Patient Scenario

AN ADOLESCENT WITH A POSTPARTAL COMPLICATION

Pamela Barth is a 17-year-old, G1P1 woman transferred to the postpartal service
following the birth of a 9 lb 4 oz infant boy.

CHIEF CONCERN:
“Should I be bleeding this much?”

HISTORY OF PRESENT CONCERN:

The client gave birth to a 9 lb 4 oz boy under epidural anesthesia at 7:25 am following
a 14-hour labor. Membranes had been ruptured for 26 hours. Modified Crede’s
maneuver was used to deliver placenta. Fifteen units of Pitocin in 500 ml of lactated
Ringer’s were administered intravenously following birth. Blood loss from birth is
estimated at 750 ml. At present, the client reports vaginal bleeding is so heavy she is
saturating a perineal pad every 20 minutes.

FAMILY PROFILE:
She lives with mother, two older sisters, and two nieces in a three-bedroom house. The
family income is from social security and additional government subsidies. The family
members are vegetarians because “meat is too expensive.” Pamela has “borrowed”
supplies for baby from sisters. The father of child is said to be supportive but did not
come to be with her in labor.

HISTORY OF PAST ILLNESS:

She had chickenpox at age 5 years. She had facial acne since she was 12 years old.
She had no major illnesses and no hospitalizations.

GYNECOLOGIC HISTORY:
Menarche was at age 10 years; cycle duration: 29 days; menstrual flow duration: 5
days. She has no STIs. She is not using a contraceptive before present pregnancy.

OBSTETRIC HISTORY:
She had no previous pregnancies. This pregnancy was not intended but was not
unwelcome. She has no complications during pregnancy except for minimal edema;
proteinuria of 2+ and blood pressure increase to 140/98 mmHg for last 2 weeks.

REVIEW OF SYSTEMS:
Neurologic: Treated for 5 years when younger for “small seizures”; no longer takes
medication for this
Mouth: Severe malocclusion treated with oral braces since age 14 years
Breasts: Mild breast engorgement; pleased to be breastfeeding

PHYSICAL EXAMINATION:
General appearance: Apprehensive-appearing, slender teenager; temperature: 98.6°F;
BP: 100/60 mmHg.
HEENT: Integument: five black comedones present on forehead; mouth: full upper and
lower metal braces present; no ulcerations or abrasions on gumlines
Chest: Heart rate: 100 beats/min; no murmurs present; lungs: rhonchi present in upper
lobes; respiratory rate: 22 breaths/min
Abdomen: Soft; fundus palpated at 2F above umbilicus and boggy; massaged and large
firm clot 5 cm in diameter expelled vaginally; fundus somewhat firmer following
massage but height did not change
Perineum: Intact perineum; no external hemorrhoids; lochia: continuous bright red
vaginal flow present; no clots

LABORATORY RESULTS:
Hemoglobin: 8.9 g/dl
WBC: 25,000/mm3

Pamela is diagnosed as having mild uterine atony.