What is the first step in postpartum hemorrhage management?

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Fundal massage is used first because the most common cause of postpartum hemorrhage is uterine atony—the uterus isn’t contracting well enough after birth to compress bleeding vessels. Gently and continuously massaging the fundus encourages the uterus to contract, which helps stop the bleeding immediately and also helps express any clots that might be preventing contraction. It also gives you a quick check of uterine tone: if the fundus firms with massage, you’ve started to correct the atony; if it remains soft, you know you need additional interventions.

After establishing a firm uterus, you would typically administer a uterotonic like oxytocin to maintain tone. If the uterus stays boggy despite massage and uterotonics, you escalate to other measures such as further uterine compression techniques, packing, or advanced therapies as per protocol. Rinsing the uterus with saline isn’t an initial step to control the bleeding, and packing is a subsequent measure when conservative methods don’t stop the hemorrhage.