Clinical case presentation pg

1. Case presentation 6
Presented by,
Vishnu vardhan S
RA2122204010004
MPT ORTHOPAEDICS I YEAR
02/11/2021

2. DEMOGRAPHIC DATA:
Name: mrs. Mathubala
Age: 27
Gender : female
UHID NO: 2180978 ; Date of assessment: 01/11/2021
Address: Urappakkam
Chief complaint: pt complaints of discomfort on back while feeding the baby in sitting
posture
Present history: pt has underwent vaginal delivery with episiotomy on 31/10/2021 and
now presented with discomfort on sitting while feeding.

3. Past history: no relevant history
Obstetrics history
Vitals : BP: 100/60 mmhg; PR: 76 bpm
On observation:
● Body built: mesomorphic
● Posture: slouched sitting
● Gait: wide based
No. Of
delivery
Mode of delivery Any
complications
Baby sex Baby weight
1 Vaginal delivery - Male 2.80kg
2 Vaginal delivery - Male 2.75kg

4. On palpation : at episiotomy site
● Warmth : present
● Tenderness: grade 2
● Swelling: present
On examination:
● Range of motion and power was unable to check since patient said she was tired and not willing to do.
● Infant feeding:
- mode: breast feed
- Nipple: everted; breast size: medium; areola : dark pigmented
- Posture: slouched sitting position
- Hold: cradle hold
- Latch on: areola part is covered into baby’s mouth; mother can hear the sucking sound
- Frequency: 2 hours once

5. Provisional diagnosis:
Vaginal delivery with episiotomy PND-1 has difficulty in feeding while sitting.
Management:
● Goals:
- To teach relaxation techniques
- To teach breastfeeding techniques
- To teach back support and feeding positions
- To encourage pelvic floor muscles strengthening
- To encourage ambulation

6. ● Means:
- Active range of motion to bilateral limbs encouraged
- Breathing exercises and relaxation techniques emphasised
- Back support with pillows on low back
- one pillow on lap while feeding the baby
- Kegel’s exercises encouraged
- Ambulation within the ward

7. Thank you