This is post-operative case of 25 years old, Parity2 Living2 Abortion0, fourth post-partum day following lower section cesarean section due to obstructed labor.
Name: ************ *********
Age: 26 years
Sex: Female
Address: ************ ***********
Occupation: Teacher
Education: Bachelor level
Religion: *******
Husband’s name: ******** *** ******
Husband’s occupation: Teacher
Duration of marriage: 4 years
** name of patient, husband and address are hidden for privacy of the patient.
P2 L2 A0
LMP (Last menstrual period): 19 May 2021
EDD (Expected date of delivery): 26 February 2022
DOD (Date of delivery): 23 February 2022
POG (Period of gestation): 40 weeks
DOA (Date of Admission): 22 February 2022
DOE (Date of examination) 27 February 2022
Chief complaints
Today is fourth post-partum day following lower section caesarian section due to obstructed labor. Today she complaints of pain at incision site.
History of present illness:
According to the patient, she was apparently well 5 days back with at her 40th week of pregnancy. She developed labor pain, which was at lower abdomen, sudden on onset, gradually progressive, dull aching, radiating towards back and thigh without known relieving factors. The pain lasted for 2 minutes with 5 minutes of pain free duration. There was no history of fever, burning micturition and per vaginal discharge. She was brought to obstetric ward of ……. Hospital and kept under observation for 8 hours. There was no progression of labor as the presenting part was not descending. She was diagnosed obstructed labor and undergone for emergency Lower section caesarian section.
Today is fourth post-partum day and she complains pain at incision site, which was acute on onset, dull aching, not radiation, aggravated on movement and relieved on rest and taking medications. No history of fever, malaise, burning micturition, vomiting.
History of present pregnancy:
Not planned pregnancy, spontaneous conception. Not counselled with doctor before conception.
Pre pregnancy weight: 56 kg (2 months before missed period).
There was missed period and pregnancy diagnosed by UPT kit at home at 4 weeks of due date.
1st trimester:
1 antenatal visit at2rd month. Blood tests and USG done.
Taken folic acid.
There was history of excessive vomiting for which she was under anti-emetic medications.
No history of fever, PV discharge and bleeding, no suprapubic pain, no history of rashes and burning micturition.
According to the patient, her vitals and investigations were at between normal range.
2nd trimester:
Amenorrhea continued.
Quickening perceived at 5th month and were more than 10 fetal movements per day.
3 antenatal visits. Iron, calcium taken. USG done at 5th month and shown no any fetal anomalies.
Taken single dose of Tetanus toxoid at 5th month.
According to the patient, her vitals and investigations were at between normal range.
No history of blurring of vision, headache, suprapubic pain, fever, burning micturition, PV discharge and bleeding.
3rd trimester:
Amenorrhea continued. Continued taking iron and calcium. Continued perceiving fetal movements.
3 antenatal visits. No history of PV bleeding, suprapubic pain, headache, swelling of limbs.
No history of raised BP, fainting attacks.
At term (40th week of gestation) she was undergone for lower section caesarian section due to obstructed labor and delivered live female baby weighing 3.2 kg, cried immediately after birth.
Obstetric History:
P2 L2 A0
| S.N. | Date and year | Pregnancy events | Labor events | Mode of delivery | Puerperium | Baby |
| 1. | 2020-05-18 | Well covered antenatally, uneventful. | Uneventful. | Spontaneous normal vaginal delivery. | Uneventful. | Healthy living, baby boy, weighing 2.9 kg, cried immediately after birth, breastfed till 6 months, well immunized, well and living. |
| 2. | 2022-02-23 | Well covered antenatally, uneventful. | Uneventful | lower section cesarian section due to obstructed labor | Uneventful | Healthy living, baby girl, weighing 3.2 kg, cried immediately after birth, breastfed till now, well immunized till now, well and living. |
Menstrual History:
LMP (Last menstrual period): 19 May 2021
Menarche at 11 years of age.
Cycle occurred at 28-30 days, regular, the period lasted for 4 days with 2 pads per day and no clots passed. There was no history of dysmenorrhea.
Past history:
No history of DM, TB, Hypertension, thyroiditis and asthma in past. No history of surgeries in past.
Drug and allergy history:
No known drug reactions and food allergy in past.
Family history:
No history of DM, TB, Hypertension, thyroiditis and asthma in her parents, other family member and siblings.
No history of multiple pregnancies, fetal anomalies in family. No history of blood dyscrasias in family.
Socioeconomic history:
There are 4 members in family, 2 of them are earning members. The house is paucca, 4 rooms with proper ventilation, separate kitchen and toilet. Use water from tap and cook food in gas.
Personal history:
Mixed diet, no history of alcohol intake and cigarette smoking. Normal sleep, appetite, bowel and bladder habits.
Contraceptive history:
No history of use of contraception.
