-sections were not for a valid medical reasons. So this is largely an OB- made problem. Honestly, if i died from having a repeat c-section or my baby died in a vbac, the responsibility would mainly lay in the fact that i couldn't find a doctor to be there to catch my frank breech first baby. Yes, it is risky to have a c-section. Yes, it is risky to have a vbac. Sometimes woman have a catastrophic rupture and sometimes they die during a RCS. If there weren't so many doctors doing frivolous primary c-sections in the first place, there wouldn't be the problem of having to choose between two risky things, kwim?
Yeah, I do KWYM. And I agree. But I also think part of the responsiblity lies in the litigious culture in the US. I think many OBs are terrified of a law suit and that drives their decision making, instead of what is best for this particular patient. That sucks and it's not right and it should not enter their decision making. Their oath is to first do no harm & if they're pushing surgery which is risker than a breech birth, it's wrong. There certainly are crappy doctors who push for a C-section because it's 7:30 on a Friday night and they want to get home. My Mom swears that her doc pushed Pitocin on her with my sister because he wanted to get to a golf game on a Saturday. I think many OBs are human and think about themselves and protecting their careers in addition to what's best for their patient. And I think there is some collective cultural responsibility for that. That's all I meant.

It's sad that things like breech birth are less and less a part of medical training and there are fewer and fewer OBs who even know how to do them. :

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#26 of 37 Old 08-03-2007, 08:55 PM
 
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If there weren't so many doctors doing frivolous primary c-sections in the first place, there wouldn't be the problem of having to choose between two risky things, kwim?
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#27 of 37 Old 08-03-2007, 11:09 PM
 
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I just picked up a copy of the new book "Pushed" by Jennifer Block; its awesome! Anyway, I'm up to the section about VBACs and the more I understand about uterine rupture, the more puzzled I am: I simply cannot make sense of why the obstetrics community (and women in general) take a c-section (and all of its' potential risks) so lightly...but quiver in fear at the extremely rare chance of uterine rupture???? When you get right down to it, isn't a c-section essentially a planned uterine rupture? Even my new midwife, while acknowledging how rare rupture is, says that its "something they worry about" with this ominous look on her face. Isn't normally the patient who has the irrational fear and the provider who reassures the patient with the facts? Something is just inherently backward about this whole thing: is there any other area of the medical community (plastic surgeons aside) where people are encouraged to undergo unnecessary surgery for something that will remedy itself with time?
It's about the lawsuits. If you have a catastrophic rupture and sue, you'll probably win because they didn't "do" something (ie the c/s) quickly enough.

What I'm dumbfounded by (and I haven't read all the replies so someone may have mentioned this already) is that the TOTAL risk of rupture is the same or lower than the likelihood that an amniocentesis will cause a miscarriage.....and only about 30% of ruptures are even catastrophic. Some are simply dehesciences (sp?), places where the scar pulls apart slightly with no harm to you or the baby. But amnio's are treated way more casually than VBAC, and I've never heard of a hospital "banning" amnio.
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#28 of 37 Old 08-04-2007, 02:30 PM
 
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About home birth having fewer instances of uterine rupture, that may be true. But it may take a home birth midwife a long time to rack up 200 VBAC mamas, so just talking to one and asking if she's seen it, the answer is probably not.


ITA. I wish Homefirst, the home birth docs in Chicago, would publish their stats. They have 30 years and 14,000 births as a track record. I suspect that their rupture rate is the certainly no more than the statistical norm.
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Originally Posted by grumpyshoegirl View Post
What I'm dumbfounded by (and I haven't read all the replies so someone may have mentioned this already) is that the TOTAL risk of rupture is the same or lower than the likelihood that an amniocentesis will cause a miscarriage.....and only about 30% of ruptures are even catastrophic. Some are simply dehesciences (sp?), places where the scar pulls apart slightly with no harm to you or the baby. But amnio's are treated way more casually than VBAC, and I've never heard of a hospital "banning" amnio.
Good point!

~Marie : Mom to DS(11), DS(10), DD(8), DD(4), DD(2), & Happily Married to DH 12 yrs.!
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#30 of 37 Old 08-04-2007, 04:16 PM
 
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With respect to the issue of lawsuits:

Canada is not known for having as litigious a culture as the US. Nonetheless, I see all the same justifications for c/s and RCS here as a I see in the US. I was still forced (as in prepped for surgery while screaming "no, I don't want a c-section", then given anesthetic without being told once I was in OR) into my first surgery, and my objections to my 2nd and 3rd were completely ignored. After 41w5d and over a week of prodomal labour, I was told that if I didn't have the surgery, I wouldn't have a doctor. C/S rates here are climbing. VBAC is hot topic, and while it's given lip service the first time around VBAmC is absolutely not allowed, and licensed midwives cannot attend them. The OB I was seeing the last two times (didn't have an OB for my first) informed me that we follow the US's lead. For example, ACOG apparently changed, or was considering changing, "post-date" guidelines to require induction or c/s at 41 weeks, whereas the Canadian guideline at the time was 41w, 3d. According to the OB, the SOGC (Society of Obstetricians and Gynecologist of Canada) will probably change their guidelines to the US ones.

So, even though the c/s rate and denial of VBAC is frequently laid at the door of the litigious US culture, and I frequently see universal health care cited as a cure...we have the same problem in Canada, despite having universal health care, and not having the same litigiousness of culture. There's more going on here than lawsuits. Is the problem as bad here? I don't think so - but it's still bad, and getting worse.

Lisa, lucky mama of Kelly (3/93) ribboncesarean.gif, Emma (5/03) ribboncesarean.gif, Evan (7/05) ribboncesarean.gif, & Jenna (6/09) ribboncesarean.gif
Loving my amazing dh, James & forever missing ribbonpb.gif Aaron Ambrose ribboncesarean.gif (11/07) ribbonpb.gif

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