A 26-year-old woman, P1, experiences massive vaginal bleeding immediately following an uncomplicated vaginal delivery of a 4.1 kg infant. Physical examination reveals a soft, boggy, poorly contracted uterus that extends 3 cm above the umbilicus. Placenta and fetal membranes were delivered complete, and the genital tract is free of lacerations. What is the immediate first-line medical intervention for this postpartum hemorrhage?

Answer and explanation

Correct answer: A. Uterine fundal massage and intravenous oxytocin infusion

  1. Step 1: Uterine atony is the most common cause (> 70-80%) of early postpartum hemorrhage (PPH).
  2. Step 2: The initial evidence-based management consists of immediate bimanual uterine fundal massage to stimulate mechanical myometrial contraction combined with first-line intravenous oxytocin (e.g., 20-40 units in 1000 mL crystalloid).
  3. Step 3: Second-line uterotonics (methylergonovine, carboprost/PGF2-alpha, misoprostol) and intravenous tranexamic acid (WOMAN trial protocol) are added if atony persists.
Answer
Uterine fundal massage and intravenous oxytocin infusion.
Why not the others: 'Immediate emergency peripartum hysterectomy' is the final invasive rescue measure reserved for intractable bleeding after medical and uterine-preserving surgical interventions fail; 'Recombinant factor VII' is an expensive experimental agent with arterial thrombosis risk; 'Bilateral internal iliac artery ligation' is an invasive operative procedure indicated only after uterotonics and intrauterine balloon tamponade fail.

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