 Okay, so I'm now going to introduce Belle. Let's get right in there and give Belle as long as we can to talk about her study. So Belle is an Australian registered nurse and midwife and she's currently completing her PhD with the Susan Wacken School of Nursing Midwifery at the University of Sydney. Belle has qualifications in midwifery, nursing and paramedicine and has over 15 years clinical experience in a variety of hospital and community settings. Belle's research explores the administration of intravenous fluids to women in labor, applying knowledge from her emergency trauma and critical care experience to examine this contemporary clinical practice. Belle has a passion for research, education, patient safety and the implementation of evidence-based care. And Belle won't be on the screen, she's going to be just using her audio today so she won't have her video going. And so welcome Belle. Thank you Hazel, good day everyone. It's great to be joining you from Sydney, Australia. Today I am here to talk to you about my PhD research that explores the administration of IV fluids to women during labor and birth. Before I begin, I'd like to acknowledge the Gadigal people of the Aurora Nation, traditional custodians of the land on which the University of Sydney campuses stand and to pay my respects to their elders past, present and emerging. So IV fluids and labor. This research was born through my confusion and curiosity. I've had the great opportunity through my career to experience a wide variety of clinical areas and learning. I started out my health education in paramedicine before moving into nursing and later midwifery. While most of my education was completed in Australia, my initial maternity education was at Georgetown University in Washington DC during a semester abroad. As a nurse in Australia, you would have mostly found in an emergency department. However, I have rotated for many specialties and health settings. My background is important. As it helped shape my view and understanding of IV fluids. Coming from a background where IV fluids were encouraged to be strictly monitored and used with caution, I did not find the same when I moved into midwifery. Here I saw IV fluids administered more freely and for indications that when I asked, no one could really provide an answer. Today's presentation will focus on the first two stages of my PhD. The first stage being a retrospective clinical chart review and fill a balanced documentation audit and the second, a qualitative interviews with midwives across Australia. Before moving into the studies, I just want to provide a little bit of background about what we currently know about IV fluids. Firstly, it is quite a common intervention here in Australia. It can be estimated that over half of all women who birth in Australian hospitals will receive IV fluids at some point during their labor and birth. Reasons women may receive IV fluids can include administration of medications such as IV oxytocin, for a preload prior to epidural energizer to manage signs of fetal distress, as well as maternal hydration and for emergency situations such as sepsis and postpartum hemorrhage. However, at present, our practices in Australia are largely undescribed. Also, as an offshoot of this, we also don't know what effect our current practice has on women and their babies. This is important because there are recognised risks of IV fluid administration. For example, infection, fluid overload, electrolyte disturbance, and near-natal transit technique. Additionally, recent research also questions of the IV fluid administration can influence neonatal birth weights and breastfeeding. With this in mind, the first step in my part of my PhD was to perform a retrospective clinic chart review and fluid balance audit to help gain a bit more understanding about how IV fluids were currently being used. The aim of the study was to describe the current practice of registered moisturiser managing IV fluids to women during labor. And the primary objective was to determine the level of the completion of new sapphire state standardised fluid balance documentation, which have provided examples in the pictures below. The review included IV fluid orders, fluid balance charts, clinical progress notes, and the labor partogram. Charts included in the study with those of first-time mothers who presented the birth unit in documented spontaneous labor with one baby in a head down position and who had received IV fluids during labor. The sample included 107 first-time mothers. The median maternal age was 33 years and the median gestational age was 40 weeks. The study took place at a Metropolitan Tertiary Referrable Hospital in New South Wales, Australia, and was conducted between the 1st of October, 2016 to the 22nd of March, 2017. For the fluid balance audit, a 24-point audit tool was developed and this comprised of 12 criteria, of which you'll see in a couple of slides. This graph is showing that the majority of the 107 fluid balance chart scored less than 50% of the total possible score. However, 19 women did not have a chart completed, so they were excluded from the audit analysis. This was because it was unknown whether a chart was completed and missing or never commenced in the first instance. With this taken into consideration, the lowest score was three out of 24 and the highest was 17 out of 24 and the main score was 10. This table breaks down the results into the 12 criteria that made up the fluid balance chart audit. I would like to bring your attention to the area in blue. This relates specifically to IV fluid input. As you can see from the numbers, the majority of the charts were partially completed when it came to documenting IV fluid input. This may describe in the practice challenging. Aspects of the practice I was able to establish included indications for IV fluids, the most common indication being epidural analgesia with concurrent oxytocin infusion and the second being epidural analgesia on its own. Maternal hydration was an indication for IV fluid use in 20 of the hundred and seven women with maternal and or fetal maternal concern, the least likely indication to be documented, which was for 11 women or 10%. The type of IV fluids used were the 0.9% normal saline or heart men's with many women receiving both. When it came to estimating the volume I ministered, I was only able to estimate minimal and maximum volumes. The estimated median minimal volume was 2,000 mils ranging from 500 to 4,000 mils and the estimated maximal volume was 3,500 mils raining from 1,000 mils to just short of six litres. Additionally, an unexpected finding of the study was a low level of IV fluid order completion. 13 charts were excluded for varying reasons, but overall a low 10% of charts were found to be fully completed. The most common reason for incompletion was no written prescribed order for IV fluids with 62 of 94 charts found to have IV fluids administered in labor without a written prescribed order. This was recognized to be an abloscope of practice for midwives at this facility. However, the study is limited in its findings to explain as to why this occurred. Following these results, I was left with so many more questions. What do these results mean? What was the reason behind them? I could only have views that were multiple interrelated factors at play. So from there, I set out to conduct qualitative interviews with midwives across Australia to see if I could learn more about what midwives think, believe and understand about IV fluids, as well as the documentation relating to them. The aim of the interviews was to examine what influences a midwife to document maternal fluid balance when a misdring IV fluids to women during labor and birth. The primary objective was to determine barriers of facilitators to documenting maternal fluid balance by midwives. A semi-structured interview schedule consisting of eight open-ended questions with follow-up prompts and probes was developed. And I used the ComB model of behavior to help guide the development of the interview schedule. The ComB model of behavior has been widely used to identify what needs to change in order for a behavior change intervention to be effective. However, as it identifies three factors that need to be present for any behavior to occur, namely capability, opportunity, and motivation, I believed it to be a good fit for my needs. The interview questions explored four main areas. Firstly, understanding of indications for IV fluids. Secondly, identification of current practice. Thirdly, benefits and complications of IV fluid administration. And fourthly, barriers and facilitators documentation. Face-to-face telephone and online video calls are offered with thematic analysis used to interpret the data. Allegable participants include registered midwives and postgraduate registered nurse midwifery students. Bachelor midwifery students were not invited as they are unable to administer IV fluids independently. However, I did aim to include recent graduates as part of the sample. Participants were primarily recruited for email and social media advertisements. Allegibility was screened by a survey asking for current clinical professional role, midwifery experience, and areas of work, i.e. whether they worked in the birth unit or antenatal. 66 registered midwives and 30 postgraduate registered nurse midwives. Students completed the survey. A maximum variation sample was used so I could try and get a variety across Australia for both continual care, like different models, so continual care versus working in birth unit, birth centers, as well as geographical locations, so metropolitan and rural. Overall, 24 were invited to participate. 10 did not respond to or unable to arrange a time. I did not attend the schedule interview, so overall 11 were interviewed. Interviews ranged from 24 to 47 minutes and all main states and territories of Australia were represented apart from Tasmania, with nine participants from metropolitan areas and two from rural. However, some of the participants did have quite a very background. For example, previous home birth midwives now working in metropolitan center. From the analysis, eight major themes were identified, which included 16s relating to understanding influences around IV fluids and two themes that's physically around documentation. The first theme identified awareness of practice. This theme explored reason for IV fluids. Midwives recognized that IV fluids were commonly used during women's labors and births. The indications midwives spoke about were similar to what I had found in the literature review. These include induction and augmentation of labor, epidural preload, medication administration, fetal compromise and maternal hydration. Additionally, it was recognized that IV fluids were commonly used as a first line response for many situations as captured in this quote. When I think about interpreting this fluids in labor, I think about, I guess, because of my background, I think that's often fairly given ad hoc. If we've got a fetal tachycardia, if we've got the woman looks a bit dry, if she's having an induction, there's always some fluids around. So I feel like fluids is often a first line response for different issues in labor and I'm always cautious about that. Additionally, this theme also captured variations in clinical practice. For example, factors such as IV fluid type, volume of IV fluids and rate of IV fluids varied between facilities. This also included different processes for induction of labor. Midwives who had clinical practice in different facilities also recognized this variation too. The second theme was triggers and habits. This theme identified that midwives believed that the administration of IV fluids and labor had been normalized. However, it was recognized as a clinical practice that could be improved with several midwives reporting that there was a habit of it not being well done. That was expressed over some of the reasons that IV fluids were used. For example, IV fluids for reduced variability of the fetal heart rate. This was reported by one of the nurse midwives from New South Wales who stated, I think it's one of those practices again that we do perhaps to make our feels better in a failless power situation. Additionally, there was conflicting use where the IV fluid should be used in women during normal physiological labor. While some midwives reported that IV fluids should not be required, two senior midwives discussed how IV fluids may help to keep women progressing on a normal pathway, particularly in cases where the women is experiencing recurrent vomiting and unable to tolerate oral fluids. Four processes around the IV fluid administration was also explored in this theme. This is sort of captured in the quote below. So, well, why do we need IV fluids to begin with? Because I think, well, if a woman's in a normal spontaneous labor, she shouldn't need them. So yes, I start to think, okay, she may be not on a normal pathway, medically managed, but why does she need them? The third theme to emerge was workplace and professional culture. Midwives identified that decision-making around IV fluids and labor rested largely with midwives. The need for medical consultation and prescribed order was recognized, but it was common for midwives to report on accepted practices in their individual workplaces where this may be likely to occur in retrospect. Influences around expectations and accepted practice included the indications for IV fluids, workplace culture, midwifery, medical relationships, and medical officer availability. For example, when IV fluids were administered for a more routine reason, it was more likely that IV fluids were to be started by midwives and then fully described by a doctor in retrospect. Another possible reason that IV fluids may be started prior to a medical review included that there was an expectation that IV fluids would already be in progress when a concern arose with this expectation coming from both senior midwifery staff and now medical colleagues. One midwife spoke about the differences in working in a small rural unit. I've worked in a couple of small units now and the doctors aren't necessarily present, or even if they are, you're often talking in emergency situations, they're just not. You're not going to delay and you're working with usually senior midwife who assumes control of the situation and has enough clinical experience that if she's prompting the administration of fluids, you trust that it's wise judgment. This was also reiterated by more senior midwife who's seen rural experience. Teamwork with our medical colleagues was also raised at various times through the interviews. One senior midwife spoke about how IV fluid practices had changed over time. Initially, you couldn't put IV fluids up because none of the midwives could cannulate. So you had to have a medical person come and then do that. And now everyone, well, not everyone, but a lot of midwives can cannulate and if you can't as a midwife, you'll get you made up a corridor to put a cannular in to put fluids in. But it's who's running the show? Who's in charge here? It becomes a bit of a control thing. Do they instate these fluids or do you instigate these fluids? This quote sort of suggests that there may be political components surrounding IV fluids and labour. With one midwife reporting a disappointment that IV fluid is being removed from the birth unit, birth unit setting, so birth centre, as it's received out of their scope of practice. Workplace leaders were also identified to influence workplace and professional culture. For instance, in units where workplace leaders were acknowledged, stricter monitoring on maternal fluid balance, awareness of complications, proactive education and undertaking of research and or quality improvement projects were reported. Workplace leaders may have been midwives, obstetrician, anaesthetist or managers. However, one thing that did stick out was that the wishes of the woman was not a theme that strongly came through. Whilst it was touched on lightly by a couple of midwives, it was a theme that you may have expected to come through in greater depth. This doesn't mean it is missing, but it does raise the questions of whose needs we are meeting as a priority. The fourth theme was foundational knowledge. Midwives reported learning about IV fluids mostly in the clinical environment. Many participants had difficulty recalling if they had ever had formal education around IV fluid administration during labor. Nurse Midwives recognized that IV fluid knowledge was expected to be a pre-existing knowledge when they came into midwifery. However, one participant recognized that nursing education does not generally cover IV fluid management in labor and that this contributes to a gap in knowledge. Additionally, Midwives reported peer learning as a potential reason for relaxed fluid balance management during labor care. I'm just brainstorming here, but I don't know that we teach our student midwives about the importance of it that well. So whether or not we're just blasé and going from one generation of midwives to the next generation of midwives. The fifth theme explored was perception of risk, and this was both risk for ministering IV fluids and risk if you didn't. Midwives reported on possible complications of IV fluids, including fluid overload, hyponatremia, infection, pain, breast edema, and falsely high neonatal birth rates. However, some midwives also recognized that their understanding of potential complications was minimal. The cascade of intervention was brought up with some participants discussing the greater picture, recognizing that labor and birth does not occur in isolation and that there can be foreign effects. I've seen women with breastfeeding issues, and I know everything we do at that point has a follow on effect. It's easy when you work in a birthing unit to have the baby out and we're all good enough we go to the ward and that's it on to the next thing. But I think looking at it from a perspective where you think about the longer-term impacts of that all this fluid to a woman and what that actually means. Balancing safety and risk was a particular concern for midwives working in rural facilities. Here it may be more routine to err on the side of caution and place an IV see at the commencement of labor or praying to sudden the induction process. This was reported to be due to low levels of people available help if an emergency was to occur. In birth units where this was not a concern midwives reported alternate views, arguing that intervention should only be applied when required, recognizing that interventions can carry with them unwanted consequences and they have timing resources to intervene if necessary. The healthy woman was also identified as a reason for a perceived low sense of risk. Midwives reported working primarily with young healthy women with good hearts that can compensate for extra volume from IV fluids. However, this was recognized that this could contribute to a false sense of security and potentially lead to a burst of maternal and natural outcomes. Finally, the impact of seminal events was also identified in this theme. Several midwives reported being aware of major clinical incidents relating to IV fluid administration, mainly these related to women who experienced lower load of load and acute primary edema. Clinical incidents were recognized to be triggers for clinical practice reviews and increased education. However, it was unclear whether seminal events impacted care and perception of this risk long term. The sixth theme was professional standards and regulations. Midwives reported on a lack of clinical guidelines. This reported as being odd or unusual, but guidelines that exist including IV fluids that were unusually non-pacific. So all they say with an epidural prior to commencement secure intravenous access and commit intravenous fluids. That's all they say. So they don't say what rate or how long to start it or whether you need to do a preload. They just don't say it. They just say have access and through running, but that's really vague. So whereas everything else like vibrantly BP for 15 minutes are the parts of that guideline are really specific because I don't think we have good quality events on it. The lack of clinical guidelines likely promotes variations in clinical practice. Additionally, it does not appear to stop us from referring to guidelines that do not exist. For example, APP or as per policy policy was commonly reported as a way medical officers prescribed the rate for IV fluids during labor despite the lack of policy to refer to. Several midwives also discussed awareness of lack of evidence and identified the need for greater evidence in clinical guidelines to help guide safe practice. In relation to documentation, the monitoring and documentation of maternal flu balance was recognized to be important. However, in some interviews just how important was recognized by the midwives in the latest stages of the interview after they had the opportunity to discuss and reflect. The most frequent point made about the importance of monitoring maternal flu balance was that the general we don't know who will be important for until it is too late. I think we generally have a healthy cohort of women that we're caring for. So it's only really when things go badly wrong that the importance of this kind of stuff is highlighted. So I think there's a little bit of apathy about keeping track of all that. To emphasize this, one of the midwives told us a story about a case where she had a woman with undiagnosed gestational hypertension that turned into postpartum preeclampsia. The woman ended up in ICU with pulmonary edema. She was so unwell and when they looked back, they were unable to determine what her output had been in labor. According to the pardogram and the flu balance chart, she basically hadn't passed urine for about 12 hours. So they decided that she was dehydrated and they'd given her some fluids. The midwife reported that was a really long labor, pumping in fluids, fluids, fluids and more fluids. And this resulted in the woman ending up critically unwell. The final theme identified barriers to fluid balance documentation. It was reported in the interviews that the flu balance charts were seen as a low priority. Midwives were reported forgetting to document it and that it just simply wasn't a habit to complete. Competing priorities and ease of access document was brought up by several midwives. However, one midwife reported that these reasons are not enough to justify why flu balance charts are poorly filled out generally. I don't think it's busy enough all the time to explain why they're so poorly filled out generally. Whenever we're looking at them in clinical issues or doing audits, and that's just not midwifery, it's across the board by the way. But yes, I think business and acuity is one of the barriers, but I think there's also a bit of apathy towards the importance of it midwifery. But what does all this add up to? Well, before I finish, I do just wanna leave you with one last quote. I think it is one of the most poorly managed aspects of intrapartum care, and I've always thought that. And I've always, in previous roles, wanted to find good evidence and there isn't any. And it's been really curious to me how when I go from facility to facility, everyone has different practices and never really understands why they do it. So in conclusion, this is an important area that needs further research. Midwives are integral to the administration of Abbey Fluids and Labor, and therefore our involvement in research on long-term medical colleagues is important to help and ensure we provide the best possible care to our women and birthing people. For my PhD so far, I have established that there is a wide variety in clinical practice and that midwives recognize there is both room and need for improvement. Additionally, the lack of evidence in clinical guidelines is a barrier. Improved flow and balance documentation is one that we could help us to improve knowledge around this practice. With more accurate documentation, we'll be able to increase our knowledge of current practices and have a better understanding of what research could help us to provide safe holistic care. For this to occur, addressing barriers, such as lack of education and promoting facilities, such as ease of access will be important for this to occur. With further research in mind, it is hoped that the first stage of my PhD will be a cohort study examining maternal neonatal outcomes of Abbey Fluid Administration and Labor. I look forward to be able to bring this knowledge to you in the near future. I would like to acknowledge my MFIL supervisors, Professor Sally Tracy and Dr. Donna Hart and my PhD supervisors, Professor Julie List, Dr. Brad DeViers and Dr. Heather Sheppard for their support so far. Before I finish and hand over back to Hazel, I would like the opportunity though to ask you guys some questions. If that's okay. Preferably answering in the chat box. So my first question to you is that when you are documenting Abbey Fluids Administration and Labor, where do you actually document? So yeah, I'll just repeat the question. So yeah, when you're giving Abbey Fluids and Labor, where do you actually document the Abbey Fluid Administration? So whether it's maternal fluid balance chart. So we have a couple of answers here. We've got the email, the electronic maternal record, and medication charts, in the bodies of notes. So maybe progress notes. Yeah, and while you're doing, yeah, while you're doing that, the other question, I do have a question, is that if you had to pick one spot to record where you write about Abbey Fluids or record Abbey Fluids, where would that be in the maternal records? So if you're choosing only one area that you think it should be? Yeah. Where should that be? Okay. So other areas that have been noted for, for writing them is on the pardogram, on the fluid orders, CTG, fluid balance chart, medication charts. But now for this next question, we've got on the pardogram in the E-maternity, if they're using the electronic version. Orders, there's a variety, isn't there, Belle? Yeah. The nurses flow chart, CTG. I suppose this also reflects that some of us are still paper and some of us are going to be a genetic electronic. Yes, and that would be very, that would be varied across country as well as across, across nations. Yeah. And also locations, so whether home or in hospital, or by centre. So you, Rachel also used to use, used to write, rate per mil type of fluid in a half hour in notes. Lucy's got an electronic fluid balance chart and fluid orders. It's a real variety, isn't it? Yeah. And one of the last people I just sort of typing up, my last question is more of a curiosity and whether you can actually help me. So I'm actually looking to see if anyone is aware of any specific guidelines relating to IV fluids in your area. So if you do have any, my contact details are on this last slide, or you can contact in the chat. But that is my last question. It's been great to have you, but I'll hand it back over to Hazel to see if there's any questions. Sure. So if you do have any policies or guidelines that you're aware of, maybe take a screenshot now so that you can email them to Belle because she'd really like to have a look at them. Rachel's saying here, basically anywhere you can, it's something going into the body therefore extremely important to document. Absolutely. And some, some wonderful presentation there. Now, I didn't see too many questions. If you do have a question for Belle, we've got the time to be able to really explore this. So if you have any questions that you could pop in the chat or you want to ask, then please let us know. Hi Hazel and Cole, hi everybody. There were a couple of questions during the conference, during the presentation. I just wanted to point out Lucy Sutherland, you mentioned that you are now told not to preload, prior to, without being so, prior to giving an epidural. And I was just wondering, what's your experience of the instance of fetal bradycardia with that? And is that mainly for women who will have a pre-client cell? So what's the question for Belle then from that? So for Belle, yes. So Belle, have you, have you, or did you find out anything about the preloading, using fluid for preloading and whether that impacted fetal heart rates? Yeah, so preloading, I'm aware that other people looking into it. So I'm looking more into general IV fluid use as opposed to specifically preload, but I'm aware that it is sort of an issue of contention. Megan's just got a question here. It is known how, is it known how IV fluids cause breast edema, also the effect on baby weight? Yep, so I believe there's a couple of studies out of Canada that have looked at that. So I'm not sure if we have strong evidence, but it's one of those things that could make sense. And I believe that people around the world are looking into it. Certainly seems like this is a topic that needs further, further evidence and more information, more research. Red is saying that should be curious to see how many babies lose more than 10% fluid, 10% weight with all this fluid. Because obviously that can then be, that can be quite a difficult thing to then manage, isn't it, if there is that 10% loss of weight? Did you read anything or know anything about that, Belle? No, a little bit then. It was brought up by most of the midwives in the study as one of the sort of cascade of interventions. So if IV fluids do contribute to a greater birth weight of the baby, are we actually pushing babies over that 10% threshold that we have here in Australia? So are they more likely to require formula? Are we also affecting their breastfeeding? So is it a double barrel of, are we causing breastfeeding problems and also having babies with false high birth weights? So it's definitely an area that requires looking into. Yeah, absolutely. Rachel's saying evidence-based birth, so that's that website about evidence-based birth, discusses some of that research as well. So that might be something for people to go and have a look at. But yeah, so we're really setting up. Setting up women and then babies to have issues with breastfeeding because of this extra weight that could be on babies that they can then lose. Now Cecilia earlier was saying that interestingly that IV fluids weren't allowed in birth centers that you mentioned, because you did mention that in the presentation that one of the themes that came out was that IV fluids were removed from birth centers do you want to tell us a little bit more about that though? So I'm not too familiar with that, but it was one of the birth center midwives saying that they used to give IV fluids when it became necessary to sort of help keep a woman there. So for example vomiting, so nothing too sort of serious or concerning, but maybe like a liter of fluids if someone wasn't able to tolerate oral fluids just to help keep them hydrated. And so they didn't require transfer to the delivery suite. And this was to help in keeping with what the woman's wishes want, what they wanted, they wanted to be in the birth center and not the birthing unit. So it's interesting to say that it also happened in other parts as well as in Australia. So how were you saying then that it was then removed, then IV fluids were then removed from the birthing centers so they could no longer do that? It was recognized as, it was basically recognized that midwives are not able to prescribe IV fluids. So if IV fluids had them, they were using them, but then it was identified that they can't prescribe them so therefore they shouldn't be using them in that environment, is that what you're saying? Yeah, so it's being aware that we actually do need prescribed order. I imagine some places may actually have standing orders to allow midwives in specific situations to administer IV fluids, but I believe that wasn't the case for that specific birth center. Yeah, absolutely, it would depend on what the midwives can do. So Cecilia was saying in Canada, midwives can use IVs at home births, mostly to administer antibiotics for TB, prophylaxis, or other post-partum hemorrhage butyotonics, and most midwives attend uncomplicated births in hospitals without citing an IV line. Certainly at home birth in Australia, you have to be an endorse midwife, which does give you endorsement for prescribing. So if you really needed to, you could use IV fluids and you could prescribe that yourself. So that's a bit of a difference from home to hospital there. Not that I think it would be used very, very often at all but certainly maybe in the treatment of PPH, for example. Yeah. Nicole, do you have any other questions there? I've just noticed Lucy's comments, just what she's typing in now. So yes, so Lucy's sort of writing about that she's noticed that when she's changed facilities or changed states perhaps, that there is a difference between fluids being titrated carefully and now being running more freely. And so that was definitely something that midwives had worked in various facilities or various states, hadn't noticed that sort of everywhere they go was a little bit different. Yeah, that's challenging then, isn't it? Because then that also then shows that maybe this is an area that is more based on behavior and tradition than evidence and best practice because wherever the tradition is in that particular unit, that is what is happening. So yeah, certainly looking at this is potentially something that really needs to be brought into the evidence-based arena to really be thinking, why are we doing this and is it necessary? And so Lorraine's saying, when the premises based on a just-so story, then no wonder there was so much contradictory practice. That's right, when we just do it because we've always done it, then we've always done it a little bit differently in each place. That is interesting. One of the things I discovered during a literature review and sort of going back to where Ivy Fluid started, there was an obstetric textbook, which I can't remember when it was from, but in the sort of guide about giving Ivy Fluids, the instructions was, quote, say try 500 mils or try 1,000 mils. So it wasn't like we have evidence for A, B and C, it was say try this, see if it works. Yeah, I can imagine. And I think also some of it really stems from the need to be doing something, for that we can never just watchfully wait and see what happens. We have to kind of be active and we can actively put in an Ivy Canyon, we can actively get the fluids going, we can actively then watch it and monitor it while they're naturally just sitting and waiting and watching. And we can understand why that occurs. Yes. Okay, well, if there's no more questions, we might go through the final slides. Belle, if you just want to, on this, okay, I can do that. I'm just going to make Nicole the presenter so that Nicole's able to go through those final slides. But thank you for the really interesting presentation, Belle. I just think it's something that is showing that there's a real gap and a diversity of practice. So really important topic and well done on one of your earliest presentations and coming and doing that here for us here at the VIGM. It's a great platform to tell us about your PhD work. It's certainly something in my Masters in PhD that I really loved coming into VIGM and sharing my initial findings. So hopefully you'll come back and you'll tell us about the next lot of findings from as your PhD progresses into different stages.