Should the uterine fundus be soft in a postpartum woman?

Should the Fundus Be Soft Postpartum?

No, the uterine fundus should NOT be soft postpartum—a soft, boggy fundus is pathological and indicates uterine atony, the most common cause of postpartum hemorrhage. 1

Normal Postpartum Fundal Characteristics

The normal postpartum uterus should be:

• Firm and well-contracted upon palpation, not soft or boggy 1
• Located at or near the umbilicus immediately after delivery 2
• Descending approximately 1 cm (one fingerbreadth) per day during normal involution 2
• At the level of the symphysis pubis or slightly below by one week postpartum 2

Clinical Significance of a Soft Fundus

A soft, boggy fundus represents uterine atony and constitutes a medical emergency:

• Uterine atony accounts for 70-80% of all postpartum hemorrhage cases 1
• It is the leading cause of early PPH (within first 24 hours after delivery) 1
• Failure of the uterus to contract properly allows continued bleeding from placental implantation site vessels 3

Immediate Management When Fundus Is Soft

When you encounter a soft fundus postpartum, follow this algorithmic approach:

1. Perform vigorous bimanual uterine massage to stimulate contraction 4, 3
2. Administer uterotonic medications immediately:
   • Oxytocin is the cornerstone of therapy 3
   • Consider ergot alkaloids or prostaglandins as second-line agents 3
3. Give tranexamic acid 1 g IV over 10 minutes within 3 hours of delivery (effectiveness declines 10% every 15 minutes of delay) 5
4. Reassess fundal tone after these interventions 1

Differential Diagnosis When Bleeding Persists Despite Firm Fundus

If postpartum hemorrhage continues but the fundus becomes firm after massage and uterotonics, the diagnosis is NOT uterine atony—look for alternative causes:

• Genital tract lacerations are the most common cause when the uterus is firm 1
• Perform systematic visual inspection of cervix, vaginal walls, perineum, and periurethral area under adequate lighting 1
• Consider examination under anesthesia if patient cannot tolerate adequate inspection 1
• Retained placental fragments should be evaluated with transvaginal ultrasound with Doppler 1
• Coagulopathy requires assessment with PT/PTT, fibrinogen, and platelet count 1

Special Consideration: Lower Uterine Segment Atony

Be aware of a rare but distinct entity:

• Primary atony of the lower uterine segment can occur with a well-contracted fundus and upper segment but a ballooned-out lower segment 6
• This presents as continued bleeding despite a firm fundus on palpation 6
• Ultrasound examination can identify this condition 6

Assessment Technique Pitfalls

To accurately assess fundal firmness:

• Empty the bladder first—a distended bladder falsely elevates apparent fundal height and interferes with accurate palpation 2
• Place patient supine with knees slightly flexed 2
• Use the ulnar edge of one hand to identify the firm, rounded upper border of the uterus 2
• Apply gentle but firm pressure to accurately determine position and consistency 2
• Increased body mass index makes accurate palpation more challenging 2

Documentation Requirements

Always document:

• Fundal consistency (firm vs. soft/boggy) 2
• Location relative to anatomical landmarks 2
• Presence of tenderness during palpation 2
• Response to massage and uterotonic therapy 1