QUEROL, Zachary Ivan G.

OB-Gyne Rotation - TMC

MD20-0177 Case-Write Up

LOW-RISK POSTPARTUM CARE

I. SUBJECTIVE

HISTORY TAKING

IDENTIFYING INFORMATION

NAME: MAA
AGE: 39 y.o.
OB SCORE: G3P2 (2-0-0-2)
SEX: Female
ADDRESS: Makati
RELIGION: Catholic
CIVIL STATUS: Married
OCCUPATION: Financial adviser

CLINICAL HISTORY

CHIEF COMPLAINT: Perceived uterine contractions

HISTORY OF PRESENT ILLNESS:

The patient is a 39-year-old, G3P2 (2-0-0-2) pregnancy uterine at 39 2/7 weeks age of gestation, cesarean section
due to arrest of cervical dilatation, who came in for perceived uterine contractions.

3 hours PTA, patient experienced perceived uterine contractions with good fetal movements (≥ 10 kicks in 1 hour).
No associated vaginal bleeding, ruptured bag of waters, or vaginal discharge. Prenatal check up with AP was done,
where the cervix was noted to be dilated to 1 cm. Patient was advised pre-labor consult and was admitted thereafter.

TRIMESTRAL HISTORY:

FIRST TRIMESTER:
Patient had a planned pregnancy. After 2 weeks of missed menses, patient tested positive on pregnancy test.
Consultation with AP was done at 4 weeks AOG and had regular prenatal checkups every four weeks. Patient was
given prenatal meds (Hemarate, Calciumade, MVT). Complete blood count, urinalysis, syphilis tests were done and
were unremarkable. She had a history of UTI and was prescribed Co-Amoxiclav for 7 days with good compliance.
Denies exposure to radiation. Denies exposure to TORCH infections or teratogens.

SECOND TRIMESTER:
Patient has regular prenatal checkups every four week intervals. Multivitamins continued in addition to Obimin
Plus. Hepatitis vaccine and Tetanus vaccine were given. Hematocrit, hemoglobin, oral glucose tolerance test, and
congenital anomaly scan were unremarkable. No urinary tract infections or blood pressure elevations. Patient was
diagnosed with hypothyroidism but was cleared by endocrinologist. Not given any medications. No other maternal
illnesses.

THIRD TRIMESTER:
Patient had regular prenatal checkups every two-week intervals. Multivitamins were continued. Group B
Streptococcus and complete blood counts were unremarkable. Pelvic ultrasound was unremarkable. No other
maternal illnesses.

REVIEW OF SYSTEMS

General (-) Generalized body weakness

Musculoskeletal (-) Masses, (-) rashes, (-) muscle aches, (-) joint swelling, (-) joint pain, (-) numbness, (-)
stiffness
Integumentary (-) Pallor, (-) pruritus, (-) changes in hair/nails, (-) dryness, (-) color changes
HEENT (-) Headache, (-) dizziness, (-) blurring of vision, (-) tinnitus, (-) epistaxis, (-) ear discharge, (-)
cervical lymphadenopathies
Respiratory (-) Dyspnea, (-) hemoptysis, (-) cough, (-) wheezing
Cardiovascular (-) Palpitations, (-) chest pains, (-) syncope, (-) orthopnea
Gastrointestinal (-) Nausea, (-) vomiting (-) dysphagia, (-) heartburn, (-) constipation, (-) diarrhea, (-) abdominal
pain, (-) bloody stools, (-) abdominal distention
Endocrine (-) Heat intolerance, (-) cold intolerance, (-) polyphagia
Genitourinary (-) Discharge, (-) rashes, (-) dysuria, (-) hematuria, (-) oliguria, (-) urinary retention (-) urinary
frequency, (-) frothy urine
Neurological (-) Paralysis, (-) tremors, (-) involuntary movements, (-) seizures, (-) changes in mood, attention,
speech, memory, insight, or judgment

PAST MEDICAL HISTORY

Known diseases include childhood bronchial asthma (last attack: childhood). No HTN, Type 2 DM, PTB, thyroid,
kidney, liver disease. No previous MI or stroke.

Known allergy to Ibuprofen.

Previous surgery include:

s/p cesarean section (2017)
s/p repeat CS (2018)

COVID-19 history:
No history of COVID-19 infection
Vaccine: Primary dose + 1 Booster

FAMILY HISTORY

On the paternal side, there is known illness of Hypertension, Myocardial infarction and Asthma. No known
illnesses on the maternal side.

PERSONAL AND SOCIAL HISTORY

• Non-cigarette and vape smoker.

• Occasional alcoholic beverage drinker
• Educational Attainment: College degree
• Occupation: Financial adviser (desk job)

REPRODUCTIVE HISTORY

Menarche started at 14 y.o., with regular menses interval, lasting for 3-4 days, using 4-5 pads per day that are
moderately soaked, and associated with dysmenorrhea and headache.
Last menstrual period was on February 11, 2023 and previous menstrual period was in January 2023.

Estimated due date by LMP is on November 18, 2023.

SEXUAL HISTORY

No history of pelvic infection or STI. No prior contraceptive use.

Age of first coitus was at age 22 yo. Age of first pregnancy was at age 33 yo. Number of sexual partners is 2. No
post-coital pain. No bleeding after coitus.
 OBSTETRIC HISTORY

Date BW Sex AOG Status Place Outcome Complications

G1 Jan. 22, 2017 2978 g F 40 1/7 weeks Alive TMC CS None
G2 Dec. 12, 2018 2800 g F 39 weeks Alive TMC CS None
G3 Current

STAKEHOLDER ANALYSIS

NAME/ROLE STAKE/WIIFM STAND INTENSITY OF DEGREE OF INSIGHT &

STAND INFLUENCE ACTION

Patient Decision maker Ally High High Educate patient

about the plan
through the use of
the CEA method
Wants tubal
ligation

Baby Care is affected by Neutral No stand None ---

the health of the
patient

Husband Breadwinner Ally High High Provide needs for

mother postpartum
and new child

Mother of patient Caregiver Ally High High Take care of

patient while in
recovery
postpartum

Children of patient Emotional support Ally Medium Low Help in taking care
of patient by giving
emotional and
moral support
II. OBJECTIVE

PHYSICAL EXAMINATION

PHYSICAL EXAMINATION

GENERAL SURVEY Awake, alert, not in cardiorespiratory distress

ANTHROPOMETRICS Height: 152 cm

Current weight: 60 kg
Pre-pregnancy weight: 67 kg

VITAL SIGNS BP: 91/61 mmHg

PR: 78 bpm
RR: 18 cpm
Temp: 36.4℃
SpO2: 99% at room air

HEENT Pink palpebral conjunctiva, anicteric sclerae. Flat, non-distended neck veins.

CARDIOVASCULAR Adynamic precordium, normal rate, regular rhythm, (-) murmurs

CHEST AND LUNGS Symmetric chest expansion, clear breath sounds

ABDOMEN Soft, non-tender abdomen

Fundic height: 33 cm
Fetal heart tones: 120 bpm

PELVIS/GU TRACT Speculum exam: deferred

Internal exam: cervix 1 cm dilated, station -2, intact bag of waters

EXTREMITIES Full and equal pulses, CRT < 2 secs, no signs of cyanosis

CARDIOTOCOGRAPHY

Figure 1. Baseline 125 bpm, moderate variability, with accelerations, no decelerations,

with 2 mild contractions 10 minutes apart
III. ASSESSMENT

SALIENT FEATURES

• 39 yo, G3P2 (2-0-0-2), previous CS, 39 2/7 • Stable vital signs

weeks AOG • IE: 1 cm cervical dilation
• Perceived uterine contractions • Baseline 125 bpm, normal variability, with
• (+) fetal movement, (-) vaginal bleeding, (-) accelerations, no decelerations, many fetal
watery discharge movements, with 2 mild contractions 10
• Regular prenatal check-ups since March 2023 minutes apart
• PMH: Childhood asthma

INITIAL IMPRESSION

G3P2 (2-0-0-2) Pregnancy uterine 39 2/7 weeks age of gestation, cephalic in labor; Previous cesarean section for
arrest of cervical dilatation.

IV. PLAN

For repeat cesarean section and bitubal ligation.

V. DISCUSSION: POSTPARTUM CARE

Puerperium is defined as the time following delivery of the infant. This starts within first 2 hours after delivery,
and lasts 4-6 weeks after delivery. In this timespan, the concerns of the postpartum mother must be addressed.
According to Williams Obstetrics (2022), the following are the top concerns in postpartum care: pain after cesarean
delivery, feeling stressed, breastfeeding issues, perineal pain after vaginal delivery, inadequate education about
newborn care, help with postpartum depression, perceived need for extended hospital stay and need for maternal
insurance coverage postpartum.

Immediate monitoring of vital signs is done after delivery. Cardiac output remains elevated for 24-48 hours
postpartum, but returns to pre-pregnant levels after 1 week. Blood pressure and pulse rate is checked every 15 minutes
for 2 hours, while temperature is taken every 4 hours. Inspection should also be done. The uterus should be assessed
for postpartum hemorrhage. The uterus should be tonically contracted (stone-hard) to rule out uterine atony, which is
the most common cause of postpartum hemorrhage. This is usually caused by retained placenta or blood clots within
the uterus. Other causes of postpartum hemorrhage include subinvolution of the uterus, disseminated intravascular
coagulation defects, and lacerations in the cervix, vagina or perineum. Subinvolution is the arrest or delay of uterine
involution. Common causes for subinvolution includes infection (i.e., endometriosis), retained placental fragments, or
incompletely uteroplacental vessels. For acute endometritis is due to ascending infection from the cervix and vaginal
vault, caused most often by Chlamydia trachomatis. Endocervical infections disrupt the barrier functions of the
endocervical canal, allowing the infection to ascend. Symptoms would include abrupt onset of pelvic pain, dyspareunia,
and vaginal discharge. The gold standard treatment is clindamycin and gentamicin, plus ampicillin if suspected with
sepsis or enterococcal infection. To help with uterine contractions for subinvolution and avoid excessive bleeding from
the uterus, methylergonovine can be given. The perineum is checked to assess for excessive vaginal bleeding or
discharge. Watch out for hematoma if within 24 hours postpartum and infections after 3rd - 4th day postpartum. For
perineal care, the vulva should be cleansed from the anterior to posterior area towards the anus.

Abdominal wall relaxation should also be achieved. If abdomen is flabby or pendulous (diastasis recti), the
patient can use an ordinary girdle. Exercises to restore abdominal wall tone can be done. It can be started at any time
after vaginal delivery. For after cesarean delivery, it can be done as soon as abdominal soreness diminishes.

Early ambulation should be done to reduce bladder complications, lessen frequent constipation, reduce risk
of puerperal venous thrombosis and reduce risk of pulmonary embolism. For vaginal delivery, early ambulation should
be done within 12-24 hours. For cesarean delivery such as the patient, ambulation should be done after 24 hours to
avoid pressure on the surgical scar.

The postpartum mother should also be informed of the changes of maternal anatomy in puerperium. For the
vagina and vaginal outlet after vaginal delivery, it is distended and has smooth walls within 24 hours, and thickened
due to vaginal epithelium proliferation with return of ovarian function within 4th-6th weeks postpartum. For the cervix
after vaginal delivery, the cervical os would dilated and stretched within 24 hours, remains edematous after 1 week,
and would be contracted parous cervix after 4 weeks. However, it would not return to its pre-gravid appearance. On
the other hand, mothers who underwent cesarean section delivery would have a non-parous cervix. For the uterus, it
would remain stone-hard, contracted, and would be found below the umbilicus within 24 hours. The fundus of the uterus
would normally descend 102 cm every 24 hours. Within 1 week, the uterus would descend halfway between the
umbilicus and symphysis pubis. Within 8 weeks, the uterus would be completely involuted and would be normally found
above the symphysis pubis. Vaginal discharge of decidua, epithelial cells and red blood cells should be expected.
Lochia rubra would have red, heavy discharge in the first few days postpartum and would indicate uterine subinvolution.
Lochia serosa would have a paler red, moderate discharge within 2 weeks postpartum. Lochia alba would have a pale
white discharge within 3 weeks postpartum. Afterpains from labor, most commonly secondary from uterine involutions,
should also be expected. It occurs during the first 2-3 days of puerperium, with intensity decreasing after 1st postpartum
day. It would be more pronounced as parity increases and worsens when the infant suckles. In the primipara, uterus
tends to remain tonically contracted after delivery. In the multipara, it contracts vigorously at intervals similar to (but
milder) the pain of labor contractions. For the management, analgesics can be given such as paracetamol.

Exclusive breastfeeding for at least 6 months is important in child development. For this, breastfeeding
techniques should be taught. For a mother post-cesarean delivery, the best breastfeeding position would be the football
hold since it places the baby away from the abdomen and surgical site to avoid pressure. Signs of proper breastfeeding
include proper position (baby’s neck not twisted or flexed, chest is facing mother’s chest, ear, body is close to mother,
back is supported), proper attachment (baby’s mouth is wide open, baby’s chin touches breast, mother’s areola is not
visible, baby’s lower lip is curled outward) and milk transfer (audible swallowing, no pain in milk transfer, full letdown of
milk).

Routine check-ups occurs within the 12 weeks postpartum. The first postnatal visit occurs 48-72 hours of life,
while the seconds postnatal visit occurs after 7 days of life. Family planning and birth control can be discussed during
subsequent visits. An effective method for a postpartum mother would be the Lactational-Amenorrhea method, wherein
ovulation is prevented due to breastfeeding. Suckling induces reduction in GnRH, preventing release of luteinizing
hormone and follicle-stimulating hormone needed for ovulation and resulting to amenorrhea. This is effective as long
as the mother’s monthly bleeding has not returned, the baby is exclusively breastfed day and night, and the baby is
less than 6 months old. For a cesarean delivery, if hormonal contraception is considered, combination pills must be
avoided. This is because the estrogen component increases the risk of blood clot formation, which increases the risk
of thromboembolic events. Therefore, progestin-only pills, injectables or implants can be recommended to increase
cervical mucus thickening for prevention of sperm passage and to make the uterus lining thinner for prevention of egg
implantation. Intrauterine devices like copper-bearing IUDs or levonorgestrel-containing IUDs can be given to mother
immediately after birth as the implant can be readily place. Sterilization is also an option, such as in the patient, who
opted for bitubal ligation. For females, ligation of fallopian tubes can be done either with the modified Pomeroy or with
salpingectomy. The modified Pomeroy can cause reversible infertility since the tubes can easily be anastomosed. A
salpingectomy is the removal of the fallopian tubes, which causes irreversible infertility. Aside from this, salpingectomies
can also be a preventive measure to avoid the possibility of having ovarian cancer.

References:
Cunningham F, & Leveno K.J., & Dashe J.S., & Hoffman B.L., & Spong C.Y., & Casey B.M.(Eds.), (2022). Williams
Obstetrics, 26e. McGraw Hill. https://obgyn.mhmedical.com/content.aspx?bookid=2977&sectionid=249396578