Pathophysiology & Risk Factors

Early postpartum hemorrhage occurs within 24 hours of delivery, classically defined as blood loss ≥500 mL after vaginal birth or ≥1,000 mL after cesarean. Uterine atony — a soft, boggy, poorly contracting fundus that fails to clamp down on uterine vessels — causes roughly 80% of cases. When the fundus is firm but bleeding continues, suspect a genital-tract laceration or retained placental fragments instead. Risk factors raise your index of suspicion before the bleeding starts.

Signs & Symptoms

EarlyProgresses →

Boggy uterus Hallmark

Fundus above umbilicus

rising fundus signals blood pooling

Fundus deviated to one side

often a full bladder, not atony — catheterize first

Bright-red lochia rubra

Saturating pad in under 1 hour Hallmark

Large clots

clot larger than a golf ball

Tachycardia Hallmark

earliest vital-sign change; precedes hypotension

Anxiety

Thirst

Cool, pale skin

Diaphoresis

Late / Severe

Hypotension

appears only after ~15–20% volume loss

Altered level of consciousness

Hypovolemic shock

Diagnostics & Labs

Diagnostic

Fundal palpation

should be firm, midline, at/below umbilicus

Bladder scan

rule out distension displacing the uterus

Type and crossmatch

prepare for possible transfusion

Monitor

Quantitative blood loss Hallmark

weigh pads/drapes; 1 g = 1 mL; visual estimate underreads 30–50%

Lochia assessment

quantity, color, clot size

Serial vital signs

every 5–15 min; watch for rising heart rate

Interventions & Priorities

Firm fundal massage Hallmark

first independent nursing action; no order needed

Call for help

activate hemorrhage protocol

Empty the bladder

void or straight/indwelling catheter; full bladder blocks contraction

Large-bore IV access

16–18 gauge; second line for blood products

Rapid isotonic crystalloid

lactated Ringer's or normal saline

Administer oxytocin

first-line uterotonic per order

Bimanual compression

cup fundus, support lower segment if tone not sustained

Notify provider

structured report: QBL, vital signs, interventions done

Prepare second-line uterotonics

Treatments & Medications

Second-line uterotonics — know the contraindication

Avoid inMemory hook

MethylergonovineHypertension / preeclampsiaM = MAP (raises BP)

CarboprostAsthmaH = Huffing (bronchospasm)

MisoprostolFew contraindicationsSafe in HTN + asthma

Avoid in

Methylergonovine: Hypertension / preeclampsia
Carboprost: Asthma
Misoprostol: Few contraindications

Memory hook

Methylergonovine: M = MAP (raises BP)
Carboprost: H = Huffing (bronchospasm)
Misoprostol: Safe in HTN + asthma

Patient Teaching

Report continued heavy bleeding

soaking a pad in under 1 hour

Report passing large clots

Report dizziness or lightheadedness

Empty bladder regularly

a full bladder prevents the uterus from clamping down

Massage own fundus if boggy

as taught before discharge

Report Nowescalate immediately

Uncontrolled bleeding Hallmark

saturating more than one pad per hour

Boggy uterus unresponsive to massage

Rising heart rate

earliest sign of compensated blood loss

Hypotension

Signs of hypovolemic shock

cool clammy skin, altered LOC, low urine output

Clinical Pearl

Massage, empty the bladder, medicate — in that order (MEM). Methergine avoids hypertension, Hemabate avoids asthma; a boggy uterus plus a rising pulse is PPH until proven otherwise.