A 28-year-old primigravida delivered vaginally 2 hours ago. She is now bleeding heavily with soaked pads every 5 minutes. Uterus is soft and boggy on palpation. Vital signs: BP 100/60 mmHg, HR 110/min, RR 20/min. What is the most appropriate immediate next step in management?

## Management of Immediate Postpartum Hemorrhage (PPH) ### Clinical Assessment **Key Point:** This patient has signs of active PPH with a soft, boggy uterus — the hallmark of uterine atony, which accounts for 80% of PPH cases. **Clinical Pearl:** The combination of heavy vaginal bleeding, tachycardia (HR 110), and borderline hypotension (BP 100/60) indicates **moderate hemorrhage** requiring immediate uterotonic therapy, not observation or advanced interventions. ### Stepwise Management Algorithm ```mermaid flowchart TD A[Postpartum Hemorrhage]:::outcome --> B{Uterus tone?}:::decision B -->|Soft/Boggy| C[Uterine Atony]:::outcome C --> D[Bimanual compression + IV oxytocin]:::action D --> E{Bleeding controlled?}:::decision E -->|Yes| F[Continue oxytocin, monitor]:::action E -->|No| G[Add ergot/misoprostol + assess for other causes]:::action G --> H{Still bleeding?}:::decision H -->|Yes| I[Consider balloon tamponade or OR]:::urgent B -->|Firm| J[Retained products/Trauma]:::outcome J --> K[Examine cervix/vagina, ultrasound]:::action ``` ### Why Bimanual Compression + Oxytocin First? 1. **Uterine atony is the most common cause** — soft uterus is pathognomonic 2. **Immediate hemostasis** — mechanical compression + oxytocin-induced contraction occludes bleeding vessels 3. **No delay for imaging or advanced procedures** — this is a time-critical emergency 4. **Cost-effective and reversible** — no need for blood products or OR yet **High-Yield:** The "4 T's" of PPH causes are **Tone** (atony, 80%), **Tissue** (retained products), **Trauma** (lacerations), **Thrombin** (coagulopathy). Always start with tone management. ### Oxytocin Dosing in PPH - **IV infusion:** 10–40 units in 500 mL NS at 500 mL/hr (or faster if severe) - **IM:** 10 units (if IV access delayed) - Onset: 2–3 minutes IV; 3–7 minutes IM **Warning:** Do NOT give ergot alkaloids (ergotamine, methylergonovine) before delivery of the baby or in presence of hypertension — risk of tetanic uterine contraction and retained placenta. [cite:Williams Obstetrics 26e Ch 41]