What is the initial postpartum management for a boggy uterus with heavy lochia?

• A. Uterine massage and assessment of bladder; administer a uterotonic (e.g., oxytocin)
• B. Perform manual exploration of the uterus
• C. Initiate antibiotics and isolation precautions
• D. Prepare for immediate cesarean delivery

Answer: (A)

Uterine atony is the most common cause of postpartum hemorrhage, and a boggy uterus with heavy lochia shows the uterus isn’t contracting enough to close off the blood vessels. The first management is to stimulate contraction and remove any factor preventing it. Fundal massage physically compresses bleeding vessels and helps the uterus firm up. At the same time, emptying or assessing the bladder is important because a full bladder can impede contraction and keep the uterus in a soft, boggy state. Giving a uterotonic, such as oxytocin, strengthens and sustains uterine contractions to achieve hemostasis.

This approach is prioritized over other options because antibiotics and isolation are for infection control, a cesarean delivery is a surgical intervention for a different set of emergencies, and manual exploration is reserved for scenarios like suspected retained placental tissue after initial measures have been attempted. If bleeding persists after these initial steps, escalation to additional uterotonics, tranexamic acid, fluids, or surgical interventions would be considered.