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Post Natal Case

The patient is a 21-year old female who delivered a healthy female baby via emergency c-section after experiencing bleeding. She has no significant medical or surgical history. Her postnatal recovery has been uncomplicated with normal lochia, breastfeeding, and baby vital signs. Both mother and baby are otherwise healthy on examination.

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Himanshu Adhikari
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8K views

Post Natal Case

The patient is a 21-year old female who delivered a healthy female baby via emergency c-section after experiencing bleeding. She has no significant medical or surgical history. Her postnatal recovery has been uncomplicated with normal lochia, breastfeeding, and baby vital signs. Both mother and baby are otherwise healthy on examination.

Uploaded by

Himanshu Adhikari
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPT, PDF, TXT or read online on Scribd
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POST NATAL CASE

Patient’s particulars
• Name- Mrs. Shabana Sheikh
• Age- 21 yrs
• Residence- Kondhwa
• Education- 10th std.
• Married for 3 yrs.
• Blood group- O+
Presenting complaint
• 21 Yrs old lady has delivered on 10 May 2009
and is in ward 24 for Post-Natal care.
History of presenting complaint
• My patient was pregnant for 36 weeks and
was apparently asymptomatic till 9th May,
2009 when she had bleeding per vaginum.
• The bleeding started in the morning and
lasted for 2-3 hrs. She reported to the
hospital.
• An ultrasonography was done and the foetal
heart sounds were found to be diminished.
Thereafter she was admitted in the hospital.
History of presenting complaints
contd.
• She developed labour pains on the night of 9th
May which were temporarily relieved by
medication and she was taken up for an
emergency caesarian section on 10th May.
• The surgery was a lower segment caesarian
section.
• The patient delivered a female baby weighing
2.5 kgs at birth. The baby cried at birth and
there were no complications.
History of presenting complaint contd.
• There is h/o lochia rubra, which is non foul smelling.
No h/o bleeding or any other discharge per vaginum
post delivery.
• No complaints of breast tenderness or pain during
breast feed.
• Breast feeding was started on the 2nd day of delivery
because the patient was unconscious due to
anaesthesia. The baby was given artificial feed on the
first day.
• The baby has been given BCG and zero dose of OPV. No
h/o fever, jaundice. Urine output adequate. Meconium
has been passed.
Antenatal history
• My patient is P1 L1.
• LMP- 9th Sept, 2008.
• EDD- 16th May, 2009.
• She was a booked case; pregnancy detected at
6 weeks.
• Nausea and vomiting were present for 8-10
days in the 2nd month.
• Quickening perceived at 6 months.
Antenatal history contd.
• No h/o fever, rashes, discharge and bleeding
per vaginum.
• She reported to the hospital for regular check-
up as per the advised schedule. However, no
USG was done during the entire antenatal
period.
• She was given iron, folic acid and calcium
tablets and 2 doses of tetanus toxoid during
the antenatal period.
Antenatal history contd.
• Dietary history
MEAL DIET QUANTITY/NO. CALORIE INTAKE

BREAKFAST Tea 1 cup 150 Kcal


LUNCH Rice 1 cup 170 Kcal
Roti 2 160 kcal
Mutton 3/4 cup 260 kcal
Plain dal 1 cup 200 Kcal
EVENING SNACK Tea 1 cup 150 Kcal
Apple 1 65 Kcal
Banana 1 90 Kcal
DINNER Rice 2 cups 340 kcal
Roti 1 80 Kcal
Dal 1 cup 200 kcal
Mutton 3/4 cup 260 Kcal
Antenatal history contd.
• Total calorie intake- 2075 Kcal
• Total protein intake- 60g
• My patient gained around 15 kgs of weight
during the period of gestation.
Menstrual history
• Menarche at the age of 13 yrs
• Cycles regular 2-3/ 28-30 days, no associated
pain, no menorrhagia.
Past history
• This was her first pregnancy.
• No past h/o any gynaecological or obstetric
complaints.
• No history of diabetes mellitus, hypertension,
tuberculosis or any other chronic illness.
• No history of any major medical/surgical
intervention in the past.
Personal history
• My patient consumes a mixed diet.
• Normal bladder and bowel habits.
• No h/o alcohol or tobacco consumption.
• No contraceptive measures practised .
Family history
• No relevant family history
Social history
• My patient is a housewife, married for 3 yrs.
• She is educated till 10th std.
• Resides in kondhwa with her husband who
works in a private company and earns around
Rs.8000 a month.
• The house is a rented pucca house with 1
bedroom and a separate kitchen and an
attached bathroom.
• Lighting and sanitation facilities are adequate.
Social history contd.
• They avail medical services from command
hospital which is 2 km from their residence.
Transport facilities are adequate.
• The family relations are good and the relatives
are supportive. There are no social stigmas
associated with the birth of a girl child.
General examination- mother
• My patient was conscious, co-operative and
comfortable.
• Height -152 cms, weight- 58 kgs, BMI- 25.10.
• Patient was afebrile.
• Pulse- 88/ min, regular, normo volumic,
bilaterally synchronous, all peripheral pulses
present, no delays.
• Respiratory rate- 18/ min, thoraco- abdominal
General examination contd.
• Blood pressure- 124/ 82 mm of Hg, rt. Arm
supine.
• No pallor, icterus, cyanosis, clubbing, pedal
edema or generalised lymphadenopathy.
Systemic examination- mother
Inspection
• Abdomen appears distended. Skin shows
stretch marks and linea nigra. The umbilicus is
central in position and not everted.
• A linear 15cm incision which has been sutured
is present about 7cm above the pubic
symphisis.
• The incision is clean and dry. No signs of
inflammation seen.
Systemic examination contd
• No obvious lumps visible.
• The genital area appears normal. Lochia rubra present.
Non foul smelling.
• Breasts appear normal. No visible discharge. No nipple
retraction.
Palpation
• The abdomen is tender on palpation at the site of
incision. The feel in all the quadrants is elastic and they
are non- tender.
• The upper border of the uterus is felt at the level of the
umbilicus.
Systemic examination contd.
• The breasts were non- tender on palpation.
No discharge. Milk is expressed normally.
• All other systems – no abnormality detected.
General examination- neonate
• Baby is active, not irritable, feeding well.
• Heart rate- 142/ min
• Temperature- afebrile
• Respiratory rate- 40/ min
• Weight- 2.51 kgs
• Length- 48 cms
• Head circumference- 34cms
• Chest circumference- 32 cms
• The site of cord appears healthy and non
infected.
General examination contd.
• Plantar creases are present and deep.
• No visible deformities.
• Moro reflex, rooting and sucking response,
grasp reflex present.

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