IUGA Scoring System (3)
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Transcript of IUGA Scoring System (3)
Scoring System to Predict Levator Ani Injury in Vaginal Delivery
BUDI IMAN SANTOSO, SpOG(K) Department of Obstetric and Gynecology, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
Mortality and Quality of Life
“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”
“Therefore a mother must not be died during pregnancy or delivery, thereafter they should have a good quality of life. That’s
what we called complete.”
WHO: Definition of “Health”
LEVATOR ANI AVULSION & PELVIC FLOOR DYSFUNCTION
It carries the risk of:
• Urinary incontinence
• Fecal incontinence
• Pelvic organ prolapse
• Sexual dysfunction
Cost & Quality of Life Problems
Which one do we prefer?Caesarian section or vaginal
delivery?
Lavender T, et al. Cochrane Database of Systematic Reviews 2012, Issue 3. Art. No.: CD004660.
Mother’s request for C-section…
What is the real reason?Pain? Age? Timing? Pelvic Floor Dysfunction
(Incontinence, Prolapse, Sexual Dysfunction) ? Or simply the doctor’s busy schedule?
LET’S DO THE COUNT!!
THE DECISION OF C-SECTION DEPENDS ON:
Obstetricians
FETUS MOTHER
Health system
Obstetrical Uni-HospitalMidwives
Society
Childbirth
WHAT IF…
• We could predict the occurrence of levator ani avulsion?
• We could recognize those women who are at risk to have PFD?
• Impossible like the crystal ball? • As precise as measuring the nautical mile?
(compass, telescope, sextant)
A prospective cohort study has been conducted in Jakarta as an attempt to predict levator ani avulsion caused by vaginal delivery
HP DIETZ1, BUDI IMAN SANTOSO2
Nepean University of Sydney & University of Indonesia
FAKTOR RISIKO OBSTETRIK
FETAL BIRTH WEIGHT>3500 gVAGINAL LACERATION/
EXTERNAL ANAL SPCHINCTER TEAR
EPISIOTOMYSECOND STAGE > 1 HOURVACUUM/FORCEPS DELIVERY
PELVIC FLOOR DYSFUNCTION
DEMOGRAPHIC RISK FACTORS
OLD MATERNAL AGE BODY MASS INDEX ETHNICITY
TRAUMA ON PUDENDAL NERVE
TEARS OF PUBORECTALIS MUSCLE
LEVATOR ANI AVULSION AFTER VAGINAL CHILDBIRTH
EXCESSIVE STRAIN (BIOMECHANIC)
Urinary Incontinence
Fecal Incontinence
Pelvic organ prolapse
Sexual dysfunction
OUR CONCEPT
• Design: quantitative, cohort
• June 2010 – Desember 2011 at Cipto
Mangunkusumo Hospital
Subjects were nulipara women who had their vaginal birth
at maternal age of 37 weeks or more
The exclusion criteria were: complications of pregnancy or
other comorbidities, were not able to deliver the baby
at the study sites and subjects who already had levator
ani avulsion prior to the delivery.
METHOD
Levator ani avulsion was evaluated using 4D pelvic floor
USG during pregnancy, six weeks and three months after
delivery
METHOD
RESULTS… Two prediction models were obtained:
• The discrimination value (AUC) :• model 1 = 0.921 (95%CI: 0.859-0.983) • Model 2 = 0.976 (95%CI: 0.948-1.000)
Parameter Comparison between model 1 and model 2
Prognostic value Prognostic value of model 2 is better than model 1. However, the prognostic values of both models are quite strong.
Feasibility Model 1 is feasible in all health care centers. Almost every health care personnel are able to evaluate stage 2 labor and perform episiotomy.
Model 2 is feasible for health care centers where the medical personnel able to evaluate perineum rupture.
Model 1 and Model 2
Variables Patient’s
scoreTotal score
Conclusion
Probability of avulsion on three-month observation
Risk classification
Episiotomy Score 0 Score 1 Score 2 Score 3 Score 4
1.04.4
16.746.979.5
Low risk (total score of 0-1) Moderate risk (total score of 2) High risk (total score of 3-4)
Yes (score 1)
No (score 0)
Stage 2 labor
≥65 minutes (score 2)
<65 minutes (score 0)
Fetal birth weight
≥3325 gram (score 1)
<3325 gram (score 0)
Name : ___________________________ Age : ___________________________Medical record number : ___________________________
SCORING CARD – MODEL 1
Suggestion:______________________________________________________________________________
Name : ___________________________ Age : ___________________________Medical record number : ___________________________
SCORING CARD – MODEL 2
Suggestion:______________________________________________________________________________
Variables Patient’s
score Total score
Conclusion Probability of avulsion on three-month observation
Risk classification
Perineum rupture Score 0
Score 1
Score 2
Score 3
0.50
5.60
40.20
88.30
Low risk
(total score of 0-1)
High risk
(total score of 2-3)
Yes (score 2)
No(score 0)
Second stage ≥65 minutes (score 1) <65 minutes (score 0)
A patient has the following characteristics: had undergone episiotomy, duration of second stage labor ≥65 minutes, and fetal birth weight ≥3325 gram. How great the probability of bad avulsion on 3 month observation and what is the risk classification?
SCORING CARD – MODEL 1 SAMPLE
Suggestion: The subject is at high risk for levator ani damage. Normal delivery may cause levator ani injury in this subject. Please discuss with your physician for the best mode of next delivery.
______________________________________________________________________________
Variables Patients’
ScoreTotal score
Conclusion Probability of avulsion on three-month observation
Risk classification
Episiotomy1
4
Score 0 Score 1 Score 2 Score 3 Score 4
1.04.4
16.746.979.5
Low risk (total score of 0-1) Moderate risk (total score of 2) High risk (total score of 3-4)
Yes (score 1) No (score 0)Second stage
2 ≥65 minutes (score 2) <65 minutes (score 0)Fetal birth weight
1 ≥3325 gram (score 1) <3325 gram (score 0)
A patient has the following characteristics: perineum rupture grade 3 and 4 and second stage labor of ≥65 minutes. How great the probability of bad avulsion on three month observation and the risk classification?
SCORING CARD – MODEL 2SAMPLE
Suggestion: The subject is at high risk for levator ani damage. Normal delivery may cause levator ani injury in this subject. Please discuss with your physician for the best mode of next delivery.
______________________________________________________________________________
Variables Patient’s
scoreTotal score
Conclusion
Probability of avulsion on three-month observation
Risk classification
Perineum rupture
2
3
Score 0
Score 1
Score 2
Score 3
0.50
5.60
40.20
88.30
Low risk
(total score of 0-1)
High risk
(total score of 2-3)
Yes (score 2)
No (score 0)
Stage 2 labor
1 ≥65 minutes (score 1) <65 minutes (score 0)
For the well-being of Indonesian Women
"Every baby's first breath on Earth could be one of peace and love. Every mother should be healthy and strong. Every birth could be safe and loving. But our world is not there yet,"
Mother Robin Lim – Winner of CNN Heroes 2011