A 32-year-old G2P1 at 39 weeks gestation undergoes normal vaginal delivery. Five minutes after placenta expulsion, brisk continuous vaginal hemorrhage ensues, totaling 700 mL. On examination, the uterine fundus is soft, boggy, and palpated above the umbilicus. What is the first-line management sequence?

Answer and explanation

Correct answer: B. Bimanual uterine massage and intravenous oxytocin infusion

  1. Step 1: Postpartum hemorrhage (>500 mL following vaginal delivery) with a boggy, enlarged uterus indicates uterine atony (the most common cause, accounting for 70-80% of PPH).
  2. Step 2: First-line standard of care is immediate bimanual uterine massage paired with high-dose intravenous oxytocin to stimulate myometrial contraction.
  3. Step 3: If atony persists, second-line uterotonics (ergometrine, carboprost, misoprostol) and intrauterine balloon tamponade are instituted before considering surgical interventions.
Answer
Bimanual uterine massage and intravenous oxytocin infusion.
Why not the others: Hysterectomy is the last resort; intrauterine balloon and embolization are used after medical uterotonics fail.

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