Key Assessment Findings
- Fundal Position: A fundus displaced above the umbilicus suggests the uterus is filling with blood and clots.
- Fundal Consistency: A soft or boggy fundus indicates the myometrium is not contracting to compress vessels at the placental site.
- Bleeding: May present as a steady trickle or sudden gush of bright red blood; lochia flow may be heavier than expected.
Immediate Nursing Interventions
- Fundal Massage: Support the lower uterine segment with one hand and gently but firmly massage the fundus with the other until it becomes firm. Never massage a firm uterus.
- Empty the Bladder: A distended bladder displaces the uterus and prevents contraction; assist the client to void or perform straight catheterization if needed.
- Administer Uterotonics: As prescribed, administer oxytocin (Pitocin) as a first-line agent, followed by methylergonovine (Methergine), carboprost (Hemabate), or misoprostol (Cytotec) if bleeding persists.
- Monitor Vital Signs: Assess for tachycardia and hypotension, which are late signs of hypovolemia from postpartum hemorrhage.
- Quantify Blood Loss: Weigh pads and linens (1 gram = 1 mL blood loss) to accurately estimate blood volume lost.
Expected vs. Abnormal Findings (First 12 Hours Postpartum)
| Assessment | Normal Finding | Abnormal (Uterine Atony) |
|---|
| Fundal Position | At or 1-2 fingerbreadths below umbilicus | Above umbilicus, often deviated to one side |
| Fundal Consistency | Firm | Soft, boggy |
| Lochia | Rubra, moderate flow, small clots | Heavy rubra, large clots, or sudden gush |
Risk Factors for Uterine Atony
- Uterine overdistension (multiple gestation, polyhydramnios, macrosomia)
- Prolonged or precipitous labor
- High parity
- Chorioamnionitis
- Use of magnesium sulfate or halogenated anesthetics