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Obstetric Fistula An Overview

Obstetric Fistula An Overview. Contents. What is obstetric fistula? Epidemiology Vesicovaginal Fistula Why do fistulas occur in young girls? The obstructed labor injury complex Treatment Surgical management of urinary incontinence after obstetric fistula repair Campaign to end fistula

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Obstetric Fistula An Overview

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  1. Obstetric FistulaAn Overview

  2. Contents • What is obstetric fistula? • Epidemiology • Vesicovaginal Fistula • Why do fistulas occur in young girls? • The obstructed labor injury complex • Treatment • Surgical management of urinary incontinence after obstetric fistula repair • Campaign to end fistula • References

  3. “ My name is Zorah. I am 14 years old. I was promised in marriage when I was 3, betrothed at 10, and pregnant at 12. After 3 days of labor, I was carried on a stretcher to a hospital, where my baby died 2 hours later. The obstructed labor left me incontinent. I smell, and I feel so ashamed. Federation International Gynecologists Obstetricians

  4. “Every minute, a woman dies in pregnancy or childbirth, and for every woman who dies, 20-30 others will survive but with morbidity, one of which is obstetric fistula” 13 .

  5. Obstetric fistula (or vaginal fistula) is a severe medical condition in which a fistula (hole) develops between either the rectum and vagina or between the bladder and vagina after severe or failed childbirth, when adequate medical care is not available

  6. What is obstetric fistula? • Injury of childbearing from prolonged obstructed labor w/o timely medical intervention – (typically a caesarean section) to relieve the pressure. • The baby usually dies. • The women is left with chronic incontinence. • Women often abandoned by husband and family, and ostracized by her community. • Prospects for work and family life greatly diminished.

  7. 18th Century obstetrical drawing of obstructed labor from absolute cephalopelvic disproportion. From William Smellie’s Sett of Anatomical Tables, 1752. Epidemeology1 Source: The Lancet 2006; 368: 1201-1209

  8. How big a problem is this? • Estimates of 2-7 million women affected. • Estimates of >75,000 new cases each year. • Estimates of 3-5 cases per 1000 pregnancies in developing countries. • Limited indigenous surgical repair capability. • Cultural and religious worldviews serve to perpetuate the status quo: • “whatever will be, will be” • In many places women currently have neither the education, resources, nor rights to change the underlying causes of fistula. • Note: the occurrence in the western world approaches 0. Source: Aust N Z J Surg 2000; 70: 851–854

  9. Socioeconomic factors in obstetric fistula formation. • Younger women predisposed to dystocia due to narrow pelvic architecture. • Marriage at early age, before pelvis growth is complete. • Malnourishment retards maturation. • Lack of access to emergency obstetric services. • Poverty, illiteracy and limited educational opportunities. • Note: Maternal mortality and obstetric fistula rates in Western Europe and the USA at the beginning of the 20th century were similar to those in the developing world today…dramatically reduced between 1935 and 1950 due to access to emergency obstetric services. Source: Lancet 2006; 368: 1201-1209.

  10. Moderate-sized vesicovaginal fistula from obstructed labor. Catheter passed through the urethra is clearly visible through the bladder base, which is missing. Vesicovaginal Fistula1 Source: Source: The Lancet 2006; 368: 1201-1209

  11. Rectovaginal Fistula • Most rectovaginal fistula result from poorly repaired obstetric lacerations • Proper recognition and repair of obstetric lacerations can eliminate most RV fistula

  12. Why do fistulas occur in young girls? • Increased incidence of cephalopelvic disproportion. • Pelvic bone immaturity. • Reduced birth canal size before age 18. • Reduced inlet, midplane, outlet dimensions. • Onset of puberty later in malnourished women. • Net = “Low” gynecological age. • Chronological age minus the age at menarche. • Younger age at marriage.

  13. Small (44Kg) Short (<150 cm) Married Early (mean age = 15.5 years) Now Divorced 49% Separated 22% Uneducated 78% Poor/Rural (>95%) Developed fistula as primagavida 46% 824/899 fetal deaths 75/899 live births 14 died in first month >50% of these women endured fistula for 1-9 years before seeking treatment. Avg. fistula 3.5 cm 92% repair success The Typical Patient14 Source: Am J Obstet Gynecol 2004; 190: 1011-1019

  14. Articles on Association of Age, Gynecologic Age, Cephalopelvic Disproportion, and Obstructed Labor15 Source: J Midwife Womans Health 2005; 50: 286-294.

  15. Urological injury Vesicovaginal fistula Urethrovaginal fistula Ureterovaginal fistula Uterovaginal fistula Complex combined fistulas Urethral damage, including complete urethral destruction Bladder stones Stress incontinence Marked loss of bladder tissue from extensive pressure necrosis Secondary hydroureteronephrosis Chronic pyelonephritis Renal failure Gynecological injury Amenorrhoea Vaginal stenosis Cervical injury, including complete cervical destruction Secondary pelvic inflammatory disease Secondary infertility Gastrointestinal injury Rectovaginal fistula formation Rectal stenosis or complete rectal atresia Anal sphincter incompetence Musculoskeletal injury Osteitis pubis Neurological injury Foot-drop from lumbosacral or common peroneal nerve injury Complex neuropathic bladder dysfunction Dermatological injury Chronic excoriation of the skin from maceration by urine or faeces Fetal injury Fetal case-fatality rate of about 95% Social injury Social isolation Divorce Worsening poverty Malnutrition Depression (sometimes with suicide) Premature death The obstructed labor injury complex10 Source: The Lancet 2006; 368: 1201-1209

  16. >90% of neonates stillborn, another 3% died the first week postpartum. Cause of death usually asphyxia or septicemia. After intrauterine fetal death, the head collapses, which facilitates vaginal birth Complications of obstructed labor: pressure necrosis of neonatal scalp2 Source: The Lancet 2006;368: 1210

  17. Factors include: Socio-economic Nutrition Education/literacy Early marriage Harmful traditional practices (female circumcision). Psychosocial damage Result: Suffering ,illness, and premature death. The obstetric fistula pathway1 Source: Source: The Lancet 2006; 368: 1201-1209

  18. Common comorbitities associated with Fistula • Gynecologic • Amenorrhea • PID • Musculo-Skeletal • Lower limb contracture 20 to nerve damage. • Neurological • Foot drop from sacral and perineal nerve compression • Neurogenic bladder dysfunction • Dermatologic • Ammmonical dermatitis • Vulvar excoriation Source: Campaign to End Fistula Printed Materials

  19. Psychosocial damage resulting from obstetric with fistula • More devastating than the physical injury. • Divorce and abandonment. • Cast out by their families. • Social Pariahs. • Many treated as having received a punishment from God for sexual misbehavior. • Depression, anxiety and other forms of mental health dysfunction common. Source: Lancet 2006; 368: 1201-1209.

  20. Early Detection and Treatment. • Catheterization • Viable treatment during first 90 days +/-. • Avoid urine flowing through fistula. • Promotes spontaneous closure of fistula. • Foley for 6-8 weeks. • Prevention • For women in prolonged labor. • Continuous catheterization. • Administration of antibiotics postpartum.

  21. Fistula Examination .

  22. Simple vs. complicated vesicovaginal fistula.5 Source: Am J Obstet Gynecol 2006; 195: 1748-1752.

  23. Treatment • Surgery to repair the fistula. • At cost of $250+/- plus transport costs. • Few hospitals with few trained surgeons. • Rehabilitation • Stretching and mobilizing limbs. • Physiotherapy of lower limbs, foot. • Psychological and emotional counseling. • Employment skill building. • Outreach • Crucial to recruiting women for treatment. • Locate, educate, and transport. • Treated women as role models.

  24. Preoperative Care • Early detection/treatment of fistula is rare. • Fistulas in patients exist for months to years. • Malnutrition and Anemia • Physical Therapy • Lower limb weakness. • Muscular contractures. • Complete physical examination • Fistula location with Foley and Dye. • Rectovaginal fistula rule out. • CBC and STD Labs.

  25. Surgery performed in the in dorsal lithtomy position. Careful vaginal examination essential to ensure no other fistulas present. 16-18F Foley placed in bladder. Success Rate >90% reported in multiple studies. Surgical Repair of Vesicovaginal Fistula Source: European Urology 2006; 50: 1000-1005.

  26. Martius Graft

  27. Postoperative Care • Catheters left in place. • Urethral 1 week. • Supra pubic 2 weeks. • Clamped for short periods to accustom the bladder to distention. • Confined to bed rest for 2 weeks. • Bedsore preventative steps. • Abstain from intercourse for >3 month. • Family planning education. • Advise future deliveries be cesarean.

  28. Surgical management of urinary incontinence after obstetric fistula repair12 • >25% of women still incontinent after fistula repair. • Most common in women who had a urethral-vaginal fistula. • Second operation can be done to repair using a combination of uretheralisation (urethral lengthening), plus fibromuscular sling of rectus fascia. Source: BJOG 2006; 113: 475-478

  29. Helping women to reintegrate into society Education and training in work skills. Health education sessions and family counseling services Raising awareness of obstetric fistula locally and globally. Gaining agreement and resources for change. Preventing Obstetric Fistula Source:Int J Gynecol Obstet 2006; 94: 254-261.

  30. Obstetric fistula and stigma9 • Women’s Dignity Project (WDP) work on obstetric fistula has two main themes: • Poverty, which precludes access to care, and • Power of society to reject, banish and isolate • Three types of engagement by WDP: • Action-oriented research • Partnerships of people and institutions committed to equitable treatment of women • Challenging underlying policies that create and perpetuate stigmatizing conditions and poverty Source: The Lancet 2006; 367: 535-536

  31. Campaign to end fistula • A part of the United Nations Population Fund (UNFPA), goals include: • Universal access to reproductive health services by 2015 • Universal primary education and closing the gender gap in education by 2015 • Reducing maternal mortality by 75 per cent by 2015 • Reducing infant mortality • Increasing life expectancy • Reducing HIV infection rates Source: Campaign to End Fistula Printed Materials

  32. Campaign to end fistula www.endfistula.org/movie/wm_english.htm

  33. Summary • A very real problem with an annual rate of new cases > indigenous repair capability. • The pool of affected women is growing faster then the ability to effect surgical repair, even if it was freely available to all who needed it. • The surgery repair is moderately complex and inexpensive, but the real need is to avoid the occurrence of obstetric fistula in the first place. • Success will require fundamental changes: • in the availability of emergency obstetric treatment • in tradition and cultural mores regarding early marriage, • and an elevation in the respect for the human rights of women in general, and young girls in particular, in the developing world.

  34. Every Baby Should be Well Born and Wanted

  35. References • Wall LL. Obstetric vesicovaginal fistula as an international public-health problem. Lancet 2006; 368: 1201-1209. • Van Beekhuizen HJ, Unkels R, Mmuni NS, Kaiser M. Complications of obstructed labour: pressure necrosis on neonatal scalp and vesicovaginal fistula. Lancet 2006; 368: 1210. • Norman AM, Breen M, Richter HE. Prevention of obstetric urogenital fistulae: some thoughts on a daunting task. Int Urogynecol J 2006; (Epub ahead of print). • Pushkar DY, Dyakov VV, Kosko JW, Kasyan GR. Management of urethrovaginal fisyulas. European Urology 2006; 50: 1000-1005. • Roenneburg ML, Genadry R, Wheeless CR. Repair of obstetric vesicovaginal fistulas in Africa. Am J Obstet Gynecol 2006; 195: 1748-1752. • Mishra SK, Morris N, Uprety DK. Uterine rupture: preventable obstetric tragedies? Aus and NZ J of Obstet and Gynecol 2006; 46: 541-545. • Jokhio AH, Kelly J. Obstetric fistulas in rural Pakistan. Int J Gynecol Obstet 2006; 95: 288-289. • Serour GI, (FIGO Committee Report). Ethical guidelines on obstetric fistula.Int J Gynecol Obstet 2006; 94: 174-175. • Bangser M. Obstetric fistula and stigma. Lancet 2006; 367: 535-536. • Donnay F, Ramsey K. Eliminating obstetric fistula: Progress in partnerships. Int J Gynecol Obstet 2006; 94: 254-261. • Ramphal S, Moodley J. Vesicovaginal fistula: obstetric causes. Curr Opin Obstet Gynecol 2006; 18: 147-151. • Browning A. A new technique for the surgical management of urinary incontinence after obstetric fistula repair. BJOG 2006; 113: 475-478 • WHO. In: Lewis G, de Bernis L, editors. Obstetric fistula: guiding principles for clinical management and program development. Geneva: WHO Press; 2005. • Wall LL, Karshima JA, Kirshner C, Arrowsmith SD. The Obstetric vesicovaginal fistula: characteristics of 899 patients from Jos, Nigeria. Am J Obstet Gynecol 2004; 190: 1011-1019. • Miller S, Lester F, Webster M, and Cowan B. Obstetric fistula: A preventative tradegy. J Midwife Womans Health 2005; 50: 286-294. • R.F. Zacharin, A history of obstetric vesicovaginal fistula, Aust N Z J Surg 2000; 70: 851–854

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