Client Tracker Check boxes indicate selection of multiple answers if appropriate. I. Quality Assurance Required Data Circles indicate mutually exclusive answer options.
Patient ID:______Patient Initials:____ Date of Assessment (dd/mm/yyyy): ______Contact phone #: ______Facility: ______Facility Record No: ______Phone owner: Country: Patient Child Bangladesh Nigeria Spouse Other family DRC Uganda Spouse family Neighbor/friend Guinea Togo Sibling Other: ______ Niger Other: ______
II. Obstetrics and Gynecology Profile Age on date of assessment (in years): ______Pregnant on data of assessment: Yes Menopause status: No Pre-puberty Pregnancy: Premenopausal Total # births: _____ # live births: ______ Menopausal Age of menopause (in years): ______# stillborn: ______# children alive now: ____ Uterus status: Lactating: Yes No Intact Last menses: ______ Removed Congenitally absent (dd/mm/yyyy or # of weeks prior to exam) Age menarche (in years): ______
III. Pertinent History Prolonged/obstructed labor (P/OL) sequelae of labor reported to have lasted 2 or more days on history (check all that apply): None Other bone sequelum Fistula urinary tract Chronic pelvic or leg pain onset after P/OL Fistula colorectal tract Infertility onset after P/OL Urinary incontinence onset after P/OL Vaginal scarring Fecal/flatal incontinence onset after P/OL Depression or anxiety onset after P/OL Diastasis pubis Stillborn Footdrop Hypoxic liveborn (e.g. flaccid, cerebral palsy, Osteomyelitis developmental delays, other neuro) # prior surgeries for POP symptoms: _____ # prior surgeries for incontinence symptoms: _____ (intact anatomy and/or fistula) Fistula etiology/etiologies (check all that apply): Indeterminate Infection (schistosomiasis, amebiasis, Obstetric labor > 2 days (obstetric = due to lymphogranuloma) ischemia/necrosis from P/OL) Cancer Unclear if obstetric or iatrogenic: obstructed Trauma due to pelvic crush or impalement injury labor > 2 days with cesarean Trauma due to sexual violence Iatrogenic operative vaginal birth Trauma due to genital cutting done by traditional Iatrogenic cesarean birth cutter or vaginal packing traditional rituals Iatrogenic non-obstetric pelvic surgery Trauma due to genital cutting done by licensed Congenital defect - ectopic ureter, cloacal clinician defect, other
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IV. Staging and Diagnoses
Fistula level of complexity (surgeon assessment): Fistula staging system used: Cannot determine (check all that apply and specify staging) Simple None Moderate Goh – specify staging: ______ Complex, eligible for surgical repair Waaldijk – specify staging: ______ Complex, not eligible for surgical repair Panzi – specify staging: ______ Tafesse – specify staging: ______POP staging system used: Other: ______– specify staging: ______(check all that apply and specify staging) None Baden Walker – specify staging: ______ POP Q –specify staging: ______ Other: ______– specify staging: ______
Fistula diagnoses (check all that apply): No fistula Urethro-vaginal fistula – Ureteric fistula to uterus [list R L] Partial Ureteric fistula to vagina [list R L] Posterior urethra absent Vesico-uterine fistula Urethra absent Vesico-cervical fistula Urethra separated from bladder Vesico-vaginal fistula – Urethra not patent Midline, not circumferential Rectovaginal Circumferential High Lateral Mid-vagina Pericervical Low vagina 4th degree tear Pelvic organ prolapse (POP) diagnoses (check all that apply): No POP Posterior POP – enterocele Apex POP – Posterior POP – rectocele Uterus intact, cervix normal length Posterior POP – perineal damage Uterus intact, cervix hypertrophied Posterior POP – perineum completely Uterus out, cuff descending disrupted/absent Anterior POP – Levator(s) not intact (total atrophy) Central defect Levators intact – Paravaginal defect(s) 1. Diastasis: Yes No Central and paravaginal 2. Contraction Normal Absent function: Impaired Incontinence/urinary and colorectal diagnoses (intact anatomy) (check all that apply): None, normal urinary tract & colorectal tract Urinary incontinence – Ureteric stenosis [list R L] Stress (SUI) Kidneys hydronephrosis [list R L] Urge or overactive bladder (OAB) Voiding dysfunction due to bladder outlet Mixed SUI/OAB obstruction up to an including urinary retention Fecal incontinence, sphincteric – Constipation To flatus Severe hemorrhoids To flatus and soft stool Worms To flatus, soft and hard stool
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Genital tract diagnoses (check all that apply): None [normal uterus, tubes, ovaries, vagina, Cancer of ovaries perineum, labia, clitoris] Pelvic tuberculosis Uterine fibroids Vaginal stenosis Endometritis Mild Suspected Asherman's syndrome Moderate Uterine rupture, acute or chronic Severe Cervical laceration Completely scarred shut Cervical stenosis with hematometra Prior FGC Cervix deviated into rectum or bladder No sebaceous cyst(s) Tuboovarian abscess With sebaceous cyst(s) Ovarian mass, cystic or solid Suture granuloma Cancer of cervix Gishiri cutting Cancer of uterus (sarcoma or endometrial) V. Admission Date admitted to facility Admission to facility indicated: (dd/mm/yyyy): ______ Admit for non-surgical No admission indicated therapy – fistula, POP or Admit to hospital for stabilization incontinence before surgery Admit for surgical therapy Admit to housing facility for – fistula, POP or stabilization before surgery incontinence VI. Non-surgical
Non-surgical therapy(s) for fistula, POP, incontinence, genital tract (check all that apply): Overactive bladder medications Pessary (amitryptiline, other anti-cholinergic) Catheter Pelvic floor physical therapy Debridement Dilators Other: ______ Timed voiding bladder drills
Staged treatment indicated: Yes No
Non-surgical therapy outcome(s) for fistula, POP, incontinence, genital tract (check all that apply): Fistula – POP– Incontinence– # of day(s) catheterization as therapy: ______ Worse with pessary Worse No change or worse after catheter therapy No change with No change Smaller but still patent after catheter pessary Somewhat improved, therapy Somewhat improved, persists Closed after catheter - incontinent of urine persist with pessary Significantly improved, Closed after catheter - continent of urine Cured with pessary persists Cured
VII. Surgical
Date of surgery (dd/mm/yyyy): ______Type of anesthesia (check all that apply): Route of operation (check all that apply): No anesthesia General anesthesia - endotracheal tube Vaginal Sedation only Spinal or epidural Abdominal Ketamine Local infiltration Combined vaginal/abdominal Other: ______
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Surgical therapy(s) for fistula, POP, incontinence, genital tract (check all that apply): Fistula Procedures Vaginal – Vaginal – Vesico-vaginal Graft perineal/buttock/groin Small midline R Large circumferential L Multiple R+L "On the bone" lateral Graft peritoneal anterior compartment Peri-cervical Graft peritoneal posterior compartment Vesico-cervical fistula Vesico-uterine fistula Abdominal – Paravaginal bladder mobilization Urethral reanastomosis, circumferential Anterior bladder mobilization Vesicovaginal – Posterior vesico-uterine bladder mobilization O'Conor (bi-valve) Urethral fistula partial Cystotomy (no bi-valve) Urethral re-anastomosis, posterior Vesicouterine Urethral re-anastomosis, circumferential Vesicocervical Urethral reconstruction – anterior bladder tube Uretero-uterine Urethral reconstruction – labial/vaginal skin Recto-uterine tube Rectovaginal Urethral reconstruction – buccal mucosa graft Ureter dissection Urethral reconstruction – other Ureteric catheterization Ureteric "railroad" re-implantation [list R L] Ureteric re-implantation direct Ureteric catheterization Ureteric re-implantation non-refluxing Rectovaginal – Psoas hitch Small-medium Boari flap Circumferential mid-low vagina Graft peritoneal Circumferential high vagina/cervix Graft omental J-flap With 4th degree Vaginal cecum or sigmoid harvest for neo- Rectal advancement flap vagina Levatorplasty interposition over RVF Other concurrent surgeries: ______ Cloacal defects - combination VVF RVF Blue test intra-op – Perineoplasty at RVF Negative Sphincteroplasty at RVF Positive Graft Martius Diversion procedures – R Urinary diversion: type: ______ L Colostomy, type: ______ R+L
POP Procedures Enterocele repair – Apex compartment – Sac not excised Hysteropexy (select suspension anchor below) Sac excised Trachelorrhaphy for cervix hypertrophy, cm excised: ___ Anterior compartment – Hysterectomy (select vaginal cuff suspension Anterior colporrhaphy anchor below) Paravaginal repair – Uterus absent (select vaginal cuff suspension Abdominal anchor below) Vaginal Fallopian tube(s) excised (list R L) Posterior compartment & perineum – Ovary(s) excised (list R L) Colporrhaphy Suspension to: Without levatorplasty Sacrum With levatorplasty Uterosacral ligaments abdominal approach Site-specific rectovaginal fascia repairs Uterosacral ligaments vaginal approach Perineorrhaphy Sacrospinous ligament(s) [list R L] Complete perineoplasty
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Incontinence Procedures Pubovaginal sling – Other urinary incontinence (e.g. bladder augment for low volume, Rectus fascia low compliance bladder), specify: ______ Fascia lata Anal sphincteroplasty – Other Overlapping "vest over pants" Urethropexy – "End to end" Burch/abdominal "U" configuration anchored to perineum fascia Vaginal Anal incontinence operation, type: ______
Genital Tract Procedures Uterine reconstruction for uterine rupture Vaginoplasty – Myomectomy Graft peritoneal or rectus muscle flap Hysterectomy – non-POP indication Neo-vagina large intestine Vaginoplasty – Neo-vagina skin graft (McIndoe) Obliterative or strictured vaginal fibrosis dissection Cervicoplasty Graft labial, perineal or buttock flap Cervical re-vaginalization
Surgical therapy outcome(s) for fistula, POP, incontinence, genital tract (check all that apply): Fistula urinary tract– POP – Incontinence urinary tract SUI – Persists/recurred Not improved no change Closed, incontinent Partial cure reduced Closed, continent Complete cure cured Fistula colorectal tract – De novo urinary Incontinence urinary tract OAB – Persists/recurred incontinence after OAB persistent Closed, incontinent POP surgery OAB de novo Closed, continent De novo colorectal De novo bladder outlet Fistula surgery impact on genital tract - incontinence after obstruction, voiding difficulty Vagina normal contour POP surgery Incontinence colorectal tract – Cervix normal contour and patency De novo vaginal No change Vagina fibrosis requiring stricture after POP Reduced reconstruction surgery Cured Cervix stenotic or other defect De novo rectal stricture causing requiring cervicoplasty pain or constipation
# days catheterization after fistula surgery: ______# of month(s) follow-up: ______VIII. Complications and Sentinel Events Sentinel events summary: Sentinel event(s) occurred, tracker not completed No sentinel event(s) Sentinel event(s) occurred, tracker completed
Treatment complications (check all that apply): Anesthesia & Intra-operative: Post-operative: Cardio-Respiratory: Ureter or kidneys Admission to intensive Uro-peritoneum High spinal Intestines care Feco-peritoneum Aspiration Major blood vessels Post-fistula repair wound Hemo-peritoneum Respiratory Surgical hemorrhage breakdown Hematometra arrest requiring blood Ureteric obstruction Meno-uria Cardiac arrest transfusion Immediate recurrence POP Feco-uria Death intra/post-op in hospital Sepsis IX. Discharge
Date of discharge (dd/mm/yyyy): ______Total length of stay (LOS) at facility (#days):______
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X. Safety Checklists Completed Checklist Completed Check one box for each checklist. 1. Surgical candidacy Not completed Completed partially Completed fully 2. Pre-op clearance Not completed Completed partially Completed fully 3. WHO surgical safety Not completed Completed partially Completed fully 4. Operation report Not completed Completed partially Completed fully 5. Patient transport Not completed Completed partially Completed fully 6. Post-op daily care Not completed Completed not all days Completed all days 7. Discharge summary Not completed Completed partially Completed fully
XI. Family Planning Counseling Sessions Timing of FP Counseling Check only one box, except for questions on method(s). Eligibility & Assessed, eligible – Assessed, not eligible needs Needs FP Not assessed assessed No FP needs Deferred Spermicide Current None IUCD Diaphragm contraception Rhythm Vasectomy Cervix cap 1. Admission method(s) Withdrawal Tubal ligation Oral pills Condom male Abstinence (check all that Depo-Provera Condom female Other: _____ apply) Implant Current Yes contraception Deferred No needs renewal Eligible for FP– 2. Pre- Counseling Not eligible for FP Counsel completed Deferred treatment completed Counsel not completed Eligible, requested – Tubal-ligation Eligible, not offered/no counseling 3. Intra-op Not done during surgery Not eligible Completed Eligible for FP– 4. Post- Counseling Not eligible for FP Counsel completed treatment completed Deferred Counsel not completed Eligible for FP– Counseling Not eligible for FP Counsel completed Deferred completed Counsel not completed Spermicide Contraception None IUCD 5. Discharge Diaphragm method at Rhythm Vasectomy Cervix cap discharge Withdrawal Tubal ligation Oral pills Condom male Abstinence (check all that Depo-Provera Condom female Other: _____ apply) Implant
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