Webinar Follow-Up: What has the Pinard Taught Us?

July 11, 2018

 

On June 21, 2018, Ginger and Lesley from the Grow Midwives team hosted an intimate webinar exploring the lessons the wonderful tool known as the Pinard has taught the midwifery community.  

If you would like to follow along with the presentation, Ginger’s Prezi can be found here.

Ginger: Well let's let's just get started and we'll see what happens. What might be good is really for everybody to just, I know all of you but I'm not sure it's true the other way around. So Tracy do you want to start?

Tracy: Yeah. I am a nurse midwife I'm down here in Texas. Now I had the privilege of meeting Ginger through Baby Company when new baby company as a midway in Charlotte. So I'm now down here in Texas helping open up a joint CNN CPN practice. It's been quite an adventure.

Ginger: And as Birth Center too right Tracy?

Tracy: Yeah birth center, clinic all of those things. So it'll be the first practice in the area.

Ginger: Wonderful. Tracy is one of those frontier students who went straight through her DNP.

?: And just what area of Texas are you?

Tracy: I'm in like the greater Houston area so north Houston and there's one birth center here that's been here for like 20 years. And then all of a sudden you know they're starting to start copulate. So goods that CPM and CNM get out to help the CPN for sure and the hospital setting there's a big gap now.

Judy: I've been a midwife for a very long time now in Kansas but I live in Arizona retired.

Leslie: I'm Ginger's partner in Grow Midwives. Charleston birthplace open 10 years.

Ginger: There we go. You're coming through now. Portia can you tell us a little bit about who you are? Do you hear us OK? There's somebody on a phone call can you tell us who you are?

Sherilyn: This is Sherilyn.

Ginger: Oh hi Sherilyn how are you?

Sherilyn: Yes good. Sherilyn Gibbs here and I'm actually on call so I don't know if I'm going to be able to stay on for the whole time but I am a nurse midwife in Allentown Pennsylvania and I've been a midwife for over 20 years and I'm interested in what you're going to share tonight. I was the happy recipient of one of the special 10 years that your husband made at the annual meeting. So that was pretty special.

Ginger: Cool cool. Well you know the goal of tonight I think is to talk about how we can make a difference as midwives that all of us on this call know, I don't think I'm going to tell you anything that will surprise you other than maybe you didn't know the New Zealand Prime Minister was attended by a midwife in the last 12 hours who delivered her baby and that a toilet roll paper is available to us yet to ausciltate fetal heart tones if we need to. But really the point is to sort of lay the groundwork about what has the pinar taught us and what have we lost in sort of the technology that's emerged pretty much since the 70s and in this time of maternal mortality and high c section rates and poor maternal outcomes of all kinds. Are we contributing to that by not being able to introduce intermittent auscultation in hospital settings? So that's sort of the framework about this and to share that Leslie and I and in similar and different ways have a lot of experience in change projects as well as this particular topic. And certainly Sharilyn knows that sometimes having expertise come when you're facing those needs for change can be advantageous but also to help you know that there is an immense amount of resources available for you to learn about how to address this issue of electronic fetal monitoring in our country. And can we get intermittent auscultation for low risk healthy pregnant women. So let's talk a little bit about the Pinard it's kind of cool I think to know the history and of course it's named after a male physician. French probably I'm not going to pronounce his name right because I've never spoken French but Alfred Pinard at the young age of thirty nine designed this tool to specifically hear fetal heart tones. And at the same time his neighbor and his colleague nearby from Germany, Dr. Christian Leopold, within the same year these two guys were sort of working together and sort of gave us what we know as the Leopold hand maneuvers to ascertain the position of the baby. So by combining the technique of how painting the baby's backside will give you a much better, and all of you must know this using a Doppler, or where you're placed that electronic fetal monitor on the baby's backside gives you much more clarity and pronounced sound of the rhythm of a fetal heart rate than let's say if you placed it over the baby's abdomen or the lower portion of the baby's body. So typically with a Pinard with really good ears you can auscultate fetal heart tones by about 18 weeks. So one of the things I would love to know from this group: I grew up, as did Judy, I'm not sure about others on this phone call but until the 70s, mid 70s for me, the only thing we use was the scope. We didn't have Doppler or electronic fetal monitors on Labor and Delivery Unit. Is that true for anyone else on this phone call?

Judy: Yep.

Ginger: Was that you Judy?

Judy: Yep, that's true.

Ginger: Sherilyn? have you ever used a scope in a hospital for someone in labor?.

Sherilyn: No I haven't.

Ginger: OK. And Tracy I'm pretty confident you probably have not. So you know we're going around with these unicorn things on our head which is this one right here. That's how we listened to heart rates when moms were in labor in Topeka until about 1974. So that is what I grew up on. Not the Pinard and not the Doppler. And there is a skill set. Just like how you learn to use a stethoscope and learning how these devices work. But that does take a little bit of time but it's not rocket science. So they're actually still used today and I think it's pretty telling this is the British Journal of Obstetrics and Gynecology in the fall of 16 described in this article, they are used regularly by European countries, the midwives in European countries, and obviously in most developing countries because if you think you're going to find a battery in sub-Saharan Africa to replace your Doppler that's dead you're wrong. So the point of using the Pinard is really to determine a fetal heart rate and also to be able to detect fetal bradycardia you're not going to be able to interpret a level 1 to Level 2 or a level 3 by using a Pinard. Now some will make the case that you can do that and in fact I'd describe that using a Doppler but not with a Pinard. So as we go through this presentation I think it's really important to know that there have been comparisons studies done between continuous fetal monitoring and intermittent auscultation. But within the context of the Pinard and those who need that resource we really don't have any well powered randomized studies and we probably never will. That to me does not mean we have to prove it's useful. Rather its utility based on the efficiency for the group that it's intended to be used for.

Ginger: So I'm gonna show you this short exam with a Pinard that I found on YouTube. That's that's me getting ready to catch a baby with an RN at the Topeka Birth Center. This was many years ago listening for fetal heart tones while the mobs pushing pushing so let's pop over here.

Video: Hello. Today I'm going to visit Louise a pregnant client and listen to her baby's hearbeat with a fetal stethoscope. I've got two examples here. This one is the more traditional midwives fetal stethoscope it's called a Pinards. This one's in plastic. They also come in metal and wood. They come in varying lengths. This one is the shorter version and this one here looks more like a stethoscope it's got two ear pieces but then it has the trumpet at the end which goes on the mother's abdomen. The advantage of fetal stethoscopes to a mother is that the baby is not going to be exposed to any unnecessary ultrasound waves which can be really advantageous for some women in particular. They really low tech cheap devices to use. They don't really require batteries. They're also brilliant tools for midwives and it helps a midwife ascertain the lie of the baby in the abdomen and that you can only really hear the heart clearly when the stethoscope is placed over the baby's back. So they're very useful tools. I keep a midwife's skills to a finely tuned ear. (Video demonstration)

Ginger: So one of the things that you'll see in a lot of textbooks or in learning how to use the fetascope and the Pinard and even the Doppler if there's any uncertainty is the feel the mom's pulse at the same time that you're listening to the baby's heart rate. Just for affirmation and confirmation that you really are ausculating the baby and not mom. So let's talk for a minute about electronic fetal monitoring and its history and sort of its implications in the conversation. So it really was described as early as 1958. For any of you that have sort of heard some presentations by core metrics and some of those earlier companies that came out with the Monitor they credit Haun and Calahan with the use of electronic fetal monitoring. They pretty much honed in on it by 1968 in terms of marrying the fetal heart rate with the fetal ECG and the entire ability to act accurately capture, as clear as possible, the heart rate through the scalp electrodes so by the early 70s probably between 70 and 75 most larger hospitals had the core metrics monitor coming down the hallway. And to this day, and I've talked about it on several occasions, I was a labor and delivery scrub nurse at the time hadn't graduated from nursing school yet but was on the O.B. unit, and remember the day that the core metrics machine came down the hallway and sort of what happened after that which was the nurses fascination with technology and moving away from using the fetascope with our patients to using the Monitor on absolutely everybody that it could be used on. So since its emergence in 75 which estimating about 20 percent of women having the fetal monitor were now at the literature will basically say 80-90 percent of women in the United States have an electronic fetal monitor during their labor. So what happened? What happened in the 70s? Anybody want to guess what we began to see with the onset of the fetal monitor?

?:the c section rate went way up.

Ginger: Yep it sure did. And what happened in the childbirth education movement we have any ideas? We actually began to see the number of people investing in childbirth education begin to take a dip as more and more women had their babies and basically said look I was in bed, I had this machine on, they're still getting medication for pain management. Now although they're in bed with a variety of types of pain medication, you couldn't really do all those midwifery pearls but honestly non pharmacologic management techniques that often were used before the fetal mongered was placed because it was believed to and it is very difficult to monitor someone unless you have telemetry units now to be able to do anything but lay flat bed was pretty much the expectation. So what's the evidence say now? So I'm curious has anybody seen the AC and M pearls that are devoted to really promoting physiologic birth? the amount of Whitney pinners practice at GW.

?: Yes I have. It's wonderful.

Ginger: Does anybody not know about this? It's a great great deck full of evidence to be able to have a grand rounds. And I just pulled out a few slides related to intermittent auscultation and there are more studies since this PowerPoint was designed in 2012 and I understand they're actually updating it right now. So as of the time of the publication of these slides, there were already four randomized controlled trials with over 13000 women looking at IA intermittent auscultation with the Doppler not a Pinard and electronic fetal monitoring. And obviously we had an increase in the c section rate an increase in fetal scalp blood sampling and absolutely no difference in perinatal mortality. The other things that the evidence found, and this was from a Cochrane analysis of 13 randomized controlled trials comparing electronic fetal monitoring to intermittent auscultation, was again an increased rate of c section vacuum forceps. No difference in perinatal mortality, no difference in C.P. and no difference in Apgar scores less than seven at five minutes. Now Akug has come out with a new statement since 2009 and it's referenced in this presentation, which continues to not only support the need but it's not advocating for routine use of EFM but now they're actually advocating for more action, which is to support women and to train staff that want to use intermittent auscultations. So this slide is good but I think we have a newer one with a new clinical bulletin that sort of supersedes the statement that they made at this point in time.

And Cochrane has also come out with another study in February of 17 which continues to substantiate the same research that's been done now for well over 20 years related to outcomes. Other than reducing rates of neonatal seizure, without a relationship to serve cerebral palsy or any other standard of neonatal well-being, the risks associated with continuous fetal monitoring remain unchanged. Increase C section rate, increased instruments, and the question becomes: we're researching something we know that has been proven over and over and over and yet we haven't changed anything in terms of the percentage of women in hospital who either are required to use EFM encouraged to or don't know it's an option. So what about intermittent auscultation? A separate study that Cochrane did again in 2017, compared continuous fetal monitoring with the Doppler and they are associated with higher rates of c section compared to the routine pinard monitoring. I think that's really pretty fascinating. So what does that mean? That even challenges the question even further in terms of using a Doppler over pinard. Now how do we convince a public who wants to hear the baby's heart rate that my baby's OK? That's all going to play into this. Right? The need and the wants of the parents. But I think at the bottom of the story is the Pinard has stood the test of time in terms of its reliability and use for determining the health and well-being of the fetus. So what what's some good news? And Lesley you may want to correct me on some of the words I'm choosing here about CABC accredited freestanding birth centers, but I believe it's true that if there is a need for either an admission assessment or monitoring of a mom due to risk factors, she should be admitted and transferred to the hospital for increased monitoring and that EFM is not used in these settings. Is that true?

Lesley: It can't be used continuously but they do allow in admission strip.

Ginger: So for those of you on this call, you want to talk a little bit about...Tracy, you have some experience. And you're working on a birth center right now. How do you think families differ in this whole fetal monitoring issue in a birth center versus when they're managed in a hospital?

Tracy: I think women love the thought of not being strapped down. That's always their selling point. In a birth center a lot of these women are coming in educated already which is great in a lot of primaries tips which is even more shocking in this area. And I just can't believe it. I mean I just praise them for even looking at their options. But you know I thought EFM couldn't be used at all in Labor admission to a burn center. And whenever I've had some experiences where you just can't help but wonder like what would that strip would look like or what could it have looked like. What if I put her on for a minute? And just realizing that they allow an admission strip makes me I don't know, it gives me mixed feelings because I'm like, if I did that on everyone, I think more people wouldn't have a birth center birth. But how do you satisfy your knowledge and knowing that everything's OK? So I think families don't know any other way when they're in the hospital and I think when they realize what a birth center offers they prefer to use EFM.

Ginger: Other comments or Leslie, your thoughts about what would be the purpose of doing that?

Leslie: The purpose of doing the admissions strip as part of the assessment of their tolerance of labor to be able to look at and determine what category. And then after that it can't be used again. If there's D cells that are noted after that and the determination is made that they go to the hospital. Because what the studies found through the PDR the ABC data set was that it was helpful in some cases for an admission strip to be done. And in many cases it was the only way the birth center could remain open, that there were compromises made and with supervising physicians that in states that required that that wanted the strip initially done. There's also an argument for liability that it is protected liability-wise for the birth center which shows that the baby was healthy and normal category 1 stripped on admission. But the studies also showed that if you're wondering what would this strip sound like if it was put on a monitor? The studies show that all that did was delay getting the mother to the hospital, and if there is a concern enough for the mother to need monitoring enough to take her to the hospital.

Ginger: Exactly. Yeah I'm not sure I've seen sufficient evidence to suggest that that strip does anything. An admission strip that it is.

Tracy: Is the is there any standard on how long the strip needs to be before admission? Like what if the baby's in a sleep cycle? So now it's hard to know if it's Category 1 or is there anything on that?

Lesley: Well if she's in labor, which she should be if you're doing an admission strip, you're going to have a negative CST which is better than an NST. So you just call it a negative CST and be done with it. So it shouldn't take longer than 10 to 20 minutes.

Ginger: Does that makes sense Tracy?

Tracy: Yeah I'd love more information on that so hopefully maybe you can send me somewhere to get some resources on that.

Lesley: It was a big debate whether to allow the admission strip or not but there were many birth centers that would not have been able to remain open if they were not allowed to do intermission strip.

Ginger: Yeah and that's good history to know. In the 40 years of Topeka birth center in the first 14 that I worked there, the first 14 we didn't even have a fetal monitor when I worked there. So again I see the need for compromise and this could be one of those. I put it as positive news because if you look at the outcomes of newborns in the studies that have been done, and we know as Leslie has said, that continuous fetal monitoring is not used at birth centers settings. That's a pretty strong correlation that you can use to argue the fact that it's not necessary. So I think that's a positive that birth center data will share as time goes on and very important data. But the challenging news is that despite the professional recommendations, the global practice of intermittent auscultation as an alternative, in the United States, uniquely in the United States, we still monitor nearly all women because most of them attend birth in the hospital. So if you're thinking about change, that can only happen by educating everybody that's a touch-point related to the potential barriers. So that could be as Leslie mentioned liability, the risk management department, the unit managers who are going to have to figure out how to train and staff the nurses on the unit. Do you need more of them? Some will argue yes you do because of how you monitor these patients once they're in active labor. You're going to have to purchase dopplers and get the fetal monitor out of the room which is typically a piece of temptation if it's within arm's reach. And everybody has to be educated about the protocol that's used so you're all speaking the same language between the nurse, the midwife, the physician, and the residents. So I'm not saying these things are impossible, in fact there's going to be examples of very large teaching hospitals that have completely transformed their c section rates by introducing intermittent auscultation, but it takes money, it takes time, and it takes a culture shift. Those are very complicated.

So where do you find resources to get started? I'm hopeful that everybody on this call, although I haven't met everybody, Portia? I'm still not sure if you have audio, we'd love to know who you are. ECNM has a product called Birthtools.org that is recognized even by AIM, the group of collaborators that are putting bundles together to improve outcomes. Birthtools.org is the first reference for interment auscultation initiation in hospitals and it will give you a tremendous amount of resources. I'll show you a snapshot of that in a minute. And I also wanted you to see a Coggs newest dated February 17th committee opinion which actually says to facilitate, which is essentially an action item verb, so this need to sort of initiate intermittent auscultation is really being promoted by ECOG. But of course everything has to trickle down to the community hospital right? Or to a hospital where you are practicing. So many will argue, including myself, that it is the gateway to promoting physiologic birth because everything hinges upon the mobility and really the ability for the mom to guide her pain management. Whether that's in water, whether that's ambulating, or whatever that might be that takes her out of her hospitals who don't have the ability to ambulate. But even those who do, the more someone's wired to technology we know the less likelihood of that mom getting direct one on one support. Whether that's through the nurse or the midwife and a doula isn't going to be able to manage the assessments that go along with how this happens. So this is a screenshot of the resources available on birthtools.org on intermittent auscultation. So this DNP student at the University of Minnesota, I watched the training video. She really does a great job. It was a fun video to watch I hadn't watched it till last week. There is an example of what Highland Hospital was using so that the nursing staff could begin to understand the critical nature. And I think this is true of birth centers as well. Tracy when I was still a baby in company with you we were working on a skills assessment for all staff being checked off on how to do intermittent auscultation. It isn't just putting the Doppler on the belly getting the baseline heart rate and going oh it's fine. There really is a protocol that needs to be adopted and some other examples that are here as well. But what I did was pull up on the internet my favorite one, which isn't in birthtools.org. Aliza Burrell is a nurse midwife that helped work on the AI protocol for ECNM. She is the midwife who led the facilitation of intermittent auscultation at the University of Colorado Health Sciences in Denver. This is a very large teaching hospital and Eliza's PowerPoint is available for you to download. And the protocol and essentially the way they taught all the care providers to not only perform intermittent auscultation but to document as well. So I wanted to make sure I'm not going to pull that up. It'll pop up for you and this will be available within probably a week. And to download from our website but make sure if you're interested in looking at actual protocol and how someone implemented this in a large teaching hospital, Eliza did a genius job at that in Denver. So what are some of the barriers which we've already sort of slightly mentioned formal education. And by that, there are very specific protocols that need to be developed. It's part of a policy change and will be part of education and training that would be ongoing as annual competency as well as when any new staff are hired. The decision on the staff patient ratio will be based on the protocols that are adopted. But even though you're going to see different recommendations on protocol by these organizations that are listed below, they're not different enough to change the increased staffing that's required. And how midwives might be managing their patients Labor and the ability to fill the role of the nurse in that unit at any given time is really a policy discussion within a hospital because there are variances that can happen based on what the midwife is actually doing that could be routinely their purview where they are in, and yet could be helpful in terms of the protocols developed in the hospitals if residents and midwives would be allowed to do this. We talked about the training and competency routinely assess peer to peer assessment is as widely integrated. And then the consent process versus the standard of care. When there's a woman here about intermittent auscultation if she's planning a birth, wherever the birth is, how often are you going to listen to my baby if I'm in the home, from the birth center or even in the hospital. And how are those decisions made and how are people informed about their choice really before the duress of labor. So thinking about that and how much you engage in that conversation when you think about choices that promote the increased likelihood of physiologic birth. So there are a variety of resources that all validate the conversation we're having tonight. So the ACM clinical bulletin. There's a table you'll see on the next slide that I'm referencing that shows the variances in the different organizations. A1 of course has of their position that came out in 2015 on fetal heart rate monitoring and intermittent auscultation. This was a fun one that I found, the choosing wisely campaign, which is a part of the American Association of nurses, who partnered with consumer reports. And they talk about intermittent escalation and choosing wisely. I ran some questions by Kathleen Rice Stimpson if any of you know her name. She pretty big in their safety quality would of A1. After I've read this because I'm just going to go here and see if any of you note what I noted. Can you see that or can you read it? There is a line right here. IA let's you move around during labor. With IA your doctor uses a handheld device to check the baby's heartbeat at certain times during labor. Does that surprise you guys?

Tracy: Do you mean the fact that it says doctor?

Ginger: Yeah, I mean, when is a doctor going to be doing intermittent auscultation during a mom's labor?

Tracy: Never.

Ginger: Never. I mean I'm just like the whole article honestly, this is a great article. It's a quick snapshot. Like a handout. Right? That you can get patients monitoring your baby's therapy during labor by two very pretty credible groups. The American Academy of nurses and consumer reports and then all of a sudden they pop that in. But anyway I thought that was interesting. You never know what you're going to find doing a search right? The UK guidelines, you know the UK is so far ahead of us in everything related to care of the healthy low risk patient and their model of seamless care. For those of you who maybe couldn't hear me at the beginning of the phone call, the New Zealand prime minister was attended by midwives at her birth in the last 24 hours and that's not been covered in the media at all. I found the one and only little snapshot of it buried in an article. But it's important I think sometimes to realize that what we're doing in our country is just because it's routine not because it's evidence based. And how we move from that typically it is through folks like Cochrane. The highest level randomized controlled trials that are supposed to be what guides the evidence for change. And yet this is one area that has been incredibly difficult to move in the American hospital system. So this table that you see is in several publications. This is actually from the ACM clinical bulletin. And you can see the different organizations on the left. They include the Royal College of Obstetricians and the Canadian OBGYN Society. The variances on here are not that wildly different but but basically what's important for anybody that introduces a protocol is to pick one and then stay with it. Don't have people independently deciding how they're going to interpret monitoring fetal surveillance in the active phase and the second stage because you will increase your liability if it's a guessing game and that's really not the way you want to initiate the change.

Tracy: Ginger what do you think about their ranges like putting every 15 to 30 or do you feel like it should be every 15 or every 30.

Ginger: I think you need to pick an organization's protocol and that would be the best answer to the policy. So you're not finding the middle of the road but you're finding what the recommendation is. Others? Leslie you have thoughts about that?

Leslie: I agree with what you said. Picking a protocol and sticking with it. I would say here in the U.S. from medical legal standpoint, A-one is always the one that's referenced on the monitoring guidelines. So that's the reason we use that one. But I don't think you'd be wrong using any of them.

Ginger: Tracy I would refer you to Eliza's PowerPoint. She goes into that pretty much in detail and talks about the differences and how they made the decision at the University Hospital of what they were going to do. That's a great question. Others? Any experiences that you've had that you want to share?

Tracy: I notice like in the latent phase, only one one place has a recommendation. So with that is that I mean mostly in birth centers people don't show up until active labor so it's a given. But does anyone have a protocol for latent labor or know of one?

Leslie: We use A1 guidelines which say in latent labor. The only time we would have somebody admitted to the person or in latent Labor is maybe she's ruptured she needs antibiotics for GBM and she lives an hour away and we're actively trying to encourage labor.

Ginger: Ok so I have a question for you guys. This was actually a scenario that happened when Judy and I ran a practice at St. Luke's here in Kansas City on the plaza of a Bradley patient who wanted no Doppler used at any point in time in her pregnancy and only wanted a fetus scope used. How would you handle that patient?

Leslie: At our birth center, our policy is no Doppler no waterbirth. But other than that we don't we don't have a preference.

Tracy: I've always been fetascope the whole way, whatever you want, whenever you want the whole pregnancy, but in labor, I think the thing to get a good assessment I think it just depends. When you have a fetus scope usually they have to be pretty still, especially for an inexperienced fetus scope user like myself. It depends on the experience.

Ginger: Others on the call? I could tell you what we did at Luke's. Judy are you still on the call? You there? We were working with maternal fetal medicine physicians as our consultants and we used the fetus scope in pregnancy but we use the Doppler in labor. And so I get it. I'm not I'm not trying to proselytize one way or the other but I think it's pretty fascinating to look back at Cochrane who actually compared the Pinard or a fetus scope to electronic devices and actually found significant differences in outcomes. It's pretty interesting. Why we have lost the faith in a tool that has stood the test of time, I mean it's liability, it's anxiety, it's our fears. But I think you heard the UK midwife talk about the exposure of sound waves for the fetus in some moms right? Did you guys catch that?

Leslie: Yes and moms come in concerned about that.

Ginger: Right, so what do you say?

Lesley: We will use the fetus scope and the prenatal for their pregnancy. And if they want the fetus scope for labor then we just, they can labor in the tub but they have to get out. When we listen to the heartbeat and we don't do it waterbirth.

Ginger: Anybody else on the call has some thoughts or questions about that?

Sherilyn: My thoughts are that, at least in my experiences when I was actively practicing if, if you could meet a patient who is really happy if they have some say and if you can really meet her halfway and maybe promise her just you know use the fetus scope until a point where maybe you hear. If you can do that all the way through and say in labor we may have to use that or we probably will, most times people will buy that at least in a hospital setting.

Ginger: Yeah I finally opened up the chat box and Portia typed something to us. I don't know if your you're audio's not working Porsche or not but we'd love to hear more from you because I do think that intermittent fetal heart monitoring is the key to sort of decreasing the technological advances we have come to rely on and literally push on patients in ways that if they don't come educated like Tracy said, it almost becomes our personal professional bias as to how we approach it. So with that what I would love to do is to get anybody who wants to sign up for the chance to win this pinard that we will mail to you to go into the chat box and just type in a number between 0 and 100. And please if you see a number typed in pick a different number you can't pick the same number. And in just a minute we're going to ask Siri to pick a number. So those of you who want to sign up for this, and Leslie you want to sign up for it and give it to one of your midwives is fine with me.

Leslie: I had to switch from computer to phone because my internet went out.

Ginger: So we have on here five people. Portia can you hear us? I'm guessing you can. Judy are you going to type anything?

Judy: Now I'm going to but somebody else went. I'll just look at the others.

Ginger: I know Porsche's still with us but I am not sure why we're not connecting. Leslie are you going to type anything?

Leslie: I can I'm just on the audio.

Ginger: Oh you can't type I see. Do you want to or do you want to pass?

Lesley: Put in 57. Our new hire just passed your board today. Maybe she'll win.

Judy: All right I'll do it too. This is Judy. I can't type either. Put in 70 seven zero. And that's Judy. I'll give it to you for your new hire.

Ginger: Yeah we're stacking that against Tracy we can't do that.

Judy: Or maybe I'll give it to Tracy.

Ginger: Portia are you with us? If not I'm going to ask Siri to pick a number and let's see what happens. I don't know if this will work through the ear buds but we're going to try it. I haven't tested this. Hey Siri pick a random number between 0 and 100.

Siri: 58 random number between 0 and 163.

Ginger: Did you guys hear it?

Judy: 63?

Lesley: I don't know what Tracy's guess was.

Ginger: Tracy Was 3.

Tracy: Yeah mine was three.

Ginger: So I think it's so that isn't it you Lesley?

Lesley: I think so. Yeah okay. Well that is all I have. Unless you guys have some questions or comments. Love for you to spread the word about the talk tonight feel free to download it and share it. We'd love to hear any topics that you'd be interested in hearing about and I really value you all being on the call.

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