# A postpartum client delivered a 4,200-gram infant 2 hours ago and is experiencing heavy vaginal bleeding. The fundus is boggy and located 2 cm above the umbilicus. Vital signs are: BP 90/60 mmHg, HR 110 bpm, RR 22/min. Which nursing intervention should be implemented first?

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> subject: Maternal Newborn Health

## 문제

A postpartum client delivered a 4,200-gram infant 2 hours ago and is experiencing heavy vaginal bleeding. The fundus is boggy and located 2 cm above the umbilicus. Vital signs are: BP 90/60 mmHg, HR 110 bpm, RR 22/min. Which nursing intervention should be implemented first?

## 보기

1. Administer oxygen at 2 L/min via nasal cannula
2. Insert a large-bore IV catheter and initiate fluid resuscitation
3. Notify the healthcare provider immediately
4. Perform fundal massage to stimulate uterine contractions **✔ 정답**

**정답: 4**

## 해설

Fundal massage is the priority intervention for uterine atony as it directly stimulates uterine contractions to control bleeding. Other options are supportive but do not address the immediate cause.

## 심화 해설

Clinical Presentation Analysis

The client is 2 hours postpartum with a macrosomic infant (4,200 g), presenting with heavy vaginal bleeding, a boggy uterus located 2 cm above the umbilicus, and signs of hypovolemic shock (BP 90/60 mmHg, HR 110 bpm). This clinical picture is classic for uterine atony, the most common cause of immediate postpartum hemorrhage [1][4].

Pathophysiology and Clinical Reasoning

Uterine atony occurs when the myometrium fails to contract effectively after placental separation, leaving the spiral arteries at the placental site open and bleeding profusely. A boggy, displaced fundus above the umbilicus indicates a distended bladder and lack of uterine tone. The priority intervention targets the underlying cause—uterine atony—rather than the resulting hypovolemia alone. Fundal massage mechanically stimulates endogenous prostaglandin release and directly compresses the uterine muscle, promoting sustained contraction that compresses bleeding vessels [1].

Prioritization According to Evidence-Based Protocols

Structured evidence-based nursing protocols for postpartum hemorrhage emphasize a systematic, stepwise approach beginning with mechanical and pharmacological measures to restore uterine tone before escalating to more invasive interventions [2]. The initial response to a boggy uterus with active bleeding is immediate fundal massage. This intervention is non-invasive, can be performed instantly at the bedside, and directly addresses the primary etiology [1].

While the client exhibits tachycardia and hypotension indicating Class II hemorrhage, the "first" action is to stop the source of bleeding. Interventions such as oxygen administration and large-bore IV access with fluid resuscitation are critical supportive measures that should follow or occur simultaneously if additional personnel are available, but they do not correct the underlying atony [1]. Notifying the healthcare provider is necessary but should not delay immediate, nurse-initiated, life-saving measures like fundal massage [2].

Research demonstrates that uterine massage, when performed promptly and correctly, significantly reduces postpartum blood loss and is a cornerstone of prevention and early management of postpartum hemorrhage . The effectiveness of evidence-based nursing protocols lies in this structured prioritization: first, restore uterine tone; second, support circulation; third, escalate care [2].References (research sources)

- [1]Contemporary Approach to Postpartum Hemorrhage: Early Diagnosis and Evidence-Based Therapeutic Management.Research articleZúñiga Gómez E, Durán Monge PR, Castro Rivero LC. (2026) · DOI: 10.7759/cureus.107095

- [2]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]Immediate postpartum hemorrhage with referral from local clinics: More than 10-year experience at mackay memorial hospital, Taipei, Taiwan.Research articleYang YC, Chang HY, Chuang FC, Huang JP. (2026) · DOI: 10.1016/j.tjog.2025.11.027

## 임상 시나리오

Clinical Practice Guide: Immediate Management of Uterine Atony

1. First-Line Nursing Intervention

Upon identifying a boggy uterus with active bleeding, the immediate priority is **fundal massage**. This non-invasive, nurse-initiated intervention directly addresses the primary cause of hemorrhage by mechanically stimulating uterine contraction. Use one hand just above the symphysis pubis to support the lower uterine segment while the other hand massages the fundus in a circular motion until it becomes firm. This action compresses the spiral arteries at the placental site, controlling blood loss at its source.

2. Stepwise Escalation Protocol

Follow a structured approach after initial fundal massage:

- **Empty the Bladder:** A distended bladder displaces the uterus and prevents contraction. Assist the client to void or insert a straight catheter if necessary.

- **Pharmacologic Support:** If the uterus remains boggy, administer uterotonic medications as ordered (e.g., oxytocin, methylergonovine, carboprost). These agents augment endogenous prostaglandin release and promote sustained uterine tone.

- **Concurrent Supportive Care:** While managing the atony, initiate or continue vital sign monitoring, oxygen therapy to maintain saturation above 95%, and establishment of large-bore IV access for fluid resuscitation with isotonic crystalloids.

3. Ongoing Assessment and Documentation

Reassess fundal tone, location, and lochia flow every 5 to 15 minutes during the acute phase. Document the amount and character of blood loss using quantitative methods (e.g., weighing pads). Monitor for signs of resolving hypovolemia: decreasing heart rate, increasing blood pressure, and improved level of consciousness. Notify the healthcare provider immediately if bleeding persists despite fundal massage and initial uterotonic administration, or if signs of shock worsen.

## 핵심 개념

- **Uterine Atony** — Failure of the uterine myometrium to contract adequately after childbirth, the leading cause of early postpartum hemorrhage.
- **Fundal Massage** — A technique of massaging the uterine fundus through the abdominal wall to stimulate contractions and expel clots.
- **Boggy Uterus** — A soft, poorly contracted uterus upon palpation, indicating a lack of uterine tone and risk of hemorrhage.
- **Postpartum Hemorrhage** — Cumulative blood loss greater than 1,000 mL or blood loss accompanied by signs of hypovolemia within 24 hours of birth.
- **Hypovolemic Shock** — A life-threatening condition caused by a significant loss of blood or fluids, leading to inadequate tissue perfusion.

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