A nurse is reviewing the prenatal record of a laboring woman.

The clinical pelvimetry notes indicate the woman has a round pelvic inlet with a spacious midpelvis and outlet.
This pelvic type is most favorable for vaginal birth and is classified as:

Choice A rationale

Unrepaired vaginal lacerations are a possible cause of postpartum hemorrhage, especially after a large baby. However, bleeding from a laceration is typically characterized by a firm uterus with bright red, continuous trickling of blood. In this scenario, the combination of a 9-pound infant and the use of Pitocin for augmentation points more strongly toward another physiological failure of the uterine muscle rather than a simple soft tissue tear in the birth canal.

Choice B rationale

Uterine atony is the most common cause of postpartum hemorrhage. It occurs when the uterine myometrium fails to contract effectively after delivery to compress the intramyometrial blood vessels. Risk factors in this patient include a large baby (9 pounds 7 ounces), which overstretches the muscle fibers, and the use of Pitocin, which can lead to muscle fatigue. Failure of the uterus to stay firm leads to rapid, heavy bleeding from the placental site.

Choice C rationale

Puerperal infection is a postpartum infection of the reproductive tract. While it is a serious complication, it typically manifests several days after delivery with symptoms like fever (greater than 100.4 F), foul-smelling lochia, and uterine tenderness. It is not the most likely cause of an acute, heavy bleeding episode occurring only 4 hours after birth. Hemorrhage from infection is usually a secondary, delayed event rather than an immediate primary cause of heavy lochia.

Choice D rationale

Vaginal or vulvar hematomas involve the collection of blood in the connective tissue of the pelvic soft tissues due to vessel damage. While they can be caused by the delivery of a large infant, the primary symptom is usually exquisite, deep pelvic pain or a feeling of rectal pressure rather than visible heavy external bleeding. Because the blood is trapped within the tissues, it does not typically present as the mother stating she is bleeding a lot.

Choice B rationale

For a woman who is bottle-feeding, the goal is to suppress lactation and reduce the discomfort of engorgement. Applying ice packs to the breasts causes vasoconstriction and reduces the metabolic activity of the milk-producing cells. This helps decrease swelling, warmth, and pain. Cold therapy should be applied for about 15 to 20 minutes several times a day. Unlike heat, cold does not stimulate further milk production, making it the preferred choice for non-breastfeeding mothers.

Choice A rationale

Running warm water on the breasts during a shower is a technique used to stimulate milk let-down and promote flow. For a woman who has decided to bottle-feed, this is contraindicated as it encourages continued lactation and can worsen the pressure and pain of engorgement. Heat causes vasodilation and increases blood flow to the mammary glands, which would exacerbate the symptoms the patient is currently experiencing. She should avoid all forms of heat and nipple stimulation.

Choice C rationale

While a supportive bra is recommended, it should be well-fitting and firm rather than loose. A loose-fitting bra allows the breasts to move, which can cause friction and discomfort. A tight, supportive bra provides compression that helps suppress milk production and reduces the heavy feeling associated with engorgement. It also prevents the stimulation of the nipples by the fabric, which could otherwise trigger the release of prolactin and oxytocin, leading to further milk synthesis.

Choice D rationale

Expressing milk, even in small amounts, provides temporary relief from pressure but ultimately signals the body to produce more milk. This is based on the principle of supply and demand. For a mother choosing to bottle-feed, any removal of milk will prolong the lactation process and delay the natural involution of the mammary glands. To stop milk production, the breasts must remain full so that the feedback inhibitor of lactation can build up and stop synthesis.