*Normal labor and deliverySardjana AtmadjaProfessor ofOB & GYN DepartmentFaculty of MedicineSyarif Hidayatullah State University

*Objectives

At the end of session, the student is able toDiagnose true labor Describe factors influence vaginal birthAssess maternal and fetal conditionAssess progress of laborManage first stage of laborDescribe mechanism of normal vaginal deliveryDescribe steps for conduction vaginal delivery

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*Estimation of fetal age1. Naegeles rule: *EDC = LMP + 7 days - 3 months2.Fundal height3. Quickening4. Lightening5. Ultrasonography6. Fetal weight

*Fundal height measurement3632,402824

*Bipariatal diameter - BPD

*Femur length -FL

*Abdominal circumference -AC

*Diagnosis of true labor painHistoryA history of regular painful uterine contraction in every 5- 8 min, accompanied by the history of a bloody show or spontaneous rupture of membranePhysical examinationReduction of interval between uterine contractions Abdominal pain of increasing intensity Cervical effacement ( 50%) Cervical dilation ( 2 cm)

* Different between true labor and false labor

Uterine contraction

regular

irregular

Interval

decrease

irregular

Duration

increase

irregular

Intensity

increase

irregular

Cervical change

progress

no change

*Vaginal birth

*Stage of laborFirst stage ( true labor pain until cervix fully dilate or 10 cm Latent phaseActive phaseSecond stage(cervix fully dilate until deliver the baby)Third stage (deliver the baby until deliver placenta)

*Management in first stage :admission assessmentTake history: LMP, EDC , labor pain , bleeding, ruptured membrane, fetal movement, maternal diseases, review ANC records , lab testPerform physical examination : 2.1 General examination2.2 Leopold maneuver, 2.3 Auscultation fetal heart sound 2.3 Uterine contraction2.4 Pelvic examination

*First Leopold

*Uterine contraction (Power)IntervalDurationIntensityGood contraction ( I= 2-3 min, D 45-60 sec)? If not : correct by using oxytocic drug

DIntervalIntensity

*Pelvic examination

1. Birth canal2. Cervical condition and related part

*Birth canal ( passage)Inletdiagonal conjugate diameter > 12 cmMid pelvisinterspinous diameter > 10 cmOutletsubpubic angle > 90 0intertuberosity diameter > 10 cm

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*Cervical condition and related partCervical condition* dilatation 0-10 cm* effacement 0-100%

* NulliparousMultiparous

*Cervical dilatation

*2. Presenting part : cephalicVertexFaceSinciputBrow

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*3. Position

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* Presenting part : Breech

*Presentation Denominating pointVertexFaceBreechShoulderOcciputMentumSacrumAcromium

*4. Station

*. 5 Membrane : Status : intact or rupture Color : clear or meconium stain Amount : normal or abnormal

*Assess fetal conditionAuscultation of fetal heart (normal range 120-160 bpm)High risk : 1st stage every 15 min , 2nd stage every 5 minLow risk : 1st stage every 30 min , 2nd stage every 15 minElectronic fetal heart rate monitoring (not essential in low risk pregnancy)Ultrasound (not essential in low risk pregnancy)Biophysical profile (not essential in low risk pregnancy) : 5 component: fetal tone , fetal breathing , fetal movement, NST, Amniotic fluid pocket (Modified BPP = NST + AFI)

*Characteristics of normal low-risk laborNo pregnancy complications that may affect labor( with adequate ANC)Spontaneous onset of labor between 37-42 week of gestationSingleton fetus with cephalic presentationEstimate fetal weight > 2,500 g, < 4,000 gAdequate volume of clear amniotic fluidNo abnormal intrapartum bleedingAcceptable rate of cervical dilatation (1 cm/hr in active phase)Normal fetal heart rate

*Progress of labor

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*PartographProgress of labor

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*Management in first stage (cont)Maternal vital signsRegular record uterine contraction and record fetal heart rateFood / IV fluid considerationMaternal positionAnalgesic drug considerationRecord and assess progress of labor

*Second stage Mechanism of labor : 7 cardinal movements in occiput anterior presentationengagementdescentflexioninternal rotationextensionexternal rotationexpulsionConduct vaginal delivery

*Episiotomy

type 1. median or midline 2. mediolateral

Routine episiotomyRestrictive episiotomy

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*Video viewing

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*Third stage Delivery of placentasign of placental separation (uterine sign, vulva sign, cord sign)Modified Crede, Brandt AndrewControlled cord traction

*Delivery of the placenta : Modified Credes maneuver

*Delivery of the placenta :Brandt-Andrew Maneuver

*Controlled cord traction

*Prevent postpartum hemorrhageoxytocic drugsSyntocinon : IV push, IV drip, IMMethergin : IM, IV

*Repairing episiotomy woundPerineal tear during vaginal birthFirst-degree tearSecond-degree tearThird-degree tearFourth-degree tear

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*Repairing fourth-degree perineal tear

*Postpartum care : 10 BsBlood pressureBladderBloody dischargeBasketBowelBreast engorgementBreast feedingBabyBlueBrain

*What is (are) the new evidence(s) in normal labor and delivery?

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*How do we know that we are giving the best care possible to a pregnant Woman or a Woman in labour?

How do we know we are doing most good and least harm?

*Are these procedures essential in low risk vaginal birth?Shaving perineumEnemaNPO IV fluidKeep in bedContinuous fetal monitoringEpisiotomyDorsolithotomy positionRush the mother to push

*Evidence-based practice Clinical expertise, experience, skills and judgmentBest available evidence

Woman needs, values, preferences and context EBP

*What is Evidence-Based Practice?EBP is the integration of best research evidence with clinical expertise and patient/parent values in context

*Level 1 1a) systematic review of randomised trials1b) individual randomised trialLevel 22a) systematic review of cohort studies2b) individual cohort (and low quality RCT)2c) outcomes researchLevel 33a) systematic review of case-control studies3b) individual case-control studyLevel 4case series (and poor quality cohort and case - control studies)Level 5expert opinionLevels of Evidence (therapeutic and preventive)+Bias +

*1. Ask an answerable question2. Access the appropriate evidence3. Appraise the evidence4. Discuss with the patient5. Assess the context of care and apply the results to clinical practice6. Evaluate your practiceThe 6 steps of EBP

Shaving for LabourTraditional belief:

To reduce infection

To facilitate suturing/makes it easier to stitch

Best Evidence:Painful, embarrassingRe-growth uncomfortableMicroabrasions cause infectionRisk of HIV transmissionNo benefits shown for shavingSmall cost benefitX

Enemas in LabourTraditional belief:

Encourages bowel movement (peristalsis) and therefore more prostaglandin is released, which in turn stimulates contractions

Shortens labour

Helps the babys head descend

Necessary to avoid soiling at the birth (keep it clean) and therefore reduce the risk of maternal and neonatal infectionBest Evidence:

Painful, embarrassingDoes not stimulate contractionsDoes not shorten labourNo difference with neonatal infectionsDoes not decrease soiling at birth, more messier bowel movementsMarginally increases cost of health care

X

Fluids and food during labourTraditional belief

Risk of inhalation if general anaesthetic needed

Keep everyone nil per mouthBest evidence

No difference in anaesthetic riskDehydration leads to acidosis, leads to fetal distressDehydration can lead to incordinate contractionNil per mouth only for specific reasonX

*Continuous fetal monitoringNo significant difference in overall perinatal death rateBut was associated with a halving of neonatal seizuresNo significant difference was detected in cerebral palsyThere was a significant increase in caesarean sectionsCarroli G, Belizan J. Episiotomy for vaginal birth. Cochrane Database of Systematic Reviews 1999, Issue 3. Art. No.: CD000081. DOI: 10.1002/14651858.CD000081

Routine EpisiotomyTraditional Belief:Clean incisionHeals betterFewer 3 and 4 degree tearsLess painUse routinely

XAdapted from the WHO Better Birth Initiative http: /www.liv.ac.uk/lstm/bbimainpage.html

*Restrictive episiotomy 27.6% (673/2441)

vs

Routine episiotomy 72.7% (1752/2409)

Six studies included

OutcomeRRCI 95%Posterior Perineal Trauma0.880.84 to 0.92 Suturing0.740.71 to 0.77 Healing Complications0.690.56 to 0.85Anterior Perineal Trauma1.791.55 to 2.07

*Cochrane Systematic ReviewAuthors' conclusionsRestrictive episiotomy policies appear to have a number of benefits compared to routine episiotomy policies. There is less posterior perineal trauma, less suturing and fewer complications, no difference for most pain measures and severe vaginal or perineal trauma.But there was an increased risk of anterior perineal trauma with restrictive episiotomy.

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How to prevent perineal tears? Best Evidence:

During PregnancyPelvic floor (Kegel) exercises during pregnancyStretching exercises during pregnancy (Yoga)Perineal massage during pregnancy

During LabourMobility in labour for good fetal positioningBirth positions off the perineum, no more lithotomies Slow pushing efforts Hot packs on the perineum during second stageUndisturbed hormones

*Mobility during labourTraditional beliefBedrest is best for the mother and baby

Less busy in the labour ward if labouring women are confined to bedBest evidenceImproved progress of labour if mobile (contractions are stronger)Augmentation less likelyLabour may be less painfulAssists with fetal descentNo harms have been associatedBest Evidence: During LabourX

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*All illustrations from: Flint, C. (1987) Sensitive Midwifery. London: Heinemann Medical Books

Continuous Support in LabourTraditional belief:

Companions discouraged because of concerns about cross infections

Extra people who are not health professionals always get in the way

There is no privacy for other women in labour

Staff are already overworked and can not care for labour support people as well

Best Evidence:

Better progress of labour

Fewer caesariean sections

Less pain

More self-esteem

Better relationship with the baby

More breastfeeding

Less depression

X

*Birth PositionsTraditional beliefSupine position and lithotomy best access for attendant

Supine safest positionBest evidenceSupine -progressive acidosis of baby, slower progress (supine hypotension)Other positions (lateral tilt, upright, squatting, forward, on all fours)less pain less vaginal traumaimproved fetal outcomeBest Evidence: During LabourX

How to prevent perineal tears? Best Evidence: During Labour

Slow pushing efforts

- stretches the perineum slowly

- non-directive pushing

- not forcing/guiding the head

- not rushing shoulders

- no holding breaths, woman breathes at her own pace

- panting/breathing the baby out

* Hot packs on the perineum during second stagePerineal Preservation and Heat Application During Second Stage of Labour - Randomised Controlled Trial, Musgrove, Heather small RCT, we need a systematic review on this

OutcomeExperimental groupControl groupComfort80%Pain relief70%Intact perineum andsuperficial tear, no sut. req.70% 54%Second degree tear17%23%Episiotomy3%6%

*Questions & Answers

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**********************************************************************From the 2005 World Health Report make every mother and child count4m child globally will not survive the first month of life, and m women will die in pregnancy, childbirth or soon after.SEA 1.4 m newborn deaths, 1.3 m still birthsAlthough a good start in life begins well before birth, it is just before, during, and in the very first hours and days after birth that life is most at risk. Babies continue to be very vulnerable throughout their first week of life, after which their chances of survival improve markedly.The main causes of neonatal mortality are intrinsically linked to the health of the mother and the care she receives before, during and immediately after giving birth. Asphyxia and birth injuries usually result from poorly managed labour and birth and lack of access to obstetric services. Many neonatal infections, such as tetanus and congenital syphilis, can be prevented by care during pregnancy and childbirth. Inadequate calorie or micronutrient intake also results in poorer pregnancy outcomes ( 6 ). It has been argued that nearly three quarters of all neonatal deaths could be prevented if women were adequately nourished and received appropriate care during pregnancy, childbirth and the postnatal period ( 7 ).

**So, how do you know that you are giving the best care possible to a pregnant women or a woman in labour?How do you know you are doing most good and least harm?Because as doctors, midwives and nurses we want to give the best care! How did I know that my daughter when she had a water birth at home that it was the best care for her and it was the least harm?

**This is a newish concept for health practitioners but it applies to everyone giving health care. Not just to doctors but nurses and midwives too. In the literature it has been shown that this approach will give the most effective care and produces good outcomes for the mother and the baby.What does the research say?What does the health professional say?What does the women say?What is the context?CPGs and CSRFor today we are just going to concentrate on the yellow circle. What does the evidence say about some of our clinical practices. How do we know what is the best available evidence? In terms of interventions, which are mostly quantitative research, we can assess the level of their quality, which looks like this**..read sideSo research plus the woman plus our clinical expertise/judgement and in context. For example if no soap is available or water for washing hands then we cant put it into practice. Anyway to put research into clinical practice there are always 6 steps involved. Taking the clinical practice example of routine episiotomies, which is common practice around the world and also in our 4 SEA countires, lets look at what those steps would involve to put evidence into practice. **Explain: systematic review and Cochrane Systematic Review with example of handwashing, effectiveness of results.Why do we wash hands? ..Prevent cross infection etc.How long should we wash our hands with ordinary soap for a social handwash between patients, after using the toilet, after eating etc (not surgical scrub)Let audience guess how many minutes or seconds does the research and systematic review say?We know hand washing is simple but very effective but as health professionals we do not comply with it. **Is it a good idea to apply routine episiotomies to all birthing women? Is it good practice to do it only for primigravidas? Does it do the most good and the least harm? Often women come up with these questions as well. Is there any research about routine episiotomies? Any published studies or research articles on this? Any systematic review published? The Cochrane Library has a review on this, what does it say?This step is important. But how do you critically appraise the evidence? How do we know it was a good study? A clinical guideline based on good evidence? In two ways: 1. Learn how to critically appraise research, attend workshops that develop your skills in this area or become involved in research yourself to find the answers. 2. The second way is to rely on organisations that produce evidenced based information. The Cochrane Collaboration is one organisation etc. Guideline clearing house for evidence based clinical guidelines is another organisation4. Discuss the treatment options with the patient. Does it make sense? Does the patient agree with the treatment option? Does she want a routine episiotomy?5. Assess the context of care and apply the results to clinical practice, individually but also institutionally. Is suturing material available? Previous 4th degree tear? Do all clinicians involved know how to prevent perineal and vaginal tears?6. Reflect on your practice and ask/listen to the woman, she might also be able to inform you about your performance or do a peer review. All this will assist you and me and all of us to giving better care that is truly evidence based. Did the episiotomy heal well? Did it extend out to a 3rd or 4th degree tear? At six weeks, how is intercourse? How did the woman feel about it?So lets have a look at the rate of routine episiotomies and what the research says, in fact a Cochrane systematic review.**Traditionally we say that shaving for labour needs to be done to reduce infection and to facilitate suturing, as it makes it easier to stitch.But what does research (the evidence) say?When re-growth occurs women scratch hence microabrasions occur and infections mightoccur. Often we do not see them as this occurs back home in the community. Thats why we often do not want to believe the research. In Australia women do not receive routine shaves, neither for vaginal or caesarean birth. But remember, evidence based practice has three components. The research states quite clearly not to shave but if the women has a forest of hair or has pubic lice then the context might require a shave, or the woman is adamant that she wants to have a shave. She needs to have all the information though to make that decision.Another clinical practice is cortico-steroids for pre-mature labour? Do you sometimes give corticosteroids to women in premature labour? Sometimes? Why only sometimes?

**Traditionally we say that giving an enema during labour needs to be done to There is a Cochrane Systematic Review that gives us the best evidence as.This gives us another clinical practice to think about. Everything we do to a woman in labour has an impact on her. We need to be so mindful of what we are doing is evidence-based. Of course now we know about enemas, how we are going to change practice. I encourage all of you here today to think about this and go home from this conference to at least take one clinical change with you that you will start working on next week. Remember change takes time but it will happen if we start one step at a time. Okay, what about shaving. Do many people in the audience do routinely shave for vaginal births and routinely shave for caesarean section? Why do we do this?

**In Australia and many other countries just prior to an anaesthetic a antacid drug is given per mouth, to alkalise the stomach contents. Women are monitored with dip stick testing of their urine for acid and then encouraged to drink more before i.v. therapy is contemplatedIt is also more cost effective not to have to insert an i.v. into every women (being unnecessarily invasive as well) and pay for the i.v. fluid replacement, when she could drink without side effects.

Up until now we have concentrated mostly on maternal well-being and evidence-based practice. Is there anyone here today that works with premature babies?? We do many procedures on these babies and therefore inflict a lot of pain. How do we inflict pain? Noise, light, cold, pushing on incubator, iv lines, surgery, gastro tubes, lumbar puncture, xrays, cold stethoscopes etc etc But traditionally we have believed neonates do not feel pain.

**It is true, for all of these reasons we do episitomies. But is that evidence based practice? Is this what the research shows. NOHere is a quick look at the statistics from the Cochrane Systematic Review .**.Followed but the authors comments for the people in the audience (like me) that get very confused by statistics**All the best as you apply these research findings into your clinical practices. Episitomies should only be used when necessary, most likely less than 10% of normal vaginal births should have had an episiotomy. Anterior perineal tears hardly ever need suturing.But if we stop applying to routinely doing episiotomies, how can we prevent tearing. This is what the research says, we can do certain things during the pregnancy, antenatally and during labour and birth**This is a snap shot of all the 9 hospitals that are involved in SEA. You can see where the two Indonesian hospitals are. Why do we do routine episiotomies in the first place?**What can you tell me about how to prevent tears?.....audience participation.I have just listed them here quickly. I will go through them in details after this slide.**Yes, these are all good reasons but what does the research say to this? The Cochrane Systematic Review shows that if we let women in labour move than improved progress of labour ensuring that the labour keeps normal, needing less interventions. If the baby is in a good position, good fetal descent, than it is more likely to have a normal restitution and sweep over the perineum with a better angle leaving it intact.Here are some diagrams to visualise how women can be mobile in labour, and not a lot of room is necessary. They can walk just around their bed.Ref. Lewis L, Webster J, Carter A, McVeigh C, Devenish-Meares P. Maternal positions and mobility during first stage labour. (Protocol) Cochrane Database of Systematic Reviews 2002, Issue 4. Art. No.: CD003934. DOI: 10.1002/14651858.CD003934.

**If women mobilise, rotate their pelvis, what happens to the baby?Do you use routine fetal monitoring at your hospitals? There is a systematic review that shows electronic fetal monitoring should only be used with high risk case. There is no place for the commonly used (in Australia too) 20min admission CTG. The research shows that interventions in particular unnessarily ceasarian sections rise. But that is for another presentation or workshop. However, if your hospital requires to have your women routinely on CTGs there is still no excuse, she still will be able to move around **Even with a monitor on, women can move around.Preventing perineal tears can also be achieved with birth positions. Traditionally we birth women lying down, the supine position and very often in lithotomy. Why do we do that? Feedback from audience

**Traditionally we have discouraged companions because of concerns about cross infections etcBut what does research (the evidence) say?Just knowing one person and having that person with the woman throughout labour and birth will make a huge difference. We have a mandate as health professionals to change this in our clinical practiceI am suppose to speak on other clinical practice as well that have been identified through our SEA-ORCHID project. Do you all give routinely enemas do women in labour? They do in many countries. Why do we do this? brainstorm **Yes, this why we normally advise women to give birth on their backs and in stirrups. But what does the research say? Does everyone understand what supine hypotension means? If not, explain. If we all know about supine hypotension, why then do we put women on their back when it comes to birth, when the fetus really needs all the oxygen it can get? Some diagrammatic illustration of birth positions follow. Please note, women do not need to be naked to give birth, this is just the artists impression.

**If you wan to show the DVD with a segment of slow perineum stretching, it is on Birth in water chpt 7 22.05 and celebrating birth chapt 9 43.46**Perineal Preservation and Heat Application During Second Stage of Labour - Randomised Controlled Trial, (Musgrove, Heather)This study sought to examine the effectiveness of hot packs via a randomised controlled trial in the second stage of labour.The experimental group received hot packs (n=36) and the control group did not (n=35). There were a total of 71 women in the study. The results show high levels of patient comfort and pain relief from hot packs. This is demonstrated by results such as: 70% of the recipients of hot packs felt the packs relieved pain and 80% said they provided comfort. The midwifery staff involved also supported the women's view that hot packs were beneficial in reducing pain and perineal damage. In the experimental group 70% of the women required no suturing, being either intact (61%) or having a superficial first degree tear (8%). A further 8% had a first degree tear sutured, 22% of this group sustained a second degree tear (17%) or an episiotomy (3%). As compared to the control group with only 54% of women not requiring suturing and a second degree tear rate of 23% and episiotomy rate of 6%, sutured first degree tears were 17%.(i.e. 16% less suturing in the experimental group). BIBLIOGRAPHY Aikins Murphy P, Feinland JB(1998) Perineal Outcomes in a homebirth setting. Birth 25(4)226-34. Argentine Episiotomy Trial Collaborative Group.(1993) Routine vs selective episiotomy: a randomised controlled trial. Lancet 342(8886-8887):1517-8. Belizan JM and Carroli G (1998) Routine episiotomy should be abandoned. BMJ 317:1389. Carroli G and Belizan J (2000) Episiotomy for vaginal birth. Cochrane Database Syst Rev (2) CD 000081. de Leeuw JW, Struijk PC, Vierhout ME, Wallenburg HC (2001) Risk factors for third degree perineal ruptures during delivery. BJOG 108(4)383-7. Eason E and Labrecque M (2000) Preventing perineal trauma during childbirth:A systematic review. Obstet Gynecol 96(1):154. (eeason@ogh.on.ca) Goldberg J, Holtz D, Hyslop T, Tolosa J (2002) Has the Use of Routine Episiotomy Decreased? Examination of Episiotomy Rates from 1983-2000. ObGyn 99(3)395-400. Klein M, Gauthier R, Jorgensen S etal (1992) Does Episiotomy Prevent Perineal Trauma and Pelvic Floor Relaxation? Curr Clin Trials 1992; i:document 10. Klein MC, Gauthier RJ, Robbins JM, Kaczorowski J, Jorgensen SH, Franco ED, Johnson B, Waghorn K, Gelfand MM, Guralnick MS, et al.(1994) Relationship of episiotomy to perineal trauma and morbidity, sexual dysfunction, and pelvic floor relaxation.Am J Obstet Gynecol 171(3):591-8 Janssen PA, Lee SK, Ryan EM, Etches DJ, Farquharson DF, Peacock D, Klein MC (2002) Outcomes of planned home births versus planned hospital births after regulation of midwifery in British Columbia. CMAJ 166(3) 315-323. Hillebrenner J, Wagenpfeil S, Schuchardt R, Schelling M, Schneider T (2000) Erste klinische Erfahrungen bei Erstgebarenden mit einem neuartigen Geburtstrainer Epi-No (First clinical experiences with the new birth trainer Epi-No in primiparous women. Z Geburtshilfe Neonatol 205(1):12-9. Labrecque M, Baillargeon L, Dallaire M, Tremblay A, Pinault JJ, Gingras S.(1997) Association between median episiotomy and severe perineal lacerations in primiparous women. Can Med Assoc J.156(6):811-3. Martin S, Labrecque M, Marcoux S, Berube S, Pinault J (2001) The association between perineal trauma and spontaneous perineal tears. J Fam Pract 50(4)333-337. Moller Bek K, Laurberg S (1992) Intervention during labor: risk factors associated with complete tear of the anal sphincter. Acta Ob Gyn Scand 71:520. Mor, Y( 1989) The 1984 National Perinatal Census. Israel J of Med Science 25:629-633. Pritchard JA and MacDonald PC (1980) Williams Obstetrics, 16th Edition. Appleton-Century-Crofts, N.Y. Shiono P, Klebanoff MA, Carey JC. (1990) Midline episiotomies: more harm than good? Obstet Gynecol 75(5):765-770. Signorello L Harlow B Chekos A Repke J(2000) Midline Episiotomies and Anal Incontinence. BMJ 320:86-90. Sleep J, Grant A, Garcia J, Elbourne D, Spencer J, Chalmers I (1984) West Berkshire perineal management trial.Br Med J (Clin Res Ed) 289(6445):587-90. Slome J (2002) A midwife`s private practice in Israel. British J of Midwifery 10(4)224-9. Sultan AH, Kamm MA, Bartram CI, Hudson CN(1993) Anal sphincter trauma during instrumental delivery. Int J Gynaecol Obstet 43(3):263-70. Thacker SB and Banta HD(1983) Benefits and risks of episiotomy: an interpretive review of the English language literature 1860- 1980. Obstet Gynecol Surv 38(6): 322-338. Wagner M(1999) Episiotomy: a form of genital mutilation. Lancet 353:1977-8. Wagner M(1994) Pursuing the birth machine: the search for appropriate birth technology. Sydney: ACE Graphics. World Health Organization (1996) Care in Normal Birth. A Practical Guide. World Health Organization, Geneva Zalcberg S, Berg A, Yuval D, Ivancovsky M (1999) Giving Birth in Israel: Findings from a 1995 Survey of Maternity Patients with Comparisons to 1993. JDC Brookdale Institute Research Report. JDC Brookdale Institute, Jerusalem.