🤱 Maternity & Newborn · Lesson 4 of 6 · 7 min
Postpartum Hemorrhage: Massage First, Then the Drugs
🩸 The fundus feels like a soft water balloon and the pad is soaked in 15 minutes. Your hand is the first intervention, and the exam wants your hand before it wants a phone call.
💡 Key idea
Boggy fundus: massage. Deviated fundus: empty the bladder. Then oxytocin; no methylergonovine with hypertension, no carboprost with asthma. Firm fundus with bleeding means a laceration.
🧠 Why it matters
POSTPARTUM HEMORRHAGE is blood loss of 1,000 mL or more, or any loss with signs of hypovolemia; UTERINE ATONY is the most common cause, especially after a long labor, a large baby, twins, oxytocin use or a full bladder. The fundus should be FIRM, MIDLINE and at or near the umbilicus right after birth (about 1 cm above it by 12 hours), then descend about 1 cm (one fingerbreadth) a day. A BOGGY fundus gets FUNDAL MASSAGE first, with one hand supporting the lower uterus; a fundus deviated to the side usually means a FULL BLADDER, so have the client void or catheterize. Medications: OXYTOCIN first, then METHYLERGONOVINE (contraindicated in hypertension), CARBOPROST (contraindicated in asthma) and MISOPROSTOL. A firm fundus with continued bright red bleeding suggests a LACERATION or retained fragments, which need the provider. Assess LOCHIA: rubra (red, days 1 to 3), serosa (pink-brown, days 4 to 10), alba (white-yellow, to about 6 weeks); saturating a pad in 15 minutes, large clots or a foul odor are reported. The BUBBLE-HE assessment covers breasts, uterus, bladder, bowels, lochia, episiotomy or perineum, hemorrhoids and legs (check for unilateral swelling, warmth or tenderness; Homans' sign is unreliable), and emotions. BABY BLUES (tearfulness in the first 2 weeks) are normal; POSTPARTUM DEPRESSION lasts beyond 2 weeks and impairs function; POSTPARTUM PSYCHOSIS, with hallucinations or thoughts of harming the infant, is an emergency. Every unsensitized Rh-NEGATIVE pregnant client receives Rh immune globulin at 28 weeks, and again within 72 hours after birth if the baby is Rh-positive.
🏥 In the real world
👐 Two hours after a long labor the fundus is boggy and displaced to the right. The nurse massages until it firms, then helps the client to the bathroom; 700 mL of urine later, the fundus returns to midline and the bleeding slows. Oxytocin runs as ordered. The sequence was hands, bladder, drug. The exam will offer the drug first and the phone call second; both are wrong as the first step.
📌 Takeaways
- Fundus firm, midline, descending 1 cm a day; boggy means massage
- Displaced fundus means a full bladder
- Oxytocin first; methylergonovine not with hypertension; carboprost not with asthma; Rh immune globulin within 72 hours
📖 Terms in this lesson
Uterine atony: A uterus that fails to contract after birth, the most common cause of postpartum hemorrhage; massage the fundus first.
Lochia: Vaginal discharge after birth that progresses from red (rubra) to pink-brown (serosa) to white (alba).
Rh immune globulin: The injection given to Rh-negative mothers at 28 weeks and within 72 hours after delivering an Rh-positive baby, to prevent antibodies against future babies.
BUBBLE-LE (postpartum assessment): Breasts, Uterus (fundus firm, midline), Bladder, Bowel, Lochia, Episiotomy or incision, Legs (clots), Emotions: the postpartum head-to-toe order (older form BUBBLE-HE, H for Homans' sign).
Methylergonovine, carboprost and misoprostol: The drugs given when massage and oxytocin fail to stop postpartum bleeding: methylergonovine is withheld for hypertension or preeclampsia, carboprost for asthma, and misoprostol is expected to cause fever, chills and diarrhea; recheck the fundus and bleeding after each.
Rho(D) immune globulin: A blood product given IM to an Rh-negative mother with a negative antibody screen at 28 weeks, within 72 hours of delivering an Rh-positive baby, and after miscarriage, abortion, amniocentesis or abdominal trauma; it is useless once the mother has already formed antibodies.
✅ Test yourself
One hour after delivery, the nurse finds a boggy fundus and heavy bleeding. What is the first action?
- Administer methylergonovine
- Notify the provider
- Increase the IV rate
- Massage the fundus
Answer: D · Massage the fundus
Fundal massage stimulates contraction immediately and is the first-line intervention for atony.
A postpartum client with a blood pressure of 158/98 has uterine atony unresponsive to massage. Which medication should the nurse question?
- Oxytocin
- Misoprostol
- Methylergonovine
- Carboprost
Answer: C · Methylergonovine
Methylergonovine causes vasoconstriction and is contraindicated in hypertensive clients.
The fundus is firm and midline, but the client continues to pass bright red blood in a steady trickle. What does this finding suggest?
- A cervical or vaginal laceration
- Uterine atony from an overdistended uterus
- A full bladder displacing the uterus
- Normal lochia rubra on the first postpartum day
Answer: A · A cervical or vaginal laceration
Bleeding despite a well-contracted uterus points to trauma of the birth canal or retained fragments, requiring provider evaluation.
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