In the fourth stage of labor, the nurse finds the client's perineal pad saturated with blood and blood soaked into the bed linens under the client's buttocks. What is the nurse's initial action?

• A. Call the obstetrician.
• B. Assess the client's vital signs.
• C. Gently massage the uterine fundus.
• D. Administer a 300-mL bolus of a 20 units/L oxytocin solution.

Answer: (C)

In the fourth stage of labor, postpartum hemorrhage is most often caused by uterine atony, where the uterus isn’t contracting firmly after delivery. When you see a saturated perineal pad and blood on the bed, the priority is to assess the uterus and its fundal tone. If the fundus is boggy (soft and not well contracted), gentle massage of the uterus helps stimulate contraction and compress the blood vessels at the placental site, which is the fastest way to reduce bleeding. Once the uterus becomes firm, continue to monitor the fundus and bleeding closely and address any other sources of blood loss as needed. If the fundus remains boggy or bleeding continues despite massage, escalate to appropriate pharmacologic uterotonics and notify the obstetric team per protocol.