Labor Pain Research Articles

Effectivity of Walking Epidural Analgesia in Normal Labor to Reduce Labor Pain and Improve Neonatal Outcome

Background: In Indonesia itself, only 15% of 2,700 labor women felt the pain was tolerable, meanwhile 85% said the pain was moderate until unbearable. Usage of epidural anaesthesia for pain relief in labor is common but controversies still persist about its effect and side effect on labor process. Neuraxial block especially epidural also not yet well known in Indonesia.Objective: This research aims to study maternal visual analogue scale (VAS) score changes before and after walking epidural anesthesia (WELA) and fetal outcome after birth. Methods: This research is an experimental design with one pre-test and post-test group. Data was taken from Unggul Karsa Medika Hospital and Permata Hati Clinic medical records from 2017 until 2022. Ethical approval was approved by Unggul Karsa Medika Hospital Ethical Committee (003/KEP-LIT/III/2023). After that all of 450 patients’ data was then analyzed by Wilcoxon with IBM® SPSS Statistic 26th with α=0.05.Result: Statistical analysis shows there was significant decrease of pain severity with initial VAS 7.58 to 3.37 after WELA procedure (p 0.0001). APGAR scores of all the foetus were normal with no asphyxia present.Conclusion: Our findings demonstrate the benefit of WELA for both of mother and fetus. was significantly decrease in VAS score during labor. Fetal outcome was also notably great after labour process and usage of epidural could decrease the risk of fetal acidemia and distress which reduce caesarean section rate. Usage of WELA in Indonesia could be encourage and recommended as an alternative to elective caesarean section.

The Effect Of Effleurage Massage On Reducing 1st Stage Labor Pain

The Effect Of Effleurage Massage On Reducing 1st Stage Labor Pain

“…We never considered it important…”: a qualitative study on perceived barriers on use of non-pharmacological methods in management of labour pain by nurse-midwives in eastern Tanzania

BackgroundA significant number of women experience labour without effective pain management and thus suffer from unbearable labour pain to the extent they term labour as the most agonizing event in their lives. Unresolved labour pain can lead to stress, fear, and confusion, which may compromise placental perfusion and lead to birth asphyxia. Although various pharmacological and non-pharmacological labour pain management methods exist, the use of non-pharmacological methods (NPMs) to manage labour pain has remained low in low-resource settings. This paper explored the barriers for using NPMs to manage labour pain by nurse-midwives in eastern Tanzania.MethodsWe conducted an exploratory qualitative study with 18 nurse-midwives purposefully recruited from the labour wards of two selected district hospitals in eastern Tanzania. Qualitative content analysis guided the data analysis.ResultsTwo categories illustrating barriers to using NPMs were generated: individual-level and institutional-level barriers. Individual-level barriers include (i) limited competencies of nurse-midwives on the use of NPMs for managing labour pain, (ii) inadequate exposure to labour pain management practices, (iii) misconceptions about labour pain relief, and (iv) a lack of opportunities for knowledge acquisition. The institutional barriers include (i) a critical staff shortage amidst many clients and (ii) an unfavourable healthcare facility environment.ConclusionThe implementation of NPMs for labour pain management by nurse-midwives in eastern Tanzania faces several institutional and individual barriers. We recommend addressing both supply- and demand-side barriers. Strengthening nurse midwives’ competencies in NPMs adoption and use and improving the facility environment to ensure privacy during labour can be a starting point for addressing supply-side issues. We recommend dispelling myths and misconceptions through health promotion education to address demand-side barriers.

Effect of Sacral Warm Compress on Perception of Labour Pain among Parturient Mothers during First stage of Labour at Selected Hospital, Coimbatore

An interventional study was conducted to assess the effect of sacral warm compress on the perception of labour pain among parturient mothers during the first stage of labour at Sri Ramakrishna Hospital, Coimbatore. Quasi- experimental pre-test post-test control group design was adopted for the study. Purposive sampling method was used and 40 parturient mothers were included based on inclusion and exclusion criteria. Every alternative sample was assigned to experimental group [n=20] and control group [n=20]. The pre-test was conducted to assess the perception of labour pain by using questionnaire and numerical pain rating scale. Sacral warm compress was applied for 20 minutes at every 1-hour interval during the active phase of the first stage of labour. The post-test was conducted using the same tool to find the effect of sacral warm compress on parturient mothers during the first stage of labour. The mean and standard deviation pre-test and post-test pain score of mothers in the experimental group were (7.13, 5.09) and 0.849, 0.875 respectively with a mean difference of 2.04. It proves that there is an effect of sacral warm compress on the perception of labour pain among parturient mothers in the experimental group (t= 3.883; p=0.001). The mean and standard deviation of post test scores of mothers in the experimental and control group were 5.09, 7.495 and 0.875, 0.467 respectively with a mean difference of 2.405. It proves that there is an effect of sacral warm compress on perception of labour pain among parturient mothers in experimental group (t=10.48; p = 0.001). The findings reveal that application of sacral warm compress is highly significant and effective in reducing the perception of labour pain among parturient mothers during active phase of the first stage of labour. Keywords: Parturient Mothers during first stage of labour, Perception of labour pain, Sacral Warm Compress.

Progressive Muscle Relaxation Training During Pregnancy: Effects on Mental State, Delivery and Labour Pain - a Prospective Study.

Progressive muscle relaxation is a widely used technique for relaxation, but studies are rare about efficacy on pregnancy and perinatal outcomes. Aim of our study was to determine whether progressive muscle relaxation affects anxiety and depression levels of pregnant women, pregnancy outcomes, labour pain and analgesic requirements. 156 pregnant women were enrolled in a prospective non-randomized controlled cohort study. The control group received standard antenatal care and classes only, while the intervention group additionally received progressive muscle relaxation training once a week for six weeks. Anxiety, depression and current strain were measured in a pretest-posttest experimental design using self-report scales at baseline (1 st survey), 5 weeks later (2 nd survey) and during puerperium (3 rd survey). Numeric Rating scales were used for measuring labour pain and satisfaction with analgesic treatment in the 3 rd survey. Fifty complete questionnaires from each group were analysed. There were no differences in mental status between the groups at baseline. Progressive muscle relaxation training significantly reduced depression levels. Trait anxiety, reflecting a person's basic anxiety decreased significantly in both groups during puerperium. No differences in pregnancy outcomes, labour pain and analgesic requirements could be shown within both groups in general. Nonetheless, women attending more than five progressive muscle relaxation courses reported significantly less labour pain within the group and compared to controls. Pregnant women could benefit from progressive muscle relaxation training if used continuously. Relaxation methods should be a substantial part of prenatal care and available for everyone.

Senam Birth Ball dalam Mengatasi Nyeri pada Persalinan Kala I

Physiologically, pain is generally felt by all mothers who face the birth process. Pain arises due to uterine contractions which are useful for opening the cervix. However, intense pain can disturb comfort and can affect psychological conditions. As many as 46% of primigravida mothers experienced severe pain, 64% experienced mild to moderate pain. In multigravida mothers, 37% experienced severe pain and 63% experienced moderate and mild pain. One way to overcome severe pain in the first stage is birth ball exercises. The aim of the research was to determine the effect of using a birth ball on first stage labor pain. The design of this research was a quasi-experimental one group with control group. The population in this study were all mothers giving birth at PMB Dewi Anggraini in March-April 2024, totaling 28 respondents. The sampling technique used is total sampling. Statistical tests use the Independent Sample T Test. The average pain in the intervention group was 3.52 and the average labor pain in the control group was 5.52, meaning there was a reduction in pain levels of 2.00. The significant value was found to be p: 0.001 < 0.05, meaning that there was a difference in the pain scale of the first stage of labor in the groups that used a birth ball and those that did not use a birth ball. It is hoped that health workers can improve maternal care during childbirth, one of which is by inviting mothers to use a birth ball.

Cold Compresses in Overcoming First Stage Labor Pain at PMB Andina

Cold Compresses in Overcoming First Stage Labor Pain at PMB Andina

The Effect of Birth Ball on Reducing Labor Pain in The 1st Active Phase at TPMB Wina Julaeli, S.Tr. Keb. Bdn in Labuan District, Banten Province in 2024

The expulsion of the products of conception after reaching a gestational age of more than 37 weeks, either through a natural process through the vagina (spontaneous vaginal) or through surgical action through the stomach (perabdominal), is referred to as childbirth. This study aims to determine the effect of a birth ball on reducing labor pain during the first active phase at TPMB Wina Julaeli, S.Tr. Keb. Bdn in Labuan District, Banten Province in 2024. This research design is quantitative using the Quasy Experiment research method. The design applied in this research was one group pretest – posttest with 30 respondents and data collection using observation sheets was analyzed using the Wilcoxon test. The result obtained was a significance value of 0.000, which was smaller than the significance result of 5% (p-value = 0.000 < 0.05), therefore the conclusion was that Ha was accepted, which means that there was an influence of the birth ball on reducing labor pain during the first active phase at TPMB Wina Julaeli. S.Tr. Keb. Bdn in Labuan District, Banten Province in 2024. This birth ball therapy can be used during every birth process as an option to reduce pain management for mothers in labor.

The Role of the Massage Method with Deep Breathing Relaxation in Reducing the Intensity of Labor Pain: A Randomized Clinical Trial at Mukomuko Regional General Hospital, Indonesia

Labor pain is a significant concern for expectant mothers, often leading to anxiety and potential complications. Non-pharmacological interventions like massage and deep breathing relaxation (DBR) have gained attention as safe and effective pain management options. This randomized clinical trial aimed to investigate the efficacy of combining massage and DBR in reducing labor pain intensity at Mukomuko Regional General Hospital, Indonesia. A randomized controlled trial was conducted with 100 pregnant women experiencing labor pain. Participants were randomly assigned to either the intervention group (massage + DBR) or the control group (standard care). Pain intensity was assessed using the Visual Analog Scale (VAS) before and after the intervention. Data were analyzed using appropriate statistical tests. The intervention group demonstrated a significantly greater reduction in VAS scores compared to the control group (p < 0.05). Participants in the intervention group reported higher satisfaction with pain management and a more positive childbirth experience. In conclusion, the combination of massage and DBR is a safe and effective non-pharmacological intervention for reducing labor pain intensity. This approach can be easily integrated into standard care practices, offering a valuable tool for improving maternal comfort and well-being during childbirth.

“Maternal and Perinatal Outcome in Preterm Placenta Praevia”

Introduction: Placenta previa (PP) is a significant cause of maternal and fetal morbidity and mortality worldwide. However, there is limited data from developing countries on the maternal and fetal outcomes and complications associated with placenta previa. Aim of the study: The aim of this study was to evaluate maternal and perinatal outcome in preterm placenta praevia. Methods: This prospective observational study was conducted in the Department of Gynae and Obstetrics of Dhaka Medical College Hospital, Dhaka, Bangladesh during the period from March 2010 to August 1010. Result: Total 66 patients were diagnosed with placenta previa. We found, the majority (42%) of participants were aged between 26-30 years and with lower socio-economic status significantly associated with higher prevalence due to lack of regular antenatal care. The majority were admitted at 35-37 weeks gestation, with the highest perinatal loss occurring before 30 weeks. Initial bleeding was generally small, and many presented with labor pain and anemia. Ultrasonography diagnosed 55% of cases, with cesarean sections frequently used, leading to better outcomes compared to vaginal deliveries. Severe postpartum complications like hemorrhage and urinary tract infections were common in more severe cases. Conclusion: Placenta previa is a major cause of maternal and perinatal morbidity and mortality. Early registration, regular antenatal care, early detection of high-risk cases, and timely referral to higher centers with good NICU services and blood bank facilities can help prevent these adverse outcomes.

Determinants and willingness to practice obstetric analgesia among women attending antenatal clinic at Dr. Bogalech Gebre Memorial General Hospital Central Ethiopia: a cross-sectional study

BackgroundLabor pain is uniquely experienced and described by the woman giving birth, and it is often considered one of the most excruciating experiences for many women. This study aimed to evaluate factors associated with the willingness to receive labor analgesia among women attending the antenatal clinic at Dr. Bogalech Gebre Memorial General Hospital Central Ethiopia in 2022.MethodsAn institution-based, cross-sectional study was conducted from January to March 2022. Data were collected using semi-structured questionnaires by a convenience sampling technique. Data was entered in EpiData 4.2 and exported to SPSS version 20 for analysis. Both Bivariable and multivariable logistic regressions were conducted to determine factors associated with pregnant women’s willingness to choose labor analgesia. Crude odds ratio (COR) and adjusted odds ratio (AOR) were computed to assess the association between variables.ResultsA total of 398 pregnant women have participated in the study with a response rate of 94%. Nearly 30%, (29.4%) of the pregnant women had a willingness to practice labor pain management. Being a housewife (AOR: 8.35, 95% CI: 2.07, 33.63). Women who live in urban (AOR: 2.60, 95% CI: 1.29, 5.29). Having had awareness about labor analgesia (AOR: 1.70, 95% CI: 1.00, 2.60) and the short duration of labor time (AOR: 1.84, 95% CI: 1.15, 2.96) were statistically significant with a willingness to practice labor analgesia.ConclusionWe conclude that the willingness of pregnant mothers’ toward obstetric analgesia practice was low in the study area. Being a housewife, urban residence, awareness about labor analgesia, and short duration of labor were statistically significant with the willingness of the mothers to practice labor analgesia. To increase willingness to use labor analgesia, authorities should prioritize delivering health education on pain management choices to address concerns and promote effective methods and practices.

Narative Review The Effect of Endorphin Massage and Counter Pressure During Labor On Endorphin Hormone Release

Background: Labor pain is a subjective experience associated with uterine contractions, stretching of the cervix, and descent of the fetal head. According to the World Health Organization (WHO), every year, 210 million pregnancies occur in the world, and 20 million women experience pain due to childbirth. Of the 2700 mothers giving birth, 30% experienced severe pain, 20% of labor was accompanied by very severe pain, and 15% experienced mild pain. Non-pharmacological therapy continues to be developed in the world of obstetrics, which aims to provide comfort during the birthing process. Endorphin massage and counter pressure are non-pharmacological therapies that can stimulate the release of endorphins and reduce pain and anxiety during childbirth. Objective: This study aims to determine the effect of endorphin massage and counter pressure during labor on the release of endorphin hormones and their benefits. Methods: This research method was a literature review study. Journal searches were carried out by applying online databases such as PubMed, Garuda Portal, ScienceDirect, and Google Scholar. Articles were selected based on inclusion and exclusion criteria. Results: The analysis was carried out on 32 research articles. It was found that endorphin massage and counter pressure are non-pharmacological techniques to overcome and reduce labor pain and anxiety through the help of endorphin hormones which are useful for a smooth delivery process. Conclusion: The influence of endorphin massage and counter pressure during labor on the release of endorphin hormones, which are useful for reducing labor pain, reducing anxiety, increasing comfort, and speeding up the labor process.

Risk factors for postpartum readmission: a prediction model in Iranian pregnant women

BackgroundPostpartum readmissions (PPRs) are an important indicator of maternal postpartum complications and the quality of medical services and are important for reducing medical costs. The present study aimed to investigate the risk factors affecting readmission after delivery in Imam Ali Hospital in Amol, Iran.MethodsThis retrospective cohort study was conducted on the mothers who were readmitted after delivery within 30 days, at Imam Ali Hospital (2019–2023). The demographic and obstetrics characteristics were identified through the registry system. Univariate and multivariate logistic regressions with odds ratios (ORs) and 95% CIs were carried out. To identify the most important variables by machine learning methods, a random forest model was used. The data were analyzed using SPSS 22 software and R (4.1.3) at a significant level of 0.05.ResultsAmong 13,983 deliveries 164 (1.2%) had readmission after delivery. The most prevalent cause of readmission after delivery was infection (59.7%). The chance of readmission for women who underwent elective cesarean section and women who experienced labor pain onset by induction of labor was twice and 1.5 times greater than that among women who experienced spontaneous labor pain, respectively. Women with pregnancy complications had more than 2 times the chance of readmission. Cesarean section increased the chance of readmission by 2.69 times compared to normal vaginal delivery.ConclusionThe method of labor pain onset, mode of delivery, and complications during pregnancy were the most important factors related to readmission after childbirth.

Real-time analgesic efficacy and factors determining drug requirements of combined spinal-epidural analgesia for labor: a prospective cohort study

PurposeCombined spinal-epidural analgesia (CSEA) is effective but not sufficient for labor pain. This study was conducted to assess the real-time analgesic efficacy, side effects of anesthetic drug dosage, and maternal satisfaction in labor to provide reference for the optimization of labor analgesia.MethodsThis was a prospective, cohort, single-center study that included 3020 women who received CSEA for labor analgesia. The visual analogue scale (VAS) for labor pain, real-time anesthetic drug dosage, side effects, adverse labor outcomes, factors influencing average drug dosage, and maternal satisfaction with CSEA were assessed.ResultsOverall, the VAS labor pain score was lowest at the first hour after the anesthesia was given. After 4 h for primiparas and 3 h for multiparas, the VAS score was greater than 3 but the anesthetic drug dosage did not reach the maximum allowed dosage at the same time. The average anesthetic drug dosage was positively correlated with fever, urinary retention, uterine atony, prolonged active phase, prolonged second stage, assisted vaginal delivery, and postpartum hemorrhage. The average anesthetic drug dosage was the highest in women ≤ 20 years old, those with a body mass index (BMI) ≥ 24.9 kg/m2, and those with a primary or secondary education level.ConclusionAppropriate age guidance and emphasis on education of labor analgesia, weight management during pregnancy, and real-time anesthetic dosage adjustment during labor based on VAS pain score may have positive effects on the satisfaction of labor analgesia.Clinical trial number and registryClinicaltrials.gov (ChiCTR2100051809).

Pain, Tears and Blood: Doubts about the Concept of Revolution in Ghāʾib Ṭuʿmah Farmān’s al-Makhāḍ

ABSTRACT In 1974, Iraqi-born Ghāʾib Ṭuʿmah Farmān (1927–1990) published his novel al-Makhāḍ (Labor Pains. Baghdad: Maktabat al-Taḥrīr, 1974). Farmān had subscribed to Communist ideas since his youth, a leaning for which he was also arrested, yet in this novel, he bluntly expresses his disappointment with the 1958 Iraqi revolution’s consequences and his doubts about the concept of revolution itself. In this study, Farmān’s novel will be placed within the broader historical and cultural context in which Leftist Arab intellectuals became critical of the Iraqi revolutions of 1958, 1963 and 1968 alike. A close reading of the novel, published six years after the Baʿth revolution of 1968 and the rise of Saddam Hussein to power, reveals admonitions on possible future turns of events. To wit, the concentration of power in the hands of the state and the regime, persecution of political rivals, favoring regime allies, economic disparities, as well as the discord between the noble goals of the revolution and its contradictions in the preservation of the post-revolutionary order.

The Effect of Rebozo Technique Complementary Therapy on Reducing the Intensity of Labor Pain in the First Active Phase

Persalinan merupakan proses lahirnya janin, plasenta dan membran dari dalam rahim melalui jalan lahir dikarenakan adanya kontraksi uterus, proses dilatasi serviks (membuka atau menipis) serviks, dan penurunan kepala janin sehingga menekan bagian panggul yang dapat menyebabkan nyeri. Intensitas nyeri tergantung pada kekuatan kontraksi dan tekanan yang timbul saat kontraksi, apabila nyeri persalinan tidak diatasi akan menyebabkan terjadinya partus lama. Tujuan penelitian ini untuk mengetahui adanya pengaruh teknik rebozo terhadap penurunan tingkat nyeri persalinan kala I fase aktif. Penelitian ini menggunakan quasy eksperimen dengan pre dan post test one grup control design dengan jumlah sampel 30 responden. Data dikumpulkan menggunakan lembar observasi yang kemudian dianalisa menggunakan uji Wilcoxon. Hasil penelitian ini didapatkan nilai signifikan yaitu sebesar 0,000 < hasil signifikan yaitu 5% (p-value = 0,000-0,05) maka dapat disimpulkan bahwa H1 diterima yang artinya ada pengaruh penggunaan teknik rebozo terhadap penurunan Tingkat nyeri persalinan kala I fase aktif di TPMB Hj. Lelah Partiah, S.Tr.Keb.Bdn Tahun 2024.

Education of Birth Ball Training as Therapy to Relieving Labor Pain

Labor pain arises because of the mother's physical and psychological response. Emotions become unstable due to anxiety and fear which worsen the condition of labor pain. The pain experienced by the mother during labor can give rise to fear which makes her anxious and often leads to panic attacks. This condition causes a physiological response that can disrupt the condition of the uterus when it contracts so that the impact of labor will last a long time. Usually, the mother who is about to give birth will find it difficult to adjust to the conditions of labor pain, so that uterine contractions cannot be controlled which causes the first stage to lengthen and the fetus to be disturbed. A prolonged labor process is a type of birth complication that is worrying, complicated, and unpredictable. A non-pharmacological method that can reduce labor pain is birth ball therapy. Research that has been conducted has found that birth ball exercises affect reducing labor pain. PkM is implemented through educational activities where there are 30 PkM participants. The results of the PkM implementation show that the PkM participants have been successfully educated through this PkM activity so that they can apply birth ball exercises to reduce labor pain in mothers. Due to the implementation of this PkM activity, it is hoped that there will be an increase in the knowledge of midwives who play a role in initial level services to provide appropriate steps in dealing with labor pain in mothers using complementary therapy, and birth ball exercises.

The Impact of Ice Massage at SP6 and LI4 Point on Labor Pain and Anxiety : a literature review

The Impact of Ice Massage at SP6 and LI4 Point on Labor Pain and Anxiety : a literature review

Impact of Sacral Lumbal Massage on Pain and Head Decline During First Stage of Labor

Introduction: Labor pain varies in intensity, with many women experiencing high levels during delivery. This study aims to evaluate the effectiveness of sacral massage on pain intensity and fetal head descent during the first stage of labor. Method: A quantitative study was conducted with a sample of laboring mothers divided into intervention and control groups. Participants were selected using purposive sampling, with criteria including mothers aged 20-35 years, active first-stage labor, good maternal and fetal health, cephalic presentation, and uncomplicated labor. The intervention involved lumbar-sacral massage for 20 minutes, repeated once, with intervals of 5-10 minutes. The control group received relaxation through breathing exercises. The study took place from January to March 2024. Data were analyzed using the Wilcoxon and t-tests with a significance level of 0.05. Results: The intervention group significantly reduced labor pain (pre: 6.90, post: 3.70, p=0.000). There was no significant difference in fetal head descent duration between groups (p = 0.05). Conclusion: Lumbar sacral massage is an effective non-pharmacological method for reducing labor pain and is recommended for pain management in midwifery practice.

From Rib Hump to Baby Hump-Common Questions of Patients Suffering from and Undergoing Treatment for Scoliosis-A Comprehensive Literature Review.

Background: Scoliosis, the most prevalent spinal deformity in children, is often associated with adolescent idiopathic scoliosis (AIS). Curves surpassing 50 degrees can deteriorate, especially thoracic curves, leading to pulmonary limitations. Surgical intervention is usually advised for curvatures exceeding 50 degrees to halt further progression. Severe AIS is notably more frequent in females, yet knowledge regarding subsequent pregnancies and associated risks is scarce. Female patients often inquire about conception, pregnancy, labor, and future back pain (BP) concerns. Reports on the long-term outcomes after pediatric AIS treatment and pregnancy consequences remain limited. Uncertainty looms over the likelihood of increased back pain (BP), cesarean sections (CSs), or other pregnancy-related issues following surgical AIS management. In this investigation, an attempt was made to scrutinize the existing research on individuals afflicted with scoliosis who received either conservative or surgical treatment, with the aim of delineating crucial and pragmatic findings that can serve as a compass for spine surgeons when counseling young patients with adolescent idiopathic scoliosis regarding the ailment, its repercussions, the available treatment modalities, and the associated outcomes. A comprehensive analysis pinpointed the optimal data at hand. Consequently, the primary objective of this investigation was to assess the patient-reported and clinical consequences in scoliosis patients who have undergone segmental posterior fusion and subsequently conceived. Conclusions: While the majority of individuals with AIS are capable of conceiving and bearing children, they may encounter greater challenges in fertility than healthy women unaffected by AIS. Pregnant women with a prior history of spinal fusion for AIS can undergo pregnancy and childbirth with no significant escalation in perinatal complications. Women who have undergone surgical procedures for AIS have been observed to exhibit a prevalence of back pain comparable with that of healthy pregnant women; however, a higher incidence of low back pain is evident when spinal fusion is extended to the L3 or L4 vertebra. Although back pain is a common occurrence in pregnant women with AIS, the spinal alterations induced by pregnancy are typically minor and transient. In comparison with healthy women, individuals with a history of spinal fusion necessitate cesarean sections more frequently. The degree of correction loss during pregnancy is lower in previous reports involving pedicle screw instrumentation than in previous reports involving Harrington or hybrid segmental instrumentation.