A postpartum patient reports heavy lochia with clots and a firm fundus after initial treatment. What is the next likely cause?

• A. Uterine atony from overdistended uterus.
• B. Retained placental fragments.
• C. Endometritis.
• D. Hematoma.

Answer: (B)

When the fundus is firm after initial treatment for postpartum hemorrhage, ongoing heavy lochia with clots suggests tissue remains inside the uterus rather than the uterus failing to contract. Retained placental fragments prevent complete occlusion of the blood vessels at the placental site, so bleeding continues from those residual tissues even though the uterus can still contract to a firm tone. This differs from uterine atony, where the fundus is soft or boggy because the uterus itself isn’t contracting well; endometritis would typically bring fever, uterine tenderness, and foul-smelling lochia rather than just clots; a hematoma usually presents with localized pelvic pain and a mass rather than diffuse heavy lochia. In this situation, further assessment like ultrasound and possible removal of the fragments (e.g., curettage) are the appropriate next steps.