From the Guidelines
A slightly deviated and above umbilicus uterine fundus post partum is a significant finding that may indicate a full bladder or uterine atony, both requiring prompt attention. The first step should be to ensure the bladder is empty, as a full bladder can displace the uterus and prevent proper contraction, which is a common cause of early postpartum hemorrhage (PPH) 1. If the fundus is deviated (typically to the right) and palpable above the umbilicus after delivery, have the patient void or consider catheterization if unable to urinate.
Key Considerations
- If the bladder is empty but the fundus remains high and soft, uterine atony should be suspected, which can lead to postpartum hemorrhage 1.
- Management includes uterine massage and potentially medications such as oxytocin (10-40 units IV infusion), methylergonovine (0.2 mg IM every 2-4 hours), misoprostol (800-1000 mcg rectally), or tranexamic acid (1 gram IV over 10 minutes).
- The physiological basis for this concern is that after delivery, the uterus should contract firmly to compress blood vessels at the placental site; failure to do so (atony) can result in excessive bleeding 1.
Clinical Approach
- A properly contracted uterus should feel firm like a grapefruit and be located at or below the umbilicus, gradually descending into the pelvis over days following delivery.
- It is essential to monitor the patient closely for signs of PPH, such as excessive bleeding, hypovolemia, or hemodynamic instability, and to be prepared to escalate management as needed 1.
From the Research
Significance of Uterine Fundus Position
- The position of the uterine fundus postpartum is an important indicator of uterine involution and potential postpartum hemorrhage (PPH) risk 2.
- A slightly deviated and above umbilicus uterine fundus may indicate a higher risk of PPH, as it can be a sign of uterine atony or incomplete involution 3, 4.
- Uterotonic agents such as oxytocin, methylergonovine, and misoprostol are commonly used to prevent and treat PPH, and their effectiveness can be influenced by the position of the uterine fundus 3, 4, 5.
Uterotonic Agents and Uterine Fundus Position
- Oxytocin is the first-line agent for preventing PPH, and its administration can help reduce the risk of PPH and promote uterine involution 3, 5.
- Methylergonovine and misoprostol are also effective uterotonic agents, but their use may be associated with more side effects and a higher risk of PPH compared to oxytocin 4, 5.
- The position of the uterine fundus can influence the effectiveness of uterotonic agents, and a deviated or above umbilicus fundus may require adjusted dosing or additional treatment 4, 5.
Clinical Implications
- Clinicians should carefully monitor the position of the uterine fundus postpartum and adjust their management strategy accordingly 2.
- Uterotonic agents should be used judiciously, taking into account the individual patient's risk factors and the position of the uterine fundus 3, 4, 5.
- Further research is needed to determine the optimal management strategy for patients with a deviated or above umbilicus uterine fundus postpartum 6, 2.