Is there a role for TXA in postpartum hemorrhage?

In most cases, TXA is not required prehospital for postpartum hemorrhage. The mainstay of paramedic care includes prophylactic oxytocin following the delivery of all newborns, followed by targeted management based on whether the placenta has delivered.

• If the placenta is undelivered or partially delivered, and hemorrhage is occurring, attempt gentle, controlled cord traction while guarding the uterus. If bleeding continues, move to external bimanual uterine compression, which is 98% effective within five minutes (PESP 2017, p. 17).
• If the placenta has delivered, start with external uterine massage and encourage the patient to void. If ineffective, progress to external bimanual compression.

In both situations, oxytocin and mechanical techniques are typically sufficient, and transport should already be underway. These measures are designed to stabilize the patient before hemodynamic instability develops.

TXA should then only be considered in rare cases where hemorrhage is clearly ongoinga and the patient is becoming hemodynamically unstable. Importantly, postpartum hemorrhage is not an approved indication under the TXA Medical Directive, so a Base Hospital patch is required before administration.

Although the WOMAN Trial (Lancet, 2017) found that TXA reduced death from bleeding when given within three hours, its greatest impact was in low-resource settings without access to uterotonics. In Ontario, where oxytocin is available and rapidly administered, TXA should be reserved for exceptional cases with physician oversight.

References:

• Association of Ontario Midwives. Paramedic Emergency Skills Program (PESP) Manual, 2017. pp. 16–17.
• WOMAN Trial Collaborators. The Lancet, 2017; 389(10084):2105–2116.
• Ontario Base Hospital Group. ALS Patient Care Standards, Version 5.2, 2024.