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33 year old Caucasian female, G3 P1 with a history of EAB and D&C (September 08’)
followed by Dr. Crowe. The patient present to Baptist Hospital on 9/14/09 for admission
due to labor, with anticipation of a spontaneous vaginal delivery. The EDC was
09/19/2009, but at 1612 on 09/14/2009 a healthy baby girl was delivered, weighing 6 lb.
15 ½ oz. There were no atypical maternal problems during delivery, but a 2O laceration to
the interior midline between the vaginal opening and the anus occurred, but was repaired
with sutures. Lab results show HLA as A+ blood type, Rubella immune, with a negative
antibody screen, prepartum PCV 41.2 and EBL <500 mL. Other pertinent
medical/surgical history includes headaches, removal of wisdom teeth, and tonsillectomy.
Upon admission, the patient was found to have +1 pitting edema to hands, feet and legs;
insertion of epidural was completed; fetus presentation: vertex.
AAOx3 without HA/visual changes, PEARL at 3mm. Bilateral breaths sounds
clear on auscultation, RR WNL without distress upon ambulation. Skin warm, dry, color
normal for ethnicity; BP/HR WNL without the perceived sound of any
murmurs/gallops/rubs; denies chest pain or shortness of breath. ; +1 pitting edema noted
to ankles and calves with pedal pulses normal and equal. Skin intact without breakdown,
bruises or petechiae except where noted. All teeth within place, no bleeding from gums,
or thrush noted. Epidural site without active bleeding or redness, with normal sensation
and motor function following removal of epidural. Abdomen soft without complain of
nausea or vomiting; fundus firm with uterus midline, approximately 1 fingerbreadth (fv)
between the umbilicus and the top of the fundus; minimal discomfort upon palpation.
Patient able to void and empty bladder without bladder distention, only minor
pain/discomfort upon urination due to laceration (given education on use of tucks and
use of warm cleaning water to assist in relief of pain). Breast tissue soft, but engorged,
nipples without signs of cracks, blisters, reddening, inversion, bruising or bleeding;
patient visualized breast-feeding infant without distress difficulty, infant appearing to be
satiated after feedings. Lochia visualized as light, wine-colored, with only small clots
noted but without odor. Lack of hemorrhoids, edema, redness, drainage, bleeding to
perineum area but dime sized bruise near laceration, dark purple – painful to palpation.