Assessment Findings
- Primary Signs: Boggy (soft, non-contracted) uterus on palpation; fundal height elevated above the umbilicus due to blood accumulation; passage of large clots.
- Vital Sign Red Flags: Tachycardia (HR >100 bpm) and hypotension (systolic <100 mmHg or orthostatic changes) are early compensatory signs of hypovolemia; a temperature of 99.0°F (37.2°C) is within normal postpartum limits.
- Subjective Report: Severe abdominal cramping may indicate the uterus attempting to contract against retained clots.
Priority Nursing Interventions
- Fundal Massage: Immediately massage the uterine fundus using a firm, circular motion until it becomes firm. Support the lower uterine segment with one hand to prevent inversion. This mechanical stimulation triggers myometrial contraction to compress open spiral arteries.
- Lochia Assessment: Simultaneously evaluate the amount, color, and presence of clots in the lochia. Weigh perineal pads (1 gram = 1 mL blood loss) for objective measurement.
- Empty Bladder: A distended bladder displaces the uterus and prevents contraction. Assist the client to void or perform straight catheterization if necessary.
- Initiate PPH Protocol: If massage does not firm the fundus or bleeding exceeds 500 mL (vaginal delivery), escalate immediately. Notify the provider, increase IV fluid rate, and prepare for uterotonic medications (e.g., oxytocin).
Ongoing Monitoring & Safety
- Reassess vital signs every 5-15 minutes during active bleeding; monitor for narrowing pulse pressure and decreasing level of consciousness.
- Never ambulate a client with active hemorrhage or unstable vital signs due to the high risk of syncope and falls.
- Document fundal height, consistency, and lochia flow after each intervention to track response to treatment.