PainPhase 4NCT03470675
Postpartum Perineal Pain After Obstetric Anal Sphincter Injuries
A Phase 4 study testing Epidural saline + IV saline, Epidural morphine 3 mg + IV saline and Epidural morphine 3 mg + IV ketamine 0.3 mg/kg in people with Pain and Postpartum Depression, run by Northwestern University at 1 site in United States.
Trial summary
Obstetric anal sphincter injuries (OASIS) encompass both third and fourth degree perineal tears. These tears can have a significant impact on women's quality of life in the short and long term. One of the most distressing immediate complications of this severe perineal injury is perineal pain. Read more about this study
- Who is it for?
- Ages 18 years and older, women only
- Conditions the study is for
- Pain, Postpartum Depression
- What is being tested?
- Epidural saline + IV saline, Epidural morphine 3 mg + IV saline and Epidural morphine 3 mg + IV ketamine 0.3 mg/kg
- Type of treatment
- Injection or infusion
- Could I receive a placebo?
- Yes, some participants may receive a placebo
- How many people
- 67 participants
- Where
- 1 siteUnited States
- Study dates
- 27 Jun 2018to 20 Jun 2024
- Phase
- Phase 4
- Are there results?
- Yes, posted in the registrySummary in the doctors' view
Key requirements
Who can take part, as listed by the sponsor. Only the study team can confirm whether you are eligible, so take this list to your doctor.
- Ages 18 years and older
- Women only
- No healthy volunteers
- Adult, Older adult
Who may be able to join
- Age >18 years of age
- English-speaking
- Vaginal delivery (spontaneous or assisted)
- A full-term fetus (>37 weeks' gestation)
- OASIS as assessed by obstetrical provider
- Functional epidural analgesia at time of delivery
- Patient amenable to follow-up in specialty perineal clinic within the first week postpartum
Who cannot join
- Previous pelvic surgery
- History of chronic pelvic pain
- History of recurrent urinary tract infections
- Women with known malformations of their urinary tract
- True allergies to ketamine and/or morphine
- Preeclampsia or hypertensive disorder at the time of delivery
- Obstructive sleep apnea
Trial locations and contacts
1 site in 1 country.
About this study
Official title: Postpartum Perineal Pain After Obstetric Anal Sphincter Injuries: A Randomized Clinical Trial
Obstetric anal sphincter injuries (OASIS) encompass both third and fourth degree perineal tears. These tears can have a significant impact on women's quality of life in the short and long term. One of the most distressing immediate complications of this severe perineal injury is perineal pain. Women can also experience postpartum depression, dyspareunia, and altered sexual function after OASIS.
This is a randomized controlled trial to study the effects of three interventions (placebo, low dose intravenous ketamine plus epidural morphine, or epidural morphine alone) on acute pain after OASIS.
The objective of this study is to assess the incidence of perineal pain in postpartum patients 1 week after obstetric anal sphincter injuries.
- Conditions
- Pain, Postpartum Depression
- Being tested
- Epidural saline + IV saline, Epidural morphine 3 mg + IV saline, Epidural morphine 3 mg + IV ketamine 0.3 mg/kg
- Medical subject headings
- Pain, Depression, Postpartum
What participants receive
What participants receive. In a randomised study each person is assigned to one group by chance.
Epidural saline + IV salineDrug
Sterile saline injection in the epidural catheter and in the intravenous catheter
Epidural morphine 3 mg + IV salineDrug
Morphine 3 milligrams injection in the epidural catheter and sterile normal saline intravenous catheter
Epidural morphine 3 mg + IV ketamine 0.3 mg/kgDrug
Morphine 3 milligrams injection in the epidural catheter and 0.3 milligrams per kilogram weight infused in the intravenous catheter
| Study group | Role | What they receive |
|---|---|---|
| Epidural saline + IV saline | Placebo comparator | Sterile saline via the epidural catheter. Sterile saline via intravenous catheter. Receives: Drug: Epidural saline + IV saline |
| Epidural morphine 3 mg + IV saline | Active comparator | 3 milligrams morphine via the epidural catheter. Sterile saline via intravenous catheter. Receives: Drug: Epidural morphine 3 mg + IV saline |
| Epidural morphine 3 mg + IV ketamine 0.3 mg/kg | Active comparator | 3 milligrams morphine via the epidural catheter. Ketamine 0.3 milligrams per kilogram via intravenous catheter. Receives: Drug: Epidural morphine 3 mg + IV ketamine 0.3 mg/kg |
What is being measured
The primary outcome is the main question the study is designed to answer.
Perineal Pain in Postpartum Patients 1 Week After Obstetric Anal Sphincter Injuries.
Perineal pain 1 week after vaginal delivery measured using the VRS (verbal rating scale). The scale is scored 0 no pain (good)and 10 highest pain (poor).
Measured: 1 week after vaginal delivery
Secondary outcomes (21)
Perineal Pain
Perineal pain day 1 after delivery using the McGill Pain Questionnaire (MPQ). This is a 15 question survey describing pain on a scale. The scale is scored 0 no pain and 3 severe pain.Combined score 0 low and 45 high pain.
Measured: Day 1 after delivery
Perineal Pain
Perineal pain day 7 after delivery using the McGill Pain Questionnaire (MPQ). This is a 15 question survey describing pain on a scale. The scale is scored 0 no pain and 3 severe pain.Combined score 0 low and 45 high pain.
Measured: 1 week after delivery
Assessment of Maternal-infant Bonding
Assessment of maternal infant bonding using the Maternal Postnatal Attachment Scale (MPAS) questionnaire. 19 total question survey which is scored 1= low attachment and 5 = high attachment for each question. Total scores 19 low attachment (poor) to 95 high maternal infant attachment (good).
Measured: 1 week after delivery
Presence of Postpartum Depression
Presence of postpartum depression 7 days after delivery determined by using the Edinburgh Postnatal Depression Scale questionnaire. The questionnaire uses 10 questions scored 0 low to 3 high for a total score of 0 low- 30 high. High scores indicate potential for depression.
Measured: 1 week after delivery
Brief Pain Inventory (BPI-ST Short Form) Current Pain
Part 1 of the 7 question survey (Current Pain). 0 no pain -10 worst pain you can imagine scale.
Measured: 1 week after delivery
Presence of Postpartum Depression
Presence of postpartum depression 6 weeks after delivery determined by using the Edinburgh Postnatal Depression Scale questionnaire. The questionnaire uses 10 questions scored 0 low to 3 high for a total score of 0 low 30 high. High scores indicate potential for depression.
Measured: 6 weeks after delivery
Perineal Pain
Perineal pain 6 weeks after delivery using the McGill Pain Questionnaire (MPQ). This is a 15 question survey describing pain on a scale. The scale is scored 0 no pain and 3 severe pain.Combined score 0 low and 45 high pain.
Measured: 6 weeks after delivery
Assessment of Maternal-infant Bonding
Assessment of maternal infant bonding using the Maternal Postnatal Attachment Scale (MPAS) questionnaire. 19 total question survey which is scored 1= low attachment and 5 = high attachment for each question. Total scores 19 low attachment to 95 high maternal infant attachment.
Measured: 6 weeks after delivery
Brief Pain Inventory (BPI-ST Short Form) Current Pain
Part 1 of the 7 question survey (Current Pain). 0 no pain -10 worst pain you can imagine scale.
Measured: 6 weeks after delivery
Perineal Pain
Perineal pain 3 months after delivery using the McGill Pain Questionnaire (MPQ). This is a 15 question survey describing pain on a scale. The scale is scored 0 no pain and 3 severe pain.Combined score 0 low and 45 high pain.
Measured: 3 months after delivery
Assessment of Maternal-infant Bonding
Assessment of maternal infant bonding using the Maternal Postnatal Attachment Scale (MPAS) questionnaire. 19 total question survey which is scored 1= low attachment and 5 = high attachment for each question. Total scores 19 low attachment to 95 high maternal infant attachment.
Measured: 3 months after delivery
Female Sexual Function
Female Sexual Function Index questionnaire (FSFI).This is a 19 question survey which is scored 2 low sexual function to 36 high sexual function.
Measured: 3 months after delivery
Brief Pain Inventory (BPI-ST Short Form) Current Pain
Part 1 of the 7 question survey (Current Pain). 0 no pain -10 worst pain you can imagine scale.
Measured: 3 months after delivery
Promis 29 Profile (Physical Function Question Only)
29 question recovery survey, 28 questions scored 1 low to 5 high and one question scored 0-10 for pain. Low combined total score (poor) 28 High combine 150 total score (good).The PROMIS-29 questionnaire is then scored by summing raw item responses (1-5 scale) for seven domains (four questions each) and a 0-10 pain rating, then converting these to T-scores (mean=50, SD=10). A higher T-score indicates higher physical function.
Measured: 3 month
Promis 29 Profile (Anxiety Function Question Only)
29 question recovery survey, 28 questions scored 1 low to 5 high and one question scored 0-10 for pain. Low combined total score (poor) 28 High combine 150 total score (good).The PROMIS-29 questionnaire is then scored by summing raw item responses (1-5 scale) for seven domains (four questions each) and a 0-10 anxiety rating, then converting these to T-scores (mean=50, SD=10). A higher T-score indicates higher anxiety.
Measured: 3 month
Promis 29 Profile (Depressive Symptoms Question Only)
29 question recovery survey, 28 questions scored 1 low to 5 high and one question scored 0-10 for pain. Low combined total score (poor) 28 High combine 150 total score (good).The PROMIS-29 questionnaire is then scored by summing raw item responses (1-5 scale) for seven domains (four questions each) and a 0-10 pain rating, then converting these to T-scores (mean=50, SD=10). A higher T-score indicates higher depression.
Measured: 3 month
Promis 29 Profile (Fatigue Question Only)
29 question recovery survey, 28 questions scored 1 low to 5 high and one question scored 0-10 for pain. Low combined total score (poor) 28 High combine 150 total score (good).The PROMIS-29 questionnaire is then scored by summing raw item responses (1-5 scale) for seven domains (four questions each) and a 0-10 pain rating, then converting these to T-scores (mean=50, SD=10). A higher T-score indicates higher level of fatigue.
Measured: 3 month
Promis 29 Profile (Sleep Disturbance Question Only)
29 question recovery survey, 28 questions scored 1 low to 5 high and one question scored 0-10 for pain. Low combined total score (poor) 28 High combine 150 total score (good).The PROMIS-29 questionnaire is then scored by summing raw item responses (1-5 scale) for seven domains (four questions each) and a 0-10 pain rating, then converting these to T-scores (mean=50, SD=10). A higher T-score indicates higher level of sleep disturbance.
Measured: 3 month
Promis 29 Profile (Social Function Question Only)
29 question recovery survey, 28 questions scored 1 low to 5 high and one question scored 0-10 for pain. Low combined total score (poor) 28 High combine 150 total score (good).The PROMIS-29 questionnaire is then scored by summing raw item responses (1-5 scale) for seven domains (four questions each) and a 0-10 pain rating, then converting these to T-scores (mean=50, SD=10). A higher T-score indicates higher level of social function.
Measured: 3 month
Promis 29 Profile (Pain Interference Question Only)
29 question recovery survey, 28 questions scored 1 low to 5 high and one question scored 0-10 for pain. Low combined total score (poor) 28 High combine 150 total score (good).The PROMIS-29 questionnaire is then scored by summing raw item responses (1-5 scale) for seven domains (four questions each) and a 0-10 pain rating, then converting these to T-scores (mean=50, SD=10). A higher T-score indicates a higher level of pain interference.
Measured: 3 month
Perineal Pain
Perineal pain 1 year after vaginal delivery measured using the VRS (verbal rating scale). The scale is scored 0 no pain (good) and 10 highest pain (poor).
Measured: 1 year after delivery
Timeline
From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.
- First posted20 Mar 2018
- Study start27 Jun 2018
- Primary completion20 May 2024
- Study completion20 Jun 2024
Resources
- Official record on ClinicalTrials.govThe registry entry this page is built from, with its full change history.
- Posted resultsParticipant flow, outcome measures and adverse events reported by the sponsor.
- Publications (4)Papers the sponsor has linked to this study.
- Other trials for PainStudies of the same condition, open and under way.
- More trials run by Northwestern UniversityThe sponsor's other registered studies.
- What the trial phases meanHow a treatment moves from first tests in people to approval.
More details
For doctors and researchers: how the study is designed, who runs it, and its registry IDs.
Study design
- Study type
- Interventional
- Phase
- Phase 4
- Primary purpose
- Prevention
- Allocation
- Randomised
- Intervention model
- Parallel groups
- Masking
- Triple blind
- Who is masked
- Participant, Investigator, Outcomes assessor
- Enrolment
- 67 participants (actual)
Sponsor and investigators
- Lead sponsor
- Northwestern University
- Sponsor type
- University, hospital or other
- Responsible party
- Principal investigator, Feyce M. Peralta, MD, MS, Northwestern University
- Investigators
- Feyce Peralta, MD, Principal investigator, Northwestern University
IDs, dates and publications
- ClinicalTrials.gov ID
- NCT03470675
- Sponsor's protocol ID
- STU00206016
- Status last verified
- Apr 2026
- First submitted
- 2 Mar 2018
- Last updated
- 24 Apr 2026
- Results posted
- Yes, on ClinicalTrials.gov
- Data monitoring committee
- Yes
- FDA-regulated drug
- Yes
- FDA-regulated device
- No
- Individual data sharing
- No
Publications
Harvey MA, Pierce M, Alter JE, Chou Q, Diamond P, Epp A, Geoffrion R, Harvey MA, Larochelle A, Maslow K, Neustaedter G, Pascali D, Pierce M, Schulz J, Wilkie D, Sultan A, Thakar R; Society of Obstetricians and Gynaecologists of Canada. Obstetrical Anal Sphincter Injuries (OASIS): Prevention, Recognition, and Repair. J Obstet Gynaecol Can. 2015 Dec;37(12):1131-48. doi: 10.1016/s1701-2163(16)30081-0.
PubMed 26637088Macarthur AJ, Macarthur C. Incidence, severity, and determinants of perineal pain after vaginal delivery: a prospective cohort study. Am J Obstet Gynecol. 2004 Oct;191(4):1199-204. doi: 10.1016/j.ajog.2004.02.064.
PubMed 15507941Chang SR, Chen KH, Lee CN, Shyu MK, Lin MI, Lin WA. Relationships between perineal pain and postpartum depressive symptoms: A prospective cohort study. Int J Nurs Stud. 2016 Jul;59:68-78. doi: 10.1016/j.ijnurstu.2016.02.012. Epub 2016 Feb 26.
PubMed 27222452Bauchat JR, Higgins N, Wojciechowski KG, McCarthy RJ, Toledo P, Wong CA. Low-dose ketamine with multimodal postcesarean delivery analgesia: a randomized controlled trial. Int J Obstet Anesth. 2011 Jan;20(1):3-9. doi: 10.1016/j.ijoa.2010.10.002.
PubMed 21224020
Study at a glance
From the registry record, last updated by the sponsor on 24 Apr 2026. Recruitment status is as the sponsor reported it: confirm with the study team.
- Official title
- Postpartum Perineal Pain After Obstetric Anal Sphincter Injuries: A Randomized Clinical Trial
- ClinicalTrials.gov ID
- NCT03470675
- Acronym / sponsor ID
- STU00206016
- Conditions
- Pain, Postpartum Depression
- Phase
- Phase 4
- Study type
- Interventional
- Recruitment status
- Completed
- Enrolment
- 67 participants (actual)
- Lead sponsor
- Northwestern UniversityUniversity, hospital or other
- Study start
- 27 Jun 2018 (actual)
- Primary completion
- 20 May 2024 (actual)
- Study completion
- 20 Jun 2024 (actual)
- First posted
- 20 Mar 2018 (actual)
- Results
- Posted 24 Apr 2026
Clinical summary
The research question as the sponsor registered it. This describes what the study plans to test, not what it found.
Obstetric anal sphincter injuries (OASIS) encompass both third and fourth degree perineal tears. These tears can have a significant impact on women's quality of life in the short and long term. One of the most distressing immediate complications of this severe perineal injury is perineal pain. Women can also experience postpartum depression, dyspareunia, and altered sexual function after OASIS.
This is a randomized controlled trial to study the effects of three interventions (placebo, low dose intravenous ketamine plus epidural morphine, or epidural morphine alone) on acute pain after OASIS.
The objective of this study is to assess the incidence of perineal pain in postpartum patients 1 week after obstetric anal sphincter injuries.
Study design
- Primary purpose
- Prevention
- Allocation
- Randomised
- Intervention model
- Parallel groups
- Masking
- Triple blind (participant, investigator, outcomes assessor)
- Number of arms
- 3
| Arm | Type | Receives |
|---|---|---|
| Epidural saline + IV saline | Placebo comparator | Drug: Epidural saline + IV salineSterile saline via the epidural catheter. Sterile saline via intravenous catheter. |
| Epidural morphine 3 mg + IV saline | Active comparator | Drug: Epidural morphine 3 mg + IV saline3 milligrams morphine via the epidural catheter. Sterile saline via intravenous catheter. |
| Epidural morphine 3 mg + IV ketamine 0.3 mg/kg | Active comparator | Drug: Epidural morphine 3 mg + IV ketamine 0.3 mg/kg3 milligrams morphine via the epidural catheter. Ketamine 0.3 milligrams per kilogram via intravenous catheter. |
Who may qualify
- Ages
- 18 years and older
- Sex
- Female only
- Healthy volunteers
- Not accepted
- Age groups
- Adult, Older adult
Key inclusion criteria (7 listed)
- Age >18 years of age
- English-speaking
- Vaginal delivery (spontaneous or assisted)
- A full-term fetus (>37 weeks' gestation)
- OASIS as assessed by obstetrical provider
Key exclusion criteria (7 listed)
- Previous pelvic surgery
- History of chronic pelvic pain
- History of recurrent urinary tract infections
- Women with known malformations of their urinary tract
- True allergies to ketamine and/or morphine
Eligibility is decided by the study team after screening; this overview does not establish that a patient qualifies. Full inclusion and exclusion criteria.
Interventions
| Intervention | Type | Arms |
|---|---|---|
| Epidural saline + IV salineSterile saline injection in the epidural catheter and in the intravenous catheter | Drug | Epidural saline + IV saline |
| Epidural morphine 3 mg + IV salineMorphine 3 milligrams injection in the epidural catheter and sterile normal saline intravenous catheter | Drug | Epidural morphine 3 mg + IV saline |
| Epidural morphine 3 mg + IV ketamine 0.3 mg/kgMorphine 3 milligrams injection in the epidural catheter and 0.3 milligrams per kilogram weight infused in the intravenous catheter | Drug | Epidural morphine 3 mg + IV ketamine 0.3 mg/kg |
Primary outcome
Perineal Pain in Postpartum Patients 1 Week After Obstetric Anal Sphincter Injuries.
Time frame: 1 week after vaginal delivery
Perineal pain 1 week after vaginal delivery measured using the VRS (verbal rating scale). The scale is scored 0 no pain (good)and 10 highest pain (poor).
21 secondary outcomes
Perineal Pain
Time frame: Day 1 after delivery
Perineal Pain
Time frame: 1 week after delivery
Assessment of Maternal-infant Bonding
Time frame: 1 week after delivery
Presence of Postpartum Depression
Time frame: 1 week after delivery
Brief Pain Inventory (BPI-ST Short Form) Current Pain
Time frame: 1 week after delivery
Presence of Postpartum Depression
Time frame: 6 weeks after delivery
Perineal Pain
Time frame: 6 weeks after delivery
Assessment of Maternal-infant Bonding
Time frame: 6 weeks after delivery
Brief Pain Inventory (BPI-ST Short Form) Current Pain
Time frame: 6 weeks after delivery
Perineal Pain
Time frame: 3 months after delivery
Assessment of Maternal-infant Bonding
Time frame: 3 months after delivery
Female Sexual Function
Time frame: 3 months after delivery
Brief Pain Inventory (BPI-ST Short Form) Current Pain
Time frame: 3 months after delivery
Promis 29 Profile (Physical Function Question Only)
Time frame: 3 month
Promis 29 Profile (Anxiety Function Question Only)
Time frame: 3 month
Promis 29 Profile (Depressive Symptoms Question Only)
Time frame: 3 month
Promis 29 Profile (Fatigue Question Only)
Time frame: 3 month
Promis 29 Profile (Sleep Disturbance Question Only)
Time frame: 3 month
Promis 29 Profile (Social Function Question Only)
Time frame: 3 month
Promis 29 Profile (Pain Interference Question Only)
Time frame: 3 month
Perineal Pain
Time frame: 1 year after delivery
Results and safety
Loading the posted results from ClinicalTrials.gov…
Research links
- Official record on ClinicalTrials.govLast updated by the sponsor 24 Apr 2026.
- Posted resultsParticipant flow, baseline, all outcome measures and adverse events.
- Background: PubMed 26637088Harvey MA, Pierce M, Alter JE, Chou Q, Diamond P, Epp A, Geoffrion R, Harvey MA, Larochelle A, Maslow K, Neustaedter G, Pascali D, Pierce M, Schulz J, Wilkie D, Sultan A, Thakar R; Society of Obstetricians and Gynaecologists of Canada. Obstetrical Anal Sphincter Injuries (OASIS): Prevention, Recognition, and Repair. J Obstet Gynaecol Can. 2015 Dec;37(12):1131-48. doi: 10.1016/s1701-2163(16)30081-0.
- Background: PubMed 15507941Macarthur AJ, Macarthur C. Incidence, severity, and determinants of perineal pain after vaginal delivery: a prospective cohort study. Am J Obstet Gynecol. 2004 Oct;191(4):1199-204. doi: 10.1016/j.ajog.2004.02.064.
- Background: PubMed 27222452Chang SR, Chen KH, Lee CN, Shyu MK, Lin MI, Lin WA. Relationships between perineal pain and postpartum depressive symptoms: A prospective cohort study. Int J Nurs Stud. 2016 Jul;59:68-78. doi: 10.1016/j.ijnurstu.2016.02.012. Epub 2016 Feb 26.
- Background: PubMed 21224020Bauchat JR, Higgins N, Wojciechowski KG, McCarthy RJ, Toledo P, Wong CA. Low-dose ketamine with multimodal postcesarean delivery analgesia: a randomized controlled trial. Int J Obstet Anesth. 2011 Jan;20(1):3-9. doi: 10.1016/j.ijoa.2010.10.002.
- Individual participant dataSharing planned: No
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Referral and contact
AzTrials does not enrol participants or take referrals. Contact the study team or a site listed below; they decide who can take part. This study is not recruiting at the moment.
Feyce Peralta, MD principal investigator
Northwestern University
1 site in 1 country: see every site and its status.
Questions about this trial
What is this clinical trial studying?
A Phase 4 study testing Epidural saline + IV saline, Epidural morphine 3 mg + IV saline and Epidural morphine 3 mg + IV ketamine 0.3 mg/kg in people with Pain and Postpartum Depression, run by Northwestern University at 1 site in United States.
The full registered description is in the About this study section and the official record.
Who may be eligible to take part?
The sponsor lists 7 inclusion and 7 exclusion criteria. Eligibility is decided by the study team after screening, so read the full criteria and contact a listed site.
Is this clinical trial currently recruiting?
The record says: finished, as of the sponsor's last update on 24 Apr 2026. Status can change between updates, so confirm with the study contact before making plans.
Where is the study taking place?
The record lists 1 site in United States. Whether a site is taking part right now should be confirmed with that site. See every site.
What are the possible benefits and risks?
They depend on the study and the treatment, and no study can promise a benefit. Some participants in this study may receive a placebo. The study team explains the known risks during informed consent, before anyone joins; the record itself does not list them.
What does this phase mean?
Phase 4 studies take place after a treatment is approved, to learn more about its long-term benefits and risks in everyday use.
Not every study follows the same path, and some studies (observational studies, device studies) have no phase.
Are results available for this study?
Yes. Results are posted in the registry (first posted 24 Apr 2026). A summary is in the For doctors view, and the full results are on ClinicalTrials.gov.
How can a doctor refer a patient or contact the research team?
The record lists no contact. The official record names the sponsor, who can be asked directly. AzTrials does not enrol participants or take referrals.
What does the primary outcome measure?
Perineal Pain in Postpartum Patients 1 Week After Obstetric Anal Sphincter Injuries. (time frame: 1 week after vaginal delivery). It is what the study was designed to measure, not a finding.
Where can I read the original study information?
On the ClinicalTrials.gov record for NCT03470675, which also lists 4 linked publications.
Does a listing mean the treatment is approved or proven to work?
No. A listing means the study is registered. It does not show that the treatment is safe, works, or is approved by a regulator.
How often is this information updated?
AzTrials copies changed records from ClinicalTrials.gov every night and reloads the whole registry every week. The sponsor last updated this record on 24 Apr 2026; AzTrials last refreshed its copy on 26 Oct 2026.