Case Study for MCN
Patient’s Name: Mrs. NSD Age: 19 years old
Date of Procedure: September 18, 2020
Preop Dx: G1P0 38 weeks AOG intrauterine pregnancy in active labor
Postop DX: G1P1 with delivery of viable male infant at 1400 hours weighing 6 lbs12oz with APGAR of 9
@ 1 min and 9 @ 5 min.
Procedure: Spontaneous Vaginal Delivery
Surgeon: Dr. Garcia and Senior Resident: Dr. Chavez
Anesthesia: Local infiltration of _____/pudendal infiltration of _√__/epidural
Estimated Blood Loss: 180 cc
Indications: This 19 y/o G1P0 presents at 39 4/7 weeks gestation by LMP with an EDC of 04/06/12, c/o
regular uterine contractions. Her prenatal course was complicated by UTI during the first trimester.
Prenatal lab data includes blood type O+, Rubella Immune negative, VDRL Non-Reactive, HepBsAg
negative, HIV Non-Reactive, COVID-19 RT-PCR test negative and CBC pre-delivery shows:
She presented at 0400 hours this am complaining of uterine contractions every 5 minutes. At
that time, her cervix was 2 cm, 90% effaced and at a –1 station. FHR was reactive and reassuring. She
remained normotensive throughout the course of her labor. Slow progress was made initially, and at
0800 hours artificial rupture of membranes was performed with a return of clear fluid. At that time, her
cervix was 5cm, 100% effaced and the fetal vertex was at a 0 station. An epidural was placed for
analgesia at this time. She progressed to complete by 1200 hours and was allowed to push, bringing the
infant’s vertex to the perineum.
Procedure: The patient was noted to be complete and pushing, so was placed in the dorsal lithotomy
position, prepped and draped in the usual sterile fashion for a vaginal delivery. (Pt. Noted to have
epidural anesthesia/1% Lidocaine was infiltrated into the perineum/a pudendal block was placed). The
patient was asked to push and the head delivered spontaneously in the LOA position, over (an intact
perineum/a midline episiotomy). The oropharynx and nasopharynx were then bulb suctioned on the
perineum. A nuchal cord was checked and (none/one) noted, and (relieved/delivered through/clamped
and cut) around head as necessary. The anterior shoulder delivered easily and the posterior shoulder
followed. The remainder of the infant was easily delivered and the oropharynx and nasopharynx was
again bulb suctioned. The infant was noted to have spontaneous cry and spontaneous movement of all
four extremities. The cord was clamped x 2 and cut and noted to have 2 arteries and one vein. The
infant was passed to the (mother’s abdomen/warmer) where (nursing/NICU) personnel were in
attendance. (Cord blood and cord pH were then obtained). The placenta delivered intact spontaneously
and the uterus was explored. 20 units of Pitocin was placed in the IV bag to firm the uterus. Examination
of the cervix and vaginal vault did not reveal any lacerations. A vaginal pack was then placed.
Examination of the perineum showed second-degree lacerations, no extension of episiotomy/urethral or
anal tears, etc. The laceration was repaired with 3-0 Vicryl in the normal fashion. The vaginal pack was
then removed. The patient tolerated this procedure well and transferred to recovery room with her
infant roomed-in. All sponge and needle counts were correct. Dr. Staff was present for entire procedure.
Post-partum: Patient is on heplock, ambulatory and on Diet as tolerated. Assessment findings revealed
that her uterus is firm and contracted. She consumes two 3/4th-filled maternity pads per 8-hour shift
with reddish lochia. Her lips are cracked and pale. She expressed that she has inadequate milk. Her
infant is not satisfied with her breast milk, so she requests to shift in formula milk. Upon assessment, her
breast is full and tender. She is sleeping most of the time because she said she had no sleep last night
because of her labor pains. She appears sleepy during the interview and could not focus well. No Bowel
Movement for 3 days.
She is receiving Mefenamic Acid 500 mg 3 x a day per orem, Cefalexin 500mg 3 x a day per orem
and Senokot 1 tablet at bedtime per orem.
Instruction: After reading and analyzing the case of Mrs. NSD
1. Identify at least 3 nursing diagnosis and prioritize.
2. Formulate Nursing Care Plan
3. Make a Laboratory Ananlysis
4. Make a Drug Study
5. Make an EBN review as part of the NCP related to the case.
