Postpartum Vaginal Delivery
UNFOLDING Reasoning
Anne Jones, 17 years old
History of Present Problem
7:00 am First Day Post-Delivery Night Shift Report:
Anne Jones is a 17-year-old G1 P1 39 weeks’ gestation who delivered a healthy male infant at 2032 yesterday. Placenta
delivered at 2045. No pain medication was given. She received a 250 mL bolus of Pitocin 30 units/500 mL IV after the
delivery of the placenta then received 200 mL/hour until the IV bag was completed.
The uterus is firm, one finger breadth below umbilicus and midline — Lochia moderate rubra. Mid-line episiotomy is
well approximated, slightly bruised and perineum is slightly swollen. She had an ice pack applied to perineum
throughout the night. Anne is up and ambulating ad lib and voiding without difficulty. She had 500 mL in/850 mL urine
out. Vital signs: BP: 124/78, P: 74, R: 18, T: 98.6 F/37.0 C, O2: 98% room air, Pain 3/10 in perineum. She is on a regular
diet. She was positive for Group Beta strep (GBS) and received a total of three doses of ampicillin IVPB during labor, her
blood type is B-, and rubella positive.
Infant Report:
Infant Apgars were 8 and 9. Weight: 7 lbs. 0 oz. (3.2 kg), 20 inches (50.8 cm) long. Baby has breast fed and latched on
for five minutes on both sides three times, and Anne is holding and talking to her baby. She plans on having the baby
circumcised. The baby had three wet and meconium diapers. Cord blood was sent.
Personal/Social History:
Anne has her mother with her and seems to be relaxed but nervous. The father of the baby is not involved. She plans on
breastfeeding for “awhile.” Anne still lives at home, and her mother is planning on helping with the new baby and
appears supportive.
Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved.
, What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse?
RELEVANT Data from Report: Clinical Significance:
Delivered healthy male 2032 last Gives timeline for birth and postpartum care and assessments
night vaginally Important to know what meds were given during labor for
No pain medication for labor follow up or to continue
Received Pitocin after delivery until Pitocin helps to contract uterus down and return to normal
bag empty Expected uterine finding for postpartum
Uterus firm, midline, one finger Lochia WNL
below umbilicus Episiotomy WNL, should assess for visual baseline to determine
Lochia moderate rubra if any changes happen
Midline episiotomy slightly bruised Ambulating and voiding WNL and expected
and swollen-using ice packs Regular diet-good to know when offering food or if pt asks for
Ambulating and voiding w/o food
difficulty Important to know status with GBS and antibiotics, rubella and
Regular diet blood type for RhoGAM
GBS +, rubella +, B- blood type Infant APGAR WNL and serves as baseline
Infant Apgar 8,9 Breastfeeding shows success at attempts and consistency,
Breastfed 5m on both sides 3x observe pt for feedback and encouragement
Holding and talking to baby Holding and talking to baby shows bonding is forming
Circumcision wanted Circumcision will need to be scheduled before discharge
3 wet, 1 meconium diaper Baby is urinating and defecating WNL and needs to be
Cord blood sent established before circumcision
Cord blood documented
RELEVANT Data from Social History: Clinical Significance:
Support system is mother Support system is important for planning discharge education
Baby father not involved No father important for decision making and sensitivity
Pt lives at home Living with Mother is good to know for support system and pt
Relaxed but nervous is not alone
Breastfeeding ‘awhile’ Relaxed but nervous is WNL ofr a 17y/o that just gave birth
Plans to breastfeed but not sure how long, important to
provide support and resources so that pt is successful
Patient Care Begins: You complete your first assessment:
Current VS: P-Q-R-S-T Pain Assessment:
T: 98.6 F/37.0 C (oral) Provoking/Palliative: Breastfeeding
P: 76 (regular) Quality: Cramping and tenderness of perineum
R: 18 (regular) Region/Radiation: Uterus and perineum
BP: 125/80 Severity: 4/10
O2 sat: 98% room air Timing: When breastfeeding and continuous for perineum
What VS data are RELEVANT and must be interpreted as clinically significant by the nurse?
RELEVANT VS Data: Clinical Significance:
Temp, HR, RR, WNL for vitals is important for baseline
BP, O2 WNL Pain from breastfeeding and perineum from episiotomy- will need to address
Pain 4/10
Current Assessment: Mom
GENERAL Calm and quiet appears tired. Baby in a crib next to the bed.
APPEARANCE:
Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved.
UNFOLDING Reasoning
Anne Jones, 17 years old
History of Present Problem
7:00 am First Day Post-Delivery Night Shift Report:
Anne Jones is a 17-year-old G1 P1 39 weeks’ gestation who delivered a healthy male infant at 2032 yesterday. Placenta
delivered at 2045. No pain medication was given. She received a 250 mL bolus of Pitocin 30 units/500 mL IV after the
delivery of the placenta then received 200 mL/hour until the IV bag was completed.
The uterus is firm, one finger breadth below umbilicus and midline — Lochia moderate rubra. Mid-line episiotomy is
well approximated, slightly bruised and perineum is slightly swollen. She had an ice pack applied to perineum
throughout the night. Anne is up and ambulating ad lib and voiding without difficulty. She had 500 mL in/850 mL urine
out. Vital signs: BP: 124/78, P: 74, R: 18, T: 98.6 F/37.0 C, O2: 98% room air, Pain 3/10 in perineum. She is on a regular
diet. She was positive for Group Beta strep (GBS) and received a total of three doses of ampicillin IVPB during labor, her
blood type is B-, and rubella positive.
Infant Report:
Infant Apgars were 8 and 9. Weight: 7 lbs. 0 oz. (3.2 kg), 20 inches (50.8 cm) long. Baby has breast fed and latched on
for five minutes on both sides three times, and Anne is holding and talking to her baby. She plans on having the baby
circumcised. The baby had three wet and meconium diapers. Cord blood was sent.
Personal/Social History:
Anne has her mother with her and seems to be relaxed but nervous. The father of the baby is not involved. She plans on
breastfeeding for “awhile.” Anne still lives at home, and her mother is planning on helping with the new baby and
appears supportive.
Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved.
, What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse?
RELEVANT Data from Report: Clinical Significance:
Delivered healthy male 2032 last Gives timeline for birth and postpartum care and assessments
night vaginally Important to know what meds were given during labor for
No pain medication for labor follow up or to continue
Received Pitocin after delivery until Pitocin helps to contract uterus down and return to normal
bag empty Expected uterine finding for postpartum
Uterus firm, midline, one finger Lochia WNL
below umbilicus Episiotomy WNL, should assess for visual baseline to determine
Lochia moderate rubra if any changes happen
Midline episiotomy slightly bruised Ambulating and voiding WNL and expected
and swollen-using ice packs Regular diet-good to know when offering food or if pt asks for
Ambulating and voiding w/o food
difficulty Important to know status with GBS and antibiotics, rubella and
Regular diet blood type for RhoGAM
GBS +, rubella +, B- blood type Infant APGAR WNL and serves as baseline
Infant Apgar 8,9 Breastfeeding shows success at attempts and consistency,
Breastfed 5m on both sides 3x observe pt for feedback and encouragement
Holding and talking to baby Holding and talking to baby shows bonding is forming
Circumcision wanted Circumcision will need to be scheduled before discharge
3 wet, 1 meconium diaper Baby is urinating and defecating WNL and needs to be
Cord blood sent established before circumcision
Cord blood documented
RELEVANT Data from Social History: Clinical Significance:
Support system is mother Support system is important for planning discharge education
Baby father not involved No father important for decision making and sensitivity
Pt lives at home Living with Mother is good to know for support system and pt
Relaxed but nervous is not alone
Breastfeeding ‘awhile’ Relaxed but nervous is WNL ofr a 17y/o that just gave birth
Plans to breastfeed but not sure how long, important to
provide support and resources so that pt is successful
Patient Care Begins: You complete your first assessment:
Current VS: P-Q-R-S-T Pain Assessment:
T: 98.6 F/37.0 C (oral) Provoking/Palliative: Breastfeeding
P: 76 (regular) Quality: Cramping and tenderness of perineum
R: 18 (regular) Region/Radiation: Uterus and perineum
BP: 125/80 Severity: 4/10
O2 sat: 98% room air Timing: When breastfeeding and continuous for perineum
What VS data are RELEVANT and must be interpreted as clinically significant by the nurse?
RELEVANT VS Data: Clinical Significance:
Temp, HR, RR, WNL for vitals is important for baseline
BP, O2 WNL Pain from breastfeeding and perineum from episiotomy- will need to address
Pain 4/10
Current Assessment: Mom
GENERAL Calm and quiet appears tired. Baby in a crib next to the bed.
APPEARANCE:
Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved.
