Scoring System to Predict

Levator Ani Injury in

Vaginal Delivery
BUDI IMAN SANTOSO S!O"#$%
Department of Obstetric and Gynecology,
Faculty of Medicine, Universitas Indonesia,
Jakarta, Indonesia
Mortality and Quality of ife
Health is a state of complete physical, mental and
social well-being and not merely the absence of
disease or infrmity
Therefore a mother must not be died during
pregnancy or delivery, thereafter they should have
a good quality of life. Thats what we called
complete.
WHO: Definition of Health
OU!I"#
evator $ni $vulsion
Pelvic Floor defects:
a hidden epidemic defects for the last 60 years
L&VATO' ANI AVULSION ( P&LVI) *LOO'
D+S*UN)TION
It carries t,e ris- o./
%
Urinary
incontinence
%
*ecal incontinence
%
Pelvic organ
!rola!se
%
Se0ual
dys.unction
Cost & Quality of Life Problems
&'ic' one do (e prefer)
*aesarian section or vaginal
delivery)
Lavener !" et al# Co$hrane Database of %ystemati$ &evie's (0)(" *ssue +# ,rt# -o#: CD00.660#
Lavener !" et al# Co$hrane Database of %ystemati$ &evie's (0)(" *ssue +# ,rt# -o#: CD00.660#
?
Mot'er+s re,uest for *-
section.
&'at is t'e real reason)
/ain) $ge) !iming) /elvic Floor Dysfunction
0Incontinence, /rolapse, 1e2ual Dysfunction3 )
Or simply t'e doctor+s busy sc'edule)
L&T1S DO T2& )OUNT33
/elvic Floor Dysfunction 4
t'e real reason)
!5# D#*I1IO" OF *-1#*!IO"
D#/#"D1 O"6
Obstetricians
FETUS MOTHER
Health system
Obstetrical
UniHospital
Mid!ives
Society
"hildbirth
&5$! IF.
/
&e could predict t'e occurrence of
levator ani avulsion)
/
&e could recogni7e t'ose (omen ('o
are at risk to 'ave /FD)
/
Impossible like t'e crystal ball)
/
$s precise as measuring t'e nautical
mile) 0compass, telescope, se2tant3
1o, fear of /FD after vaginal birt'))
8no(ledge s'ould be
/O&#9 instead of F#$9
PELVIC FLOOR DYSFUNCTION
Pelvic 4oor
dys.unctio
n
Levator ani
avulsion
Vaginal
delivery
5c,ild6irt,
S"OR#$% S&STEM
! prospective cohort study has been
conducted in "a#arta as an attempt to
predict levator ani avulsion caused by
vaginal delivery

HP DIETZ
1
, BUDI IMAN SANTOSO
2
Nepean University of Sydney University of
Indonesia
*A$TO' 'ISI$O
OBST&T'I$

*&TAL BI'T2
7&I"2T89:;; g

VA"INAL
LA)&'ATION5
&<T&'NAL ANAL
SP)2IN)T&' T&A'

&PISIOTOM+

S&)OND STA"& 8 =
2OU'

VA)UUM5*O')&PS
D&LIV&'+
P&LVI) *LOO'
D+S*UN)TION
D&MO"'AP2I) 'IS$
*A)TO'S

OLD MAT&'NAL
A"&

BOD+ MASS
IND&<

&T2NI)IT+
T'AUMA ON
PUD&NDAL
N&'V&
T&A'S O*
PUBO'&)TALIS
MUS)L&
L&VATO' ANI
AVULSION A*T&'
VA"INAL )2ILDBI'T2
&<)&SSIV&
ST'AIN
#BIOM&)2ANI
)%
Urinary
Incontinence
*ecal
Incontinenc
e
Pelvic organ
!rola!se
Se0ual
dys.unction
OU! "ON"EPT
/
Desi0n: 1uantitative" $ohort
/ 2une (0)0 3 Desember (0)) at Ci4to 5an0un6usumo
Hos4ital
Su6jects (ere nulipara (omen ('o 'ad t'eir vaginal
birt' at maternal age of :; (eeks or more
T,e e0clusion criteria (ere6 complications of
pregnancy or ot'er comorbidities, (ere not able to
deliver t'e baby at t'e study sites and sub<ects ('o
already 'ad levator ani avulsion prior to t'e
delivery=
M&T2OD

$evator ani avulsion was evaluated using %&
pelvic 'oor ()* during pregnancy, si+ wee#s
and three months after delivery
M&T2OD
9#1U!1
9#1U!1.
!(o prediction models (ere obtained6
/ !'e discrimination value 0$U*3 6
/ model , - ../0, 1/23456 ..72/-../789
/ :odel 0 - ../;< 1/23456 ../%7-,....9
/arameter *omparison bet(een model > and
model ?
/rognostic
value
/rognostic value of model ? is better
t'an model >= 5o(ever, t'e prognostic
values of bot' models are ,uite strong=
Feasibility Model > is feasible in all 'ealt' care
centers= $lmost every 'ealt' care
personnel are able to evaluate stage ?
labor and perform episiotomy=
Model ? is feasible for 'ealt' care
centers ('ere t'e medical personnel
able to evaluate perineum rupture=
Model > and Model ?
MO'E( ) MO'E( *
!5# 1*O9I"G *$9D6 B>I>S>A
0@UDI IM$" 1$"!O1O $11#11M#"!3
Aariables
/atient+
s score
!otal
score
*onclusion
/robability of avulsion on
t'ree-mont' observation
9isk classiBcation
#pisiotomy
1core C
1core >
1core ?
1core :
1core D
>=C
D=D
>E=;
DE=F
;F=G
o( risk
0total score of
C->3
Moderate risk
0total score of
?3
5ig' risk
0total score of
:-D3
Hes 0score >3
"o 0score C3
1tage ? labor
IEG minutes 0score
?3
JEG minutes 0score
C3
Fetal birt' (eig't
I::?G gram 0score
>3
J::?G gram 0score
C3
"ame 6 KKKKKKKKKKKKKKKKKKKKKKKKKKK
$ge 6 KKKKKKKKKKKKKKKKKKKKKKKKKKK
Medical record number 6 KKKKKKKKKKKKKKKKKKKKKKKKKKK
1*O9I"G *$9D 4 MOD# >
1uggestion6
KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK
"ame 6 KKKKKKKKKKKKKKKKKKKKKKKKKKK
$ge 6 KKKKKKKKKKKKKKKKKKKKKKKKKKK
Medical record number 6 KKKKKKKKKKKKKKKKKKKKKKKKKKK
1*O9I"G *$9D 4 MOD# ?
1uggestion6
KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK
Aariables
/atient+
s score
!ota
l
scor
e
*onclusion
/robability of avulsion
on t'ree-mont'
observation
9isk
classiBcation
/erineum rupture
1core C
1core >
1core ?
1core :
C=GC
G=EC
DC=?C
LL=:C
o( risk
0total score
of C->3
5ig' risk
0total score
of ?-:3
Hes 0score ?3
"o0score C3
1econd stage
IEG minutes
0score >3
JEG minutes
0score C3
, 4atient has the follo'in0 $hara$teristi$s: ha uner0one e4isiotomy" uration of
se$on sta0e labor 768 minutes" an fetal birth 'ei0ht 7++(8 0ram# Ho' 0reat the
4robability of ba avulsion on + month observation an 'hat is the ris6 $lassifi$ation9
1*O9I"G *$9D 4 MOD# >
1$M/#
1uggestion6 !he sub:e$t is at hi0h ris6 for levator ani ama0e# -ormal elivery may
$ause levator ani in:ury in this sub:e$t# Please is$uss 'ith your 4hysi$ian for the best
moe of ne;t elivery#
KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK
Aariables
/atient
s+
1core
!otal
scor
e
*onclusion
/robability of avulsion
on t'ree-mont'
observation
9isk classiBcation
#pisiotomy
>
D
1core C
1core >
1core ?
1core :
1core D
>=C
D=D
>E=;
DE=F
;F=G
o( risk
0total score of
C->3
Moderate risk
0total score of
?3
5ig' risk
0total score of
:-D3
Hes 0score >3
"o 0score C3
1econd stage
?
IEG minutes
0score ?3
JEG minutes
0score C3
Fetal birt' (eig't
>
I::?G gram
0score >3
J::?G gram
0score C3
, 4atient has the follo'in0 $hara$teristi$s: 4erineum ru4ture 0rae + an . an se$on
sta0e labor of 768 minutes# Ho' 0reat the 4robability of ba avulsion on three month
observation an the ris6 $lassifi$ation9
1*O9I"G *$9D 4 MOD# ?
1$M/#
1uggestion6 !he sub:e$t is at hi0h ris6 for levator ani ama0e# -ormal elivery may
$ause levator ani in:ury in this sub:e$t# Please is$uss 'ith your 4hysi$ian for the best
moe of ne;t elivery#
KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK
Aariables
/atient+
s score
!ota
l
scor
e
*onclusion
/robability of avulsion
on t'ree-mont'
observation
9isk
classiBcation
/erineum rupture
?
:
1core C
1core >
1core ?
1core :
C=GC
G=EC
DC=?C
LL=:C
o( risk
0total score
of C->3
5ig' risk
0total score
of ?-:3
Hes 0score ?3
"o 0score C3
1tage ? labor
>
IEG minutes
0score >3
JEG minutes
0score C3
!'e 1oft(are
BLAST System
#$vailable in Indonesian anguage3
Patient *entity
Di the 4atient ha
4erineal ru4ture9
<es=-o
Ho' lon0 'as the
(
n
sta0e labor9
>68 min
?@ 68 min
"oncl+sion:
Levator ,ni ,vulsion
Probability at +
r

month: AA#+ BHi0h
&is6
%u00estion:
*O"*U1IO"
*O"*U1IO"
*O"*U1IO".
*or t,e ?ell@6eing o.
Indonesian 7omen
M#very babyNs Brst breat' on #art' could be one of peace and
love= #very mot'er s'ould be 'ealt'y and strong= #very
birt' could be safe and loving= @ut our (orld is not t'ere
yet,M
Mot'er 9obin im 4 &inner of *"" 5eroes ?C>>
!s the cloud will soon be clear=
>??$ @A >?!B, &?!B=
TH!@C DA(