Patient Information: Anne Haydon History, Medications, and Lab Work

Patient information:

Anne Haydon is a 19 year old gravida 1 Para 1 39 weeks’ gestation who delivered a healthy male infant at 2030 yesterday. She is a high school graduate who works as a CNA at a local long term skilled nursing facility while she attends community college. Her long term goal is to become a nurse.

Anne currently lives with her mother who is very supportive of Anne. Anne plans to return to her job and college studies following her maternity leave. Anne is a non-practicing Lutheran. She denies alcohol intake during her pregnancy, denies smoking during her pregnancy, admits to occasional use of marijuana during the first two trimesters of her pregnancy. Anne has a history of Diabetes Mellitus Type 1, initially diagnosed at age 11. Anne admits to not consistently following her prescribed diabetic regimen but “I did pretty well with it while I was pregnant”.  Anne is currently using an insulin pump to manage her diabetes; it is a basal-bolus regimen using Lispro insulin (Humalog). Anne also states that the baby’s father is not involved, and she will be raising her son alone with the assistance of her mother.

Lab work (pre-delivery):

Blood type A

Ph: Positive

Antibody screen: Negative

Hemoglobin 12.2

Hematocrit: 36%

WBC: 8,200

Platelets: 172,000

STI: Negative for Gonorrhea and Chlamydia

Hepatitis B: Negative

Urine culture: Negative

Urinalysis: protein negative. Positive presence of glucose

A1C: 6.8

Fasting glucose: 152

Rubella: Immune

Home medications:

Daily prenatal vitamin

Lispro insulin via insulin pump

Acetaminophen (Tylenol) 500 mg prn discomfort/headache

Anne admits to taking a daily baby aspirin (80 mg). She states that her OB-GYN did not prescribe it but takes it because she heard it would protect her placenta against Covid.

Birth was vaginal with use of forceps to facilitate delivery of infant. Anne received a 250 ml bolus of Pitocin 30 units/500 ml IV after the delivery of the placenta then received 125 ml/hour of LR until the IV bag was completed.

Baby information:

Infant Apgar’s were 8 and 9. Weight: 7 lbs. 0 oz. 3.2 kg 20 inches (30.8 cm) long. Baby breast fed and latched on for five minutes each side three times post-delivery. Anne held infant skin to skin during remainder of birth process.

Post-delivery day 1:

Current orders:

Vital signs Q ½ hour following delivery, then q 4 hours X 24 hours, then q 8 hours

Diet:Regular

Activity: ad lib as tolerated, may shower when stable and ambulatory

IV therapy: Lactated Ringer’s solution at 125 ml/hour, DC when vital signs are stable, vaginal bleeding normal, and toleration PO fluids well

Add oxytocin 10 units to IV immediately after delivery of placenta

Dermoplast spray to hemorrhoids, apply to episiotomy prn if requested, , as often as 6 X/hour

Tucks pads at bedside prn for hemorrhoids, may be applied to rectum as often as 6 X/hour

Bisacodyl suppository 10 mg or Fleet Enema daily prn for constipation, if requested

Colace tab 1 po at bedtime prn for constipation, if requested

Magnesium hydroxide/aluminum hydroxide/simethicone (Maalox) 30 ml po, if requested, as often as 1 X/hour for indigestion

Prenatal vitamin 1 po daily as dietary supplement

Ibuprofen (Motrin) 800 mg po q 8 hour prn for cramping pain

Acetaminophen (Tylenol) 325 mg 1-2 tab po q 3 hour prn for mild to moderate pain

Oxycodone/acetaminophen (Percocet) 5/325 mg 1 tab po q 4 hour prn for severe pain

Zolpidem (Ambien) 5 mg po at bedtime prn for sleep, if requested

RhoGAM if RH negative and eligible

CBC 24 hour postpartum

Ice to perineum X 12 hour postpartum

Sitz bath q 4 hour after 12 hour for perineal discomfort

Continue home blood glucose control protocol as per home