In this episode, we discuss guidelines about bulb suctioning at the time of delivery. Then we discuss the nearly 100 year old schedule of prenatal visits and how these can be modernized. Finally, we discuss the next Eat, Sleep, Console approach for neonatal abstinence.
0:02
Neonatal Suctioning
Reforming Prenatal Visits and Outdated Recommendations
Streamlining Prenatal Visits and Remote Monitoring
The Controversy Surrounding Home Dopplers
Efficiency and Effectiveness of Prenatal Visits
Prenatal Care and Biomarkers for Preeclampsia
Comparing Methods of Diagnosing NAS
Follow us on Instagram @thinkingaboutobgyn.
In this episode, we discuss guidelines about bulb suctioning at the time of delivery. Then we discuss the nearly 100 year old schedule of prenatal visits and how these can be modernized. Finally, we discuss the next Eat, Sleep, Console approach for neonatal abstinence.
0:02
Neonatal Suctioning
Reforming Prenatal Visits and Outdated Recommendations
Streamlining Prenatal Visits and Remote Monitoring
The Controversy Surrounding Home Dopplers
Efficiency and Effectiveness of Prenatal Visits
Prenatal Care and Biomarkers for Preeclampsia
Comparing Methods of Diagnosing NAS
Follow us on Instagram @thinkingaboutobgyn.
This is thinking about OBGYN with your hosts Antonia Roberts and Howard Harrell.
Howard:Antonia.
Antonia:Howard.
Howard:What are we thinking about on today's episode?
Antonia:We're going to talk about the frequency of prenatal visits, with some interesting historical tidbits in there, as well as new evidence about the optimal management of newborns with potential neonatal abstinence syndrome. But first, what's the thing we do? For no reason, antonia.
Howard:Well, how about bulb suctioning the mouth and nose out of the baby at the time of delivery?
Antonia:All right. This, I think, has been pretty routine for a while, especially with caesareans. I'm sure this still happens fairly often throughout the country and probably the world. So the idea is that the fluid, like the amniotic fluid, that's in the mouth or the nose of the baby right at birth, can include the airway or even be aspirated during those first breaths that they take. So what's the evidence on this practice?
Howard:Well, this hasn't been a recommended practice for many years, but I think, like a lot of things, especially things with something as common as how to deliver a baby, there's just a lot of inertia and tradition in what we do, so most older physicians or I guess anyone who's trained before 2013, which would include me were likely told to suction the infant's mouth and nose immediately after delivery, even before the first breath, if possible, and then those physicians continue to teach that to the next generation as just how you do it. It's a basic, simple thing, but way back in July of 2013, there was a study published in the Lancet which gave us information about this practice that we didn't have before. They randomized 488 infants born at the University of Alabama, Birmingham beyond 35 weeks gestation to either traditional bulb suctioning or to just wiping the face off with a towel, and they found no difference in a variety of respiratory outcomes that they measured in the first 24 hours of the newborn's life.
Antonia:And we should point out that by sticking a bulb in the babies, the back of their mouth or their nose, there is the potential for causing bradycardia or even apnea, so it's not a completely harmless procedure.
Howard:Yeah, and actually the recommendation to routinely suction normal newborns was removed back in 2006 in our neonatal resuscitation guidelines in the United States, but it was replaced with a statement that wiping or suctioning could be used. Either one, wiping the face off or suctioning, could be used, and they gave it to the reader as an equivalent choice between those two things.
Antonia:Yeah, so that's basically still like a green light for everyone who was already doing it to just keep doing it, because it says you can.
Howard:Right. They didn't say not to do it. Now there were several smaller studies and other pieces of evidence at that time that it wasn't a useful practice, and this was coming out at about the same time when our view of suctioning meconium with an endotracheal suction device was also being removed from our guidelines as long as the infant was vigorous by 2010,. Before the study I mentioned was published, the International Liaison Committee on Resuscitation clarified that suctioning wasn't necessary. Finally, in 2015, the Neonatal Resuscitation Program guidelines removed the recommendation to routinely suction non-vigorous babies born through meconium-stained fluid.
Antonia:That's right, because we were already supposed to stop suctioning vigorous babies' mouths and noses almost 10 years before that.
Howard:Yeah, there was some small population follow-up studies that questioned the impact of this change for non-vigorous meconium-stained infants, but so far no quality data has led to a change of that recommendation. But the current guidelines from many years say not to bulb suction vigorous babies with clear fluid, but perhaps just to wipe the face if there's lots of secretions and if the baby's non-vigorous bulb suctioning can be performed as part of stimulation. The goal here is to stimulate the infant and the bulb is quite good at doing that. So if the baby's gasping, not breathing, has poor tone or you feel that the secretions are blocking the airway and the child's having breathing problems because of that, then you can still suction.
Antonia:And remember that this is actually, I think, easy to mix up, but the mouth before nose, or M before N, because this helps lower the risk of aspiration, in case you put the bulb in the nose first and it causes the baby to gasp, and they gasp whatever fluid is in their throat. So get the throat stuff out first. Mouth before nose.
Howard:It works well as long as you know the alphabet.
Antonia:Yeah.
Howard:And yeah, so the same rules apply for meconium-stained fluid as well.
Antonia:now yeah, so no suctioning for most infants has been the rule for more than five years now.
Howard:That's right, but old habits die hard.
Antonia:Yes, well, let's move on. Let's talk about the frequency of prenatal visits. There's a systematic review that discusses the evidence about the number and frequency of visits during pregnancy in the July 2023 Green Journal, and you and I have talked about this often on before over the years. But there's not a lot of evidence for how we do prenatal visits in the United States and it is quite a bit different than in Europe, for example, and other countries, and there's really no reason to believe that we have better outcomes because of how we do it compared to how they do it. But before we talk about the article, why don't you tell us about the history of why we do our prenatal visits the way we do them now?
Howard:You do that just to make me happy.
Howard:So, not everybody cares, but it is fascinating. So our current schedule for prenatal visits has literally been unchanged since 1930. So in 1930, the United States Department of Labor Children's Bureau published a booklet called prenatal care and I'll put a link to it so folks can look at it. It's fascinating. It's definitely worth spending a few minutes with the PDF. This was a 71 page booklet that covered most everything about pregnancy and was taken as sort of guideline for the standardization of prenatal care and prenatal visits at the time. One thing you'll see in it is that much of what's there we know today is simply not true. But also a lot of it will still look familiar as some of the traditional knowledge or maybe we should call it folk tales about pregnancy and prenatal care that's been handed down over generations in our specialty.
Howard:So this was very influential and came about at the dawn of the modern prenatal care system. We didn't have many interventions to offer pregnant women in 1930. But within a few years of this publication we would see dramatic breakthroughs that did significantly lower maternal mortality and neonatal mortality. Specifically, we would see the introduction of sulfa antibiotics and then eventually penicillin and that, combined with a few other things like the introduction of ergotamines in the 20s that became more common, heparin in 1937, and even just blood transfusion becoming more widely available, all these things combined to just make a dramatic difference in the next few years in maternal and neonatal outcomes. So while those improved outcomes are not really attributable to anything in this pregnancy, prenatal guide, at the time people saw this programmatic adoption of all this schedule and advice and all that stuff as something associated with it. And since things were getting better, and year by year it was getting better, we just followed this for decades.
Antonia:It's almost like it was viewed as part of a bundle of just across the board improvements. I guess that's a lucky coincidence for that prenatal care booklet then. So does it specifically recommend how often prenatal visits should be?
Howard:Yes, it says that the doctor will want to see the patient at least once a month during the first six months, every two weeks or oftener in the next two months and every week in the last month.
Antonia:Oftener, not more often.
Howard:I didn't write it, but that's the word. The federal government wrote it. Okay, but in any event, it says that each of those visits will look into her general condition, take her blood pressure, analyze her urine and carefully weigh her. And I think the key to understanding where the frequency of visits comes from is in that statement. And as the frequency is basically what folks do today, where patients might be seen monthly until 28 weeks, and then twice a month until 36 weeks and then a weekly after that, it's literally the same thing. It hasn't changed, except in the rest of the world and among individual physicians. Nope, not everybody follows that and they may modify that with fewer visits for low-risk patients.
Antonia:Yeah, I do think there's a range. I was actually trained on a little bit less frequent nine-visit pathway for routine care, so that was, I'd say, just a slight modification of what you just listed. So every four to six weeks in the beginning of pregnancy, then at least every four weeks in the third trimester, but at least every two weeks really, when patients were at term. And often the only reasons we would increase that frequency, if not for a medical complication like diabetes or hypertension or something, would really just be for scheduling reasons, because oftentimes, unfortunately, our schedulers couldn't make the schedule out for as far as six weeks ahead. They'd be stuck at sometimes just a few weeks ahead. So sometimes we would do every four weeks for our own scheduling reasons, but I don't know if that's really a universal issue. So what were you saying about understanding the reason for this schedule?
Howard:Well, another really important thing that had just happened and that was really having a big impact at that time on our understanding of obstetric science, was the widespread adoption of the blood pressure cuff and an understanding of how hypertension affected pregnancy. So the first edition of Williams Obstetrics does it mention blood pressures at all? Because we didn't know anything about it, at least not in any way that related to pregnancy or something that you could clinically use or measure reliably. It was an invasive measurement, if anything. We certainly knew about what was then called toxemia, what we now today call preeclampsia, but we didn't even know that that was related directly to hypertension. The blood pressure cuff had been invented in 1881, but there wasn't a practical version of it until 1896, and even then it wasn't widely available for many years later.
Antonia:You mean the sphygmomanometer?
Howard:I wasn't going to say the word, but if you would like to say that, you can use it. I don't think I can say that word if we're being honest, so I'm going to stick with blood pressure cuff.
Howard:But, yes, and importantly, in 1901, it was actually Dr Harvey Cushing of Cushing's Disease Fame who brought an example of a blood pressure cuff to the United States and began using it, and at the time this just was able to measure the systolic pressure. In 1905, Nikolai Kortakov of the Kortakov Sounds introduced the idea of the diastolic measurement as well, and so it was after that time that we first started learning about blood pressure, at least in an academic setting. The first edition of Williams' Aesthetics was published a year or two before then, but finally in the second edition there's at least a mention of blood pressures. But it really wasn't until 1916 that William Baum invented a practical working blood pressure cuff that they called at the time the Baumanometer, which is a bit easier to say.
Howard:And then the idea of monitoring blood pressure really took off because there was a product available that anybody could buy and we were learning about what that meant, and it became routine over the next few years in a healthcare setting. So by the 1930, we understood clearly that toxemia was related to hypertension, and there's actually an illustration on page four of this 1930 guide, a little picture showing the physician taking the mother's blood pressure. That was new to patients we were educating patients about the importance of it and what it was and how you took a blood pressure. It's right above the description on how often their prenatal visit should be, because that was the main reason why the visits were occurring.
Antonia:All right, and we should review what this book says about toxemia, aka preeclampsia. I've been looking through this book the electronic version while you've been talking. I'm just trying to look for that, but I found some other gems instead, so here's just a few of them, quoting intercourse during the early months of pregnancy is a frequent cause of miscarriage. And then it also says that no sex should occur in the last three months of pregnancy because it'll cause both labor and septicemia. Okay, and it has a lot of clothing and fashion recommendations. Like you can't wear round garters or tight any tight bands. That part maybe makes sense.
Howard:Pressure on the baby, I guess.
Antonia:Yeah, but it does still note that dresses for pregnant women should be attractive.
Howard:Well, there you go.
Antonia:Their words. And then in the activity section I see that horseback riding and tennis are forbidden. That's good, At least the horseback riding part, I think.
Howard:Can you play tennis on horseback? Probably not, probably not Okay.
Antonia:Taking trips should be avoided, because the trip can cause you to lose your pregnancy. Driving on rough roads should be avoided, and I guess I don't know what the rate of car accidents were back then.
Howard:People still think they can go drive on a gravel road and put them into labor and stuff like that comes from this advice.
Antonia:Yeah, a long railroad trip can cause either miscarriage or premature delivery. Such great information here, I wonder what my patients would think if I started telling them this. And oh and then it says that you should meet chocolate while you're pregnant.
Howard:Well.
Antonia:How about that?
Howard:No chocolate for you. Well, you can laugh at it, but remember we're still doing prenatal visits the same way this book told us to. I think that's the point here is how scientific was much of this advice, with the same lack of evidence that's behind a lot of the things you just quoted not eating chocolate, etc. And frankly, I know of doctors out there today that still tell women that sex can cause a miscarriage and some of the nonsense that this book really popularized. I'm definitely not claiming we should recommend this book to pregnant women as a guide for essential care.
Howard:But to answer your questions about toxemia, it does share what was the prevalent idea at the time that there was a buildup of toxins or waste products in the blood that were poisoning the mother over time because it wasn't being eliminated by the mother's monthly menses or through some other waste elimination process, which they focused a lot on bowel movements as well as a way of eliminating waste.
Howard:But one of the key recommendations was that the mother had her blood pressure taken regularly at each doctor visit and have her urine examined for protein. They understood those things about toxemia, about preeclampsia, and our modern prenatal care system is essentially built around those two principles. So there's a lot of other nonsense in the recommendations too that sound like good medical advice if you have a 1930s pathophysiology understanding perhaps but are not scientific like avoiding salt, drinking eight glasses of water a day, wearing lightweight clothing. But it was a huge breakthrough at the time to understand that protein area and hypertension were signs of what we now call preeclampsia and once outcomes, as I said, started getting dramatically better in the next few years. For all those other reasons, this program of visits and a lot of the advice in that book stuck without question.
Antonia:That's interesting. I'll have to keep reading through this. I know that in the past, enemas were a big thing and I wonder if that's because pregnant women get constipated and Well, they do talk about eliminating waste and preventing things from happening.
Antonia:So yes, they thought constipation would cause preeclampsia. That's interesting, okay. Well, I see in another section here it lists a lot of reasons for miscarriage that include heavy work such as washing, sweeping, lifting, moving furniture, using a sewing machine, dancing, skating, tennis again, golf, horseback riding, climbing, bouncing in roads on the car or those long train journeys. And they say that intercourse, besides causing miscarriage, can also cause retroversion of the uterus. Ooh, maybe they were, really, I don't know. And the best way to prevent miscarriage is to prevent overexertion, even to the point of promoting bed rest in the early, like the first trimester or whenever they found out they were pregnant, and a lot of those things are absolutely incorrect ideas that a lot of them are probably still prevalent today.
Howard:I do have to admit I was reading some of this activity portion to a female medical student and the part about not washing and sweeping and lifting while you're pregnant she found quite appealing and wanted to preserve that for her husband, I think. But yeah, well, okay. Well, that brings us to this new article that you mentioned. So there's been a lot of interest for a number of years in reforming the frequency of visits or finding at least some evidence for what we do, and eliminating unnecessary visits or replacing them with something else. And I think this caught some steam during the COVID-19 pandemic, although now I think most places have just reverted back to whatever pre-pandemic practices were.
Howard:But during the COVID-19 pandemic, when we weren't able to see patients as easily, we thought which visits can we eliminate? How can we do this remotely, things like that. So as we move into an age of home blood pressure monitoring, that's becoming more accurate, other blood tests that maybe can predict who's going to get preeclampsia and the first trimester, or some combination of blood tests plus maternal risk factors, something like that, to know who the right high-risk patients are, or even things like the uterine artery notching index as part of some predictive algorithm, it will become more and more feasible to eliminate many unnecessary visits for women who are ultimately at some low risk of developing preeclampsia, especially if you realize that the only reason that that patient is there is maybe to check protein in a urine and to check your blood pressure based upon this 93-year-old screening guideline.
Antonia:We do still need to talk about how many times a urinalysis or urin dipstick should be done during pregnancy. I know there's at least in my most recent electronic health record for every visit there's a spot where we're supposed to put in what's the urine protein and ketones. But we can save that every visit. Urine dipstick maybe for another thing. We do for no reason segment some other time because there's no science behind checking it every single visit.
Antonia:The home blood pressure monitoring systems are still being refined for feasibility and cost-effectiveness. So I think the best evidence says so far it hasn't changed outcomes due to detecting anything earlier, like detecting a high reading earlier than otherwise would have been detected without the home system. But at the very least it can reliably reduce trips to the office. That would have mainly just been for checking that blood pressure. And of course we don't just check the blood pressure great by like. We embellish those visits with other things like face-to-face counseling. We try to use that time to address patient concerns. We check the baby's heart rate too. But the bottom line is the majority of prenatal visits revolve around checking the blood pressure.
Howard:Right, and typically in the United States women are receiving 12 to 14 office-based visits, even for low-risk pregnancies, somewhat more than the nine-visit pathway that you talked about in your training, which I think is closer to a lot of European programs, and in other parts of the world those visits are reduced down to as few as six, seven or eight visits.
Antonia:Yeah, so let's think about what the average visit in the US looks like now, or the average course of visits throughout a pregnancy, and what they could look like instead. And again, this is a little bit more frequent than what I was trained on, so I'm not as familiar with just a routine 14 visit pathway, but I might be in the minority or my training program might be in the minority there. So you count. While I'm listing these off, I'm going to go with the every month, then two weeks and one week.
Howard:I only have 10 fingers. Let me take my shoes off. Okay, hang on Okay, go ahead.
Antonia:So there's an initial visit, say around six weeks, to establish viability and dating. Then a month later you got 10-week follow-up. Month later, 14 weeks, 18 weeks, Anatomy ultrasounds at 20 weeks, even though that's now a two-week gap. But then you got to fill in a month from 18 weeks you have 22-week visit, 26. Then now we hit 28 weeks. So we have to double that frequency. So 28-week visit, then 30, 32, 34, 36 weeks. Now we hit the weekly schedule, so 36 to 37, 38, 39, 40, maybe even 41. After that, hopefully she'll just have her baby already.
Howard:That caused me pain just listening to that many visits.
Antonia:Yeah, me too. I'm out of breath just listening to those. I would expect every pregnant woman going through that kind of a schedule to be begging for an induction or begging for a scheduled delivery as early as possible, just so she can stop coming out to the office so often. How many did you count when I listed those?
Howard:Well, that was 16 total. Now I didn't count the 20-week because that realistically that's probably done at the 18.
Howard:It's done at the same time as the visit, Although not always Some people send that patient to a separate clinic or something for ultrasounds, so it might be an extra visit. We're not even talking about patients that have to go to high risk for ultrasounds or some other clinic to get their stuff done. Of course, most women don't have a 41-week visit and then you might skip the 28 and go from 26 to 30 or something like that. Realistically, if you get rid of a couple there, then you end up with that 14 weeks that a lot of folks have. But we could cut that down to six to nine visits pretty easily for low-risk patients.
Antonia:Yeah, a lot of those visits don't have anything extra being done. They're literally just blood pressure and, nowadays, of course, fetal heart rate check, possibly that year analysis. If that's done at the practice, then whatever additional education and support is requested or just built in to that schedule, let's review what this could or maybe even should look like for a low-risk patient.
Howard:Okay, Well, you can come in for your first visit and get labs and an ultrasound and accurate dating of your pregnancy in around six weeks, something like that whenever they get in. In a single-payer system like the military, it's typical to push for that first visit to be out to even 10 or 12 weeks, because you're more likely to get an accurate ultrasound, even if the dates don't line up with her last period as expected. But in a typical US health system where we're competing for those patients and those early visits and the patient wants the early visit, then that will get her in there earlier. It gives her the earliest answer. That's what she's looking for, and so every prenatal office is going to offer a six-week or so visit to somebody now days. So then after that six-week visit she can come in again for 10 or 12 weeks for non-invasive prenatal screening.
Antonia:Yeah, so just because we used to just just be like, yeah, go to the lab in a few weeks.
Howard:If we stretch that out to 12 weeks then you're going to have less insufficient testing done because some of those 10 weeks will come back insufficient. So that also saves time and money. But maybe somebody wants it exactly at 10 weeks, particularly if they're at higher risk to have earlier time to deal with the information. But typically that will be tied into a visit. It doesn't have to be. You could say just come back for the test when you're 10 to 12 weeks at the lab and pick it up. But I also think there's some logic to making sure that they have cardiac activity before you waste the money on the test in the case of a miscarriage. So I think in practical terms most of us are going to see the patient, make sure she has cardiac activity, discuss the test with her and then do that. So that's a second visit. And also we're learning more and more about at that visit about how we might stratify the patient for preeclampsia and now we don't know what that looks like yet, but it could be blood testing, it could be ultrasound testing, it could be a combination of things, a nomogram that helps to understand if this person it might be an increase risk for preeclampsia and you might consider early testing for diabetes if she has certain risk factors. We've talked about that a lot, that the evidence on that practice is quite poor, but certainly some patients definitely have risk factors sufficient for screening. Then you could have her come back at 18 or 20 weeks for the anatomic ultrasound, which often is done in the clinic, not at a separate radiology facility like you're used to, but it isn't always. Some practices might send that patient to the local maternal fetal medicine office for an ultrasound or something like that, but that's a third visit and then return at 26 weeks to 28 weeks for blood count and glucose tolerance testing and Rhogam if she's Rh negative, perhaps a type and screen if necessary. Most blood banks should be able to use a type and screen for up to two weeks for Rhogam purposes, although in the civilian world we just give the Rhogam based upon the first trimester type and screen, we don't have to draw a second one Interesting, so that actually saves that testing and you could just have the patient come back at 28 weeks and do or 27, 28 weeks, something like that and do Rhogam, third trimester labs if you think they're necessary glucose tolerance testing etc. And then she could come back at 32 weeks where you might give her the Tdap shot and whatever else counseling or things are necessary.
Howard:Then 36 weeks for her group B strep swab and make sure the fetus is cephalic, and then maybe even just 41 weeks after that if she's still undelivered for discussion about induction of labor. And of course that could be Shut down sooner if the patient desired an elective induction or needed to repeat cesarean or something like that. So that's how you get to six or seven visits and it's still possible to do that with enhanced blood pressure screening. If we did this remotely, if the patient did it at home, essentially A lot of the psychosocial support and educational programs and even screening for depression or domestic violence or things like that could be done online Through virtual visits or virtual group visits or with community health workers who go to the home or doulas or other methods of supporting that. And this includes things like prenatal classes or support groups Again, which could be done in person or online for the patient. A lot of resources for that now.
Howard:But essentially what we've done is get rid of all those visits that are really just there for checking the blood pressure.
Antonia:Yeah, even I still get a little bit antsy about the concept of going just from 36 to 41 weeks with no visits in between. But you just laid out you know that's still possible and valid to do, as long as we're accounting for the blood pressure somehow. And I think we all did become a lot more comfortable during the COVID pandemic with virtual visits. And now we've learned from that that the outcomes are the same Even when you don't make patients come in to every single visit, like when you still have some of those visits, but have them over the phone or some other remote method. And although the bump trial showed that checking blood pressures at home did not improve outcomes, that was being done in addition to also doing standard care, where it's also being checked regularly in the office.
Howard:Yeah, that was extra blood pressure checks not the ones that we recommend anyway.
Antonia:Yeah, so obviously extra, extra blood pressure checking does not help. But that same technology that exists for that remote monitoring could be utilized to replace the in-office monitoring of blood pressure. That wouldn't necessarily the benefit of that would be reducing an office visit. That could be very inconvenient for the patient. And one big thing missing from all of this that we've just been talking about of how to do the blood pressure remotely is fetal heart tones. I know they did not have dopplers or ultrasounds in widespread use back when that 1930s prenatal care guide was written and you can't hear much with a Panards deathoscope before the third trimester. You certainly can't expect a woman, just a lay person at home, to hear anything. I've actually tried it on myself and I just I didn't hear anything.
Howard:And that can be anxiety provoking.
Antonia:Yeah, yeah, exactly. So how would we get well? Firstly, I know people have come to expect to hear that heartbeat when they come to the clinic, and if we just tell them, actually you don't need to come back for five more weeks, they're gonna. They're gonna think like well, should I buy a Doppler on Amazon Because I want to hear that heartbeat. So what do you have to say about that?
Howard:Well, I think in some ways this is like patients have come to expect yearly pap smears or yearly pelvic and breast exams too in their 20s.
Howard:We have built into that maybe a false sense of reassurance or meaning. Patients will say, oh, it sounds very strong, Did it sound strong? Was it a good heartbeat? As if we're doing some qualitative analysis of the heartbeat and that it has a reassurance about something. So I think it depends too about whether or not the mother is in a gestational age where she can feel movement or not. But you know, the reality of it is, if they can feel movement, they know that the baby's alive. But it definitely has become normalized. And the other thing we could talk about is fundal heights, right. But you know, yes. So now that we can easily view or listen to the baby's heartbeat, as soon as there's cardiac structures formed, that's become a highly motivating factor for patients to come into the office, and maybe that's a good thing in that it encourages them to come to get prenatal care. But it's maybe a bad thing that we've made that mean something to the patient that it doesn't actually mean. If they are a gestational age where they can't feel movement, I suppose it's reassuring to know that their baby is still alive.
Howard:Besides that, there's no medical value to auscultating or doppelring it's not really auscultation the heart rate in the office.
Howard:And I'm not talking about, of course, indicated and natal testing, stress tests or things like that. I'm talking about using a doppler and just listening to the heart tones for five seconds. In arguments about detecting brady arrhythmias or tachy arrhythmias, they certainly don't withstand scientific scrutiny at all. We do not do that to screen for brady and tachy arrhythmias. During the COVID pandemic at least, where a lot of patients weren't coming in, some facilities did experiment with just handing out dopplers and blood pressure cuffs to their patients to allow them to get this reassurance outside of the office and that might cut down on unscheduled visits for anxious mothers, things like that. But otherwise, as I said, there's no medical value and I certainly wouldn't expect that to be cost effective and it might just be anxiety and visit promoting when patients try to listen to their heartbeat all the time, Not once a month but every day, because they have a doppler, and then when they can't find it, they're in the emergency department for seven hours.
Antonia:Yeah, I've had plenty of patients that told me they went ahead and bought their own doppler. I used one of their friends commercially purchased dopplers and I think it definitely creates a risk of worry because if she puts it on her belly she is going to expect to hear the heartbeat. She's not going to be like maybe I won't. Whatever she puts it on, she's not going to want to stop until she hears those pulses. And the earlier it is in the pregnancy, the more difficult it is to find because of course that heart is going to be so tiny. But regardless of that fact, if she doesn't hear it even if it's I don't know six weeks, 10 weeks even it becomes this emergency in her mind, like she's not going to stop thinking about what if it's a miscarriage?
Antonia:And I've had these same patients tell me they went to the emergency room in the first trimester not because they had any symptoms at all but because they hadn't heard the heartbeat and they wanted to hear it. They've gone to the emergency room for that and obviously that's not an appropriate use of emergency services. But in those stories I've never heard of them getting turned away. So they get seen and triaged and all of that, get an ultrasound and then they get referred for an acute follow-up visit.
Howard:Right, come back, come in the next day, because we saw the heartbeat.
Antonia:Yeah, yeah, exactly.
Howard:Very frustrating.
Antonia:Yeah, so because of the absence of medical value of having, especially of having, home dopplers, but really even of regular in-office dopplers, the possibility for unnecessary worrying and use of resources as I just described an example of, I definitely wouldn't want to recommend home dopplers, maybe unless the patients have been trained to use it, if it's like a nurse, other medical provider and they don't have the tendency to freak out if they can't hear it right away. But that's not going to be the majority of people.
Howard:And I think they're in the pandemic. When people were recommending that, they were recommending it because they didn't understand the value of doctors. There's not a medical reason to do it, and I would extend this conversation perhaps to fundal heights, although even with six or seven visits, even if you believe in fundal heights, you could still do one at those visits. But it's not like you're coming in every two weeks so that we can measure your belly. I don't do it at all because there's simply no scientific evidence that says that it has any validity. But in a world where the only purpose of the visit was to check your blood pressure, that fills a bit hollow, and so we've added these other things.
Howard:Like you know, these reassuring things, the mother isn't reassured when she comes in. You tell her blood pressure is normal. But she is reassured if you listen to the heart tones and put our hands on the belly or put a tape measure on the belly. But again, that's kind of like being saying that I do pap smears and pelvic exams every year because the women are reassured by it. That's on me for creating a false understanding and a false sense of security about what those things actually mean. But you know, Tom Cruise just bought an ultrasound machine when his wife was pregnant with Suri, and they actually passed a law in California to make it illegal for non-physicians to buy ultrasound machines they call it the Tom Cruise law. But as an obstetrician you have access to one, so if you're pregnant you can just pop on the ultrasound when you're at work, whenever you want to.
Antonia:Yeah, I guess it is easy for me to sit here as an obstetrician who's been pregnant to say, yeah, you don't need to do dopplers, because of course one of my job perks is I can do dopplers every day if I want, for free, and if I can't hear anything for some reason, I can no big deal.
Antonia:I can just walk into the next room at the end of the day and just look at my tiny baby for as long as I want. I did that with our toddler co-host, who's just outside playing right now. But I also remember, though, by the time I was feeling him consistently kicking in the second half. By then I really I didn't really want to put gel on my belly all the time and get all messed up, so I lost the motivation. By the time I felt that movement, even though I could have gotten all this bonus ultrasounding practice, the kicking was good enough for me. I think it's really probably for most people that first half of pregnancy where they're not feeling movements. All they get any signs of life is that little doppler, that little ultrasound. So they're hanging on to that.
Howard:Yeah, and that just affects a few visits early on anyway. So for fetal heart tones, women just need to hold out until right around the anatomy scan or use a home doppler. It's also the time when they're going to get the most difficulty hearing. It is when the fetus is still little. And we didn't mention weight checks either, and of course, those could also be done at home, and there are a lot of the companies that we're doing validated blood pressure cuffs and online communication with your EHR. We're also doing that with scales that are communicate with Bluetooth and then send that information back into our chart, and we've.
Howard:And again, the only thing we have to add to that is assessing the weight of the baby. And even if we're not doing fundal heights, of course there is still the idea of palpating and feeling. But we're talking about low risk patients. We're not talking about people who don't, who otherwise have an indication for ultrasound assessment of fetal weights, like diabetics and hypertensives and things like that. And for those normal low risk patients, simply screening them with manual palpation for growth abnormalities when they come in for their group B strep and those other visits is going to be more than enough.
Antonia:Yeah, Fetal growth restriction does sometimes occur in low risk women as well. It's just a lot more rare. But as far as I know, even screening with those manual palpation, leopold maneuvers I don't know that it's been established as something that's useful or necessary in low risk women.
Howard:Yeah, right, but someone, of course, would use that as an argument for what they're doing in those in-person visits, just like the heart, tones or the weight or whatever.
Antonia:Okay. Well then, what else does that leave us with as far as reasons to come into the office? I think that's the education and the opportunity for the patient to ask questions and get them answered right away.
Howard:Yeah, I think that's right, and that's why we have to think about a way, I think, of replacing that in-person education with other venues, whether it be online or with virtual visits or support groups or nurse educators or things like that. There are apps now that do this that are validated. There was a study in this month's greener grade journal I can't remember which that looked at a validated program for preterm labor education and actually studying it. It works. It's online or app-based kind of thing. So we definitely live in an age where that's doable and, frankly, people are going to get more quality education from a programmatic series of YouTube videos or app or something like that. Then they're getting haphazardly at five-minute prenatal visits. So education is definitely a valuable portion of prenatal care. But it would be nice, too, if questions could be answered and education provided whenever questions arose, not just at your visit every one month or three weeks after you have the problem. So we need a more modern system that might do that job better and, as I said, that could be a series of videos or other resources for patients to look at weekly or every other week or something like that does a much better job of making sure everything gets delivered systematically and answering questions that when they come up. There are apps and stuff now that are using the AI or other things to help answer questions. As they come up. You can text the app and ask things like that, but there's lots of ways of doing that, lots of opportunities for creativity that would make this better.
Howard:So I think even education and counseling are not specific reasons to have patients come in for extra and perhaps unnecessary in-person visits.
Howard:Now I'm not promoting 24-7 on-demand access through the chart for patients to message or questions to their doctors and expect immediate and comprehensive answers.
Howard:This is overwhelming folks and other specialties like internal medicine, where physicians are spending increasing amounts of time responding to unscheduled patient questions without getting compensation, and this is a situation where our billing codes don't really support that and they're too complicated and cumbersome for physicians to utilize when they do. There was actually a great editorial in the New England Journal of Medicine last month about a physician. I think it was in the New England Journal it might have been Jama about a physician internal medicine doctor during the pandemic, struggling for hours a day with just the onslaught of how the EHR had allowed patients to send in questions, and it was really well written and worth reading. I'll try to remember to put a link to it, but that's why we need other systems and again, apps and things like that. A lot of the questions that women have have been answered a thousand times, so we just need to direct them to the questions in AI systems or out there already. That can help do that.
Antonia:Yeah, so you're talking about using various educational and technological tools that would make more efficient use of physicians' time with patients, because there are days where the same question like let's say I have 10 patients in a row that will ask the same question and I'll say the same answer 10 times in a row Whereas if there was just an easy way to get that answer out in one blast in a different format to them, then we could just move on to whatever the follow-up questions are of that. We're just something else when they're seeing me. But it can be so easy to give in to demands for more and more access with time we don't actually have when we're finally out of the clinic and we're charting and looking through the messages and stuff, because we know that if they can't reach us and get an answer from us, then they might just turn to TikTok or something that we don't want them to look to with their questions and then that's just going to raise even worse questions back to us. So it would be great if there was an established way, of course, to compensate physicians proportionately for whatever medical counseling or education that they do electronically. But I think in that case patients would also probably want to know are they going to be charged a copay because they sent a question in the patient portal? So I think that's still an active area of refinement in our medical system. But I know there's lots of great resources out there right now to answer those most pressing and most common pregnancy related questions.
Antonia:So it's just a matter of finding what actually gets through most effectively, because I've seen, at least in some past clinics I worked at the big handouts that are made for each visit and I don't know how much they actually read through. Yeah, exactly. So let's talk about this systematic review about the prenatal visit frequency. So they looked at five randomized controlled trials and then also five non-randomized controlled trials that in some way sought to compare a decreased number of prenatal visits in some of the ways we've described and then looked at outcomes like gestational age at birth or likelihood of small for gestational age size babies, also likelihoods of low apcar score, nicu admission, maternal anxiety, preterm birth and comparing those to just the standard prenatal visit schedule. One thing they noted was a lot of outcomes that we care about from pregnancy don't have a plausible biologic connection to how the antenatal care is structured or how frequently it's split out into, and the bottom line is they found that doing fewer visits didn't affect any of those outcomes.
Howard:Yeah, I like this idea of biologic plausibility. If you look back in that book from the 1930s that we were making fun of, you'd think it would be really important to tell women what not to do to avoid miscarriage or to prevent development of toxemia and all these complications. But as we said here today, there is literally virtually nothing I can do to prevent a miscarriage or preterm birth in a low-risk patient. I can assess a woman's need for baby aspirin at her first needle visit for risk factor reeclampsia until to take it. If she actually has anaphylsyliponemobius syndrome, I can prescribe her an anicoagulant, things like that. I can assess her risk factors for things that might lead to a benefit from enhanced screening with ultrasound or NST, or maybe find somebody who needs a serclage or something like that.
Howard:But the outcomes that we care about are just not affected by most of the things we're doing at routine prenatal care visits, particularly for low-risk patients, like listening to the heart tones, for example, and there's some evidence that getting patients out of our clutches and away from some of the unnecessary tests and over-testing and too many ultrasounds that we do is actually associated with improved outcomes, so the inverse actually may be true. I think we're still digesting a lot of this data that we had during COVID, where women in many cases did get fewer ultrasounds or fewer non-stressed tests or fewer visits due to the pandemic. But when women had fewer visits and fewer ultrasounds we didn't see any problems and in some cases we might have seen improved outcomes. We saw, for example, a lower rate of iatrogenic prematurity in a lot of studies without a commensurate worsening of outcomes.
Antonia:Yeah, there's a recent report from the CDC we can put a link to that that shows that still, births in the first year or two of the pandemic were flat, they did not increase and that was in the context, as we just said, of fewer prenatal visits due to the pandemic and also people having COVID. And we know that COVID severe COVID at least actually does increase the risk of certain adverse outcomes.
Howard:So we would have expected an increase.
Antonia:Yeah, exactly, but there wasn't an increase. So that's pretty good proof. I think that at least listening to the heart tones once a month on a scheduled day cannot predict or prevent a fetal demise. Probably also throw in there the fundal height and the maternal weight for starters, so the regular fetal heart tones, though. It's just not a plausible way to prevent still births.
Antonia:Women were always free to come in anyway if they had a concern or a problem and obviously if they had risks for fetal demise they would still be getting that extra testing, even during the pandemic. But maybe we should talk for a minute about go back to these early blood tests that are being developed and published about to help screen patients at risk for preeclampsia. The first one of these tests has been FDA approved recently and it's part of this conversation we're having now, because we're talking about taking low risk women and not checking their blood pressures as often. And again, the main reason to do that is to find preeclampsia or some other hypertensive disease on that spectrum. The first time.
Antonia:Mom may not have any historic risk factors because she never had a prior pregnancy, but that just means that her any risk related to prior pregnancy outcomes is an unknown. It's a question mark. So because of that uncertainty, right now we still consider null parity to be a moderate risk factor for preeclampsia, like when we're looking for who we should prescribe aspirin to. So this FDA approved test would be one way to get further information, especially in these unknown cases, and it measures the ratio of serum soluble FMS like tyrosine, kinase one, or for short you could say S-FLIT that's how I pronounced that acronym, s-flit one placental growth factor. So do you think this test could help us determine who might need more visits, especially if you're looking at a nullic risk patient, or who could get less visits during their prenatal care?
Howard:Well, this test was originally validated in a trial published in the New England Journal of Medicine in 2016.
Howard:And the problem with this study mainly was that it looked at the development of preeclampsia within one week of the test as a way of excluding preeclampsia or the prediction of preeclampsia within four weeks of the test, and it was still pretty bad at that.
Howard:It did successfully exclude the development of preeclampsia in the subsequent week, with a negative predictive value of 99.3%, but the positive predictive value for development of preeclampsia within the subsequent four weeks if the ratio was above 38, was only 36%, and it was very nonspecific and nonsensitive. So this test isn't going to be the one that helps at least by itself helps us determine whether or not a woman is at risk of developing preeclampsia for our whole pregnancy and, honestly, compared to what we're doing now, I'm not sure it adds much of anything to prenatal care. It's not super valuable to know that someone is not going to develop preeclampsia in the next one week, especially if I have her there and can check her blood pressure, and obviously, if I'm doing the test, I'm concerned about her and I'm probably going to have her come back in a week.
Antonia:Yeah, because she can't do this test at home and send you the results. So this isn't something that would contribute to remote weekly monitoring in any way. And if she's doing it at the initial visit, then you don't care that someone at six weeks is not going to develop preeclampsia by seven weeks, just to check in.
Howard:I already knew that.
Antonia:Yeah. So instead we could just have her come back and check her blood pressure the following week and skip the lab draw. That would be a lot cheaper than doing this test or, for that matter, check her blood pressure at home, but I think it's being sold as something valuable for women with ambiguous presentations as well. So, in other words, let's say she already has chronic hypertension and maybe she has some fluctuation in her blood pressure. Is this just the chronic hypertension or is she now developing preeclampsia? But normally in those situations we would be getting a serum chemistry anyway, so we would already be getting labs. So then this would just be another lab that could be helpful for distinguishing that. But there's a current review article from March of 2022 in a journal called Pregnancy and Hypertension and it doesn't really indicate a useful way of integrating this test, this new FDA approved test, into practice.
Howard:Yeah, there was also an editorial in the February 21st 2023 edition of JAMA called Biomarkers and the Risk of Preeclampsia that I think is relevant to this discussion.
Howard:So this accompanied the trial that discussed the cessation of aspirin we talked about before and the optimal timing for that, and in a recent letter to the editor by Baha Sabai to the authors of that study, he comments on the poor predictive value of the biomarkers used in the first trimester testing and their poor correspondence with subsequent preeclampsia development and actually concludes that quote using more biomarkers could be harmful and less is probably more in quote.
Howard:So I think the bottom line is these biomarkers are interesting, but they're not yet ready for prime time. I do think it will happen eventually and some combination of biomarkers plus or minus urinary notching index, plus or minus other demographic risk factors will help us better understand who's at risk for preeclampsia. But for the time being, I think the easy solution is still look at historic risk factors and to have women check their blood pressure at home with validated cuffs, perhaps connected to an app on the phone that records the blood pressures and registers them in our EHR for us and they can be instructed on what values to call or come in for, or a more sophisticated system would flag those blood pressures and automatically trigger a clinic nurse to contact them for elevated pressures or something like that, to come in and be assessed, and in most cases when they come in they'll be normal. It's just an error in the reading, perhaps, and we can be reassured by that, and the main reason for their visit is over with so.
Antonia:Yeah, an error, or at least just a temporary fluctuation rather than a sustained severe range pressure. So this review article has a table of different studies and the frequency of visits recommended by different organizations, and even among those recommendations there's quite a bit of variety. But, of note, the World Health Organization recommends visits at 12 weeks, then 20, 26, 30, 34, 36, 38, and 40. So that is eight visits, of which five, like more than half of them, are all in the third trimester. But if you add that early confirmation of pregnancy visit that you were talking about, the six-week visit, then that's still only nine visits. That's pretty similar to what you described earlier. So is this kind of what you do now for your low-risk patients?
Howard:Yeah, essentially, maybe one or two differences. But yeah, for low-risk patients I don't start more frequent visits really until the very end and don't start weekly visits honestly until 38 weeks, depending on how their visits fall out. I do recommend for women that I'm worried about to check their blood pressures at home in between visits and they'll let me know if there's a problem and that saves them a trip just to check their blood pressure.
Antonia:And yeah, just to reiterate, that's not the same thing as doing frequent office blood pressure monitoring plus the additional home monitoring that was in the Bump Trial. That's just saying I want to check your blood pressure every two weeks, whether it's in the office or at home, starting at whatever you would want, at 28 weeks or starting at 36 weeks, depending on the situation. So that could be very appropriate for someone, for example, with chronic hypertension, who's not on medications, so that's someone who does have a higher risk of developing a hypertensive disorder but otherwise has no indication for ananatal testing. That would already be bringing them in.
Howard:Right, and for some of my patients, that can save them three hours round trip, when the only reason to come in to see me was to check their blood pressure.
Antonia:Well, this review seems to indicate that's a good strategy and that we need to rethink how we're delivering prenatal care and maybe update our thinking, since we're coming up on the 100th anniversary of that prenatal care booklet. Yeah.
Howard:Well, by the way, even for higher risk patients, this doesn't change much. If the purpose of having those higher risk patients come to the office was to check their blood pressure, you can still have them check it at home, and that's what we've learned during COVID. With validated blood pressure cuffs and stuff, we still can't get around office visits for necessary and indicated ultrasounds. If a patient needs follow-ups to their anatomy scan or growth surveillance or things like that, or Doppler studies, they need to have a sonographer and an appropriately transition performing that and reading that. But in 2023, we can check blood pressures and weights at homes and we can track them into our system or log them or something like that, and review them remotely.
Antonia:Okay, well, let's move on. We were still going to talk about neonatal abstinence. So did you know that every 18 minutes in the US, another newborn is diagnosed with a neonatal abstinence syndrome?
Howard:I couldn't have told you the time, but thank you, I'll now get that trivia question correct.
Antonia:You're welcome. Well, there is a study in the New England Journal of Medicine from June 2023 that looks at the traditional method of diagnosing NAS, which is based on Finnegan scores, and they compare this to an emerging method called the Eat Sleep Console approach.
Howard:Yeah, I think it's widely known that the use of the Finnegan scoring system to diagnose NAS is associated with wide variation in diagnostic rates due to the subjectivity built into the scoring system. So the result is that NAS is much more common in some hospitals than in others. The hospital in which the baby is born becomes the most important predictor, rather than other maternal or newborn factors, for the subsequent diagnosis of NAS and in particular the need for medication withdrawal therapy. This is particularly troubling because there can be economic incentives for some hospitals to overdiagnose NAS, so it would be nice to have a more consistent and reliable method.
Antonia:Yeah, it would. The Finnegan score has been around for over 50 years, which predates the opioid epidemic in the US, but in 2014, someone named Matthew Grossman proposed a new method called the Eat Sleep Console approach, which has gained momentum around the country, but until now there hasn't been a very good systematic review or any systematic data about its use.
Howard:Yeah, I followed Grossman's work for a while and he's done a lot of good work in this area, and he's also very interested in the effective cognitive bias in the delivery of care which meshes in. Obviously, something like a subjective scoring system for newborns that determines whether or not that newborn receives opioid medications is rife with all the problems related to cognitive bias. So I think it's a natural extension of those concerns that he would propose a better way.
Antonia:Yeah. So the Eat Sleep Console approach is a functional assessment tool that looks at the severity of neonatal withdrawal based on their ability to eat, sleep and be consoled. So it highlights the importance of non-pharmacologic adjunctive interventions that would console most babies, like skin to skin contact, clustered care, meaning like rooming in together with the mom whenever possible, breastfeeding and having a low stimulation environment.
Howard:Yeah, and we've been using a lot of these principles to lower the need for medication therapy for newborns in our hospital, and a lot of hospitals have been. If you think about it, taking the infants away and putting them in the busy and noisy mickey, away from the mothers, discourages skin to skin contact, it discourages breastfeeding and it certainly is not a low stimulation environment. As much as you try to make it one, it still isn't. So Grossman has led the way in this multimodal approach.
Antonia:Right. The sleep console approach says that if the infant can eat adequately so either breastfeeding or bottle feeding, if they can sleep well and then if they can be consoled, usually by one of those methods or just having the parent hold them, sing to them and that kind of thing, then they don't need medication to treat withdrawal. But on the other hand, a Finnegan score includes several other really subjective assessments on things that don't affect their eating or sleeping or really any functional outcomes, and those assessments can lead to just arbitrary introduction of giving narcotics to the infant as a withdrawal treatment.
Howard:Definitely.
Howard:If folks have never calculated one of these scores before, you can Google it and see what's on there. But it includes things like frequent yawning or nasal stuffiness or sneezing or even nasal flaring. It has rather subjective criteria like excessive suckling or increased muscle tone or how much high-pitched crying the infant has whatever high-pitched is and whatever how much is. Those things are all subjective and hard to define and have intra-observer variability. That's not desirable.
Howard:So if a child has three successive scores greater than eight, then that usually leads to pharmacologic treatment in most programs and an infant would have a score of eight just if it was deemed to have loose stools plus some sneezing, nasal stuffiness, frequent yawning, nasal flaring and modeling of the skin. And assessments of all those things have a great deal of subjectivity in them. There's more, but I picked those just because they're all very subjective. None of those things I just listed necessarily affect the ability of the child to be comforted or to eat or to sleep, and there are lots of ways to get to a score greater than eight without having anything directly related to the functional well-being of the newborn.
Antonia:Yeah, and there's probably plenty of other things besides a narcotic withdrawal that could cause some of those symptoms, like there could be even some genetic syndromes which would have no benefit of being given morphine or whatever else they might be given. But then if you introduce bias to the provider and the provider for some reason thinks oh this mom I think she was on opioids or something they're going to tend to diagnose NAS when they're using this Finnegan scoring system with all the subjective parts of it and in some cases it's not necessarily just a bias about a particular mother, it could just be the prevailing bias of the nursery in terms of how often NAS occurs, how often it's treated with medical therapy. So they might think, oh, any baby that's got a lot of nasal flaring and yawning, they've probably have NAS because it happens so often here. And then they might have a pretty low threshold for defining some of these markers as signs of NAS and then diagnosing it. So we don't have a universal agreement, for example, on what is modeling of the baby's skin.
Howard:Right, yeah, there are a lot of subjectivity there and there could be the role of racial bias, socioeconomic bias, et cetera. You just assume, based upon some bias about the patient, that their baby should be withdrawing from drugs and she might have even had a drug screen that was positive, but that. And you just think, well, she's lying about how much she used. And then some cases, no drug screens positive. And you see reports, as we talked about in a previous episode, about people withdrawing from SSRIs. Well, okay, so does SSRI withdrawal indicate introduction of an opiate to the newborn? So it really has gotten out of hand quite a bit. But that's the importance of this study. And so they compared the approach to this traditional flawed Finnegan score. And what did they find?
Antonia:Well, this was a clustered, randomized controlled trial at 26 different hospitals and they enrolled infants born at greater than 36 weeks gestation and in total they had 1,305 infants and they found that newborns in the group had no more adverse outcomes than those in the traditional care and Finnegan approach. But they found that the babies in the group were discharged home on average at about eight days of life, compared to more than 14 days of life with the Finnegan group, so that's almost a week earlier and overall there was a 16% rate of adverse outcomes in the Finnegan group compared to 14% adverse outcomes in the group. And that included things like subsequent hospital visits, like additional hospital visits and traumas and even death of the newborn by three months of age. There were actually two deaths in the usual care slash Finnegan group and zero in the Eat Sleep Console group
Howard:Well. So this study definitely adds to what we've, I think, already been seeing in various called improvement projects around the country that this approach should be the standard of care. And another way of stating, I think, the results of the study is that if you choose to use the traditional model, utilizing Finnegan scores, then you're nearly doubling the length of stay and the cost of treatment of those newborns, with no improved outcomes associated with that expense and length of stay. So of course we'll see how long it takes for hospitals to switch to this model, because they may be doing so against their own financial interests in terms of how much money is generated for care of these newborns. But of course it's the right thing to do for the patients.
Antonia:All right. Well, I think that's about it that we've got for today. So we'll wrap up the thinking about OBGYN website. We'll have links to a lot of the stuff we discussed today. And we'll be back in a couple of weeks.
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