Pre-Term Labor a Maternal Synopsis
Uploaded by DZZY2 on Feb 20, 2012
Patient NB is a 21 year-old G1T0P1A0L1. NB delivered a baby girl at 33.1 weeks gestation on 5/3/2011. Her LMP was on 09/13/2010. Her estimated due date was 6/20/11. She is five feet four inches and her weight at delivery was 153 pounds. Her prenatal labs include an ultrasound on 2/11/11 and an AFP, which was not elevated. Her delivery was complicated with preterm labor. She arrived at the hospital completely effaced and 4cm dilated. Delivery was eminent, and at 1219 on 5/3/2011 she delivered her preterm baby girl vaginally. She had an epidural with fentanyl 15 ml/hr for pain relief, and suffered a superficial bilateral vaginal tear from the delivery. Her uterus has remained contracted. Her lochia is rubra small. She does not have a significant history as this is her first pregnancy and delivery. Patient denies drug and alcohol use. Patient denies smoking. She has no history of depression. Her husband is in the military and is stationed in Iraq, but he was able to get discharged for 1 week for the delivery. Patient will be staying with parents in IL, for a few weeks, until the baby is stable and discharged. She will than return to Kansas City, where she lives. In Kansas, she does not have family and has only a very small support system.
NB was18 hours post-delivery. Her main concerns at this time were afterbirth pains, especially after pumping and breast pumping instructions. Her baby was premature and was in the NICU, so she was pumping breast milk for the baby. Upon doing her assessment her vitals were as follows: T 98.7, P 88, R 14 and BP 118/72. Her uterus is well contracted, midline, and the fundus is 1cm below her umbilicus. Her lochia is rubra and she complains of after pains. Her breasts were soft but slightly engorged with nipples erect without redness; she is voiding large quantities with each void without discomfort or burning. Her perineum was very slightly swollen and she did have a normal bowel movement on 5/3/11. Her homan’s sign is negative. The baby was being cared for in the NICU, and she appears to be in good spirits as her husband is arriving from Iraq.
Baby Synopsis
Baby girl B is a preterm infant delivered via vaginal delivery...