 At this juncture I'm going to introduce our presenters for today. We have Ruth and Angela. I believe we can all see them at the shared video. Ruth is an associate dean and professor at Azusa Pacific School of Nursing in Azusa, California. Dr. Ruth has been awarded numerous state and federal grants to support midway free education. Most recently she was the PAI on HRSA, Advanced Nursing Education Workforce. Grants that expanded women's health services in a rural health clinic and provided traineeship to midway free students in underserved and rural areas. In 1991, Dr. Ruth founded a last midway free practice in downtown Los Angeles, which continues as the largest OBGYN midway free practice in Los Angeles, offering water, bath and collaborative midway OBGYN management. In addition to her academic role, Dr. Ruth continues in this full scope practice where she precepts medical residents and nurse midway students. The professional services include her current role on the NICE Nurse Midway Free Advisory Committee for the California Board of Registered Nurses, past president of the California Nurse Midway Association, contributor or reviewer for the Journal of Midway Free and Women's Health, and trainer or perinatal home visitors as part of Los Angeles Best Babies Network. By such interests as gestational weight gain, gestational diabetes, newborn male circumcision, rural health issues related perinatal health, and midway free management, intrapartum and postpartum. That's Dr. Ruth. Next is Angela. Angela is an assistant professor and the program director of the Women's Health Nurse Practitioner and Nurse Midway Free Program at California State University in Fillerton, California. Dr. Sojobi is also an experienced certified midwife of 28 years and currently provide care to women at Martin Luther King Community Hospital in Southern California. As a certified nurse midwife, Dr. Sojobi seeks high quality and equitable healthcare to women throughout the lifespan with a special emphasis on the prevention of adverse perinatal outcomes. As an educator, Dr. Sojobi's goal is to help students become intentional learners who believe in lifelong learning and actively seek knowledge. To assist women and to achieve optimal health. Dr. Sojobi's research focus is on applying a socio-ecological model to study chronic illnesses, particularly gestational diabetes, with a focus on how social support can enhance self-management and glycemic control. Those will be our presenters for today. I'll hand over to him so that we can take him through. Okay, Angela. Very good. Actually, what I'm going to do is if it's okay with everyone, Angela, first of all, thank you for everyone for allowing Angela and I to be a part of this and for Jackson and all of those at the IDM for figuring out all of our time zones. Lucky we're all here, I guess. I'm, I'm doing a little traveling in Italy. Angela, my midwife buddy and colleague is an LA and Jackson is in Kenya and all of you are where you are. So that's, it's pretty cool. So I'm going to, I'm going to be the I'm on an iPhone. So, Angela is going to be advancing the slides for the parts of my presentation. Sorry, I know that's a little irritating. But I also want, as, as Angela and I talk about this substance that we use or starting to use, I want you to think about ways that you can join the conversation after the presentation because Angela and I decided to do this because we want to hear from you. And we're in the United States. And I would love to hear what's going on in your part of the world. With that being said, I'm not going to read the objectives verbatim. You'll see these as we go through. So go ahead and go to the next slide, Angela. Hang on one second. If Jackson is still, they, oh, there we go. I do have control now. Okay. There we go. All right. So this, this slide is, I think for, for folks that are here, this is, we know this, that we know that hemorrhage, specifically postpartum hemorrhage is a leading cause of maternal mortality and morbidity worldwide. From a US perspective, even in our resource rich country, 11% of pregnancy related deaths were due to hemorrhage. And this is in a setting that has things that has IVs that has pharmacologic agents that has Bakri balloons and all those kind of fancy schmancy things. You know, on the bigger scale globally postpartum hemorrhage is associated with 25%. Or one out of four delivery associated deaths. And I want to, to go ahead, Angela, and I want to be very clear that we're going to really focusing on postpartum hemorrhage today, recognizing that obstetrics hemorrhage can occur, can occur antipartily as well. But 80% of obstetrics hemorrhage actually occurs postpartum. Next. So in this world view, you may not be able to read this very well, but what this is is maternal mortality per 100,000 live births. And this is a World Health Organization slides, and I'll read down there. So it postpartum hemorrhage accounts for 8%. 8% of maternal deaths in the developed countries. And you're thinking, well, Ruth, you just said it accounted 11. Well, that's 11% of the United States. But now when we throw in the other developing developed nations, industrialized nations, it's actually about 8%. However, what is concerning in and of itself, beyond that, that is concerned, but in less developed countries, up to 60% of maternal deaths in developing countries. And, you know, you can't see this very well on the bottom left is the legend. And the darkest, darkest purple rectangle there actually represents, it represents 1000 deaths per 100,000. And you don't see a lot of those darker, but if you see the the pinker ones toward the bottom of the scale, kind of the fuchsia and the less pink, those are those are like 500 to 999 maternal deaths out of 100,000 way way more than we need at all. So let's let's talk about that and hopefully we'll get some good interaction on how we can be part of the chain. So next slide please. So in the United States, I'm showing this slide because I have had the opportunity to present this with another colleague, Sarah Obermeyer, who's now actually I guess I should put a shout out for frontier nursing university she's now a faculty she was a co faculty with me. But we wanted to point out that in the United States, as in many other countries, there are national and statewide initiatives to address obstetric hemorrhage and postpartum hemorrhage specifically, and I've listed those on the left, I won't read those. I want you if you have not figured out what those are in your district in your country in your area, please, please see what those are and of course the World Health Organization is kind of our go to as midwives globally. And on the right, you'll see some things. I tried to include all sorts of clinicians, but one of the things that you I noticed that we had at least one community member on here and you may not be the person that's actually touching the child bring in labor and attending their birth, but you may be in a position in a community to identify the the woman who has definitive risk factors that may even risk her out of delivering in your, your community that she may actually need to go to a higher level of care. So anyways, we're trying to make this a little bit of something for everyone so go ahead Angela next slide. I'm going to talk about physiologic changes of pregnancy and how tranhexamic acid or TXA works. Next slide. So in this one, this is one of those those of us that have gone to a lot of schooling I know there's a lot of us on this call cumulative there's a lot of years of schooling here right. I think many people when they hear about the clotting cascade, they are eyes roll back in their head, and they're like, are you kidding. What do we have to know about that. You know, there's extrinsic and intrinsic factors and I am going to try to point out some critical things. First of all, pregnancy number one is a physiologic hyper coagulable state. And this is a preventive state women that are in pregnancy. And if you could go to the next slide again Angela it flipped back. So, fortunately women have this ability to clock better during pregnancy. Okay, they have increasing clotting factors. Decrease in fibrinolysis we're going to be talking about that term quite a bit fibrinolysis license means cutting, cutting fibrin. So if you have a decrease in your fibrinolysis that means your clots stay around better. So I want you to go to the right on the slide and you can see at the there's the the little you see that red blood cells kind of circulating and the left and that is injury that's representing injury that's occurring when there is actually birth. When the placenta comes off the myometrium that is basically an injury. And what we want to happen is we want to have our friends the platelets, which you can see in the middle little picture the platelets aggregate to the place where there's injury. Okay, so the platelets are there. And they are waiting, they're waiting for fibrin to come and actually thrombin activates pro thrombin are to the fibrinogen to make fibrin. And I wanted to mention something fibrinogen. I wanted to mention this, if any of you have access to seeing lab work on your gals. When they're maybe maybe they have a hypertensive disorder and you happen to have run some some lab work on them to see if they may have actual preeclampsia. You'll notice on many of our women you see higher fibrinogen. Well, that's a good thing. That's a good thing that's an insoluble part of the plasma to protein and actually when it is converted to plasma and as you can see there. Fibrin sorry, not this is where the slides get small fibrin fibrin contributes to the platelets to make a wonderful clot. And the main concept of this slide is for you to think we want to maintain clot ability, we want to maintain fibrin. And that's exactly what TXA does. If you go back to the bottom left of the slide you will see a part that says in severe blood loss when you have women and I know this happens especially some of you that are in rural areas for a for a piece of time I was in Kenya, and they they had IVs there, but they had no blood products. And when there was severe blood loss, they women could actually lose enough of their blood where they had really so few platelets left that they could even start the clotting process. And again, fibrinogen and platelets both are necessary for that. So that's the first slide I want you to tuck that away remember fibrin is our friend. Okay, in terms of postpartum hemorrhage next slide. And this one is a common. If you want to call it mnemonic that we use in OB, it's the forties tone tissue trauma thrombin. Well really there's two reasons why women can have experienced death or mobility relative to hemorrhage. And there are somebody else talking. Can you hear that I benefited. Thank you. Thank you. There are of these four etiology of hemorrhage there are really two that we want to think about that are germane here it's tone. And then ultimately, we're thinking about clotting. Okay. And you can see that little picture there is a kind of a cross section of a placenta is the you upside down placenta inside the you which is the uterus. And you can see that when the placenta is coming through the bottom of the vaginal vault you can see up above that there is this little open area at the at the top of the inverted you that that is basically a wound. And that's a wound that we want to shut down and typically it does because the myometrium the muscle of uterine wall closes down and clamps off those vessels. The placenta comes out and then hopefully we have nice tone sometimes occasionally there is tissue and maybe a piece of the placenta and maybe excess clots that may limit the ability for the uterus to become tonic or toned. And then there's other things that can happen trauma, you see at the bottom, there can actually be lacerations even even in lower resource settings that don't have forceps and vacuums that to help that vaginal verse that need help. There can actually be enough manual or digital, if you want to call it manipulation of the tissue that there can be vaginal sulcus tears that are created digitally and then of course, the last there are women that come into pregnancy that may even have clotting disorders problems of coagulation that we don't know about next slide. So this is basically TXA. So how does it work. So TXA is a synthetic analog it means it's a look alike of an amino acid called lysine. And what it does and if you can see on the bottom left. So remember fibrin is our friend. We want to keep fibrin around to prevent postpartum hemorrhage. Well what TXA does it inserts itself into plasminogen and actually prevents you can see the international symbol there for it does not allow. It's not allowing plasminogen to convert to activate plasmin. And when plasminogen cannot activate to become plasmin then we preserve you can see again the international symbol going from plasmin down to our fibrin clot instead of going to the far right where we see fibrin degradation products. In other words breakdown of clots we have maintenance of the fibrin clot. So again TXA and this is kind of a double negative is an anti fibrinolytic agent is an agent that protects against the lysis of fibrin clots. How cool is that. Okay, next slide. So, Angela is actually going to talk a little more about its actual clinical use on set of action is rapid to typically given IV administration. It's excreted primarily through the kidneys and half life is two hours on what we're typically interested as as those dealing with persons or women that are child bearing is well what about the baby doesn't get to the baby. Does transfer in very miniscule amounts in breast milk and a number of places that Angela and I looked. There's no adverse outcomes among breast and infants whose mothers took TXA in dosages even up to four grams daily. Okay, so that is much, much more than we give times one or times two in the immediate postpartum period. So again the studies, you know, went the end mile. If you want to say it but we are going to talk about a very focused finite emergency use of TXA today. Next slide. So I'm going to turn it over to Angela. Hi everyone. So I'm going to talk about the use of TXA to treat postpartum hemorrhage in the United States. TXA was initially approved by the federal drug and administration in the United States as for the treatment of heavy menstrual bleeding. However, several studies have demonstrated that it's used in in reducing the need for blood product transfusion for postpartum hemorrhage is valid. So there are off-label clinical applications used in trauma and surgery gastrointestinal bleeding and also in postpartum hemorrhage. So TXA can be administered early or intravenously. It is currently being used early for abnormal UDRIME bleeding but in the United States we use it intravenously for the prevention of postpartum or treatment of postpartum hemorrhage. For abnormal UDRIME bleeding, the IUD, the Nebulogestral IUD has been found to probably have more effectiveness than TXA. Let's see. So the revitalized definitions for postpartum hemorrhage is accumulative blood loss of over a thousand mils or equal to a thousand mils of blood loss, accompanied by symptoms of hypovolemia within 24 hours following the birth process. Any blood loss, 500 to 900 milliliters, if it's accompanied by signs and symptoms, hypovolemia, which are target cardiac hypertension, tachypnea, oliguria, pallor, dizziness or altered mental status, should also trigger increased supervision and potential interventions as clinically indicated. Now there are certain risk factors for postpartum hemorrhage. I will discuss them in low, medium and high risk. So women who have a singleton pregnancy, they've had fewer than four previous births. They have an unscarred uterus, which means they hadn't had any UDRIME surgeries and don't have a history of postpartum hemorrhage or categorized in low risk risk factors for postpartum hemorrhage. Women who have had prior sefection or any other UDRIME surgery have had more than four previous births, had prolonged use of oxytocin in the later. Corium nineties or the use of magnesium sulfate, have large fibroids, UDRIME fibroids, have multiple gestations or have mild thrombocytopenia, which is 100 to 149,000. These women will be categorized as medium risk. High risk women, though, are the women that have a history of postpartum hemorrhage in previous births. They have a hematocrit of less than 30, so they are nimic. They have a known coagulation defect, had some bleeding on admission, history of previa, placenta previa, in-creator or per-creator. They have abnormal vital signs like tachycardia and hypertension. These women will be categorized as high risk for postpartum hemorrhage. So there have been several studies to evaluate the use, effectiveness and efficiency of TXA, the antephyrbunelidic effect of TXA. There is an international placebo-controlled trial that evaluated the effects of early administration of a short course of TXA on death, vascular occlusive events and the receipt of blood transfusion. This study included 20,211 adult trauma patients with significant hemorrhage. These patients had systolic blood pressure less than 90 or heart rate greater than 110 bits per minute. And they were at risk for significant hemorrhage and they were within eight hours of injury, the injury that led to the hemorrhage. These women were randomized into the TXA or placebo category. The result shows that all course mortality significantly reduced in the TXA group. The risk of death due to bleeding was also significantly reduced in the TXA group and there was no apparent increase in fatal or non-fatal occlusive events in both groups. And by the way, this study was across 40 countries and 274 hospitals. Another study, the World Maternal Antifibrinolytic Trial, the Women Trial, also an international study was a randomized double-blinded placebo-controlled trial of women 16 years or older with postpartum hemorrhage after vaginal birth or C-section. This study was conducted across 21 countries and 193 hospitals. Postpartum hemorrhage was clinically defined as estimated blood loss of greater than 500 milliliters after vaginal birth or 1,000 milliliters after C-section or any blood loss sufficient enough to compromise hemodynamic stability. There were 20,060 women in this study. They all received usual care but were also randomized to TXA or placebo group. This study showed that death due to bleeding significantly reduced in the women that had TXA, especially in women given treatment within three hours of given birth. There was no significant difference in thromboemboletic events amongst between the placebo and the TXA group. Hence, TXA reduces death due to bleeding in women with postpartum hemorrhage with no adverse effects. When used as a treatment for postpartum hemorrhage, TXA shall be given as soon as possible after the bleeding onset. So, here is information about what the different organizations have to say about TXA. The World Health Organization recommends that TXA shall be used in all cases of postpartum hemorrhage regardless of whether bleeding is due to genital tract trauma or other causes and shall be part of a standard postpartum hemorrhage treatment package. The American College of Obstetrics and Gynecology in the United States recommends that TXA shall be considered in the setting of postpartum hemorrhage when initial medical treatment fails. The California Maternal Quality Care Collaborative recommends that TXA is used as an agent treatment and not a primary treatment for postpartum hemorrhage. Placement of TXA in hemorrhage guidelines will depend on local resources. So, now to administer TXA, the initial dose should be given within three hours after birth or the bleeding incident. The dosage is one gram in 10 milliliters or 100 milligrams per male, and it should be given IV over 10 minutes, which equates one milliliter per minute. It should not be mixed with blood for transfusion or solutions containing mannitol or penicillin. A second dose of TXA may be given within 30 minutes after 24 hours and after 24 hours after the first dose. A history of current thrombosis is contraindicated in the use of TXA. Meta-analysis reported that there's no increased risk of adverse events compared to placebo, and I will pass this on to Ruth. I think you muted, Ruth. I am. Who muted me? Was it me? So, I'm sorry about that. So, we're going to, we're going to, this is our last objective. It actually is objective three, not two. And I noticed that Angela said a little kind of what I call, so we like to think, I'm going to be honest with this. I like to think that TXA has a role in prevention of postpartum hemorrhage. And I know Angela does too. So, we decided to take a look at the literature and see what was going on. And I'll just lead off this section with, here's an example of a case. Angela looked at, showed you different risk factors for postpartum hemorrhage in the high risk category. Do you remember the first two, the first one was a history of postpartum hemorrhage. Wow, of course. Somebody with a history of that same, that same stuff may be recurring, right? She has the same uterus, the same whatever conditions may be there. And then the second one was actually anemia. And we know that even in the United States, believe it or not, we have many of our women come into childbearing very anemic. And so we have had, I wouldn't say many, but we've had several cases. I can think of one where we had a woman exactly that came in in early active labor, history of postpartum hemorrhage or hemoglobin of nine. And she's going to have a baby within an hour, an hour and a half. She's six centimeters and she's a mole tip. And she's like telling me that was terrible, what happened last time. They gave me blood, all this kind of stuff. So anyway, so we talked, I work in a hospital setting with Angela where it's one midwife and one OB and whatever comes in we handle. And we talked to our OB colleague and he says, yeah, let's give some TXA to this gal so it can get on board and be ready prior to that placenta coming out. Because remember, it does have some five to 15 minute timer it takes to work. So in that case, again, a team effort, we talked about it. We talked to anesthesia. We're all on board the nurses, of course, and we talked to the patients say we're going to give you something. We don't want that to happen again. We have these other things that we can use that are more commonly used, but we want to have like all hands on deck. So anyways, I wanted to start that off with that is kind of Angela and my is kind of passion. And I was frankly really excited when the World Health Organization really proposed that TXA be part of the package of treatment for postpartum pamphlet. So anyways, let me let me go on to this next slide. So first of all, all of us that actively attend births active management of third stage of labor. That means we do that. That's our first step to prevent postpartum hemorrhage. Really two things that we have a uterotonic available. Remember, we talked about tone being a really important one that we want to help the uterus tone itself as much as possible. That's typically oxytocin problem of oxytocin. It actually denatures. If you don't have good refrigeration in some local or some areas of the world is very difficult to keep in a reasonable potency to be used. Okay, but oxytocin is what's recommended. And then cord traction, cord traction by someone who has been trained to do that. Because remember, we want to have some cord traction that's enough to help assist the placenta to deliver a little earlier than it would naturally because if it stays in there as long as it normally would, it may be in there for hours. I mean, those of us that work in hospital settings, we always crack up because whatever the paramedics or EMTs come running in with somebody that's had a baby at home. The placenta is always still in, even if it's two, two hours earlier, you know, that the uterus is a muscle and it will push out the placenta. But remember, in the meantime, when the placenta is waiting to be pushed out, a huge retro placental clot is developing. That is part of the mechanism for the placenta to actually deliver. If we have trained birth attendants, midwives, nurses out there that actually know how to create enough cord traction to gently ease out that placenta, we can diminish that huge amount of blood that's kind of trapped behind there. And that actually is one very important step. Next slide. Eudotonics. These are what I just mentioned. Eudotonics are things that tone the uterus. Methrogen is one that we use. We don't use it in women with high blood pressure because it's a vasoconstrictor. Potosin, at least that's what we call it in the United States. I think in the UK it's centosinon and I know there's a lot of other, it's a synthetic oxytocin. We do use that. And you can see on the bottom are two prostaglandins that are available as well. But I would say the two go-to in our first line are typically Potosin. And then if they're able to take it based on their risk profile, metrogen, and then we consider using hemabate or cytotech. Next slide. So really quickly, so what does literature say about prevention? So I was, when I was reviewing some of these studies and Angela has looked at these and then the collaborator on a couple of the articles that we've written on Dr. Sarah Obermeyer, I was a little bit depressed at first because I thought there is no absolute definitive answer to that question yet. And I wanted there to be because I wanted there to be some protocol. And long story made short, there really isn't yet. And let me just show you. So here is a very, it's a good study with a reasonable amount, pick out my glasses so I can see this on my phone here. So this was done in France, got close to 4,000 women enrolled in vaginal delivery. It was a randomized control trial that compared all women got oxytocin, but the control, the treatment group got oxytocin and TXA. So we're going to see does TXA, how does it fare in women who end up having, in terms of blood loss specifically. So the primary outcome was actually blood loss and really there was no difference in blood loss between the two groups. You're like, oh shoot, too bad. You know, wanted it, wanted it to be yes. Secondary outcomes, severe postpartum blood loss. There really was not that much difference between the groups either. Important part of the study, however, was it continued to demonstrate the safety of using TXA in this group of almost 4,000 women. There were no thromboembolic events in the treatment group compared to the control group or the group that got TXA compared to the control group. But this is what I want you to think about because I know that we are taking care of women who fall into high-risk categories. The problem with the study, and this is on even the best randomized controlled trial, the researchers will talk about the limitations and the limitation in this study. It was not, it did not look at subgroups of women. It did not look at the women who had a history of postpartum hemorrhage, who had issues low hemoglobin, things I've talked about before. Therefore, it's findings are really limited to the generalized use of TXA. And it was really not for use of women at risk for PPH like the case study that I mentioned earlier. Okay, next slide. Okay, so a Caesarean. I know a number of you out there in our practice, Angela and I are first assistants for Caesarean. So we're a part of that woman's care from labor through the time that we decide she needs a Caesarean through the Caesarean and after. And you think, well, it's actually be considered, well, maybe it's a good thing to prevent hemorrhage in women having Caesarean. Well, this was an interesting, a systematic review. So it looked at a number of studies and a meta-analysis of 18 RCTs. So it looked at 18 studies and it kind of glommed them into one big study and they, these are the study results. I'll talk about some of the problems with that, but the positive, it showed some trends. It showed that there was in terms of Caesarean use. There was a 60% reduction in the risk of mild to moderate PPH, which in this study was in many of the studies defined at only 400 CCs EBL. And there was actually in terms of severe PPH a 68% reduction. Okay, you say, okay, well, that sounds good. However, here comes the however, the limitations was that when you have 18 different studies done internationally in different countries, the definition of PPH was different. There was the one gram protocol was only used in 14 of the 18 studies. So you had four studies that use a slightly different protocol. And there was heterogeneity of the participants. Some of the women, some of the women had higher risk factors than others. So anyways, it showed some trends, but really didn't show us absolutely that it prevents postpartum hemorrhage and Caesarean. So next slide. So this is, this is what is going on now. And I'm going to show you a couple of studies that are in process that they're, I just want you to stay tuned. And I know you'll get the slide references for later. So please stay tuned. I know I've been checking on these. And actually, this is the trap to trial. And this is one that was designed the same way as the other French studies, same researchers. It was on Caesarean. And I should go ahead. This actually is a completed study. I'm going to show you, but this study did show that in this study for Caesarean, there were significantly fewer women with blood loss, greater than a thousand milliliters, which Angela mentioned is really the current definition that could be used, at least that's what's being used in the United States. Okay. However, there was no difference in the use or need for additional agents or transfusion. In other words, there was some slightly different, different blood loss, but it did not change the management significantly. Remember TXA, remember Angela showed you the two studies TXA prevents reduces mortality, which is obviously really what the bottom line is we want to reduce mortality related to postpartum hemorrhage. It showed some difference in terms of blood loss, but not reduction in mortality. So therefore I'm just going to read this orange box. This study does not suggest that prophylaxis or prophylactic use of TXA. Two minutes window. Okay, I'm going to take a little longer because we actually use 10 minutes to do the introduction. So sorry, I'm going to, I'm almost done. Okay. Thank you, Jackson. So this study does not suggest that it has significant benefits at this point for women experiencing Caesarean in this general group. Again, a general group. So going to the next slide. We're almost done you guys. Hang with me. So again, there's two studies and these are the ones I mentioned before. There is a randomized controlled trial with 11,000 women, women, which is underway to assess whether prophylactic TXA reduces the risk of PPH and women undergoing Caesarean. Okay. So keep track of that. You can see the clinical trials.gov number there. And this will be a very important one in terms of whether or not we will use it for prevention in terms of Caesarean. The next slide, and this is the other one I went to tell you about that actually is more germane to us because we are most likely with vaginal birth. This is another study that's underway that recognizes that one of three pregnant women worldwide are anemic and therefore are much more susceptible to the morbidity related to postpartum hemorrhage and ultimately mortality. So this is a study that is looking at women specifically who are anemic. It is looking at that one subset that was not addressed or could not be addressed in that smaller study. It's looking at anemic women only and whether the use of prophylactic TXA will be beneficial for reducing mortality. Okay. So I just I want that to be to stay tuned and I'm going to close at the next two slides and then we'll get a little discussion time here. Okay. So, you know, as Angela mentioned, the United States does not use TXA. We do not use TXA as a part of our standard package of postpartum hemorrhage treatment. We use it as a secondary kind of we've already used our oxytocin, our methyrgine, our cytotech, our hemobate, whatever we've done. And now we consider, wow, well, maybe it's not, maybe it's a clot problem. Remember TXA fixes clot problems. So we use it as adjunctive therapy. However, there is a researcher, Sudha, who's in the references that you'll see that talks about that increasingly because TXA is pretty inexpensive that TXA may be considered or actually could be later on could be cost savings. There may be cost savings when used routinely for PPA. So I just want to mention that to you, we are a high resource setting in low resource settings. Remember the World Health Organization has already stated that because they talk about the world and they recognize that most of the world's babies are born in low resource settings. TXA being a part of the treatment package can save lives. And that's, that's the bottom line. So go ahead, I hear a dog barking there. So that must mean the signal for the presentation almost be over. When the dog barks, it means it's time to go. All right. So the conclusions here. So let's be comfortable and familiar with its use. Let's, let's identify risk factors. Find the women in your community who have had hemorrhages before in the context of childbirth. Let's get them to a higher level of care or get, get materials ready for them. Okay. And really important things that Angela mentioned that TXA should be given within three hours. It should not be used in women with the history of thromboembolic disease. That is a given. That is absolute contraindication. Okay. And then just remember there is high quality research on the use for prevention underway. It's not completely clear yet, but I feel like even in the next several years, there will be some high, really high quality studies, not that the ones that have been done already have not high quality, but they just had enough limitations that we can't apply them yet. But there may be some suggested ability to use it more regularly for prevention in resort risk rich countries as well. So let's just, I think that's the conclusion part. Let's step through the references so they get on the video. That's one page. You can look at those later. Next page of references. And then there's a last page of references. And then there's just a thank you slide.