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”

OUTLINE

Levator Ani Avulsion

Pelvic Floor defects: a hidden epidemic defects for the last 60 years

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.

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!!

Pelvic Floor Dysfunction – the real reason?

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)

So, fear of PFD after vaginal birth?? Knowledge should be

POWER instead of FEAR

PELVIC FLOOR DYSFUNCTION

Pelvic floor dysfunction

Levator ani avulsion

Vaginal delivery /childbirth

SCORING SYSTEM

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

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

MODEL 2 MODEL 1

THE SCORING CARD: B.I.S.A (BUDI IMAN SANTOSO ASSESSMENT)

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)

The SoftwareBLAST System

(Available in Indonesian Language)

Patient Identity

Did the patient had perineal rupture?Yes/No

How long was the 2nd stage labor?<65 min>= 65 min

Conclusion:Levator Ani Avulsion Probability at 3rd month: 88.3 (High Risk

Suggestion:

CONCLUSION

CONCLUSION

CONCLUSION…

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

As the cloud will soon be clear…

FEEL NO FEAR, DEAR…

THANK YOU