Which is the most likely cause of hemorrhage in a postpartum patient with a boggy uterus?

• A. Retained placental tissue
• B. Coagulopathy
• C. Infection
• D. Uterine atony

Answer: (D)

The main idea here is postpartum hemorrhage caused by uterine atony, meaning the uterus isn’t contracting effectively after delivery. When the uterus contracts firmly, it compresses the vessels at the placental site and stops the bleeding. A boggy, or soft, uterus shows that the muscle tone is low and contractions are weak or absent, so the placental bed bleeds freely and hemorrhage ensues. That classic finding makes uterine atony the most likely cause in this scenario.

Retained placental tissue can also cause heavy bleeding, but the key feature is not a soft uterus—the ongoing issue is often the presence of placental fragments delaying full contraction. Coagulopathy leads to bleeding due to clotting problems rather than a noncontracting uterus, and infection presents with fever and uterine tenderness rather than primarily a soft uterus. So the sign of a boggy uterus most directly points to atony as the cause.