# A nurse is caring for a 25-year-old postpartum client who delivered 6 hours ago and is experiencing heavy vaginal bleeding with saturation of a pad every 20 minutes. Which nursing action should be the priority?

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> subject: Maternal Newborn Health

## 문제

A nurse is caring for a 25-year-old postpartum client who delivered 6 hours ago and is experiencing heavy vaginal bleeding with saturation of a pad every 20 minutes. Which nursing action should be the priority?

## 보기

1. Massage the uterine fundus firmly **✔ 정답**
2. Encourage the client to ambulate to the bathroom
3. Administer prescribed pain medication
4. Document the bleeding pattern in the medical record

**정답: 1**

## 해설

The client shows signs of postpartum hemorrhage (heavy bleeding, large clots, pallor, dizziness). Priority is firm fundal massage to promote uterine contraction and control hemorrhage. Other options are less urgent.

## 심화 해설

Understanding the Priority: Postpartum Hemorrhage

The scenario describes a client 6 hours postpartum saturating a pad every 20 minutes. This rate of blood loss is a critical sign of postpartum hemorrhage (PPH), a leading cause of maternal mortality globally [1]. In this acute situation, the nurse must immediately act to prevent progression to hypovolemic shock. The primary goal of initial nursing management is to halt the bleeding by addressing the most common cause: uterine atony [1][4].

Analysis of Nursing Actions

The priority action is to massage the uterine fundus firmly. A boggy, non-contracted uterus fails to compress the open vessels at the placental site, leading to rapid hemorrhage. Firm fundal massage stimulates uterine muscle contraction, which mechanically constricts these vessels and is a cornerstone first-line intervention in evidence-based PPH protocols [2][3]. This aligns directly with the "intervention" and "management" components highlighted in nursing care strategies to reduce the risk of shock [1].

The other options are inappropriate as a priority. Encouraging ambulation is contraindicated during active heavy bleeding due to the risk of orthostatic hypotension, syncope, and falls from volume depletion. Administering pain medication, while eventually important for comfort, does not address the life-threatening cause of the hemorrhage and delays critical intervention. Documentation is a necessary legal and clinical step, but it must never take precedence over a direct hands-on intervention to control active bleeding in an emergency [3][4].

Pathophysiology and Clinical Rationale

After delivery of the placenta, hemostasis at the implantation site is primarily achieved by the contraction of the uterine myometrium, which acts as a "living ligature" to compress bleeding vessels. When the uterus is atonic, this natural mechanism fails, leading to rapid blood loss. The rate of pad saturation—every 20 minutes—indicates blood loss that can quickly exceed the body's compensatory capacity. The immediate physiological objective is to restore uterine tone. Firm fundal massage provides direct mechanical stimulation, promoting the release of endogenous prostaglandins and facilitating sustained contraction. This intervention is the first step in the sequential, evidence-based management of PPH, preceding pharmacological agents like oxytocin and more invasive procedures [2][4]. Delaying this action to perform non-urgent tasks allows for continued blood loss, increasing the risk of coagulopathy and hemodynamic instability [3].References (research sources)

- [1][Postpartum hemorrhage: Nursing interventions and management to prevent hypovolemic shockHemorragia pós-parto: intervenções de enfermagem e gestão para prevenir o choque hipovolêmico].Research articleCastiblanco Montañez RA, Coronado Veloza CM, Morales Ballesteros LV, Polo González TV, Saavedra Leyva AJ. (2022) · DOI: 10.15649/cuidarte.2075

- [2]Evidence summary of best practices for prevention and management of postpartum hemorrhage in obstetric clinical practice.Research articleBai Y, Hu Q, Zhang J. (2026) · DOI: 10.3389/fmed.2026.1823590

- [3]Effectiveness of evidence-based nursing protocols in managing postpartum hemorrhage after vaginal delivery: a prospective observational quality-improvement evaluation.Research articleChen Y, Ling M, Nan D, Zhang Z, Liu S, Kou M, Pan X. (2026) · DOI: 10.1007/s00404-026-08393-4

- [4]Peripartum Haemorrhage, Diagnosis and Therapy. Guideline of the DGGG, OEGGG and SGGG (S2k, AWMF Registry No. 015-063, August 2022).GuidelineSchlembach D, Annecke T, Girard T, Helmer H, Kainer F, Kehl S, Korte W, Kühnert M, Lier H, Mader S, Mahnken A, Maul H, Pfanner G, Ramsell A, Surbek D, Tiebel O, Zinßer L, von Heymann C. (2023) · DOI: 10.1055/a-2073-9615

## 임상 시나리오

Clinical Practice Guide: Immediate Management of Postpartum Hemorrhage

**Scenario:** A 25-year-old postpartum client, 6 hours post-delivery, is saturating a pad every 20 minutes. This rate of blood loss is a critical sign of postpartum hemorrhage (PPH) and requires immediate intervention to prevent hypovolemic shock.

**Priority Action Rationale:** The most common cause of early PPH is uterine atony. The nurse's immediate priority is to perform firm fundal massage to stimulate uterine contraction, which mechanically constricts the open vessels at the placental site and controls the bleeding.

Step-by-Step Fundal Massage Technique

- Explain the procedure to the client and ensure privacy.

- Position the client supine with the bed flat if tolerated.

- Gently locate the uterine fundus; it may feel soft or "boggy."

- Place one hand just above the symphysis pubis to stabilize the lower uterine segment.

- Use the other hand to cup and massage the fundus in a circular motion until it becomes firm and contracted.

- Once firm, gently but consistently express any clots from the uterus while supporting the lower segment. Do not over-massage a firm uterus as this can cause muscle fatigue and relaxation.

- Reassess the fundus and bleeding every 5-15 minutes.

**Safety Alert:** Do not encourage ambulation during active heavy bleeding due to the risk of orthostatic hypotension, syncope, and falls. Administering pain medication or prioritizing documentation over direct intervention delays life-saving care and is inappropriate as the first action.

**Ongoing Management:** While one nurse initiates fundal massage, another team member should activate the facility's PPH protocol, ensure IV access with a large-bore catheter, administer uterotonic medications as prescribed (e.g., oxytocin), and prepare for fluid resuscitation and continuous vital sign monitoring.

## 핵심 개념

- **Postpartum Hemorrhage (PPH)** — Cumulative blood loss of 1000 mL or more, or blood loss accompanied by signs/symptoms of hypovolemia within 24 hours of birth; often indicated by saturation of a perineal pad within 15-20 minutes.
- **Uterine Atony** — A lack of uterine muscle tone and contraction after delivery, which is the most common cause of early postpartum hemorrhage because the relaxed uterus cannot compress open vessels at the placental site.
- **Fundal Massage** — A first-line intervention for uterine atony where the nurse places one hand just above the symphysis pubis and the other on the uterine fundus, massaging firmly until the uterus becomes firm and contracted to control bleeding.
- **Hypovolemic Shock** — A life-threatening condition resulting from a significant loss of blood or fluids, leading to inadequate tissue perfusion; a primary concern in uncontrolled postpartum hemorrhage.

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