Tracking your baby's movements at approximately the same time every day is an inexpensive, non-invasive, effective way to monitor your baby's well being. It can potentially catch a problem before it affects the baby's heart rate. Kick counts are generally recommended for mothers starting at 28 wks. Mothers with high-risk pregnancies are admonished to start them at 24-26 wks. Here's a site with more information. And here's a convenient chart for recording your kick counts.
Many doctors will also do regular Biophysical profiles at the end of a high-risk pregnancy to check baby's movements, heart rate & responsiveness.
But for daily assurrance that baby is doing well, a kick count can be more informative than a doppler heart monitor. And what tired pregnant mom doesn't want a good reason to lie down for a bit & bond with her baby?
Thursday, January 19, 2012
Tuesday, January 3, 2012
When to try again?
If you've had a previous loss, this question will arise and there are really two aspects to it: medically necessity and emotional readiness.
Medically, opinions vary. Research studies are conflicting. At a minimum, you should have one normal period before trying again. This helps date the next pregnancy more accurately and allows for normal buildup of the uterine lining. Generally, a longer wait is recommended for later losses. Some doctors recommend one month wait for each month along you were with the previous loss. This seems like a reasonable rule of thumb except that couples with stillbirths have a very long & difficult wait. (Though their grieving will undoubtedly be long & difficult no matter what, 9 months may be longer than truly necessary.)
Most readers of this blog will have a reason for their loss, but if you don't, it may take several months to complete testing so you know if there is anything that can prevent a recurrence. I strongly recommend testing if you've had multiple losses or even one loss after 12 weeks.
Emotionally, circumstances vary. You may feel ready at a different time than someone else with a loss- even at a different time than your spouse. I don't recommend waiting until "you are done grieving" or you may never try again. But it is often beneficial to give yourself a little time to start grieving the baby you lost before embarking on the very emotional quest for another. It takes time before the shock of the loss wears off and you genuinely start to process and grieve.
With a difficult history, you may wonder if you should EVER try again. Doctors, relatives, and friends will all have their opinions on this, but really it is something only YOU AND YOUR SPOUSE can decide. Talk together and chose together what's best for your family.
After 3 miscarriages, I talked to a woman who'd had 8 (she was now a grandmother & had to suffer through the losses before testing and treatment were available). I was in awe at her courage and tenacity. But I wondered...could I handle 3 more miscarriages? Could I handle 8 total miscarriages? How much heartbreak can you take? Then I decided I didn't have to determine beforehand my breaking point. We decided to take things one step at a time. We felt ready to try ONCE more and braced ourselves for the possibility of 1 more loss, while hoping of course for 1 more success. (Ok, my husband was hoping we'd concieve twins, so I guess he was hoping for 2 more successes at once!) But determining to not determine too much at once was helpful in gathering the courage to try again.
One baby doesn't replace another, but children do bring joy into your life. Though our miracle baby isn't in our arms yet, she's already brought joy to our hearts & we are glad we tried again.
Medically, opinions vary. Research studies are conflicting. At a minimum, you should have one normal period before trying again. This helps date the next pregnancy more accurately and allows for normal buildup of the uterine lining. Generally, a longer wait is recommended for later losses. Some doctors recommend one month wait for each month along you were with the previous loss. This seems like a reasonable rule of thumb except that couples with stillbirths have a very long & difficult wait. (Though their grieving will undoubtedly be long & difficult no matter what, 9 months may be longer than truly necessary.)
Most readers of this blog will have a reason for their loss, but if you don't, it may take several months to complete testing so you know if there is anything that can prevent a recurrence. I strongly recommend testing if you've had multiple losses or even one loss after 12 weeks.
Emotionally, circumstances vary. You may feel ready at a different time than someone else with a loss- even at a different time than your spouse. I don't recommend waiting until "you are done grieving" or you may never try again. But it is often beneficial to give yourself a little time to start grieving the baby you lost before embarking on the very emotional quest for another. It takes time before the shock of the loss wears off and you genuinely start to process and grieve.
With a difficult history, you may wonder if you should EVER try again. Doctors, relatives, and friends will all have their opinions on this, but really it is something only YOU AND YOUR SPOUSE can decide. Talk together and chose together what's best for your family.
After 3 miscarriages, I talked to a woman who'd had 8 (she was now a grandmother & had to suffer through the losses before testing and treatment were available). I was in awe at her courage and tenacity. But I wondered...could I handle 3 more miscarriages? Could I handle 8 total miscarriages? How much heartbreak can you take? Then I decided I didn't have to determine beforehand my breaking point. We decided to take things one step at a time. We felt ready to try ONCE more and braced ourselves for the possibility of 1 more loss, while hoping of course for 1 more success. (Ok, my husband was hoping we'd concieve twins, so I guess he was hoping for 2 more successes at once!) But determining to not determine too much at once was helpful in gathering the courage to try again.
One baby doesn't replace another, but children do bring joy into your life. Though our miracle baby isn't in our arms yet, she's already brought joy to our hearts & we are glad we tried again.
Friday, December 16, 2011
Ways to honor an angel
Christmastime can be bittersweet after a loss. Here are a few ideas of how to honor an angel:
Make or buy a small stocking for your baby & write a letter to tuck inside telling your baby how much you miss them &/or ways their presence in your life has made you better.
Make or buy a small ornament for your baby. It could simply be an angel ornament that reminds you of your baby or a personalized one. Here's one I made last year:
Do some kind of service in honor of your baby. Carol at a nursing home, buy warm hats & gloves for a homeless shelter to distribute, or donate baby blankets to a hospital to give patients with Medicaid coverage who deliver around Christmas.
Give yourself the gift of patience... it's emotionally exhausting to grieve. Let yourself skip a party you're not up for and forgive yourself if you don't get everything done on your list. Don't skip every event- sometimes you might surprise yourself how much you enjoy the distraction, but acknowledge that it's ok to take a slower pace given what you've been through.
If you know someone who's had a loss, they may appreciate a simple acknowledgement or gift in honor of the baby. I had a friend who's baby died before delivery. When we travelled that Thanksgiving to the coast, I wrote his name in the sand & took a picture to give to her in a holiday card. She still keeps that picture in her kitchen to look at everyday. My sister wrote a children's story for my kids describing our angels & how they are part of our family. A friend who makes jewelry made me a mother's bracelet with beads representing all the birthstones of my children including those we lost. Those gifts are precious becuase of the thought and love that went into them.
Make or buy a small stocking for your baby & write a letter to tuck inside telling your baby how much you miss them &/or ways their presence in your life has made you better.
Make or buy a small ornament for your baby. It could simply be an angel ornament that reminds you of your baby or a personalized one. Here's one I made last year:
Do some kind of service in honor of your baby. Carol at a nursing home, buy warm hats & gloves for a homeless shelter to distribute, or donate baby blankets to a hospital to give patients with Medicaid coverage who deliver around Christmas.
Give yourself the gift of patience... it's emotionally exhausting to grieve. Let yourself skip a party you're not up for and forgive yourself if you don't get everything done on your list. Don't skip every event- sometimes you might surprise yourself how much you enjoy the distraction, but acknowledge that it's ok to take a slower pace given what you've been through.
If you know someone who's had a loss, they may appreciate a simple acknowledgement or gift in honor of the baby. I had a friend who's baby died before delivery. When we travelled that Thanksgiving to the coast, I wrote his name in the sand & took a picture to give to her in a holiday card. She still keeps that picture in her kitchen to look at everyday. My sister wrote a children's story for my kids describing our angels & how they are part of our family. A friend who makes jewelry made me a mother's bracelet with beads representing all the birthstones of my children including those we lost. Those gifts are precious becuase of the thought and love that went into them.
Monday, December 5, 2011
Natural Labor Management Techniques
Being on anti-coagulants may preclude a patient from receiving an epidural. Women who are induced can time their last shot so the blood thinners are out of their system, making an epidural an option.
But, some women want to avoid extra interventions and prefer natural birth.
Even those who plan to have an epidural should prepare for the possiblity that they may have to deliver without one (because labor started spontaneously after taking a shot, the anesthesiologist is busy in surgery or labor is too short to accommodate one.) Here are a list of ideas to try in labor. Hopefully all laboring mothers can find a few things from this list that help them manage their contractions easier and more fully enjoy their birth experience. Feel free to suggest in the comments any additional techniques that helped you in labor.
Early Labor-
Try to nap even if interrupted by contractions
Watch a favorite show
Eat soup, fruit, or something light
Drink frequently
Time contractions
Take a slow walk around the block with someone accompanying you
Bathe or shower
Do easy tasks like watering plants, folding laundry, etc. to pass time
Call your doctor when contractions reach the point he/she has specified
Get a back rub
Hold each other
Turn on relaxing music
Load the car with hospital bag, water bottles, & anything else you’ll need
After arrival at the hospital-
Let the staff know your labor preferences & medical history, etc.
They’ll probably want to check you & get a fetal monitor reading for a bit,
but as soon as that’s finished, start walking the halls
Rock your hips in a circle during contractions
When back at the room, turn on relaxing music
Unpack a baby outfit so you can focus on the baby you’ll soon hold
Drink frequently & snack if hospital policy permits
Use cool cloths on neck & forehead
Focus on breathing slow & relaxed
Use a heating pad or towel soaked in warm water for your lower back & belly
Use bathroom frequently & keep drinking (this helps your Kegels relax)
Rub belly during contractions
When fetal monitor is around your belly, rub your quads instead
Stand up as much as possible
Visualize your cervix opening with each contraction
Use a breast pump to release of hormones if labor slows b/f trying pitocin
Talk to the baby
Chomp on ice chips. It feels good to bite down & hydration is beneficial
Use lotion and chapstick. Brush your hair and teeth. Try to make the rest
of your body feel good and relaxed.
Try sitting on a birthing ball
Communicate what is helpful to your hubby (quiet or music, massage or no
touching, talking or just thinking). Your mood and needs may change as
labor progresses, so if something isn’t working anymore, let him know how he
can best help at that moment
As birth is closer-
Take a warm shower or use a labor tub
Do not do math to estimate the remaining length of time- things could slow or speed up at any moment. Just do what works now to help you manage the work of this moment
Focus on slow, deep breaths
Remember you are strong & your body knows how to birth a baby.
Keep chomping on ice chips
Do “horse lips” or “blow raspberries”
Use the bathroom mirror to look yourself in the eye. Give yourself a pep talk. You can draw on your own inner strength.
Cry if it helps and don’t worry if you’re not sure whether they are tears of joy or pain or anything else- just let yourself release all the intense emotions of this incredible event!
Growl or grunt if it helps. If you start to feel this urge, it usually means you are close to pushing
Try squatting or being on all fours for pushing if laying on your back in not comfortable or effective
To push with the contractions, tuck your chin into your chest and push as it you are having a bowel movement. The more you focus on those muscles, the more effective your pushing will be. Hold your breath and have those helping you count to 10.
Feel for the baby’s head while you are pushing- this is such a tremendous motivation
Have someone grab a camera… you’re so close to seeing your cute baby for the 1st time!
After the birth-
Enjoy your baby!
Nurse and comfort and sing to them. This was quite an ordeal for them too.
Eat as soon as possible- choose fiber rich foods for the next several days & drink lots of water
Enjoy the birthing high for a couple hours, but then try to nap a bit if you can- YOU DESERVE IT!
Tasks for Father throughout labor:
Early labor- Go for a walk, time contractions, give a massage, bring her water, call doctor & anyone who needs to be notified (cancel calendar obligations, etc.) load car for hospital
At hospital- Stay with your wife (fill out insurance info. in her room if allowed), keep water filled & ice chips handy, walk the halls with her, turn on relaxing music & limit other noise, offer lots of encouragement & suggest one thing from the list above at a time (too many options are overwhelming when you are distracted by intense contractions). Encourage her to be out of bed as much as possible.
Things to say- “you’re doing great”, “we’ll get to see our baby soon”, “you’re already a great mom”, “hang in there”, “you’re so strong & you can do this”, “I’m so proud of you”, “We’re getting there”, “You are amazing”. Make her laugh if you can. Stay super positive & encouraging.
For distraction, you can ask her what she’d like to eat afterwards (unless she’s nauseous), how much dirty diapers duty you owe her for birthing the baby, what the baby will look like, who she’ll call 1st, etc.
But, some women want to avoid extra interventions and prefer natural birth.
Even those who plan to have an epidural should prepare for the possiblity that they may have to deliver without one (because labor started spontaneously after taking a shot, the anesthesiologist is busy in surgery or labor is too short to accommodate one.) Here are a list of ideas to try in labor. Hopefully all laboring mothers can find a few things from this list that help them manage their contractions easier and more fully enjoy their birth experience. Feel free to suggest in the comments any additional techniques that helped you in labor.
Early Labor-
Try to nap even if interrupted by contractions
Watch a favorite show
Eat soup, fruit, or something light
Drink frequently
Time contractions
Take a slow walk around the block with someone accompanying you
Bathe or shower
Do easy tasks like watering plants, folding laundry, etc. to pass time
Call your doctor when contractions reach the point he/she has specified
Get a back rub
Hold each other
Turn on relaxing music
Load the car with hospital bag, water bottles, & anything else you’ll need
After arrival at the hospital-
Let the staff know your labor preferences & medical history, etc.
They’ll probably want to check you & get a fetal monitor reading for a bit,
but as soon as that’s finished, start walking the halls
Rock your hips in a circle during contractions
When back at the room, turn on relaxing music
Unpack a baby outfit so you can focus on the baby you’ll soon hold
Drink frequently & snack if hospital policy permits
Use cool cloths on neck & forehead
Focus on breathing slow & relaxed
Use a heating pad or towel soaked in warm water for your lower back & belly
Use bathroom frequently & keep drinking (this helps your Kegels relax)
Rub belly during contractions
When fetal monitor is around your belly, rub your quads instead
Stand up as much as possible
Visualize your cervix opening with each contraction
Use a breast pump to release of hormones if labor slows b/f trying pitocin
Talk to the baby
Chomp on ice chips. It feels good to bite down & hydration is beneficial
Use lotion and chapstick. Brush your hair and teeth. Try to make the rest
of your body feel good and relaxed.
Try sitting on a birthing ball
Communicate what is helpful to your hubby (quiet or music, massage or no
touching, talking or just thinking). Your mood and needs may change as
labor progresses, so if something isn’t working anymore, let him know how he
can best help at that moment
As birth is closer-
Take a warm shower or use a labor tub
Do not do math to estimate the remaining length of time- things could slow or speed up at any moment. Just do what works now to help you manage the work of this moment
Focus on slow, deep breaths
Remember you are strong & your body knows how to birth a baby.
Keep chomping on ice chips
Do “horse lips” or “blow raspberries”
Use the bathroom mirror to look yourself in the eye. Give yourself a pep talk. You can draw on your own inner strength.
Cry if it helps and don’t worry if you’re not sure whether they are tears of joy or pain or anything else- just let yourself release all the intense emotions of this incredible event!
Growl or grunt if it helps. If you start to feel this urge, it usually means you are close to pushing
Try squatting or being on all fours for pushing if laying on your back in not comfortable or effective
To push with the contractions, tuck your chin into your chest and push as it you are having a bowel movement. The more you focus on those muscles, the more effective your pushing will be. Hold your breath and have those helping you count to 10.
Feel for the baby’s head while you are pushing- this is such a tremendous motivation
Have someone grab a camera… you’re so close to seeing your cute baby for the 1st time!
After the birth-
Enjoy your baby!
Nurse and comfort and sing to them. This was quite an ordeal for them too.
Eat as soon as possible- choose fiber rich foods for the next several days & drink lots of water
Enjoy the birthing high for a couple hours, but then try to nap a bit if you can- YOU DESERVE IT!
Tasks for Father throughout labor:
Early labor- Go for a walk, time contractions, give a massage, bring her water, call doctor & anyone who needs to be notified (cancel calendar obligations, etc.) load car for hospital
At hospital- Stay with your wife (fill out insurance info. in her room if allowed), keep water filled & ice chips handy, walk the halls with her, turn on relaxing music & limit other noise, offer lots of encouragement & suggest one thing from the list above at a time (too many options are overwhelming when you are distracted by intense contractions). Encourage her to be out of bed as much as possible.
Things to say- “you’re doing great”, “we’ll get to see our baby soon”, “you’re already a great mom”, “hang in there”, “you’re so strong & you can do this”, “I’m so proud of you”, “We’re getting there”, “You are amazing”. Make her laugh if you can. Stay super positive & encouraging.
For distraction, you can ask her what she’d like to eat afterwards (unless she’s nauseous), how much dirty diapers duty you owe her for birthing the baby, what the baby will look like, who she’ll call 1st, etc.
Wednesday, October 26, 2011
Necessity of treatment for recurrent loss w/ FVL
It's almost impossible to find large, randomized studies on factor v leiden and pregnancy. The stakes are high and it is difficult for researchers to recruit. So, even though these studies are small, for those of us who are looking for answers, they are very valuable.
2001 Oxford Journal Human Reproduction showed that the live birth rate for women with FVL AND a history of losses (3 losses or a 2nd or 3rd trimester loss) was even lower than the 49% birth rate for women with similar histories but who had normal Factor V genotype. This study observed pregnancies with no treatment beyond standard prenatal care.
Luckily, treating a clotting disorder can significantly improve the outcomes for women with late or recurrent losses. 2011 Habenox study showed that women with recurrent loss and diagnosed thromobophilia (FVL, Prothrombin, Protein S or C deficiencies, etc.) had approximately 70% live birth rate when treated with 40 mg enoxaparin/lovenox and/or 80mg aspirin daily. Most (90%) of the losses that did occur were 1st trimester miscarriages.
Unfortunately, not all doctors will treat recurrent loss with blood thinners. A study cited by an ACOG practice bulletin of "low risk" women (i.e. no history of recurrent loss) showed that the 134 women with FVL had comparable live birth rates to other low-risk women. For this reason, ACOG does not recommend treating women with FVL unless there is a history of clots. FVL can be very sporadic in it's effects. I had 3 full term births before my diagnosis. But, if it has caused late or multiple losses for a particular mother, the odds are stacked against her for future pregnancies without treating the FVL. (Note: Studies showing the benefits of treatment for recurrent loss are discounted by the ACOG bulletin. Thankfully, many good OBs & Maternal-Fetal medicine specialists DO treat these high-risk populations instead of sitting on their haunches waiting for a large, randomized, double-blind study verifying what more moderately sized studies have already shown- that treating the clotting disorder reduces the risk of further losses.) If you've had multiple or late losses and your doctor cites this practice bulletin as the reason you shouldn't treat your genetic thrombophilia, please find a new doctor.
2001 Oxford Journal Human Reproduction showed that the live birth rate for women with FVL AND a history of losses (3 losses or a 2nd or 3rd trimester loss) was even lower than the 49% birth rate for women with similar histories but who had normal Factor V genotype. This study observed pregnancies with no treatment beyond standard prenatal care.
Luckily, treating a clotting disorder can significantly improve the outcomes for women with late or recurrent losses. 2011 Habenox study showed that women with recurrent loss and diagnosed thromobophilia (FVL, Prothrombin, Protein S or C deficiencies, etc.) had approximately 70% live birth rate when treated with 40 mg enoxaparin/lovenox and/or 80mg aspirin daily. Most (90%) of the losses that did occur were 1st trimester miscarriages.
Unfortunately, not all doctors will treat recurrent loss with blood thinners. A study cited by an ACOG practice bulletin of "low risk" women (i.e. no history of recurrent loss) showed that the 134 women with FVL had comparable live birth rates to other low-risk women. For this reason, ACOG does not recommend treating women with FVL unless there is a history of clots. FVL can be very sporadic in it's effects. I had 3 full term births before my diagnosis. But, if it has caused late or multiple losses for a particular mother, the odds are stacked against her for future pregnancies without treating the FVL. (Note: Studies showing the benefits of treatment for recurrent loss are discounted by the ACOG bulletin. Thankfully, many good OBs & Maternal-Fetal medicine specialists DO treat these high-risk populations instead of sitting on their haunches waiting for a large, randomized, double-blind study verifying what more moderately sized studies have already shown- that treating the clotting disorder reduces the risk of further losses.) If you've had multiple or late losses and your doctor cites this practice bulletin as the reason you shouldn't treat your genetic thrombophilia, please find a new doctor.
Wednesday, September 28, 2011
When to tell
Conventional wisdom says you shouldn't announce your pregnancy until you are in the 2nd trimester when it's "safe to tell". But, for women with factor v leiden, late losses are a lot more common than they are for the average woman (who's chance of loosing the pregnancy after a heartbeat is heard drops to about 5%). I've lost 2 babies after passing the 1st trimester, well after first hearing the heartbeat, and after it was supposedly "safe" to tell.
Pros of telling early:
-support if you have a loss
-support if your pregnancy progresses, but is difficult
-lets you more openly enjoy the pregnancy early
Pros of waiting:
-fewer people to "untell" if you have an early loss
-less likely you'll hear unsupportive comments after multiple losses
I tend to announce early, but understand when couples feel like the pregnancy is too fragile or tentative to shout from the rooftops.
Tuesday, July 19, 2011
Blood thinners- injection tips
1) Give yourself a pep talk
-Think of your motivation to do this- it can help you keep your baby! It keeps you safe too from clots. If you are squeamish, take deep breaths & give yourself a pep talk. You can do this. It's very momentary & then you can pamper yourself for having the courage to do it.
-Get everything ready. Wash your hands, open the package, remove the needle cover, & have a sterile cotton swab ready.
2) Pick a spot
-The medicine must be absorbed into fat, so choose a spot on your stomach. Some doctors also say thighs are acceptable as well.
-Grab a pinch of skin & fat. Scratch with your fingernail to find a less sensitive part.
-Clean the area with alcohol.
3) Insert needle
-If you are anxious about needles or prone to get lightheaded in response to them, sit down or lay down when you administer the medicine. This may also help if you are very thin & need help grabbing a pinch of fat. (But, most of us have more than we want!)
-Look for the angled end on the needle & turn it so the narrowest part enters 1st.
-It's such a small gauge needle it should not bleed much if at all. If it does, you might have hit a blood vessel- pull it out & try a different spot.
4) Administer the medicine
-Many patients find that it is more comfortable to inject the medication slowly.
-After removing the needle, you will probably have a drop of liquid or blood at the site. You can cover it with a band aid.
-There is a little stinging for several minutes afterwards as the medication is absorbed.
Other tips
-Some women ice the spot before and after. But, pharmacists say it's best not to ice so you are getting normal blood flow to the area of absorption.
-You might want to get a sharps container to deposit the shots after use, but in some locations the law does not require this. For safety, you should at least use the needle cover that pops up by pushing firmly on the plunger after it's removed from your skin and deposit the needles in a hard plastic container (like an empty laundry jug).
-You need to take the medication at approximately the same time every day. Some choose before bed. Others might find that the fatigue of pregnancy makes it difficult to consistently do it at night & choose another time of day. Mornings are good, but showering after the shot might make the bleeding increase. Choose what works best for your schedule.
-For more tips and information, go to: lovely lovenox ladies online forum
-Think of your motivation to do this- it can help you keep your baby! It keeps you safe too from clots. If you are squeamish, take deep breaths & give yourself a pep talk. You can do this. It's very momentary & then you can pamper yourself for having the courage to do it.
-Get everything ready. Wash your hands, open the package, remove the needle cover, & have a sterile cotton swab ready.
2) Pick a spot
-The medicine must be absorbed into fat, so choose a spot on your stomach. Some doctors also say thighs are acceptable as well.
-Grab a pinch of skin & fat. Scratch with your fingernail to find a less sensitive part.
-Clean the area with alcohol.
3) Insert needle
-If you are anxious about needles or prone to get lightheaded in response to them, sit down or lay down when you administer the medicine. This may also help if you are very thin & need help grabbing a pinch of fat. (But, most of us have more than we want!)
-Look for the angled end on the needle & turn it so the narrowest part enters 1st.
-It's such a small gauge needle it should not bleed much if at all. If it does, you might have hit a blood vessel- pull it out & try a different spot.
4) Administer the medicine
-Many patients find that it is more comfortable to inject the medication slowly.
-After removing the needle, you will probably have a drop of liquid or blood at the site. You can cover it with a band aid.
-There is a little stinging for several minutes afterwards as the medication is absorbed.
Other tips
-Some women ice the spot before and after. But, pharmacists say it's best not to ice so you are getting normal blood flow to the area of absorption.
-You might want to get a sharps container to deposit the shots after use, but in some locations the law does not require this. For safety, you should at least use the needle cover that pops up by pushing firmly on the plunger after it's removed from your skin and deposit the needles in a hard plastic container (like an empty laundry jug).
-You need to take the medication at approximately the same time every day. Some choose before bed. Others might find that the fatigue of pregnancy makes it difficult to consistently do it at night & choose another time of day. Mornings are good, but showering after the shot might make the bleeding increase. Choose what works best for your schedule.
-For more tips and information, go to: lovely lovenox ladies online forum
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