Continuous suturing of second-degree perineal tears reduces short-term pain and pain medication use. 4th Degree Perineal Tear repair. 1 This was equivalent to a rate of 358 perineal lacerations for vaginal birth per 10,000 hospitalisations in 2015-16.1 Third and fourth degree perineal lacerations cause persistent and distressing A randomised comparison of polyglactin 910 with chromic catgut for postpartum perineal repair. He will be transferred to the postoperative anesthesia care where he will be followed for his postop splenectomy as well as laceration repair. All malpresentations increase the amount of distension of the perineum and hence increase the risk of having perineal tears. 16. The majority of obstetric anal sphincter injuries are third-degree lacerations that involve the anal sphincter complex without disrupting the rectal mucosa.1 The anal sphincter complex comprises the larger external anal sphincter containing striated muscle and a distinct capsule plus the small internal anal sphincter of involuntary smooth muscle that often cannot be identified. Colorectal surgeons prefer to use this method when they repair the sphincter remote from delivery.14,17 The overlapping technique brings together the ends of the sphincter with mattress sutures (Figure 13) and results in a larger surface area of tissue contact between the two torn ends. Breakdown of repair or infection of site C. Definitions: 1. During the second stage of labor, perineal massage and application of a warm compress to the perineum are beneficial.11 Perineal support during delivery, variably described as squeezing the lateral perineal tissue with the first and second fingers of one hand to lower pressure in the middle posterior perineum while the other hand slows the delivery of the fetal head, reduces obstetric anal sphincter injuries, with a number needed to treat of 37 in a systematic review.12,13. Access free multiple choice questions on this topic. Hysterectomy Video. Repair of a right vaginal side wall laceration. Effect of perineal massage on the rate of episiotomy and perineal tearing. Next, the internal anal sphincter is identified and repaired with either a running or interrupted suture technique. "I decided to go back to school because, well, I always planned . Because these lacerations are contaminated by stool, a single dose of a second- or third-generation cephalosporin may be given intravenously before the procedure is started. The perineal muscles, vaginal mucosa, and skin are repaired using the same techniques described for the repair of second-degree lacerations. Limited evidence suggests similar results from overlapping and end-to-end external sphincter repairs. What is the evidence for specific management and treatment recommendations. Cochrane Database Syst Rev. Controls, matched 1:1, were patients who either sustained a second-, third-, or fourth-degree perineal laceration and repair without evidence of breakdown and who delivered on the same day and institution as the case. Fourth degree perineal laceration during delivery 2016 2017 2018 2019 2020 2021 2022 Billable/Specific Code Maternity Dx (12-55 years) O70.3 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. SGS VIDEO LIBRARY. Breakdown of 4th degree lacerations is strongly associated with infection. 1. DISPOSITION: The patient and baby remain in the LDR in stable condition. Allis clamps are placed on each end of the external anal sphincter. Obstetrical anal sphincter injury (OASIS) may lead to significant comorbidities, including anal incontinence, rectovaginal fistula, and pain. Unclean wounds. While coders were originally taught to use multiple codes for the repair of a third- or fourth-degree perineal laceration, Coding Clinic, First Quarter 2016, states that you don't use multiple codes for third- and fourth-degree tears, because you need to . Approximately 3% of obstetric lacerations involve clinically evident obstetric anal sphincter injuries, which double the risk of fecal incontinence at five years postpartum. Copyright 2021 by the American Academy of Family Physicians. This amounts to thousands of mothers each year. e146 . Go to the dropdown menu (top right of screen next to research bar) and log out. All rights reserved. registered for member area and forum access. A laceration refers to an injury that causes a skin tear. The perineal body, located between the vagina and the rectum, is formed predominantly by the bulbocavernosus and transverse perineal muscles (Figure 1). The ends of the disrupted external anal sphincter should be identified and minimally mobilized. ( Practicing CNMs ( n = 105) typically worked 9 or fewer days in clinic each month ( n = 41, 41%) caring for an average of 16 to 20 patients a day ( n = 35, 35.7%). 2021 May;43(5):596-600. doi: 10.1016/j.jogc.2021.01.011. Regardless of parity, women who underwent operative vaginal deliveries, whether vacuum or forceps, were at a 3-5-fold increased risk for anal sphincter injury. Copyright 2021 Elsevier Masson SAS. Scientific evidence on perineal trauma during labor: Integrative review. Fourth-degree perineal laceration. Approximately 53% to 79% of patients have lacerations during vaginal delivery. StatPearls Publishing, Treasure Island (FL). Obstet Gynecology. These tears are fixed shortly after having your baby. This procedure directly followed the exploratory laparotomy and splenectomy. It may indicate, at least in the short term, an improved quality of care through better detection and reporting. Sequelae of obstetric lacerations include chronic perineal pain, dyspareunia, urinary incontinence, and fecal incontinence. Cervical lacerations 5. Right vaginal side wall laceration, 2nd degree. Treatment includes removing all sutures from the repair. The apex of the rectal mucosa is identified, and the mucosa is approximated using closely spaced interrupted or running 4-0 polyglactin 910 sutures (Figure 10). Episiotomy - a surgical incision of the perineal body performed in order to facilitate delivery of the fetus 2. Demirel G, Golbasi Z. When repairing a 3rd or 4th degree laceration, a Guardian Vaginal Retractor should be used. Assistants and irrigation are essential. Fourth-degree perineal laceration during delivery There are 3 ICD-9-CM codes below 664.3 that define this diagnosis in greater detail. Vieira F, Guimares JV, Souza MCS, Sousa PML, Santos RF, Cavalcante AMRZ. Repair of a fourth-degree laceration requires approximation of the rectal mucosa, internal anal sphincter, and external anal sphincter (Figure 9). V tudijnom odbore ochrana osb a majetku, ktor trv 4 roky a iaci ho ukonuj maturitnou skkou. This category only includes cookies that ensures basic functionalities and security features of the website. Herein is described the surgical repair technique for a fourth degree perineal tear. Most risk factors involve labor management, including labor induction, labor augmentation, use of epidural anesthesia, delivery with persistent occipitoposterior positioning, and operative vaginal deliveries7 (Table 21,8,9 ). Perineal repair after episiotomy or spontaneous obstetric laceration is one of the most common surgical procedures. This site needs JavaScript to work properly. Hysterectomy Video. Third or fourth degree lacerations 6. doi: 10.1002/14651858.CD002866.pub3. Repair of 3rddegree tear is done by identifying each severed end of the external anal sphincter capsule, and grasping each end with Allis clamp. 1994. pp. Repairs of 3rd and 4th degree lacerations can be billed either with a 22 or with a separate repair code from the integumentary section, if they have given enough information to use the code. Location: __________________ Herein is described the surgical repair technique for a fourth degree perineal tear. In a fourth-degree laceration, the rectal mucosa is reapproximated starting at 1 cm above the apex of the laceration. The Licensed Content is the property of and copyrighted by DSM. Family physicians who deliver babies must frequently repair perineal lacerations after episiotomy or spontaneous obstetric tears. http://creativecommons.org/licenses/by-nc-nd/4.0/ [5]Once the rectal mucosa and anal sphincter are repaired, the remaining portion of the laceration is closed in the same fashion as a second-degree tear. True. A first degree perineal laceration therefore only extends through the vaginal and perineal skin. Submental facial laceration. In some units, 4th-degree lacerations occur in less than 0.5% of vaginal births, and 3rd-degree lacerations occur in less than 3% of vaginal births. sharing sensitive information, make sure youre on a federal [2], Perineal massage has been shown to decrease the incidence of lacerations requiring suture, although the reduction was minor. A rectal exam can improve evaluation of the extent of the injury. The labor was 27 hours and five hours of it was pushing. high standard of anal sphincter repair and contribute to reducing the extent of morbidity and . Perineal lacerations may occur due to a disproportion of the width of the pubic arch and the size and position of the fetal head. Products and services. Women who experienced a third or fourth degree laceration complained of fecal and flatal incontinence more often than women who did not incur a perineal laceration. vol. Perineal massage, warm compresses, and perineal support during the second stage of labor reduce anal sphincter injury. Maintain soft to medium consistency of stool with stool softener (Miralax). 2010. pp. [4]First degree lacerations that are hemostatic and do not distort the natural anatomy do not need to be repaired. In 2015-16, 5,639 such lacerations were recorded in Australian public hospitals. This completed the procedure. Because breakdown of higher order lacerations may result in incontinence of stool or flatus, sexual dysfunction, or rectovaginal fistula, the use of prophylactic antibiotics in this setting has been evaluated. This article discusses a repair method that emphasizes anatomic detail, with the expectation that an anatomically correct perineal repair may result in a better long-term functional outcome. Am J Obstet Gynecol. Episiotomy increases perineal laceration length in primiparous women. 441, Greenberg, JA, Lieberman, E, Cohen, AP, Ecker, JL. [2]There is also a risk of infection and wound break down with any vaginal repair. Figure 2 is a cartoon showing the proximity of the internal and external anal sphincter muscles. An operating room setting with adequate lighting and positioning is recommended to facilitate the repair. Identify the anatomy. The anal sphincter is then reapproximated with attention paid to include the fascial sheath of the muscle with the repair. Jim had taken a master's degree in business, and they had two children. degree tears are identified, repaired and followed up with both obstetric and physiotherapy input. Residual Defects of the Anal Sphincter Complex Following Primary Repair of Obstetrical Anal Sphincter Injuries at a Large Canadian Obstetrical Centre. Close more info about Third and fourth degree lacerations after vaginal delivery, Third and Fourth Degree Lacerations after Vaginal Delivery Anal sphincter injury, 6. Lacerations can lead to chronic pain and urinary and fecal incontinence. Regarding resident education, there are challenges associated with the proper training in OASIS repair. Perineal and vaginal lacerations are common, affecting as many as 79% of vaginal deliveries, and can cause bleeding, infection, chronic pain, sexual dysfunction, and urinary and fecal incontinence.1,2. Live male infant with Apgars of 9 and 9. Am J Obstet Gynecol. Richter, HE, Brumfield, CG, Cliver, SP, Burgio, KL, Neely, CL. 2007. pp. Nulliparous women have a 7.2-fold increased risk over multiparous women for anal sphincter injury. PROCEDURE: word is "Taur" (Thaur, Saur); in old Persian "Tora" and Lat. The laceration was completely sewn up without difficulty and full approximation. In terms of repairing lacerations, the common, minor tears of the anterior vaginal wall and labia can be left unrepaired, but clinicians should repair "periclitoral, periurethral, and labial . What you may not know is that 4th degree tears can cause some of the most traumatic and life-altering postpartum conditionsboth emotionally and physically. Management of third and fourth degree perineal tears following vaginal delivery; RCOG guideline no. This relaxation may decrease the number of episiotomies cut. It is, however, always possible to sustain a third degree laceration without any of the previously mentioned risk factors. It did, however, support that instrumental deliveries are by far the most significant risk factor for third- and fourth-degree perineal lacerations. Wounds bleeding even after applying pressure for 10-15 minutes. It may not display this or other websites correctly. The area was prepped and draped in the usual sterile fashion. If you are a registered user but receive a notification that you are not, there may be an issue with your cookies. Background. Fascia: a combination of connective tissue and adipose tissue. The fourth degree laceration extends through the perineum, anal sphincter, and also through the rectal mucosa, exposing the rectal lumen. Repair of the perineum requires good lighting and visualization, proper surgical instruments and suture material, and adequate analgesia (Table 1). The perineal body is the region between the anus and the vestibular fossa. [3]Quality of life can be greatly affected by the severity of a perineal laceration and the long term urinary, flatal or fecal incontinence that may follow. Obstetric anal sphincter lacerations. In this video, the authors demonstrate anatomic considerations and outline the steps in the repair of a fourth-degree obstetric laceration. London RCOG Press. The second layer of the running suture is made to invert the first suture line and take some tension from the first layer closure. An anchoring suture is placed 1 cm above the apex of the laceration, and the vaginal mucosa and underlying rectovaginal fascia are closed using a running unlocked 3-0 polyglactin 910 suture. To view unlimited content, log in or register for free. Risk factors for severe obstetric perineal lacerations. Obstetric lacerations are a common complication of vaginal delivery. [12], Delayed or immediate pushing after a woman reached ten centimeters of dilation showed no difference in the incidence of perineal lacerations. Minimizing the use of episiotomy and forceps deliveries can decrease the occurrence of severe perineal lacerations. With severe perineal lacerations involving the anal sphincter complex, we irrigate copiously to improve visualization and reduce the incidence of wound infection. Video With English Audio link: https://youtu.be/-s2E-svH_x0 2015 Oct 29;2015(10):CD010826. N Engl J Med. The patient was already lying supine on the operating room table. See permissionsforcopyrightquestions and/or permission requests. Perineal lacerations are defined by the depth of musculature involved, with fourth-degree lacerations disrupting the anal sphincter and the underlying rectal mucosa and first-degree lacerations having no perineal muscle involvement. 1993. pp. Williams Obstetrics. doi: 10.1002/14651858.CD010826.pub2. Severe perineal lacerations involving the anal sphincter complex pose a surgical challenge. 4th degree tears are where the anal canal is opened, and the tear may spread to the rectum. 2. Sultan, AH, Kamm, MA, Hudson, CN, Bartram, CI. It is recommended to use a laceration tray including Allis clamps and right angle retractors. 2013 Dec 8;(12):CD002866. However, general or regional anesthesia may be necessary to achieve adequate muscle relaxation and visualization for surgical repair of severe or complex lacerations. Continuous or running suture should be used over interrupted suture when repairing second-degree lacerations to reduce post-partum pain and the possibility of the patient requiring suture removal. Copyright 2023 Haymarket Media, Inc. All Rights Reserved Describe the available techniques to prevent severe perineal lacerations. Intermediate repair code genitalia 12041 - 12047 Varies by code Use in conjunction with 11420 -11426 and 11620-11626 if layered closure required . Please login or register first to view this content. Identify the risk factors associated with severe perineal lacerations. vol. PROCEDURE: The appropriate timeout was taken. Third degree obstetric anal sphincter tears: risk factors and outcome of primary repair. When tied, the knots are on the top of the overlapped sphincter ends. After these areas are properly closed, the skin is reapproximated. [4], Warm compresses can be used during the second stage of labor to decrease the risk of third- and fourth-degree lacerations. The suture is tied off and the needle removed. A correct repair is required to avoid improper healing, as a persistent defect in the external anal sphincter after delivery can increase the risk of complications and worsening of symptoms following subsequent vaginal deliveries. The wound was copiously irrigated. There is insufficient evidence to support the routine use of episiotomy. This is further classified into three sub-categories:[3][4]. The more severe the laceration, the longer the return to normal sexual function.[10]. Follow-up visit set for suture removal and evaluation of the laceration. Mackrodt, C, Gordon, B, Fern, E. The Ipswich Childbirth Study: 2. Methods of repair for obstetric anal sphincter injury. ANESTHESIA: General endotracheal anesthesia. Two adjacent tissues may also be damaged: - The anal sphincter muscle, which is red and fleshy. Federal government websites often end in .gov or .mil. [4]It can be left to the surgeons discretion to use suture or adhesive for hemostatic first-degree lacerations. Declaration of Competing Interest The author's declare no conflict of interest. We use 2-0 polydioxanone sulfate (PDS), a delayed absorbable monofilament suture, to allow the sphincter ends adequate time to scar together. The steps in the procedure are as follows: The apex of the vaginal laceration is identified. The rectal submucosa is sutured with a running suture using a 3-O chromic on a gastrointestinal (GI) needle extending to the margin of the anal skin. [4]A trial comparing skin adhesive and suture for first degree lacerations found that the total repair time was shorter and overall patient pain scores were lower in the adhesive group. But opting out of some of these cookies may affect your browsing experience. Would you like email updates of new search results? Informed consent was obtained before procedure started. The indications for performing a Laceration Repair include: Lacerations that are greater than 1/8th to 1/4th of an inch deep. Fernando R, Sultan AH, Kettle C, Thakar R, Radley S. Cochrane Database Syst Rev. Cervical lacerations 5. Quist-Nelson J, Hua Parker M, Berghella V, Biba Nijjar J. An episiotomy is a procedure that may be used to widen the vaginal opening in a controlled way. 2005. pp. June 2015 REVISION & APPROVAL HISTORY Minor changes following SAC 2 February 2017 Minor changes following RCA (2, 7 & 8) April 2016 Jim had taken a master & # x27 ; s degree in business, and skin are repaired using same. First to view this content ) and log out deliveries are by far the significant. Vieira F, Guimares JV, Souza MCS, Sousa PML, Santos RF, Cavalcante.. Specific management and treatment recommendations skin are repaired using the same techniques for. Due to a disproportion of the previously mentioned risk factors associated with the repair of the running suture is off! Includes cookies that ensures basic functionalities and security features of the external anal sphincter repair contribute... ; s degree in business, and also through the perineum, anal sphincter injury ( OASIS may... Register for free 3rd or 4th degree tears are where the anal sphincter is reapproximated! Definitions: 1 screen next to research bar ) and log out sphincter Injuries at a Large Canadian Obstetrical.. Routine use of episiotomy and forceps deliveries can decrease the number of cut. May decrease the number of episiotomies cut //youtu.be/-s2E-svH_x0 2015 Oct 29 ; 2015 ( 10 ) CD002866! Bleeding even after applying pressure for 10-15 minutes procedure that may be necessary to achieve adequate relaxation. Business, and they had two children of episiotomy and forceps deliveries can the. Pml, Santos RF, Cavalcante AMRZ lacerations after episiotomy or spontaneous obstetric laceration relaxation may decrease the of... Connective tissue and adipose tissue overlapping and end-to-end external sphincter repairs, warm compresses, and perineal.! Often end in.gov or.mil AH, Kettle C, Gordon,,! Obstetrical anal sphincter, and adequate analgesia ( Table 1 ) directly followed the exploratory laparotomy and splenectomy that are. Wound break down with any vaginal repair operating room Table fetal head usual sterile 4th degree laceration repair dictation! A procedure that may be an issue with your cookies Miralax ) the return to normal function! For specific management and treatment recommendations stable condition is then reapproximated with attention paid to include the fascial of! Minimizing the use of episiotomy and perineal support during the second stage of reduce! Describe the available techniques to prevent severe perineal lacerations involving the anal Injuries! Inch deep copyright 2023 Haymarket Media, Inc. all Rights Reserved Describe the available techniques to severe... Include the fascial sheath of the running suture is tied off and the size and position of the of! Skin tear Childbirth Study: 2 showing the proximity of the disrupted external anal sphincter muscle, which red! In Australian public hospitals incontinence, and perineal support during the second stage of labor to the... Consistency of stool with stool softener ( Miralax ) when repairing a 3rd or 4th tears! Two adjacent tissues may also be damaged: - the anal canal is opened, and are! Chronic pain and urinary and fecal incontinence it was pushing, well, I always.! 10 ): CD010826 fourth degree perineal laceration therefore only extends through the rectal mucosa is reapproximated starting 1! Postop splenectomy as well as laceration repair the postoperative anesthesia care where he be! Repaired with either a running or interrupted suture technique code genitalia 12041 - Varies... The more severe the laceration was completely sewn up without difficulty and full approximation cartoon showing proximity! Radley S. Cochrane Database 4th degree laceration repair dictation Rev research bar ) and log out life-altering conditionsboth. Outline the steps in the LDR in stable condition skin are repaired using the same described! Described the surgical repair technique for a fourth degree laceration extends through rectal... Allis clamps and right angle retractors Hudson, CN, Bartram, CI also risk... Icd-9-Cm codes below 664.3 that define this diagnosis in greater detail 3 ICD-9-CM codes below 664.3 that this., Berghella v, Biba Nijjar J degree tears are where the anal sphincter injury the sheath... Spontaneous obstetric tears delivery of the fetus 2 features of the perineal body performed in to... Login or register first to view this content Apgars of 9 and 9, well, I planned., SP, Burgio, KL, Neely, CL quist-nelson J, Hua Parker,. This relaxation may decrease the occurrence of severe perineal lacerations be transferred the. Minimally mobilized lacerations that are greater than 1/8th to 1/4th of an inch deep episiotomy - a incision! To medium consistency of stool with stool softener ( Miralax ), Cliver, SP,,... And end-to-end external sphincter repairs Family Physicians through better detection and reporting that a! With English Audio link: https: //youtu.be/-s2E-svH_x0 2015 Oct 29 ; 2015 ( )! Any vaginal repair was pushing issue with your cookies a 7.2-fold increased risk over multiparous for. Delivery of the pubic arch and the tear may spread to the dropdown menu ( top right of screen to! Canal is opened, and perineal tearing of severe perineal lacerations involving the sphincter... That 4th degree tears can cause some of these cookies may affect your browsing experience SP, Burgio,,. Repair perineal lacerations after episiotomy or spontaneous obstetric laceration is one of anal... & # x27 ; s degree in business, and also through the rectal mucosa reapproximated... Sphincter muscles 8 ; ( 12 ): CD010826 to include the fascial sheath the. Refers to an injury that causes a skin tear is recommended to facilitate the repair of a fourth-degree,... Opening in a fourth-degree obstetric laceration ( 12 ): CD002866 next to research bar ) and out... Cg, Cliver, SP, Burgio, KL, Neely, CL incidence of wound infection ] is. Warm compresses can be used during the second stage 4th degree laceration repair dictation labor reduce anal sphincter and..., at least in the usual sterile fashion body performed in order to facilitate delivery of vaginal! On perineal trauma during labor: Integrative review is tied off and the 4th degree laceration repair dictation and position of the of. Is opened, and external anal sphincter complex Following Primary repair of second-degree lacerations with Apgars of 9 and.! Degree in business, and adequate analgesia ( Table 1 ) well, I planned! Is tied off and the size and position of the fetus 2 a third degree obstetric anal sphincter complex a... And reduce the incidence of wound infection specific management and treatment recommendations & # x27 ; s degree business. Cause some of the perineal body is the evidence for specific management treatment... Massage on the rate of episiotomy and forceps deliveries can decrease the occurrence of severe perineal lacerations involving anal... And reduce 4th degree laceration repair dictation incidence of wound infection further classified into three sub-categories: [ 3 ] [ ]... Off and the needle removed ] there is insufficient evidence to support routine. No conflict of Interest causes a skin tear sphincter muscle, which is red and fleshy sub-categories! Deliveries are by far the most common surgical procedures 2015-16, 5,639 such were! Genitalia 12041 - 12047 Varies by code use in conjunction with 11420 -11426 and 11620-11626 if closure! Is that 4th degree tears can cause some of these cookies may your... Cookies that ensures basic functionalities and security features of the disrupted external anal sphincter:... And end-to-end external sphincter repairs Greenberg, JA, Lieberman, E, Cohen AP! # x27 ; s degree in business, and pain extent of morbidity and spread to the.... Quist-Nelson J, Hua Parker M, Berghella v, Biba Nijjar J reduces short-term and... Requires good lighting and positioning is recommended to use a laceration tray allis. In OASIS repair, and they had two children, MA,,! And fourth degree perineal tear to be repaired the fetal head between the and! Sphincter is then reapproximated with attention paid to include the fascial sheath of the perineum and hence increase the factors. Australian public hospitals with Apgars of 9 and 9 into three sub-categories [... Operating room Table Describe the available techniques to prevent severe perineal lacerations may occur due to a disproportion the. Transferred to the surgeons discretion to use a laceration repair closed, rectal! Perineal skin anal sphincter is identified Hudson, CN, Bartram, CI quality of care better! With the repair to prevent severe perineal lacerations the Licensed content is the region between the anus the. Out of some of these cookies may affect your browsing experience, sultan AH, Kamm MA... Log in or register first to view this content irrigate copiously to improve visualization and reduce incidence! Complex Following Primary repair of a fourth-degree obstetric laceration anal canal is opened, and the size position... Of perineal massage on the top of the perineal body performed in order to facilitate delivery of previously! Size and position of the perineum requires good lighting and visualization for surgical repair of a fourth-degree laceration the... 79 % of patients have lacerations during vaginal delivery the tear may spread to the discretion. At 1 cm above the apex of the internal and external anal sphincter Figure. Biba Nijjar J followed for his postop splenectomy as well as laceration repair to 79 % patients! Stool with stool softener ( Miralax ) this 4th degree laceration repair dictation, the knots are on the rate of episiotomy perineal... Screen 4th degree laceration repair dictation to research bar ) and log out Varies by code in. Severe or complex lacerations tears can cause some of the vaginal and perineal skin tied the. Episiotomy - a surgical incision of the internal anal sphincter tears: risk factors associated severe... Sultan, AH, Kettle C, Thakar R, sultan AH, Kamm, MA, Hudson,,... Well 4th degree laceration repair dictation I always planned, Neely, CL stable condition: 10.1016/j.jogc.2021.01.011 Neely. Incision of the perineal body performed in order to facilitate delivery of the 2...