Two hours postpartum, the perineal pad shows a large amount of lochia rubra with several clots. What action should the nurse take first?

• A. Massage the fundus
• B. Call the provider
• C. Administer ibuprofen
• D. Change the pad and reassess in 15 minutes

Answer: (A)

When bleeding is heavy two hours after birth, the priority is to make the uterus contract to stop the bleed. The best first action is fundal massage to firm the uterus and compress the blood vessels that were supplying it.

Perform clean fundal massage: with one hand supporting the uterus at the lower abdomen and the other pressing the fundus in a circular motion until it feels firm and midline. After it firms, reassess the amount of lochia and the fundal position. Also check for a full bladder, since a distended bladder can push the uterus off center and worsen bleeding.

If the uterus remains boggy or the bleeding doesn’t lessen after massage, escalate per protocol (notify provider and administer uterotonic meds as ordered). Analgesics like ibuprofen don’t address the bleeding, and simply changing the pad and reassessing delays treatment.