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Postpartum Obstetrics Case Study

This case study describes an 18-year-old postpartum patient. She had a spontaneous vaginal delivery of a healthy 6.15 lb baby girl at 39 weeks. Nursing concerns include her knowledge deficits about newborn care and breastfeeding, as well as pain from vaginal tearing. Her medical history is otherwise unremarkable, though her psychosocial history notes a crowded home environment and prior assault. The nursing care plan focuses on improving parenting skills, effective breastfeeding, and managing postpartum pain.

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lms93093
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441 views20 pages

Postpartum Obstetrics Case Study

This case study describes an 18-year-old postpartum patient. She had a spontaneous vaginal delivery of a healthy 6.15 lb baby girl at 39 weeks. Nursing concerns include her knowledge deficits about newborn care and breastfeeding, as well as pain from vaginal tearing. Her medical history is otherwise unremarkable, though her psychosocial history notes a crowded home environment and prior assault. The nursing care plan focuses on improving parenting skills, effective breastfeeding, and managing postpartum pain.

Uploaded by

lms93093
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
  • Obstetrics Case Study: Introduction slide displaying the title of the case study and authorship.
  • Demographic Data: Presents the demographic and personal details of the patient involved in the case study.
  • Reason for Hospitalization: Explains the medical reasons leading to the patient's hospitalization, focusing on childbirth.
  • Medical History: Details the patient's medical background including blood type, immunization status, and prior medical conditions.
  • Family Medical History: Covers the medical history of the patient's family members, highlighting genetic or hereditary considerations.
  • Psychosocial History: Discusses the psychosocial background of the patient, including family dynamics and economic conditions.
  • Nursing Theory: Introduces Virginia Henderson's Nursing Need Theory and its application to patient care.
  • Developmental Theory: Explores Erikson's Psychosocial Developmental Theory and its relevance to the patient's life stage.
  • Nutritional Status: Assesses the patient's nutritional condition before and during pregnancy.
  • Physical Assessment: Conducts an examination of the patient's vital signs and overall physical state postpartum.
  • Focused Assessment: Focuses on a specific postpartum assessment following the acronym BUBBLE-HE.
  • Lab Values: Lists laboratory results pertinent to the patient's health including blood counts and Rh status.
  • Medications: Outlines the medication regimen for the patient during and after hospitalization.
  • Summary: Summarizes the case with an overview of patient history, conditions, and social context.
  • Summary/Analysis: Analyzes patient concerns and potential areas needing attention post-hospitalization.
  • Nursing Care: Details nursing diagnoses and care plans to address the patient's postpartum needs.
  • References: Lists the sources used to compile the case study and to support theoretical frameworks.

Obstetrics Case Study

By Lexie Scribner

Demographic Data

Patient: H.E.
Gender: Female
Age: 18
Ethnicity: White/Non-Hispanic
Allergies: None
Support System: fianc/father present,
grandmother

Reason for Hospitalization

Gravida/Para: G1 P1
Postpartum floor (5A)
Spontaneous vaginal delivery at fullterm (39 weeks 1 day)
Female baby born at 6.15lbs
Breastfeeding

Medical History
Blood Type: A +
Rh Status: +
Immunization status: Rubella Immune
HIV/Strep/Hepatitis Status: Negative
Denies relevant medical history
- no serious injuries/surgeries, no
chronic illness, no previous births,
never a smoker

Family Medical History

No significant medical history in


mother and brother
Father and Grandparents hypertension
Paternal grandfather - death of lung
cancer (smoker)
Remaining grandparents still living and
in good health

Psychosocial History

Patient and significant other graduated high


school
Neither parents are employed
Insurance: Medicaid (Jordan Valley)
No evidence of drug, alcohol, tobacco use in
the home
Home environment: crowded
History of assault: resulted in head
contusions
When asked about it mutual domestic
fight
Fine now, couple acting appropriate

Nursing Theory

Virginia Hendersons Nursing Need


Theory
Emphasizes increasing patients

independence
14 components

Developmental Theory

Erik Eriksons Psychosocial Developmental


Theory
8 stages

Trust vs. Mistrust Infancy (0-1.5)


Autonomy vs. Shame Early Childhood (1.5-3)
Initiative vs. Guilt Play age (3-5)
Industry vs. Inferiority School age (5-12)
Ego Identity vs. Role Confusion Adolescence
(12-18)
Intimacy vs. Isolation Young adult (18-40)
Generativity vs. Stagnation - Adulthood (40-65)
Ego Integrity vs. Despair Maturity (65+)

Nutritional Status

Ht: 5 1
Wt: Pre-pregnancy: 141 lbs. / 64.1 kg
Pregnancy: 169 lbs. / 76.8kg
Current: 158 lbs. / 71.8 kg
BMI: 29.9 Overweight (border line
obese)
Observation: average size in relation to
height
Concern about nutritional status

Physical Assessment

Vital Signs:

BP -124/85
Pulse 77
Resp. 14
Temp. 98.2 F
SpO2 99%
Pain 4 sourness in perineal area

General appearance: awake, up adlib,


facial expression seemed tired and
nervous

Focused Assessment

B Breast
U Uterus
B Bladder
B Bowel
L Lochia
E Episiotomy/Laceration/Edema
H Homans/hemorrhoids
E Emotional

Lab Values

High WBC (14.5 K/ul)


Low RBC (3.13 Mil/ul)
Decreased Hemoglobin (9.6 g/dL)
&Hematocrit (28.6%)
Rh positive blood
Low platelet count

Medications

Iron Preparation: Ferrous Sulfate


(Feosol) tablet 325mg
Prenatal Vitamin: Ferrous fum FA iron
800 mcg tablet
Acetaminophen 650mg q6h prn
Oxytocin
Clindamycin

Summary

Patient H.E. was an 18 year old white/non-hispanic


female. She was a G1 P1 that had at Spontaneous
vaginal delivery at full-term (39 weeks 1 day) of a 6.15
lb female baby. She initiated breastfeeding in the Labor
and delivery unit and now resides on the postpartum
floor and is doing well. Her medical history is very
minimal and her family history only incudes
hypertension and lung cancer. Her psychosocial history
is relevant with neither herself of fianc being
employed, she is covered by Medicaid insurance, and
the home environment is fairly crowded. She also has a
history of assault against her in which it resulted in her
having head contusions. The only abnormalities seen
in her physical assessment were her lack of appetite,
swelling in her perineal area, hemorrhoids, and
concerns with breastfeeding. All of these will be tended

Summary/Analysis

Concerns seen with this patient


include:
Knowledge deficits in caring for a newborn
Problems with breastfeeding
Pain from her laceration/perineal edema

Nursing Care

Diagnosis 1: Risk for impaired


parenting related to deficient
knowledge about child development,
child health maintenance, and
parenting skills as evidence by being a
teenage mother, asking basic question
during the postpartum period, and
seeming worried and quiet.

Nursing Care

Diagnosis 2: Ineffective breastfeeding


related to knowledge deficit of a teen
mother, maternal anxiety, and
interruption in breastfeeding as
evidence by being timid and nervous
around medical professionals, unsure
of positioning and how to correctly
breast feed her baby.

Nursing Care

Diagnosis 3: Acute pain related to


vaginal trauma of child birth as
evidence by a second-degree
laceration and a predominant amount
of swelling in the perineal area.

References

Ackley, B. J. & Ladwig, G. B. (2014). Nursing diagnosis and book:


An evidence-based guide to planning care (10th ed.). Maryland
Heights, MO: Mosby Elsevier.
Derricott, B. & Cartwright, C. (2013). Pregnancy: Physiologic
changes and laboratory values. Wild Iris Medical Education, Inc.
[Link] (2015). Breastfeeding warnings. Retrieved October
26,2015, from [Link]/pregnancy
George, J. B. (2011). Nursing theories: The base for professional
nursing practice (6th ed.). Upper Saddle River, NJ: Pearson
Education.
Ladewig, P.A., London, M.L., & Davidson, M. R. (2014).
Contemporary maternal-newborn nursing care (8th ed.). Upper
Saddle River, NJ: Pearson Education.
Mayo Clinic. (2015). Labor and delivery, postpartum care: Vaginal
tears in childbirth. Retrieved October 26, 2015, from
[Link]

References Cont

McLeod, S. (2014). Erik Erikson. Retrieved October 26, 2015,


from [Link]
Pagana, K. D. & Pagana, T. J. (2014). Mosbysmanual of
diagnostic and laboratory tests (5th ed.) St. Louis, MO: Elsevier
Mosby
U.S. National Library of Medicine[NLM]. (2015). Rh
incompatibility.
Retrieved October 27, 2015, from
[Link]
Vallerand, A. H. & Sanoski, C. A. (2015). Daviss drug guide for
nurses (14th ed.). Philidelphia, PA: F.A. Davis Company
Wedro, B. (2015). Anemia during pregnancy. Retrieved
October
27, 2015, from
[Link]
htm

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