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.