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Scenario Presentation

in Labor and Delivery Rooms

Presented by:
Kristina Crisostomo
Abigail Buhayo
Rachelle Ann Mapue
Chiara Pascual
Kristelie Mae A. Tillain
BSN 1Y1 – 11/ Our Lady of Fatima University
Nursing Management

• Labor Room and Delivery Room


• Room Lay-Out
• Tools and Equipment
Labor and Delivery Room

• Labor Process
• Methods of Prepared Childbirth
• True and False Labor Contractions
• Signs and Symptoms of Impending Labor
• Standards of Care Guidelines
• Stages of Labor
• Parenting Promotion
Labor Process

• From the initial prenatal visits, the nurse needs to


emphasize to the mother that labor and delivery are
normal physiologic process.
• The pregnant woman typically approaches the time
of delivery with major concerns in her personal
well-being, of her unborn child, and a painful and
difficult labor and delivery.
• Addressing these concerns and minimizing her
discomfort should be the paramount of importance
of the nurse.
Methods of Prepared Childbirth

• Grantly Dick-Read Method


• Psychoprophylactic or Lamaze Method
• Bradley Method of Delivery
• Home Delivery
Grantly Dick-Read Method

• This method is based on the idea that fear and


anticipation of pain arouse natural protective
tensions in the body, psychic as well as muscular.
• Fear stimulates the sympathetic nervous system
and causes the circular muscle of the cervix to
contract.
• The longitudinal muscles of the uterus then have to
act against increased cervical resistance, causing
tension and pain.
• Tension and pain aggravate fear, which produces a
vicious cycle of tension, pain, and fear.
Dick-Read Cont.

• A minor degree of pain, magnified by fear,


becomes unbearable.
• According to Dick-Read, prenatal courses and
training reduce fear, overcome ignorance,and build
a woman's self-confidence.
• Click here for the included methods.
Dick-Read Methods

• Explanations of fetal development and childbirth.


• Descriptions of methods available to relieve pain.
• Exercises that strengthen certain muscles and relax
others.
• Breathing techniques that will enable the woman to
relax in the first stage of labor and work effectively
with muscles used during delivery.
• Explanations of the value of improved physical
health and emotional stability for childbirth.
Dick-Read Methods Cont.

• The woman is not told that labor and delivery will


be painless; analgesia and anesthesia are available
if needed or desired.
• The woman is given empathic understanding and
support during labor by her partner, the nurse, and
the health care provider.
Psychoprophylactic or Lamaze Method

• Psychoprophylactic childbirth has a rationale based


on Pavlov's concept of pain perception and his
theory of conditioned reflexes (the substitution of
favorable conditioned reflexes for unfavorable
ones). The Lamaze method is an example of this
technique.
• The woman is taught to replace responses of
restlessness, fear, and the loss of control with more
useful activity. A high level of activity can excite the
cerebral cortex efficiently to inhibit other stimuli
such as pain in labor.
Lamaze Method Cont.

• The mother-to-be is taught exercises that


strengthen the abdominal muscles and relax the
perineum.
• Breathing techniques to help the process of labor
are practiced.
• The woman is conditioned to respond with
respiratory activity and disassociation or relaxation
of the uninvolved muscles, while controlling her
perception of the stimuli associated with labor.
Lamaze Method Cont.

• One method of control consists of breathing


normally while silently mouthing the words to a
song and simultaneously tapping the rhythm with
the fingers.
Bradley Method of Delivery

• Commonly referred to as “husband-coached


childbirth,” although the coach is not necessarily
the husband of the woman.
• Involves the concepts of leading, guiding,
supporting, caring, and fostering specific skills and
confidence.
• Coaches attend classes and learn to help the
woman long before labor begins.
• The coach serves as a conditioned stimulus using
the sound of his or her voice, use of particular
words, and repetition of practice.
Bradley Method Cont.

• Medications are not encouraged for pain relief.


Relaxation is the core component.
• Increased tolerance to pain is accomplished by
decreased mental anxiety and fear, which
ultimately decreases the awareness of the pain
stimulus.
• Occurs with cognitive and physical rehearsal.
Home Delivery

• Motivation
• Contraindications
• Alternatives
Motivation

• Belief that home birth has significant advantages


for the family and the neonate.
• Objection to the impersonal and authoritarian
atmosphere of the hospital environment with
enforced separation of woman and family.
• Desire to avoid such practices as routine cesarean
delivery for breech presentation, episiotomy,
forceps delivery, oxytocin stimulation, routine
monitoring of the fetal heart tones, and other
practices associated with hospitals.
Cont.

• Risk of in-hospital infections; belief that infant is


immune to own-home bacteria.
• Rising costs of hospitalization.
Contraindication

• High-risk indications for infant and mother.


• Patient with history of premature or postdate
delivery in previous pregnancy or previous
cesarean delivery
• Woman with medical or emotional complications.
• Patient who cannot be quickly transported to a
hospital.
Alternatives

• Alterations of hospital setting to a family-centered


approach.
• Birthing centers with adequate facilities for
emergency care for low-risk women.
• Properly educated and motivated support
personnel.
True and False Labor Contractions

True Labor False Labor


•Result in progressive cervical dilation •Do not result in progressive cervical
and effacement dilation and effacement
• Occur at regular intervals • Occur at irregular intervals
•Interval between contractions •Interval between contractions remains
decreases the same or increases
•Frequency, duration, and intensity •Intensity decreases or remains the
increase same

•Located mainly in back and abdomen •Located mainly in lower abdomen and
groin
•Generally intensified by walking •Generally unaffected by walking

•Not easily disrupted by medications •Generally relieved by mild sedation


Signs and Symptoms of Impending Labor

• Sudden burst of energy very soon before actual


labor begins (nesting instinct)
• Lightening or the feeling that the baby has dropped
lower in abdomen. In this event, breathing becomes
easier, lordosis of the spine increases, walking may
begin to be difficult and leg cramps may occur
often, and urination is more likely to occur often
since of the pressure exerted in the abdomen.
• Discharge of pinkish mucous plug or unusual
vaginal discharge.
Cont.

• Rupture of amniotic membrane (water breaks as a


trickle or gush). Note color and any odor of amniotic
fluid if not in hospital. If you even suspect your
water has broken, go to the hospital.
• Abdominal cramping, vaginal, thigh, or back pain or
pressure.
• Regular contractions with or without pain over more
than one hour.
• For contractions, monitor for length, regularity, and
duration. Monitor by feeling abdomen with
fingertips, feeling for tightening and loosening.
Cont.

• Note for timing the contraction interval, time from


beginning of one contraction to the beginning of
another contraction.
• Also for timing contraction duration, time from
beginning of contraction to end of contraction.
Stages of Labor

• Stage One
• Stage Two
• Stage Three
• Stage Four
Stage One

• Dilation from 0 to 10 cm.


• Begins with the first true labor contractions and
ends with complete effacement and dilation of the
cervix (10 cm dilation).
• The first stage of labor averages about 13½ hours
for a nullipara and about 7½ hours for a multipara.
• It has three phases:
- Latent or Early
- Active
- Panting
Latent Phase (Early)

• Dilates from 0 to 3 cm.


• Contractions are usually every 5 to 20 minutes,
lasting 20 to 40 seconds, and of mild intensity.
• The contractions progress to about every 5 minutes
and establish a regular pattern.
Role of the Nurse (Latent Phase)

• Nursing Diagnoses
• Nursing Interventions
Nursing Diagnoses

• Deficient Fluid Volume related to decreased oral


intake, lack of eating, and the energy requirement
of labor
• Anxiety related to concern for self and the fetus
• Acute Pain related to uterine contractions or
position of the fetus
Nursing Interventions
• Maintaining Nutrition and Hydration
– Provide clear liquids and ice chips as allowed.
– Evaluate urine for ketones and glucose.
– Administer I.V. fluids as indicated.
• Relieving Anxiety
– Establish a relationship with the woman/support persons.
– Provide information on the health care facility's policies and
procedures. Inform the woman/support persons of maternal status
and fetal status and labor progress.
– Explain all procedures and equipment used during labor.
– Answer any questions the woman/support persons have.
– Review the birth plan and make appropriate revisions.
– Monitor maternal vital signs. Remember the individual patient
condition is used to determine frequency of vital signs and FHR
assessment. Adjust as needed.
– Monitor FHR
Cont.

• Controlling Pain
– Encourage ambulation as tolerated regardless of membrane status
as long as presenting part is engaged. (This may vary according to
health care provider.)
– Encourage diversional activities, such as reading, talking, watching
TV, playing cards, listening to music.
– Review, evaluate, and teach proper breathing techniques.
– Encourage a warm shower. Laboring woman can sit on a chair in the
shower with the water running continuously over her lower back.
– Encourage relaxation techniques.
– Provide comfort measures.
– Use of Jacuzzi or shower for relaxation if available.
– Reposition external monitors as needed.
Active Phase

• Dilates from 4 to 7 cm.


• Contractions are usually every 2 to 5 minutes;
lasting 30 to 50 seconds and of mild to moderate
intensity.
• After reaching the active phase, dilation averages
1.2 cm/hour in the nullipara and1.5 cm/hour in the
multipara.
Transitional Phase

• Dilates from 8 to 10 cm.


• Contractions are every 2 to 3 minutes, lasting 50 to
60 seconds and of moderate to strong intensity.
Some contractions may last up to (but not exceed)
90 seconds.
Role of the Nurse (Active and Transitional)

• Nursing Diagnoses
• Nursing Interventions
Nursing Diagnoses
• Anxiety related to concern for self and fetus
• Acute Pain related to uterine contractions and
nausea and vomiting
• Impaired Urinary Elimination related to epidural
anesthesia or from pressure of the fetus
• Ineffective Coping related to discomfort
• Risk for Infection related to rupture of the
membranes
• Impaired Physical Mobility related to medical
interventions and discomfort
• Ineffective Breathing Pattern related to pain
and fatigue
Nursing Interventions
• Relieving Anxiety
– Monitor maternal vital signs and FHR, and keep the
woman/couple informed of thematernal and fetus status.
– Maternal temperature every 2 to 4 hours unless elevated or
membranes ruptured, then every 1 hour.
– Blood pressure, pulse, respirations usually every 30 to 60
minutes or as indicated by policy or maternal status.
– Evaluate FHR every 30 minutes if low-risk patient or every 15
minutes if highrisk patient regardless if monitoring is continuous
or intermittent.
– Provide encouragement and support.
– Involve the support person in the woman's care.
Cont.

• Minimizing Pain
– Encourage position changes for comfort.
– Assist the woman with breathing and relaxation
techniques as needed.
– Provide back, leg, and shoulder massage as needed.
– Assist with preparation for analgesia and anesthesia
Cont.

• Monitor the woman following administration of


analgesia/anesthesia.
– Monitor the woman's blood pressure, pulse, and
respiratory rate after initiation or re-bolus of regional
block every 5 minutes for the first 15 minutes.
– Maintain uterine displacement with hip wedge, lateral
decubitus position, or semi-
– Fowler's position with uterine displacement.
– Intervene for maternal hypotension with lateral
positioning, additional I.V. fluids as ordered, and
administration of ephedrine per institutional protocol.
Cont.

• Assess neonate for effects of maternal medication


(neurobehavioral change, such as decreased motor
tone and decreased respiratory rate). Initiate
neonatal resuscitation as indicated in accordance
with established guidelines.
• Place patient in same position for removal of
catheter as she was in during insertion.
Stage Two (Expulsion)

• Begins with complete dilation (10 cm cervix dilation)


and ends with birth of the baby.
• The second stage may last from 1 to 4 hours in the
nullipara and from 20 to 45 minutes in the
multipara.
Role of the Nurse

• Nursing Diagnoses
• Nursing Interventions
Nursing Diagnoses

• Fear or Anxiety related to impending delivery


• Acute Pain related to descent of the fetus
• Risk for Infection related to episiotomy and tissue
trauma
Nursing Interventions

• Minimizing Fear and Anxiety


– Monitor maternal vital signs as follows:
• Blood pressure — every 5 to 15 minutes depending on the
woman's status.
• Pulse and respirations — every 15 to 30 minutes.
• Temperature — every 1 hour when membranes have ruptured.
– Monitor FHR and uterine contractions every 15 minutes
in low-risk women and every 5 minutes in high-risk
women.
– Explain procedures and equipment during pushing and
delivery.
– Keep the woman or couple informed of their status.
Cont.

• Promoting Comfort
– Assist the woman to a comfortable position.
– Left or right lateral, squatting, hand and knees, or
semisitting positions may be used.
• Assist the woman with pulling her legs back so her knees are
flexed.
• Teach the woman to put her chin to her chest so her body forms
and shape while pushing.
– Evaluate bladder fullness, and encourage voiding or
catheterize as needed.
– Evaluate effectiveness of anesthesia as indicated.
Cont.
• Preventing Infection and Promoting Safety
– Prepare the birthing room or delivery room using aseptic
technique, allowing ample time for setup before delivery.
– Prepare the infant resuscitation area for delivery.
– Prepare necessary items for neonatal care.
– Notify necessary personnel to prepare for delivery.
– If delivery room is to be used, transfer the primigravida to the
delivery room when the fetal head is crowning. The
multigravida is taken earlier depending on fetal size and speed
of fetal descent.
– Place all side rails up before moving. Instruct the woman to
keep her hands off the rails,and move from the bed to the
delivery table between contractions.
Cont.

• If delivering in LDR (Labor, Delivery, Recovery) or


LDRP (Labor, Delivery, Recovery, Postpartum)
room, prepare labor bed for delivery in accordance
with manufacturer's instructions. Prepare infant
warmer and remainder of room for delivery.
• Position the woman for delivery using a large
cushion for her head, back, and shoulders.
• Elevate the head of the bed. Stirrups or footrests
may be used for foot support. Pad the stirrups.
Place both legs in the stirrups at the same time to
avoid ligament strain,backache, or injury.
Cont.

– Clean the vulva and perineal areas when the woman is


positioned for delivery.
– Guide the woman step by step during the delivery
process.
– Practice standard precautions during labor and delivery.
Stage Three (Placental)

• Begins with delivery of the baby and ends with


delivery of the placenta.
• The third stage may last from a few minutes to 30
minutes.
Role of the Nurse

• Nursing Diagnoses
• Nursing Interventions
Nursing Diagnoses

• Impaired Tissue Integrity related to placental


separation
• Risk for Injury related to potential hemorrhage
Nursing Interventions

• Promoting Tissue Integrity


– Ask the woman to bear down gently. Fundal pressure is
never applied to facilitate delivery of the fetus or the
placenta. Observe for the signs of placental separation.
• The uterus rises upward in the abdomen.
• The umbilical cord lengthens.
• Trickle or spurt of blood appears.
• The uterus becomes globular in shape.
– Evaluate the placenta for size, shape, and cord site
implantation. Evaluate placenta for Duncan or Schultze
presentation.
Cont.

• Preventing Hemorrhage
– Ensure accurate measurement of intake and output
maintained throughout labor and delivery.
– Immediately after delivery of the placenta, administer
oxytocin (Pitocin 10 to 40 units/L at 100 mU/min) either
I.V. piggyback or I.M. as directed by facility policy and
provider.
– Infuse as bolus initially, then titrate to uterus (ie, if uterus
is firm, decrease the infusion; if boggy, leave as bolus).
Pitocin should never be administered I.V. push as it can
cause cardiac dysrhythmia and death.
Cont.
– Immediately after initiating Pitocin, massage uterine
fundus until firm. Uterine massage is done with two
hands, one anchored at the lower uterine segment above
the symphysis pubis and the other hand gently
massages the fundus.
– Check to see that the placenta and membranes are
complete.
– Evaluate and massage the uterine fundus until firm.
– If bleeding continues and uterus is firm, notify health care
provider for evaluation of lacerations or retained placental
fragments. Inspection and repair of lacerations of the
vagina and cervix are made by the health care provider.
Cont.

– If still no relief, notify health care provider and prepare


patient for possible surgery (dilation and curettage, B-
lynch suture, pelvic pressure packing, and selective
arterial embolization). Autotransfusion (transfusion with
one's own blood) is also a treatment available and
approved for use by Jehovah's Witnesses.
Immediate Care for the Neonate

• Nursing Diagnoses
• Nursing Interventions
Nursing Diagnoses

• Ineffective Airway Clearance related to nasal and


oral secretions from delivery
• Ineffective Thermoregulation related to environment
and immature ability for adaptation
• Risk for Injury related to immature defenses of the
neonate
Nursing Interventions

• Promoting Airway Clearance and Transitioning of


the Neonate
– Transitioning/close observation of the neonate is
essential for at least 6 to 12 hours after birth.
– Wipe mucus from the face and mouth and nose. Aspirate
with a bulb syringe.
– Clamp the umbilical cord approximately 1 inch (2.5 cm)
from the abdominal wall with a cord clamp.
– Evaluate the neonate's condition by the Apgar scoring
system at 1 and 5 minutes after birth.
Cont.

• Promoting Thermoregulation
– Dry the neonate immediately after delivery, remove wet towels, and
place infant on warm dry towels. A wet, small neonate loses up to
200 cal/kg/min in the delivery room through evaporation, convection,
conduction, and radiation. Drying the infant cuts this heat loss in half.
– Cover the neonate's head with a cotton stocking cap to prevent heat
loss.
– Wrap the neonate in warm blankets.
– Place the neonate under a radiant heat warmer, or place the
neonate on the mother's abdomen with skin-to-skin contact.
– Provide a warm, draft-free environment for the neonate.
– Take the neonate's axillary temperature — a normal temperature is
between 97.5° and 99° F (36.4° and 37.2° C).
Cont.

• Preventing Injury and Infection


– Administer prophylactic treatment against ophthalmia
neonatorum (gonorrheal or chlamydial).
– Administer a single parental prophylactic injection of
vitamin K within 1 hour of birth.
• This is done to prevent a vitamin K-dependent hemorrhagic
disease of the neonate.
• If the parents do not want the vitamin K administered, inform the
parents that circumcision may not be performed. However,
inform parents that the Vitamin K levels will reach their peak
(without neonatal injection) at 8 days after birth.
Cont.

– While in the delivery room (DR), place identical


identification bracelets on the mother and the neonate.
The nurse in the DR should be responsible for preparing
and securely fastening the bands on the neonate.
• Information includes the mother's name, hospital/admission
number, neonate's sex, race, and date and time of birth and
other information specified in your facility's policy.
• The father or significant other may also wear a bracelet matching
the mother's.
• Footprinting and fingerprinting the neonate are not adequate
methods of patient identification.
• Complete all identification procedures before the infant is taken
from the delivery room.
Cont.

– Weigh and measure the infant shortly after birth.


• Normal neonate weight is 6 to 9 lb (2,700 to 4,000 g).
• Normal neonate length is 19 to 21 inches (48 to 53 cm).
– No later than 2 hours after birth, nursery/mother-baby
personnel should evaluate theneonate's status and
assess risks.
– Administer hepatitis B vaccine according to your facility's
policy.
Cont.

• Issues regarding promoting airway clearance,


transitioning the neonate, and promoting
thermoregulation are essentially unchanged for
home births, although Apgar scores are sometimes
not given at home deliveries.
• Eye prophylaxis is unchanged; parents may choose
to not use prophylaxis.
• Make sure attendants are familiar with neonatal
resuscitation and that emergency numbers and
procedures are readily available.
Cont.

• Vitamin K administration is not a requirement for


home deliveries. Vitamin K levels naturally increase
at 8 days of life. If infant is a boy, and parents
desire circumcision, the procedure is withheld until
after day 8.
• Identification procedures are not required for home
births, although required state paperwork must be
completed by the health care provider.
Stage Four

• Lasts from delivery of the placenta until the


postpartum condition of the woman has become
stabilized (usually 1 hour after delivery).
Role of the Nurse

• Nursing Diagnoses
• Nursing Interventions
Nursing Diagnoses

• Risk for Injury related to uterine atony and


hemorrhage
• Deficient Fluid Volume related to decreased oral
intake, bleeding, and diaphoresis
• Acute Pain related to tissue trauma and birth
process, intensified by fatigue
• Impaired Urinary Elimination related to epidural or
spinal anesthesia and tissue trauma
• Disturbed Sensory Perception (tactile) related to
effects of regional anesthesia
• Risk for Impaired Parenting related to inexperience
Nursing Interventions

• Promoting Uterine Contraction and Controlling


Bleeding
– Monitor blood pressure, pulse, and respirations every 15
minutes for 1 hour, then every
– ½ hour to 1 hour until stable or transferred to the
postpartum unit. Vital signs are taken more frequently if
complications encountered.
– Take temperature every 4 hours unless elevated, then
every 1 to 2 hours.
Cont.

• Maintaining Fluid Volume


– Maintain I.V. fluids as indicated.
– Provide oral fluids and a snack or meal as tolerated.
– Encourage drink and food before assisting the woman
out of bed.
• Relieving Discomfort and Fatigue
– Apply a covered ice pack to the perineum during the first
24 hours for an episiotomy, perineal laceration, or
edema.
– Administer analgesics as indicated.
Cont.

– Assure that epidural catheter has been removed.


– Assist the woman in finding comfortable positions.
– Assist the woman with a partial bath and perineal care,
and change linens and pads as necessary.
– Allow for privacy and rest periods between postpartum
checks.
– Provide warm blankets, and reassure the woman that
tremors are common during this period.
Cont.

• Encouraging Bladder Emptying


– Evaluate the bladder for distention.
– Encourage the woman to void.
• Provide adequate time and privacy.
• The sound from a running faucet may stimulate voiding.
• Gently squirting tepid water against the perineum in a perineal
bottle may help.
– Catheterize the woman (in and out) if the bladder is full
and she is unable to void.
• Birth trauma, anesthesia, and pain from lacerations and
episiotomy may reduce or alter the voiding reflex.
Cont.

• Assessing return of sensation


– Evaluate mobility and sensation of the lower extremities.
– Evaluate vital signs.
– Remain with the woman, and assist her out of bed for the
first time. Evaluate her ability to support her weight and
ambulate.
– Do not provide hot fluids if sensation is decreased.
Promoting Parenting

• Show the neonate to the mother and father or


support person immediately after birth when
possible.
• Encourage the mother and father to hold the infant
as soon as possible.
• Teach the mother or parents to hold the neonate
close to their faces, about 8 to 12 inches (20.5 to
30.5 cm), when talking to the baby.
• Have the mother or parents look at and inspect the
infant's body to familiarize themselves with their
child.
Cont.

• Assist the mother with breast-feeding during the


first 30 minutes, then 2 hours, after birth. This is
typically a period of quiet alert time for the neonate,
and he or she will usually take to the breast.
• Provide quiet alone time in a low-lighted room for
the family to become acquainted.
• Observe and record the reaction of the mother or
parents to the neonate.
Standard of Care Guidelines

• Establish a baseline history for the woman in labor,


including maternity history, labor events thus far,
medications, herbal preparations, allergies,
concerns, and availability of support systems.
• Determine fetal status: fetal heart rate, variability,
accelerations, decelerations, fetal movement,
cervical status. Notify health care provider of
abnormal findings.
• Assess uterine contractions in accordance with
established standards of care, facility
• policy, and maternal and fetal condition.
Cont.

• Monitor maternal and fetal status in accordance


with established standards of care, facility policy,
and maternal and fetal condition.
• Make sure that appropriate medical personnel are
available within the facility during the administration
of oxytocin (Pitocin) and prostaglandins in
accordance with ACOG guidelines.
• Perform the following interventions: change
mother's position, administer oxygen, intiate or
increase I.V. fluids, administer tocolytics.
Cont.

• Notify the healthcare provider for the following:


– Nonreassuring or repetitive variable decelerations
– Repetitive late decelerations
– Prolonged decelerations, bradycardia, or tachycardia.
– Abnormal maternal vital signs
– Nonreassuring fetal tracing.
• Assist the woman with breathing and pain control
techniques during contractions.
Room Lay-out

• Labor Room
• Delivery Room
Labor Room Lay-out

• Labor room in Fabella, a


government-run hospital in
the Philippines
Labor Room Lay-out

• Mother in the labor room.


Labor Room Lay-out

• A labor-delivery room in a
certain hospital.
Delivery Room Lay-out

• Delivery room with


necessary equipment.
Delivery Room Lay-out

• Delivery buzzer is present


in some hospitals.
Delivery Room Lay-out

• Some hospitals have these


equipment in their delivery
rooms.
Delivery Room Lay-out

• Other women would like to


give birth using birthing
pools instead.
Delivery Room Lay-out

• Doctor and nurses in


delivery room.
Delivery Room Lay-out

• Shot taken during delivery


of a baby.
Delivery Room Lay-out

• Nurses in delivery room.


Recovery Room Lay-out

• A mother breast-feeding
her twins.
• Mothers at Fabella after
delivery.
Recovery Room Lay-out

• A muti-patient post-
operative recovery room

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