1. Obstetric Fistula An 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
“ 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, 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. Epidemeology1
18th Century obstetrical drawing of obstructed labor from absolute cephalopelvic disproportion.
From William Smellie’s Sett of Anatomical Tables, 1752.
Source: The Lancet 2006; 368:

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:

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

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. Source: Am J Obstet Gynecol 2004; 190: 1011-1019
The Typical Patient14
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
Source: Am J Obstet Gynecol 2004; 190:

14. Source: J Midwife Womans Health 2005; 50: 286-294.
Articles on Association of Age, Gynecologic Age, Cephalopelvic Disproportion, and Obstructed Labor15
Authors
Description
Key Findings
Chumlea et al., 2003
USA: Cross-sectional study of 2510 females age 8–20
Median age at menarche: yrs (105 lbs)
Moerman, 1982
USA: Longitudinal study of clinical, laboratory, and x-rays of 90 adolescent girls
Pelvic inlet, midplane, and outlet clinically contracted during early adolescence (<17); growth of pelvis continues for 3 y after menarche
Treffers, 2002
Global: Literature review
Obstructed labor a major health problem for young adolescent girls, particularly in specific geographic regions
Zlatnik and Burmeister, 1977
USA: Records review of 1005 girls <17
Gynecologic age is the chronologic age minus age at menarche; Pregnant patients with low gynecologic age (<2 y) have an increased likelihood of delivering a low birth weight baby compared to those with gynecologic age >2 y; independent of chronologic age
Source: J Midwife Womans Health 2005; 50:

15. The obstructed labor injury complex10
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
Source: The Lancet 2006; 368:

16. Complications of obstructed labor: pressure necrosis of neonatal scalp2
>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
Source: The Lancet 2006;368: 1210

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

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:

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:

23. Treatment Surgery to repair the fistula. Rehabilitation Outreach
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. Surgical Repair of Vesicovaginal Fistula
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.
Source: European Urology 2006; 50:

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:

29. Preventing Obstetric Fistula
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.
Source:Int J Gynecol Obstet 2006; 94:

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:

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

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:
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:
Roenneburg ML, Genadry R, Wheeless CR. Repair of obstetric vesicovaginal fistulas in Africa. Am J Obstet Gynecol 2006; 195:
Mishra SK, Morris N, Uprety DK. Uterine rupture: preventable obstetric tragedies? Aus and NZ J of Obstet and Gynecol 2006; 46:
Jokhio AH, Kelly J. Obstetric fistulas in rural Pakistan. Int J Gynecol Obstet 2006; 95:
Serour GI, (FIGO Committee Report). Ethical guidelines on obstetric fistula. Int J Gynecol Obstet 2006; 94:
Bangser M. Obstetric fistula and stigma. Lancet 2006; 367:
Donnay F, Ramsey K. Eliminating obstetric fistula: Progress in partnerships. Int J Gynecol Obstet 2006; 94:
Ramphal S, Moodley J. Vesicovaginal fistula: obstetric causes. Curr Opin Obstet Gynecol 2006; 18:
Browning A. A new technique for the surgical management of urinary incontinence after obstetric fistula repair. BJOG 2006; 113:
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:
Miller S, Lester F, Webster M, and Cowan B. Obstetric fistula: A preventative tradegy. J Midwife Womans Health 2005; 50:
R.F. Zacharin, A history of obstetric vesicovaginal fistula, Aust N Z J Surg 2000; 70: 851–854