M.M., a 25-year-old Hispanic primigravida at 41 weeks and 6 days gestation, presented to the labor and delivery unit for postdates induction of labor, accompanied by the father of the baby. She reported normal fetal movement and denied any loss of fluid or vaginal bleeding. Her prenatal course was uncomplicated. The fetal heart rate was reassuring. Occasional contractions were recorded by the tocometer, but not felt by M.M. A pelvic exam found her cervix to be 1 cm dilated, 80% effaced, soft and posterior, with the vertex at −2 station with membranes intact. Based on a Bishop score of 7, the decision was made to proceed with induction of labor with intravenous oxytocin per hospital protocol of 1 mU every 15 minutes to a maximum of 5 contractions in 10 minutes lasting no more than 60 to 90 seconds or a maximum dose of 20 mU/min. Three hours after oxytocin was initiated, M.M.'s cervical exam was 2 cm dilated, 80% effaced, with the vertex at −2 station. The fetal heart rate baseline was 135 beats per minute with moderate variability and no decelerations. Six hours after admission, M.M. requested pain relief. Her cervical exam was 4 cm dilated, 90% effaced, with the vertex at −1 station. The oxytocin was infusing at 16 mU/min and the fetal heart rate was reassuring. Pain management options were discussed with the client and, after being counseled on the risks and benefits, she opted for epidural anesthesia.

Eight hours after admission, M.M.'s uterine contractions became difficult to detect with the external tocometer. At examination, her cervix was found to be 7 cm dilated, 100% effaced, with the vertex at 0 station. The oxytocin was infusing at 20 mU/min. The midwife counseled the client on the need to monitor uterine contractions when receiving oxytocin and the decision was made to rupture M.M's bag of waters and place an intrauterine pressure catheter. M.M.'s membranes were ruptured and it was noted that she had a moderate amount of clear amniotic fluid. The intrauterine pressure catheter was placed without complications and recorded adequate uterine contractions of 230 MvU.

Eleven hours after admission, M.M. reported rectal pressure and a desire to push. Her cervix was examined and found to be fully dilated with the vertex at +2 station, and again the fetal heart rate was reassuring. Pushing efforts were commenced.

One and a half hours later—12 and half hours after the initiation of induction—M.M. gave birth to a vigorous baby girl weighing 3000 g, with Apgar scores of 9 and 9 at 1 and 5 minutes, respectively. The oxytocin infusion was discontinued immediately after delivery. Twenty-five minutes later, the placenta was expelled spontaneously and appeared intact. An infusion of 20 units of oxytocin in 1000 cc of lactated ringers was given intravenously at 125 ml/hr.

Fundal massage was started immediately after delivery of the placenta, because the uterine fundus was found to be boggy, and vaginal bleeding continued to increase. Bimanual uterine compression was added to control the hypotonic uterine bleeding. The urinary bladder was catheterized, producing 100 ml of urine. Ten units of oxytocin were administered intramuscularly in the thigh, again with poor response. Methylergonovine maleate 0.2 mg was then given intramuscularly. The obstetrician on call was notified of the client's uncontrolled immediate postpartum hemorrhage related to atony. Four minutes after Methergine administration, the fundus was firm and bleeding minimal. Twelve hours after delivery, M.M.'s hemoglobin (Hgb) and hematocrit (Hct) were noted to have decreased 23% from her levels at admission. Her Hgb was 7.8 g/dL, and she had an Hct of 23.9%. Her vital signs remained stable throughout, urine output satisfactory, and the client was able to tolerate walking without assistance.