DATE PATIENT DETAIL OF PATIENT TREATMENT RECOMMENDATION

1. 20-04- Mrs. R P1A0 - Hematoma Evacuation - Vaginal hygiene

2022 UROGYNECOLOGY AND RECONSTRUCTIVE
DOB : 10/11/2000 Referred from Morowali Hospital with PELVIC DIVISION / Radhiah Karim
- Repair 4th degree perineal
Sanrang
- Avoid constipation
(21 years old) Vulva Hematoma and urinary th retention laceration - Use of stool softener for 2
MR : 139626 Period 20
with 2000 ml residual volume. –24 th
April 2022
- Sphincteroplasty : weeks
Educational Status History of vaginal delivery in public  Rectal mucosa repaired with - Avoid sexual intercourse
Senior High health centre. PGA 3.0 interrupted for 10 weeks
School  IAS repaired with PGA 3.0
BPJS Pre-Operative Diagnosis : - Educate to increase fiber
mattress horizontal intake and drinking plenty of
Right Vulva Hematoma + Post partum
 EAS repaired with PGA 2.0 water
Hasanuddin Urinary Retention Aa+ 4 degreeBa
th
of C
+3 +3 overlapped
+4 technique. - Perform pelvic floor and
University Hospital perineal laceration
- Perineal muscle repaired with anal sphincter exercise
Post-Operative GH Diagnosis : Pb PGA 2.0 continuous suture - Evaluation sphincter
TVL
Right Vulva Hematoma
5 + Post 3partum - 6Vaginal mucosa repaired with healing in 1-3-6-9-12 weeks
Urinary Retention + 4 degree of
th PGA 3.0 continuous suture and every 12 months
perineal laceration - Lactulose syrup 15 ml
Ap Bp D - Inform the patient about
+3 +3 NAbid/oral
the risk of recurrence, the
- Urine catheterization for 72
risk of developing anal
hours (since Morowali) +
incontinence and mode of
Starting Bladder training on
delivery for the future
4th day
pregnancy
- Misoprostol 200 mcg/8
- Avoid rectal suppositories
hours/oral
- Sodium Diclofenac 50 mg /8
hiurs/oral
- Neurobion 5000mg/drips/day
- Ceftriaxone 1 gram/12
hours/intravena
- Metronidazole 500 mg/8
hours/intravena

Pre Operative Intra Operative Post Operative

 UROGYNECOLOGY AND RECONSTRUCTIVE PELVIC DIVISION / Radhiah Karim Sanrang
Period 20th –24th April 2022

Total Case :
- Hematoma Evacuation + Repair 4th degree laceration :1
- Sacrospinosus fixation + Anterior colporrhaphy + Posterior colporrhaphy :1

Makassar , April 25th 2022

Supervisor,

dr. David Lotisna, Sp.OG (K)