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Duty Report

Wednesday, October 26th 2016


Supervisor:

dr. Sanusi Piliang, SpOG

Duty Team :
dr. Ade Ayu Chartyansari
dr. Irvan Arifianto
dr. Devi M. Syam
dr. Vivi Yovita
dr. Ivan C. Pasaribu
Department of Obstetric and Gynecology
Faculty of Medicine University Sumatera Utara
Pirngadi General Hospital
2016

Reported:
1. Post Perineal Laceration Grade IV Repair

N
o

Case

1 Mrs. H, 26 yo, P1A0


Dx:Post Perineal Laceration Grade
IV Repair
S:
O:
SP: sense : CM
BP
: 120/80mmHg
pulse : 80 x/i
RR
: 18 x/i
T
: 36,8 C
SL : Abd : Lax, perictaltic (+)
FH
: 1 fingers above
umbilicus, adequate uterine
contraction
Vaginal bleeding : (-), lochia
(+) rubra
Micturation : (+), via chateter
Defecation : (-)
P : -IVFD RL + Oxytocin 10IU
20dpm
-Inj. Ceftriaxone 1gr/12hr
-Drip Metronidazole 500mg/8hr

Procedure
Plan:
-Monitoring
urine
output, vital sign
and
vaginal
bleeding

Result

PATIENT 1

Mrs. H, 26 yo, P1A0, Bataknese, Christian, Senior High School,


housewife, wife of Mr. S, 29 yo, Bataknese, Christian, Senior High
School, enterpreneur, admitted to Pirngadi General Hospital on
October 26th 2016 with:
CC
: Placenta isnt born
T
: This had been exeperienced by the patient since she
was in labor at 14.50 WIB today on the clinic. The baby
born with birth weight 3100gr without episiotomy and
she hasnt received uterotonic.
History of previous illness
:History of previous medication
:-

History of pregnancy:
1. This pregnancy

Present State
Sens
: full alert
Anemia
: (-)
BP
: 130/90 mmHg
Icteric
: (-)
HR
: 84 times/min
Cyanotic
: (-)
RR
: 20 times/min
Dyspnea
: (-)
Temp
: 36.7C
Edema
: (+), pretibial +/+
KPR / APR : +/+
Generalized state
Head
: Eyes: Conj palpebra anemia(-/-), icteric sclera
(-/-)
cataract on ES
Ears: were within normal limits
Neck
: No enlargement of lymph node
Thorax
: Pulmo: Vesicular, no additional sound
Cardiac: Normal heart sound, no murmur/gallop
Extremity Sup : Edema (-)
Extremity Inf : Edema (-)

Localicate state
Abdomen
: symetrically enlarged
Fundal height : 3 fingers above umbilical
Vaginal bleeding
: (+)
Gaenocological state
Inspection
: Seen perineal laceration grade IV (fourchette,
perineal skin, vaginal mucosa, muscles, anal
sphincter, and rectal mucosa are torn), Blood
flow
(+)

Laboratorium report October 26th 2016 at 16.33 WIB


Hb
: 12,5 g/dL
N: 12-14/gr/dl
Haematocrit
: 36,3%
N: 36,0-42,0/%
Trombocyte : 314.000/mm3
N: 150.000-400.000/Ul
WBC
: 27.510/mm3
N: 4000-11000 U/L
Ureum
: 10 mg/dL
N: 10-50 mg/dL
Creatinin : 0.54 mg/dL
N: 0.6-1.2 mg/dL
SGOT
: 26 U/L
N : 0-40 U/L
SGPT
: 13 U/L
N : 0-40 U/L
BG adr
: 111 mg/dL
N: <140 mg/dL
PT
: 13.8
C : 15
INR
: 1.13
N : 1-1.3
apTT
: 38.3
C : 33.9
HbsAg
: Negative
HIV
: Negative

Diagnosis :
Retensio plasenta + perineal laceration grade IV + Post
partum outside
Therapy :
- Emptying bladder
- Active management third stage
- IVFD RL + Oxytocin 10 IU 20dpm
- With the streching umbilical cord at 16.15WIB, plasenta was
born, impression complete.
Plan :
- Repair perineal laseration in the emergency operating room

Post Perineal Laceration grade IV


Repair
Mother laid in ginecology table with i.v. line and chateter installed
properly
Under GA-TIVA, Aseptic and antiseptic protocol was performed
using povidone iodine 10% and 70% alcohol in the abdominal
wall. The abdomen was then covered with sterile doek except the
operating field
Perineal laseration with 7cm of length on recti mucose.
Recti mucose was sutured with simple suture using vycril 3.0 with
a distance of 0,5cm each suture. External anal sphingter was
sutured with end to end anastomosis with vycril 3.0. Posterio
vaginal wall was sutured with simple suture using chromic 2.0.
Observation of the sutured scars,bleeding was under controlled
Mother condition after perineal laseration repair was stable.

Laboratorium report October 26th 2016 at 23.00 WIB


Hb
: 15.4 g/dL
N: 12-14/gr/dl
Haematocrit
: 42.4 %
N: 36,0-42,0/%
Trombocyte : 264.000/mm3
N: 150.000-400.000/Ul
WBC
: 31.850/mm3
N: 4000-11000 U/L

Thank You

FOLLOW UP

27th October 2016 at 08 a.m


S:O

:
Vital sign
Sensorium : Compos Mentis
BP : 110/70 mmHg
HR : 88 x/i
RR : 20 x/i
T : 36,5 C

Physical and genital examination


Abdomen : Soepel,
Normoperistaltic
Fundal height : 1 fingers below
umbilicus
Vaginal bleeding : (-), Lochia (+)
Rubra
Micturition : (+) via catheter
Defecation : (-) flatus (+)
A:
- Post Perineal Grade IV repair
P:
- IVFD RL 20 gtt/i
- Ceftriaxone inj 1 gram/12 hours
- Metronidazole drip 500mg/8hours
- Ketorolac inj 30 mg/8 hours
- Ranitidine Inj 50mg/12hours

28th October 2016 at 08 a.m