Postpartum Vaginal Delivery Unfolding Clinical Reasoning Case Study 2026

Postpartum Vaginal Delivery Unfolding Clinical Reasoning Case Study 2025 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