The Case

A 27-year-old primiparous woman arrives at the emergency department after a prolonged labor at home; she is fully dilated and crowning. She has no significant health history and is only taking prenatal vitamins.

Obstetrics and pediatrics are called stat, but the patient rapidly delivers in the emergency department—a healthy 6-pound, 8-ounce girl with only a first-degree laceration. Pediatrics arrives quickly and provides neonatal assessment. Obstetrics, however, is busy doing an emergency cesarean delivery.

Shortly after the delivery of the placenta, the patient has brisk vaginal bleeding. Her vital signs are normal and stable. Lab tests are requested, and the nurse has already given oxytocin 10 mg IM and started an IV. Knowing that uterine atony is the number-one cause of postpartum hemorrhage (PPH), you start performing fundal massage. While waiting for obstetrics to show up, you think about drugs other than oxytocin that could be used for PPH (methylergonovine, misoprostol, and prostaglandins), and you remember reading something about tranexamic acid (TXA).

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