Case no

Identity
Name : Mrs E
Age : 24 years old
MR : 99 99 62
Address : Kerinci
Education : Housewife
Occupation : Senior high school
Husband
• Name : Mr. D
• Age: 28 years old
• Occupation: Private
• Education: Senior high school
Chief Complain
• A 24 years old patient was admitted to the emergency Room M
Djamil hospital on December 7th 2017 at 11.00 AM was referred from
Obstetri and gynecology polyclinic with diagnose laceration perineum
grade II on P1A0L1 post partum from another institution, Nifas Days 3
Present illness history
• Previously patient was spontaneous partum at clinic in kerinci 3 days
ago. Because of her daughter reffered to M Djamil central general
hospital she came to M.Djamil Central general hospital. Because of
the long journey, she worried about her conditions. And then she
came to obstetri and gynecology polyclinic for check up. After
examination obtained perineal laceration grade II and reffered to
emergency room.
• Fever was absent, trauma was absent
• Miction and defecation were normal
Previous illness history
• There wasn’t previous history of heart, lung, liver, kidney, DM,
hypertension, and allergy.
Family illness History
• There wasn’t history of hereditary disease, contagious and
psychological illness in the family.
Physical examination
GA Cons BP PR RR T
mild CMC 110/70 80 20 Afeb

Eyes : Conjunctiva was not anemic, Sclera wasn’t icteric

Neck : JVP 5-2 cmH2O, tyroid gland no enlargement
Chest : H/L normal
Abdoment : GR
Genitalia : GR
Extremity : Edema -/-, Physiological Reflex +/+, Pathological Reflex -/-
Obstetric Record
Abdoment :
I : no enlarged
Pa : Uterine Fundal 4 fingers below the umbilicus, uterine
contraction good
Pe : Tympani
Au : Bowel peristaltic (+) N
 Genitalia

Inspection: Vaginal bleeding (+).

Vagina was seen perineal laceration of
the vagina wall, the laceration through
40% external of anal sphincter but the
mucous rectal was intake
labotaorium
Parameter Result Normal Value Unit
Hemoglobine 9,8 12-14 g/dl
Leukocyte 7.800 5,0-10,0 103/mm3
Trombocyte 424.000 150-400 103/mm3
Hematocryte 36 37,0-43,0 %
HbsAg (-)
HIV Non reactive
Diagnose : Late HPP due to rupture perineum
grade II on P1A0L1 post spontaneous partum from
another institution
Management :
Control GA, VS
Informed consent
Antibiotic (skin test)

Plan :
Hecting perineal rupture
Dec 7th 2016 12.00 PM
Hecting perineal rupture was perfomed
Blood during operation ± 10 cc.
Diagnose :
Post hecting perineal rupture on indication perineal rupture grade II on
P1A0L1 post spontaneous partum Nifas days 3
Management post op :
Ceftriaxone inj 2 x 1gr IV
PCT 3x150 mg PO
Vit C 3x1 PO
SF 2x1 PO
•Thanks you