If the uterus remains boggy and does not respond to massage, what action best reflects escalation of care?

• A. Continue massage and reassess in 8 hours
• B. Escalate to uterotonic optimization or surgical intervention
• C. Stop all IV fluids
• D. Wait for spontaneous resolution

Answer: (B)

When the uterus remains boggy despite fundal massage, ongoing bleeding is due to uterine atony and requires moving beyond soothing the uterus to active control of the hemorrhage. The best next step is to escalate care by optimizing uterotonic therapy and moving toward surgical interventions if bleeding continues. This means ensuring maximum effect from uterotonics (for example, maintaining or increasing oxytocin and adding other agents such as methylergonovine, carboprost, or misoprostol as appropriate, with tranexamic acid considered if within the recommended window) and promptly involving surgical options (such as uterine balloon tamponade, suturing techniques, or hysterectomy) if the bleeding is not controlled. Delaying treatment by continuing massage alone, stopping IV fluids, or waiting for spontaneous resolution does not address the ongoing blood loss and places the patient at risk for shock and coagulopathy.