NCLEX Review Guide: Uterine Atony

Understanding Uterine Atony

• Uterine atony is the failure of the uterine muscles to contract effectively after delivery, preventing compression of blood vessels and leading to postpartum hemorrhage.
• Normal uterine contractions compress spiral arteries at placental site, reducing blood flow from 500-800 mL/min to minimal amounts through natural hemostasis.
• When atony occurs, the uterus feels soft, boggy, and enlarged rather than firm and contracted at the level of the umbilicus.

High-Risk Conditions

• Overdistension conditions: Multiple gestation, polyhydramnios, macrosomic infant (>4000g), grand multiparity (>5 previous births).
• Labor complications: Prolonged labor, rapid labor, use of magnesium sulfate, general anesthesia, chorioamnionitis.
• Placental factors: Placenta previa, placental abruption, retained placental fragments.

Clinical Assessment

• Fundal assessment every 15 minutes first hour, then every 30 minutes for 2 hours, then hourly for 4 hours.
• Normal fundus should be firm, midline, at umbilicus level immediately postpartum.
• Signs of atony: soft/boggy fundus, excessive lochia rubra, maternal tachycardia, hypotension, pallor.

Immediate Actions

1. Fundal massage: Place one hand above symphysis pubis, massage fundus with other hand using circular motions until firm.
2. Empty bladder: Full bladder prevents uterine contraction and proper fundal assessment.
3. Assess for retained placental fragments if massage ineffective.
4. Notify healthcare provider immediately if bleeding continues.

Pharmacological Interventions

• Oxytocin (Pitocin): First-line medication, 10-40 units IV in 1000 mL fluid, promotes sustained uterine contractions.
• Methylergonovine (Methergine): 0.2 mg IM/PO every 2-4 hours, contraindicated in hypertension.
• Carboprost (Hemabate): 250 mcg IM every 15-90 minutes, contraindicated in asthma.
• Misoprostol (Cytotec): 800-1000 mcg rectally, prostaglandin E1 analog.

Common Pitfalls

• Never massage a firm fundus - this can cause uterine inversion or increased bleeding.
• Don't assume normal vital signs rule out hemorrhage - compensatory mechanisms can mask early shock.
• Always support the lower uterine segment during fundal massage to prevent uterine inversion.

Quick Check Questions

• □ Can you identify the normal fundal height progression postpartum?
• □ Do you know the contraindications for methylergonovine?
• □ Can you demonstrate proper fundal massage technique?
• □ Do you understand when to notify the healthcare provider?

• □ I can define uterine atony and explain its pathophysiology
• □ I can identify risk factors for uterine atony
• □ I can perform accurate fundal assessment
• □ I know the priority nursing interventions for uterine atony
• □ I understand medication actions and contraindications
• □ I can differentiate uterine atony from other postpartum complications