Once the fundus is firm and she is still bleeding, the differential moves. A boggy fundus is atony; a firm fundus with continued bleeding is trauma, retained tissue, a coagulation failure — or the one emergency where reaching for a uterotonic is exactly the wrong reflex. Sort fifteen real bedside findings, run the inversion drill, then hold a fundus against the calendar with the involution ruler.
Work the bedside
Finding 1 of 15
Correct on the first attempt0 / 0
Delivery room · immediately after the placenta
She screams, and the fundus is gone
A dark red-purple mass is at the introitus. The fundus cannot be palpated abdominally — where it should be there is a dimple. Blood pressure 74/40, pulse 58, and she is grey. The placenta is still attached to the mass. Visible blood loss looks modest for how ill she is.
Shock out of proportion to the visible loss, with a slow pulse, is the vagal component — traction on the peritoneum adds neurogenic shock on top of the haemorrhagic shock. Choose your actions in order.
Steps in the right order0 / 8
Day 3
Involution descends the fundus about 1 cm — one fingerbreadth — per day, from the level of the umbilicus in the first 12 hours to non-palpable abdominally by day 10 to 14.
Lochia rubra normally lasts about 3 to 4 days before turning serosa. Rubra that persists past that, or returns after becoming serosa, is the classic subinvolution story.
Which T is this?Read the finding and commit
Waiting
Start with the discriminator you can teach in one line: a boggy fundus is atony, a firm fundus with continued bleeding is something else.
Uterine inversionThe fundus is through the cervix · get it back first
Stop before you reach for a drug
This is the one obstetric haemorrhage in which the reflex to give a uterotonic is exactly wrong. A contracting cervical ring makes replacement impossible.
Involution on scheduleFundus where the day count predicts