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Patient Name: Maria R.
Age: 23
Gravida/Para (G/P): G1P1 (primigravida)
Hospitalized for: Spontaneous vaginal delivery at 39 weeks
History/Conditions:
Anemia in pregnancy (Hgb 9.5 g/dL on admission)
Prolonged second stage of labor (3.5 hours)
Mild gestational hypertension diagnosed at 36 weeks (BP averaging 140/90)
No significant past medical history
Delivery Details:
Delivered a healthy baby boy, 7 lb 9 oz, at 8:20 AM.
Third stage of labor lasted 20 minutes.
Moderate vaginal tear requiring suturing.
Blood loss estimated at 800 mL (higher than normal).
Postpartum Nursing Unit Findings:
Fundus boggy, deviated to the right.
Heavy vaginal bleeding with large clots noted on pad checks.
Patient reports feeling dizzy, weak, and lightheaded upon sitting up.
Vital signs:
BP 90/58 mmHg
HR 118 bpm
Temp 99.2°F
Lochia: Heavy, bright red
Hgb post-delivery: 7.8 g/dL (down from 9.5 g/dL)
Interventions:
Fundal massage performed — uterus responded but remained soft after brief improvement.
Straight catheterization performed — drained 450 mL urine (bladder distention contributing to atony).
Administered IV oxytocin per protocol.
Blood type and cross-match sent.
1 unit packed RBCs ordered.
Emotional support provided; patient tearful and anxious, reporting fear about her bleeding.
Additional Anticipated/Postpartum Unit Findings:
Fatigue and pallor (due to anemia and blood loss)
Difficulty initiating breastfeeding due to exhaustion
Anxiety about newborn care and physical recovery
Close monitoring for postpartum depression risk factors
Possible delayed ambulation related to dizziness and weakness
Hematoma assessment at the perineal repair site
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