Subjective – J.J. is a homemaker and artist who completed four years of college. Besides, she also did a one-week postpartum, G3P2002, vaginal labor with SVD to a baby boy named Chase. She is also married and has a family. J.J stated that she had no complications during work, and she is currently breastfeeding, 8-10 times in a day, whenever the baby is hungry. The patient says the baby latches on just fine, and she denies any feeling of engorgement or mastitis. Besides, she had an LNG-IUS placed after birth, and she is yet to resume sexual activity.
Moreover, patient states lochia discharge being a pinkish/brownish color, denies any visual of clots, and goes through 3-4 pads a day. The patient, however, denies any cramps or leg pain or any abnormal perineum pain. She mentions performing proper perineum care. Emotionally, the patient states that she is feeling “fine” and denies any feelings of postpartum blues. Nonetheless, she says that she can easily manage depression symptoms with medication. J.J. denies any sensation of threats within any of her relationships and states not having any concern. She claimed that she currently has a stable relationship with the baby and that all household members have adjusted to accommodate her. Besides, her baby boy has a healthy sleep and fine in his crib. J.J. and her husband state performing circumcision care by keeping it hydrated and keeping pampers loose.
Objective – J.J. and her husband appeared comfortable and knowledgeable about the postpartum period. Throughout the encounter, they demonstrated maturity and ability to attend and learn the information necessary for a successful postpartum period.
Postpartum labs: Hemoglobin or hematocrit (10.5/31)
Assessment – Satisfactory 1-week postnatal course, transitioning well. Knowledgeable in breastfeeding and postpartum care since this is her third child, and she had done it before.
Plan – J.J. will continue to have a satisfactory postpartum period without any complications.
- Cervical muscles will begin to regenerate à patient will perform Kegels.
- Forms of contraceptives will be continued àpatients will keep contraceptives in place.
- Bowel/ urinary elimination pattern will remain normal à patient will increase her fluid and fiber intake.
- Patient emotional wellbeing will remain baseline for the patient à she will take her depression medications as prescribed and reach out to support symptoms if any depressive symptoms are to arise.
- Lochia’s discharge will cease after two weeks à patients will continue to monitor her discharge output and refrain from picking up anything more substantial than her newborn baby.
- The patient will attend all her follow-up appointments.