NORMAL PUERPERIUM CASE

By MBBS Gang
1. Mother Particulars:
• Name
• Age
• Religion
• Residence
• Education
• Occupation
• Socio-Economic Status
• Date of Admission
• Date of Examination
-
Husband Brief Info
• Name
• Age
• Occupation

2. PRESENTING COMPLAINTS: 26 years old female with obstetric score of

G1P1 delivered 2 days ago on 04.02.2024 through Normal Vaginal Delivery at
term. She is on Day 2 of her puerperium with
i) Discharge per vaginum x 2 Days
ii) Difficulty in Passing Stools x 2 Days

3. HISTORY OF PRESENTING COMPLAINTS:

The patient is having discharge through vagina since 2 days which is fluid in
consistency, red in colour, fishy in odour. The amount is moderate in
nature, with usage of an average of 4-5 pads / day.
There is no change in colour, consistency or odour of discharge and it is not
associated with itching.

There is presence of mild occasional discomfort and pain in the lower

abdominal region.
There is No H/O:
Fever
Painful Urination, Difficulty passing urine
Itching in Perineal Region
Swelling in Perineal Region
Malaise
Urinary Incontinence
Breast pain, painful feeding
Seizure [R/O Eclampsia]
Episodes of Black Out
Hurried Respiration [R/O DVT → Pulmonary Embolism]

No h/o of pain abdomen, leaking or bleeding per vagina.

4. MARITAL HISTORY:
Married since ___ year, non-consanguineous type of marriage.

5. OBSTETRIC HISTORY:
Obstetric score: GTPAL (G1 P 1-0-0-1)
[Gravida means a pregnancy state including present and past irrespective
of period of gestation.
Parity means only previous pregnancy / pregnancies reaching the age of
viability.
Gravida and Parity denote the number of pregnancy and not the
number of babies. Multiple pregnancy does not change the gravida or
parity state.
TPAL – Term, Pre-Term, Abortion, Living]
1st Day of Last menstrual period: 04.05.2023
Expected date of delivery: 11.02.2024
Actual Delivery on: 04.02.2024 (39 Weeks POG)
[Naegele’s Formula: The expected date of delivery (EDD) is obtained by
adding 7 days to the date of first day of the last normal menstrual period
(LMP) and counting back 3 months or forwarding 9 months. Naegele rule is
based on 28 days regular cycle.
If the cycle is shorter or longer than 28 days, EDD will be corrected
accordingly and written as 'Corrected EDD'.]
6. MENSTRUAL HISTORY:
3−5
Menarche at the age of 14 years Abbreviated as: 14
28
Past menstrual cycles were:
Regular cycles of 28days
Duration flow for 3-5days

2-3 fully soaked pads per day

Associated with dysmenorrhea and clots
7. PAST OBSTETRIC HISTORY: (N/A in this case which is G1P1).
Only for multigravida
Spacing of birth between 1st and 2nd child – ____ years.

Example Table

S. Ante-Natal
Year Labour Puerperium Baby
No. Period
Sex – Male
Spontaneous NVD BW- 2.5 kg
1. 2000 39 weeks at hospital by Normal Now 23 years
doctor old, alive and
healthy
Sex – Female
BW – 2.7 kg
Spontaneous NVD
2. 2002 40 weeks Normal Now 21 years
at home by midwife
old, alive and
healthy
Spontaneous
abortion D & E No
3. 2004 12 weeks -
(Dilatation & complications
Evacuation)
8. HISTORY OF PRESENT PREGNANCY:
ANTE-PARTUM
1st Trimester:
Spontaneous conception
Pregnancy was diagnosed by urine pregnancy test and confirmed at
the _______ hospital at 8 weeks.
Td 1st dose was taken at 12 weeks
Folic acid (0.5 mg) supplements were given
Dating scan and NT scan was done at 8weeks and 12 weeks
respectively were said to be normal.

History of nausea and vomiting. (Increased beta hCG)

History of increased frequency of micturition and thirst.
History of fatigue.
History of breast discomfort.
No history of bleeding or discharge Per vagina.
No H/O burning micturition.
No H/O excessive vomiting.
No history of fever with rash. (R/O Rubella, Varicella)
No history of exposure to radiation.
No history of drug intake.
Routine investigation of blood (CBC/Hb, Blood grouping & Rh, TSH,
FBS/ RBS/ HbA1C, HIV, VDRL, HBsAg), urine (Urine RE/ME, Urine culture &
sensitivity for asymptomatic bacteria) and PAP smear were done and found
to be normal.
2nd Trimester:
Quickening was felt at 18weeks. (Normal quickening at 16-18 weeks in
multigravida & 18-20 weeks in primigravida  Confirms dating of pregnancy)
Td 2nd dose was given at 16weeks. (Vaccination in pregnancy- Td/
TdaP (ACOG), Influenza, Covid)
Folic acid (0.5 mg) supplements were continued.
Iron (60 mg) and calcium (500 mg BD) tablets were started.
Anomaly scan was done at 20th week and was said to be normal.

No history of headache, nausea, vomiting, blurring of vision, epigastric

pain, palpitation and pedal edema.
 No history of excessive weight gain, excessive hunger and thirst,
increased frequency of micturition, fatigability.
No history of burning micturition.
No history of bleeding or leaking per vagina.
Routine investigation of blood (CBC/ Hb, 75 gm OGTT between 24-28
weeks) and urine (Urine RE/ME, Urine culture & sensitivity for asymptomatic
bacteria) were done and found to be normal.

3rd Trimester:
Continued to perceive fetal movements.
Iron and calcium tablets were continued.
Internal growth scan was done and said to be normal.
History of exertion and breathlessness.

No history of nausea and vomiting.

No history of blurring of vision, epigastric pain and pedal edema.
No history of excessive weight gain, excessive hunger and thirst,
increased frequency of micturition, fatigability.
No history of burning micturition.
No history of bleeding or leaking per vagina.
Routine investigation of blood and urine were found to be normal.

INTRA-PARTUM
Patient started having spontaneous rhythmic progressive
contractions at 6am on 04.02.2024 while at 39 weeks POG, upon which she
was admitted to CNMC&H.
Labour events:
Spontaneous
Episiotomy was given in 2nd stage
No complications in 3rd stage of labour, episiotomy repaired
She delivered vaginally after 6 hours of labour without the use of
forceps / ventouse in cephalic presentation. Placenta was delivered within
half an hour.
Baby Details: Female child of weight 2.7 Kg was born, who cried immediately
after birth. She did not require any resuscitation efforts and her APGAR score
was 10 throughout.
POST-PARTUM
Child:
• Breastfeeding started within 1 hour of delivery.
• Frequent (8-10 times) feeds from both breasts, each session lasting for
20-30 min
• Baby sleeps peacefully after feeds
• No pre-lacteal feed given
• Baby covered in warm clothes and protected from cold

Mother:
Day 0:
• Discharge P/V started
• Became mobile 4-5 hours after delivery
• Intermittent mild abdominal discomfort
• Started breastfeeding

Day 1:
• Passed Urine
• No abnormalities in discharge
• Difficulty passing stool → perineal discomfort
• No other complaints, no breast complaints
• IFA started
• Counselled about spacing

Day 2:
• Difficulty passing stool
• No other complaints, no breast complaints

9. PAST HISTORY:
No history of Hypertension, Diabetics Mellitus, Thyroid disorders.
No history of Asthma and Tuberculosis.
No history of Epilepsy and Jaundice.
No history of blood transfusions in the past.
No history of surgeries in the past.
 No H/O Anaesthetic Difficulties in Previous Surgery
No H/O Blood Transfusion
No H/O any known drug allergy
[Enquire regarding following Surgeries:
General:
Cholecystectomy
Appendicectomy
Any Laparotomy
Gynecological:
Abdominal – Myomectomy, Oophorectomy
Vaginal –
VVF Repair
CPT Repair
Amputation of Cervix
Fothergill’s Operation]
10. FAMILY HISTORY:
No significant family history.
No history of hypertension, diabetics mellitus, thyroid disorders.
No history of asthma and tuberculosis.
No history of multifetal pregnancy, congenital anomalies.
11. PERSONAL HISTORY:
Good appetite.
Difficulty in bowel movements since past 2 days
Bladder normal.
Sound sleep.
No addictive habits.
12. DIETARY HISTORY:
Time Food item Amount Calorie (Kcal) Protein (gm)
Morning
Afternoon
Evening
Night
Calories:
Consumed: ____ kcal Required: ____kcal Deficit: ____ kcal (__%)

Protein:
Consumed: ___ gm Required: ____ gm Deficit: ___ gm (__%)
13. CONTRACEPTIVE HISTORY:
14. GENERAL PHYSICAL EXAMINATION:
Verbal consent was taken. [Ensure presence of a Female Attendant.]
Patient is Conscious, Alert, Cooperative
Well oriented to time place and person.
Patient is mobile with normal gait.
Examination was done under adequate exposure of light.
Moderately built and moderately nourished
Decubitus of Choice – Sitting comfortably
Anthropometry:
Height: 155cm
Pre pregnancy weight: 48kgs
Post-delivery weight: 54kgs [Weight gain in pregnancy: 9- 12
kg, reduces by 3 kg after delivery, but some weight is put on]
BMI: 22.48 kg/m²
Pallor - Present
Icterus - Absent
Cyanosis - Absent
Clubbing – Absent
Pedal edema – Absent
Lymphadenopathy - Absent
Neck Glands – Not palpable
Head to Toe examination:
Chloasma seen over forehead and cheek.
Breast – Normal Nipple areola complex (Correct
Inverted nipple, if present by syringe method)
Spine, Thyroid were normal.
Tongue, Teeth, Gums - Normal
Calf Muscle Tenderness – Absent [R/O DVT]
Vitals: Pulse-
BP-
RR-
Temperature-
15. SYSTEMIC EXAMINATION:

Breast Examination
Inspection:
Both breasts uniform in Shape and Position, Nipples placed centrally
surrounded with areola, non-retracted, no scars and inflammation seen, no
abnormal discharge from nipples.

Palpation:
Both breasts non-tender
No engorgement
No mass felt

Per Abdominal examination: (Obstetric examination)

Ask her to flex her knees in dorso-supine position.
Patient is asked to void urine.
After taking verbal consent, abdomen was exposed from xiphisternum
to symphysis pubis.

Inspection:
Ovoid in shape.
Umbilicus is centrally placed and non-everted.
All quadrants moving well with respiration.
Linea nigra, stria gravidarum seen
No engorgement of veins
No swelling visible
No scars seen
Hernial orifices are intact.
Palpation:
All the inspected findings are confirmed.
Local temperature not raised.
Superficial: No tenderness, no mass, no organomegaly
Deep: Mild tenderness over hypogastrium
Fundal height: 12 cm above pubic symphysis
Consistency of Uterus – Firm [Soft → R/O PPH]
Percussion:
Shifting dullness absent
Auscultation:
Normal bowel sounds heard
Per Vaginal examination was not done

Other Systems
Respiratory system: Normal vesicular breath sounds heard, no added sounds.
Cardiovascular system: S1 and S2 heard and were normal, no murmur.
Central nervous system: Patient was conscious and well oriented, no FND.

16. EXAMINATION OF BABY:

History:
Female Child
Alive
Birth Weight – 2.7 Kg
Cried immediately after birth
Received BCG, bOPV-0, HepB Birth doses
No pre-lacteal feed given
Stool – Passed once, semi-solid
Urine – Passed twice

Examination:
Weight – 2.7 Kg
No swelling on the scalp
Oral Mucosa – Pink in Colour
Skin – Pink in colour (no signs of icterus, abrasion, lanugo hair)
Condition of Umbilicus – Not fallen, clamp present
Palate, Lip – Normal
Palmar Creases – Multiple present
Nipple – Full areola, Breast buds ~ 1 cm in size
Genitalia – Female child, labia majora completely covers the labia minora
No congenital anomaly
Signs of Maturity present

Reflexes:
Moro – Not done
Rooting – Present
Sucking – Present
Swallowing – Present
17. PROVISIONAL DIAGNOSIS:
A booked case of 24 years old primigravida named Mrs ABC from XYZ
belonging to Class 2 SES according to modified BG Prasad classification
and ANC card holder is GTPAL (G1P1), in 2nd day of her puerperium after
the normal vaginal delivery (with episiotomy) of a healthy baby girl of
weight 2.7 kg.

18. SUMMARY: Mrs. ABC, aged 24 years, Primigravida married for 2 years (or
3rd gravida, P2+0 L. 9-2-M) was admitted on _____ for Normal Vaginal
Delivery with an episiotomy at 39 weeks POG. First and second stages of
labour were uncomplicated and followed by the third stage without any
delay. She delivered a healthy baby girl of weight 2.7 kg. She is now in 2nd
day of puerperium and complains of vaginal discharge and lower
hypogastrium pain. She had H/O appendicectomy 4 years back. Her father
is hypertensive and mother is of normal health.
On general examination, her height is 5 feet, weight 54 kg., Pallor .......... +,
Oedema .......... Present, Pulse .......... /min., BP .......... mm. of Hg (or may write
normotensive) and any other positive findings.
Both Breasts normal, nipples central, non-retracted, surrounded by areola.
On obstetrical examination, fundus is 12 cm above pubic tubercle (normal
uterine involution)

The baby is alive, weighing 2.7 kg, mature and breast-fed and has been
immunized with BCG, bOPV-0, HepB Birth dose

Mrs. ABC is provisionally diagnosed as a mother in normal puerperium.

VIVA POINTS
1. Further Investigations:
CBC – 10g/dL
Rest parameters fine
2. Management
• Stool softener, plenty of water and Isabgol for constipation
• Reassurance for vaginal discharge as it is normal
• Cold bath or Ibuprofen for perineal discomfort