1
|
Ghulmiyyah LM, El-Husheimi A, Usta IM, Colon-Aponte C, Ghazeeri G, Hobeika E, Mirza FG, Tamim H, Hamadeh C, Nassar AH. Effect of Sustained Uterine Compression versus Uterine Massage on Blood Loss after Vaginal Delivery: A Randomized Controlled Trial. Am J Perinatol 2023; 40:1644-1650. [PMID: 34775581 DOI: 10.1055/s-0041-1739409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE This study aimed to compare the effectiveness of sustained uterine compression versus uterine massage in reducing blood loos after a vaginal delivery. STUDY DESIGN This was a prospective randomized trial conducted at the American University of Beirut Medical Center (AUBMC) between October 2015 and October 2017. Inclusion criteria were women with a singleton pregnancy at ≥36 weeks of gestation, with less than three previous deliveries, who were candidates for vaginal delivery. Participants were randomized into two groups, a sustained uterine compression group (group 1) and a uterine massage group (group 2). Incidence of postpartum hemorrhage (blood loss of ≥500 mL) was the primary outcome. We assumed that the incidence of postpartum hemorrhage at our institution is similar to previously published studies. A total of 545 women were required in each arm to detect a reduction from 9.6 to 4.8% in the primary outcome (50% reduction) with a one-sided α of 0.05 and a power of 80%. Factoring in a 10% dropout rate. Secondary outcomes were admission to intensive care unit (ICU), postpartum complications, drop in hemoglobin, duration of hospital stay, maternal pain, use of uterotonics, or of surgical procedure for postpartum hemorrhage. RESULTS A total of 550 pregnant women were recruited, 273 in group 1 and 277 in group 2. There was no statistically significant difference in baseline characteristics between the two groups. Type of anesthesia, rate of episiotomy, lacerations, and mean birth weight were also equal between the groups. Incidence of the primary outcome was not different between the two groups (group 1: 15.5%, group 2: 15.4%; p = 0.98). There was no statistically significant difference in any of the secondary outcomes between the two groups, including drop in hemoglobin (p = 0.79). CONCLUSION There was no difference in blood loss between sustained uterine compression and uterine massage after vaginal delivery. KEY POINTS · Transabdominal uterine compression and uterine massage are appropriate to prevent postpartum hemorrhage.. · No significant difference in blood loss or maternal discomfort observed between the two techniques.. · Both methods are equally effective and either one can be used based on provider preference..
Collapse
Affiliation(s)
- Labib M Ghulmiyyah
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Miami, Miami, Florida
| | - Alaa El-Husheimi
- Department of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ihab M Usta
- Department of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Cristina Colon-Aponte
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Miami, Miami, Florida
| | - Ghina Ghazeeri
- Department of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Elie Hobeika
- Department of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Fadi G Mirza
- Department of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Hani Tamim
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Caroline Hamadeh
- Department of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Anwar H Nassar
- Department of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon
| |
Collapse
|
2
|
Massoth C, Helmer P, Pecks U, Schlembach D, Meybohm P, Kranke P. [Postpartum Hemorrhage]. Anasthesiol Intensivmed Notfallmed Schmerzther 2023; 58:583-597. [PMID: 37832561 DOI: 10.1055/a-2043-4451] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
Abstract
Postpartum hemorrhage (PPH) affects about 4% of all deliveries in high-income countries and continues to rise, a trend attributable to the increase in caesarean section rates and maternal morbidity. Preventive measures such as the precautionary administration of uterotonics effectively reduce the risk of severe bleeding irrespective of birth mode. As a time-critical condition and a significant contributor to adverse maternal outcomes, PPH needs to be diagnosed early by measuring, not estimating, blood losses. Institutional treatment algorithms should be available to guide stage-based interdisciplinary management without delay. The main therapy goals are to identify the etiology and stop the bleeding by using uterotonics and mechanical and surgical interventions, to restore hemodynamic stability by volume and transfusion therapy and to optimize hemostasis by laboratory- and viscoelastic assay-guided factor replacement. This review highlights current recommendations for prevention, diagnosis and treatment of PPH.
Collapse
|
3
|
Püchel J, Sitter M, Kranke P, Pecks U. Procedural techniques to control postpartum hemorrhage. Best Pract Res Clin Anaesthesiol 2022; 36:371-382. [PMID: 36513432 DOI: 10.1016/j.bpa.2022.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 09/27/2022] [Indexed: 11/06/2022]
Abstract
Postpartum hemorrhage can occur unexpectedly and with high dynamics. The mother's life often depends on quick action and good communication within an interdisciplinary team. Knowledge of each other's therapeutic options plays a major role. Treatment procedures include obstetric, surgical, and radiologic techniques. In addition to availability and experience with the techniques, two important aspects must be considered in the selection process: the type of delivery and the cause of the hemorrhage. In particular, the distinction between pregnancies with or without disturbed placentation from the placenta accreta spectrum is crucial. From these two points of view, we discuss here different uterus-preserving and uterus-removing techniques. We describe in detail the advantages and disadvantages of each procedure. Because most therapeutic options are based on small case series and uncontrolled studies, local circumstances and physician experience are critical in setting internal standards.
Collapse
Affiliation(s)
- Jodok Püchel
- Department of Gynaecology and Obstetrics, University Hospital of Cologne, Germany.
| | - Magdalena Sitter
- Department of Anaesthesia, Critical Care Medicine, Emergency Medicine and Pain Medicine, University Hospital of Wuerzburg, Germany.
| | - Peter Kranke
- Department of Anaesthesia, Critical Care Medicine, Emergency Medicine and Pain Medicine, University Hospital of Wuerzburg, Germany.
| | - Ulrich Pecks
- Department of Gynaecology and Obstetrics, University Hospital Schleswig-Holstein, Campus Kiel, Germany.
| |
Collapse
|
4
|
Muacevic A, Adler JR, Prasad MK, Singh AV, Sharma S, Singh B, Singh TH, Kumar P, Singh HV, Singh S. Obstetric and Maternal Outcomes After B-Lynch Compression Sutures: A Meta-Analysis. Cureus 2022; 14:e31306. [PMID: 36514660 PMCID: PMC9734287 DOI: 10.7759/cureus.31306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2022] [Indexed: 11/11/2022] Open
Abstract
This review article aimed to determine the obstetric and maternal outcomes after B-Lynch compression sutures to control atonic postpartum hemorrhage (PPH). This meta-analysis was performed after registering the protocol in the PROSPERO database with the registration number CRD42022355358. Two independent reviewers systematically searched electronic databases and search engines (PubMed, Cochrane Library, and Google Scholar) to retrieve published articles from inception to July 2022. The obstetric and maternal outcomes after the B-Lynch compression suture were computed using the random-effects model in pooled proportion with a 95% confidence interval (CI). Meta-regression analysis and subgroup analysis were performed to explain any source of possible heterogeneity. Quality assessment of the included studies was done using Joanna Briggs Institute (JBI) tools which are critical appraisal tools for systematic reviews and meta-analyses. This meta-analysis included a total of 30 studies involving 1,270 subjects. The pooled proportion of B-Lynch suture alone was 91% (95% CI = 82-97%). The combined proportion of B-Lynch suture plus another compression suture was 1% (95% CI = 0-3%), and the pooled proportion of B-Lynch suture plus vessel ligation was 3% (95% CI = 1-6%). The pooled proportions of PPH controlled and hysterectomies were 94% (95% CI = 91-97%, I2 = 65.3%) and 7% (95% CI = 4-10%, I2 = 72.13%), respectively. Therefore, B-Lynch suture (either alone or in combination with other techniques) is a simple and effective measure to control atonic PPH.
Collapse
|
5
|
Yıldırım MA, Kavak SB, Kurkut B, Sanli C, Batmaz I, Bulu G. Comparison of a novel isthmic circumferential suture and Bakri balloon technique for the treatment of uterine atony during cesarean section. J Matern Fetal Neonatal Med 2021; 35:7737-7743. [PMID: 34362277 DOI: 10.1080/14767058.2021.1961724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Postpartum bleeding is a life-threatening obstetric complication. The most common cause is uterine atony. There is no method that can treat PPH with 100% effectiveness and therefore, efforts for the development of more effective conservative treatment methods continue. The aim of the study is to compare the effectiveness of the isthmic circumferential suture technique and the Bakri balloon tamponade in the treatment of postpartum bleeding due to uterine atony during cesarean operation. METHODS This study was conducted by retrospectively evaluating the cases who developed uterine atony during cesarean section. Group 1 (n = 15) consisted of the patients who had undergone the isthmic circumferential suture technique, and Group 2 (n = 15) comprised patients who had undergone the Bakri balloon tamponade. The two groups were compared with regard to obstetric characteristics, operative time, preoperative and postoperative features, and neonatal outcomes. RESULTS The groups were similar with regard to age, obstetric characteristics, preoperative complete blood count, neonatal outcomes and there was no statistically significant difference between groups. The operative time was significantly shorter in Group 1 (61.86 ± 6.7 vs. 69.53 ± 3.2 min; p < .05). The amount of intraoperative bleeding was lower in Group 1, although there was no statistically significant difference (1793.66 ± 323.96 versus 1886.33 ± 343.23 ml; p > .05). The postoperative blood loss was significantly less in Group 1 compared to Group 2 (101.37 ± 64.6 versus 169.32 ± 50.0 ml; p < .05). The postoperative 24-hour Htc values were significantly higher in Group 1 (28.83 ± 2.1 versus 27.08 ± 2.1 g/dl; p < .05). CONCLUSION Both methods are effective in the uterine atony during cesarean section. However, due to the shorter operative time and less pre-operative blood loss, the isthmic circumferential suture technique may be a better alternative.
Collapse
Affiliation(s)
- Mem Arjen Yıldırım
- Department of Obstetrics and Gynecology, Private Cihanpol Hospital, Kızıltepe, Turkey
| | - Salih Burcin Kavak
- Department of Obstetrics and Gynecology, Firat University School of Medicine, Elazig, Turkey
| | - Bülent Kurkut
- Department of Obstetrics and Gynecology, Private Cihanpol Hospital, Kızıltepe, Turkey
| | - Cengiz Sanli
- Department of Obstetrics and Gynecology, Fethi Sekin City Hospital, Elazig, Turkey
| | - Ibrahim Batmaz
- Department of Obstetrics and Gynecology, Hani State Hospital, Diyarbakir, Turkey
| | - Gulay Bulu
- Department of Obstetrics and Gynecology, Kovancılar State Hospital, Elazig, Turkey
| |
Collapse
|
6
|
Wang J, Yang H. Effect of carboprost tromethamine injection combined with modified B-lynch suture and carboprost methylate suppositories in parturients with placenta previa. Am J Transl Res 2021; 13:7812-7818. [PMID: 34377258 PMCID: PMC8340154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 02/24/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To investigate the clinical value of carboprost tromethamine injection combined with modified B-lynch suture and carboprost methylate suppositories in the treatment of placenta previa parturients with postpartum hemorrhage after cesarean section. METHODS A total of 102 parturients with placenta previa and postpartum hemorrhage after cesarean section in our hospital were selected as the study subjects, and they were divided into Group A (carboprost tromethamine injection combined with modified B-lynch suture, n=35), Group B (carboprost methylate suppositories, n=34), and Group C (carboprost tromethamine injection, n=33) in accordance with a random number table. The amounts of hemorrhaging and clinical indices in the three groups were recorded, and the rescue effects were compared among the three groups. RESULTS The amount of hemorrhaging in Group A was significantly lower than that in Groups B and C during surgery and 24 h after surgery (P < 0.05). There were markedly improved clinical indices in Groups A, B and C, showing statistical significance (P < 0.05). There were statistically significant differences in hemostatic failure rate, hysterectomy, postoperative abdominal pain and puerperal infection between Groups A and B (P < 0.05). The intraoperative indices, postoperative infection, effective hemostasis rate and rate of advanced postpartum hemorrhage in Group A were remarkably higher than those in Groups B and C (P < 0.05), showing statistical significance (P < 0.05). There were statistically significant differences in blood oxygen saturation and pulse among the three groups before surgery and 2 h after surgery (P < 0.05). CONCLUSION Carboprost tromethamine injection combined with modified B-lynch suture and carboprost methylate suppositories can reduce the amount of hemorrhaging and the risk of postoperative infection in placenta previa patients with postpartum hemorrhage after cesarean section.
Collapse
Affiliation(s)
- Jianli Wang
- Department of Obstetrics, The First Hospital of Shanxi Medical University Taiyuan 030000, Shanxi, China
| | - Hailan Yang
- Department of Obstetrics, The First Hospital of Shanxi Medical University Taiyuan 030000, Shanxi, China
| |
Collapse
|
7
|
Li GT, Li XF, Li GR, Wu BP, Zhang XL, Xu HM. Removable retropubic uterine compression suture for controlling postpartum hemorrhage. J Obstet Gynaecol Res 2021; 47:1337-1343. [PMID: 33590596 DOI: 10.1111/jog.14698] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 01/14/2021] [Accepted: 01/29/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To minimize the adverse events of uterine compression suture in controlling postpartum hemorrhage (PPH) and to search for a prophylactic approach to potential PPH. METHODS A retrospective analysis was performed in 39 women with removable retropubic uterine compression suture (RRUCS) to stop PPH due to uterine atony during cesarean section (CS). The procedure was to suspend and compress the uterus to the retropubic abdominal wall using an absorbable suture. RESULTS The technique was sufficient to stanch bleeding immediately in 36 patients (92.31%, 36/39). No morbidity or abnormalities occurred in women who underwent RRUCS. Subsequent pregnancies occurred in 10 cases, but the others lacked the desire for future pregnancy. CONCLUSION RRUCS is a simple, safe, and effective technique in controlling atonic PPH; it is also used as a prophylactic application in patients with potential PPH after CS.
Collapse
Affiliation(s)
- Guang-Tai Li
- Department of Obstetrics and Gynecology, Hebei Yanda Hospital, affiliated to Hebei Medical University, Beijing, China.,Department of Obstetrics and Gynecology, China Meitan General Hospital (Emergency General Hospital), Beijing, China
| | - Xiao-Fan Li
- Department of Radiation Oncology, Peking University School of Oncology, Peking University Cancer Hospital, Beijing, China
| | - Guang-Rui Li
- Wangjing Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Bao-Ping Wu
- Department of Obstetrics and Gynecology, China Meitan General Hospital (Emergency General Hospital), Beijing, China
| | - Xiu-Lan Zhang
- Department of Obstetrics and Gynecology, Sanya City Womenfolk and Infant Health Care Hospital, Sanya City, China
| | - Hong-Mei Xu
- Department of Obstetrics and Gynecology, Beijing Fengtai Hospital, affiliated Capital Medical University, Beijing, China
| |
Collapse
|
8
|
Tekela DD, Asmare AG, Gebremariam BM, Assegahegn CA, Wami KD, Nemomssa HD, Simegn GL. Digital postpartum hemorrhage management device (DPHMD). BMC Pregnancy Childbirth 2019; 19:438. [PMID: 31771534 PMCID: PMC6878627 DOI: 10.1186/s12884-019-2601-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 11/14/2019] [Indexed: 11/17/2022] Open
Abstract
Background Primary postpartum hemorrhage (PPH) is an obstetric emergency caused by excessive blood loss that occurs most commonly after the placenta is delivered. PPH can lead to volume depletion, hypovolemic shock, anemia, and it is the leading cause of maternal mortality worldwide. With 470 deaths per 100,000 live births, the maternal mortality ratio in Ethiopia is one of the highest in the world. It is estimated that 94% of births occur at home in Ethiopia and that 10% of maternal deaths are attributed to PPH. Currently, physicians use visual estimation to calculate blood loss and provide fluid during delivery. This traditional method is subjective and generally inaccurate. Method In this project, after delivery blood loss measurement system integrated with fluid delivery and vital sign monitoring method is proposed. The collection and measurement system collects blood loss after delivery and measures the amount of blood loss. The management system continuously monitors the mother’s heart rate and blood pressure. These vital sign values are integrated with the measured blood loss to estimate the amount of IV fluid required to be delivered for the mother. The rate of IV fluid delivery is regulated by a flow rate sensor and solenoid valve. Results The prototype was built and undergone through different tests and iterations. The proposed device was tested for accuracy, cost effectiveness and ease to use. 91.28% accuracy has been achieved and the prototype was built with less than 210 USD. Conclusion The proposed design allows physicians, especially those in low resource setting, to estimate blood loss and deliver fluid accurately. This helps to reduce maternal mortality rate that may occur due to postpartum hemorrhage.
Collapse
Affiliation(s)
- Derartu D Tekela
- School of Biomedical Engineering, Jimma Institute of Technology, Jimma University, Jimma, Ethiopia
| | - Abeba G Asmare
- School of Biomedical Engineering, Jimma Institute of Technology, Jimma University, Jimma, Ethiopia
| | - Birhan M Gebremariam
- School of Biomedical Engineering, Jimma Institute of Technology, Jimma University, Jimma, Ethiopia
| | - Christian A Assegahegn
- School of Biomedical Engineering, Jimma Institute of Technology, Jimma University, Jimma, Ethiopia
| | - Kidist D Wami
- School of Biomedical Engineering, Jimma Institute of Technology, Jimma University, Jimma, Ethiopia
| | - Hundessa D Nemomssa
- School of Biomedical Engineering, Jimma Institute of Technology, Jimma University, Jimma, Ethiopia
| | - Gizeaddis L Simegn
- School of Biomedical Engineering, Jimma Institute of Technology, Jimma University, Jimma, Ethiopia.
| |
Collapse
|
9
|
Songthamwat S, Songthamwat M. Uterine flexion suture: modified B-Lynch uterine compression suture for the treatment of uterine atony during cesarean section. Int J Womens Health 2018; 10:487-492. [PMID: 30197543 PMCID: PMC6113941 DOI: 10.2147/ijwh.s170460] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective The aim of this study was to report our clinical experience of applying a uterine flexion suture, which was modified from the B-Lynch uterine compression suture, for treating uterine atony during cesarean section. Materials and methods This is a retrospective descriptive study describing the use of a new technique, uterine flexion suture, for treating uterine atony during cesarean section. The study period was from January 2009 to December 2017 at Udonthani Hospital, Udonthani, Thailand. Uterine atony during cesarean section was treated by manual compression, intravenous oxytocin, methylergonovine maleate, and prostaglandins and then was observed for 10-15 minutes before applying a uterine flexion suture in the failed medical treatment cases. The patients were observed for vaginal bleeding, hematometra, and infection after operation. Uterine ultrasound scan results on days 1, 7, and 30 postoperation were also reviewed. Results Fifty-seven patients with uterine atony during cesarean delivery received the uterine flexion suture. The mean age of patients was 27.0 (15-44 years). Thirty-four patients were primipara. The indications for cesarean section were cephalopelvic disproportion in 27 (47.4%) cases, and previous cesarean section in 11 (19.3%) cases. Neither postoperative excessive bleeding nor hysterectomy was observed. There was no hematometra or serious postoperative complication after surgery. The estimated time for uterine flexion suture is only 2-3 minutes and was very easy to perform. Conclusion Uterine flexion suture technique, which was modified from the B-Lynch suture, was inexpensive, quick, and effective in the treatment of atonic postpartum uterus in women undergoing cesarean section.
Collapse
Affiliation(s)
- Srisuda Songthamwat
- Department of Obstetrics and Gynecology, Udonthani Hospital, Udonthani, Thailand,
| | - Metha Songthamwat
- Department of Obstetrics and Gynecology, Udonthani Hospital, Udonthani, Thailand,
| |
Collapse
|
10
|
Seidel V, Braun T, Chekerov R, Nonnenmacher A, Siedentopf JP, Henrich W. Vaginal omentum prolapse due to uterine anterior wall necrosis after prophylactic compression suture for postpartum hemorrhage: case report and review of the literature. CASE REPORTS IN PERINATAL MEDICINE 2017. [DOI: 10.1515/crpm-2016-0074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Introduction
Postpartum or peripartum hemorrhage (PPH) is a major cause of maternal death in Western industrialized countries. Fertility preserving second stage interventions following uterotonic drugs include embolization or ligation of relevant arteries, uterine tamponade or compression sutures. Little is known about the complications due to uterine compression sutures. We describe a case report in association with uterine compression sutures and provide a systematic review on necrosis due to compression sutures (CSU).
Data sources
A PubMed database search was done up to October 1, 2016 without any restrictions of publication date or journal, using the following key words: “compression suture” and “postpartum hemorrhage” or “peripartum hemorrhage”. Reported cases were considered eligible when reason for postpartum hemorrhage (PPH), type of compression suture, suture material and type of complication were described.
Results
Among 199 publications a total of 11 reported on uterus necrosis after CSU applied for PPH. B-Lynch and modifications were applied in seven cases, Cho compression sutures in three cases and in one case B-Lynch and Cho techniques were combined. In six cases no additional measures were applied, in two cases vessel ligation, in one case embolization and in one case intrauterine balloon application were applied. In one case of partial necrosis it is not reported if additional measures were applied.
Discussion and conclusion
Uterine compression sutures are a useful method for fertility preserving management of postpartum hemorrhage. The risk of serious complications demands the careful consideration of its use. More research is necessary to improve the technique.
Collapse
|