Obstetric FistulaAn OverviewBrad R MacKinnonUniversity of Vermont Contents.
What is obstetric fistula Epidemiology Vesicovaginal Fistula Why do fistulas occur in young girls The obstructed labor injury complex.
The obstetric fistula pathway Treatment Surgical management of urinary incontinence after obstetricfistula repair Campaign to end fistula.
References My name is Telanish Shabera Iam 14 years old I was promisedin marriage when I was 3 betrothed at 10 and pregnant at.
12 After 3 days of labor I wascarried on a stretcher to ahospital where my baby died 2hours later The obstructed laborleft me incontinent I smell and I.
feel so ashamed Source McKenna N Fistula pilgrims Federation International Gynecologists Obstetricians 3 dies in pregnancy orchildbirth and for every.
woman who dies 20 30others will survive butwith morbidity one ofwhich is obstetric fistula Source G Lewis WHO Press 4.
What is obstetric fistula Injury of childbearing from prolonged obstructedlabor w o timely medical intervention typically acaesarean section to relieve the pressure The baby usually dies .
The women is left with chronic incontinence Women often abandoned by husband andfamily and ostracized by her community Prospects for work and family life greatlydiminished .
Source Campaign to End FistulaPrinted Materials 5 Epidemeology 1 18th Centuryobstetrical drawing of.
obstructed labor fromcephalopelvicdisproportion From WilliamSmellie s Sett of.
Anatomical Tables Source The Lancet 2006 368 1201 1209 6 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 Limited indigenous surgical repair capability Cultural and religious worldviews serve to perpetuate thestatus quo .
whatever will be will be the will of God Allah 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 7 Socioeconomic factors in obstetricfistula formation African 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 rates in Western Europe andthe USA at the beginning of the 20th century were similarto those in the developing world today dramaticallyreduced between 1935 and 1950 due to access toemergency obstetric services .
Source Lancet 2006 368 1201 Vesicovaginal Fistula 1 Moderate sizedvesicovaginal fistulafrom obstructed labor .
Metal catheter passedthrough the urethra isclearly visible throughthe bladder base which is missing .
Source Source The Lancet2006 368 1201 1209 9 Why do fistulas occur in young Increased incidence of cephalopelvicdisproportion .
Pelvic bone immaturity Reduced birth canal size before age 18 Reduced inlet midplane outlet dimensions Late onset of puberty Malnutrition .
Net Low gynecological age Chronological age age at menarche Younger age at marriage The Typical Patient 14 Small 44Kg 824 899 fetal deaths.
Short 150 cm 75 899 live births Married Early mean age 14 died in first month 15 5 years 50 of these women Now Divorced 49 endured fistula for 1 9.
Separated 22 years before seekingtreatment Uneducated 78 Avg fistula 3 5 cm Poor Rural 95 92 repair success.
Developed fistula asprimagavida 46 71 fetuses were Source Am J Obstet Gynecol2004 190 1011 1019 11.
Articles on Association of Age Gynecologic Age Cephalopelvic Disproportion and Obstructed Labor15Authors Description Key FindingsChumlea et USA Cross sectional study of Median age at menarche 12 43al 2003 2510 females age 8 20.
Moerman USA Longitudinal study of Pelvic inlet midplane and outlet clinically contracted during1982 clinical laboratory and x rays of early adolescence 17 growth of pelvis continues for 3 y90 adolescent girls after menarcheTreffers 2002 Global Literature review Obstructed labor a major health problem for young adolescentgirls particularly in specific geographic regions.
Zlatnik and USA Records review of 1005 Gynecologic age is the chronologic age minus age atBurmeister girls 17 menarche Patients with low gynecologic age 2 y have an1977 increased likelihood of delivering a low birth weight babycompared to those with gynecologic age 2 y independent ofchronologic age.
Source J Midwife WomansHealth 2005 50 286 294 12 The obstructed labor injury Urological injury Gastrointestinal injuryVesicovaginal fistula .
Rectovaginal fistula formationUrethrovaginal fistula Rectal stenosis or complete rectal atresiaUreterovaginal fistula Anal sphincter incompetence.
Uterovaginal fistula Musculoskeletal injuryComplex combined fistulasOsteitis pubisUrethral damage including complete Neurological injury.
urethral destruction Foot drop from lumbosacral or commonBladder stones peroneal nerve injuryStress incontinenceComplex neuropathic bladder dysfunction.
Dermatological injuryMarked loss of bladder tissue fromextensive pressure necrosisChronic excoriation of the skin frommaceration by urine or faeces.
Secondary hydroureteronephrosis Fetal injuryChronic pyelonephritis Fetal case fatality rate of about 95 Renal failure Social injury Gynecological injury .
Social isolationAmenorrhoea Vaginal stenosis Worsening povertyCervical injury including complete .
Malnutritioncervical destruction Depression sometimes with suicide Secondary pelvic inflammatory disease Premature death.
Secondary infertilitySource The Lancet 2006 368 1201 1209 13 Complications of obstructed labor pressure necrosis of neonatal scalp2.
90 of neonatesstillborn another 3 died the first weekpostpartum Cause of death.
usually asphyxia orsepticemia After intrauterine fetaldeath the headcollapses which.
facilitates vaginal birthSource The Lancet 2006 368 The obstetric fistula pathway 1 Factors include Socio economic.
Education literacyEarly marriageHarmful traditionalpractices Psychosocial damage.
Result Suffering illness andpremature death Source Source The Lancet2006 368 1201 1209 15.
Common comorbitities associatedwith Fistula GynecologicAmenorrhea Musculo Skeletal.
Lower limb contracture 20 to nerve damage NeurologicalFoot drop from sacral and perineal nerve compressionNeurogenic bladder dysfunction Dermatologic.
Ammmonical dermatitisVulvar excoriationSource Campaign to End FistulaPrinted Materials 16 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 apunishment from God for sexualmisbehavior Depression anxiety and other forms ofmental health dysfunction common .
Source Lancet 2006 368 1201 Early Detection and Treatment CatheterizationViable treatment during first 90 days Avoid urine flowing through fistula .
Promotes spontaneous closure of fistula Foley for 6 8 weeks PreventionFor women in prolonged labor Continuous catheterization .
Administration of antibiotics postpartum Fistula ExaminationReprinted with permission fromthe WHO H Rochat 19 Simple vs complicated.
vesicovaginal fistula 5Source Am J Obstet Gynecol2006 195 1748 1752 20 Treatment Surgery to repair the fistula .
At cost of 250 plus transport costs Few hospitals with few trained surgeons RehabilitationStretching and mobilizing limbs Physiotherapy of lower limbs foot .
Psychological and emotional counseling Employment skill building OutreachCrucial to recruiting women for treatment Locate educate and transport .
Treated women as role models Preoperative Care Early detection treatment of fistula is rare Fistulas in patients exist for months to years Malnutrition and Anemia.
Physical TherapyLower limb weakness Muscular contractures Complete physical examinationFistula location with Foley and Dye .
Rectovaginal fistula rule out CBC and STD Labs Urethrovaginal fistula before A and after B surgical repair 4 Surgery performed in the.
in dorsal lithtomy position Careful vaginalexamination essential toensure no other fistulas 16 18F Foley placed in.
Success Rate 90 reported in multipleSource European Urology 2006 50 1000 1005 23 Postoperative Care.
Catheters left in place Urethral 1 week Urinary 2 weeks Clamped for short periods to accustom the bladder todistention .
Confined to bed rest for 2 weeks Bedsore preventative steps Abstain from intercourse for 3 month Family planning education Advise future deliveries be cesarean .
Surgical management of urinaryincontinence after obstetric fistula repair12 25 of women stillincontinent after fistula Most common in women.
who had a urethral vaginal fistula Second operation can bedone to repair using acombination of.
uretheralisation urethrallengthening plusfibromuscular sling ofrectus fascia Source BJOG 2006 113 475 .
Addis Ababa Fistula Hospital Fistula Ward Reprinted with permission fromthe WHO P Virot 26 The forgotten fistula patients Helping women to.
reintegrate into society Education and training inwork skills Health educationsessions and family.
counseling services Raising awareness ofobstetric fistula locallyand globally Gaining agreement and.
resources for change Source Int J Gynecol Obstet2006 94 254 261 27 Obstetric fistula and stigma9 Women s Dignity Project WDP work on.
obstetric fistula in eastern Africa has two mainPoverty which precludes access to care andPower of society to reject banish and isolate Three types of engagement by WDP Action oriented research.
Partnerships of people and institutions committed toequitable treatment of womenChallenging underlying policies that create andperpetuate stigmatizing conditions and povertySource The Lancet 2006 367 .
535 536 28 Campaign to end fistula A part of the United Nations Population Fund UNFPA goals include Universal access to reproductive health services by 2015Universal primary education and closing the gender gap in education by 2015.
Reducing maternal mortality by 75 per cent by 2015Reducing infant mortalityIncreasing life expectancyReducing HIV infection ratesUniversal access to reproductive health services by 2015.
Universal primary education and closing the gender gap in education by 2015Reducing maternal mortality by 75 per cent by 2015Reducing infant mortalityIncreasing life expectancyReducing HIV infection rates.
Campaign launched in 2003 and performing detailed needsassessment Source Campaign to End FistulaPrinted Materials 29 Campaign to end fistula.
Click on flash player link below or go to web address listedto start videoUNFPA Video Player Flash Player Installation urlhttp www endfistula org movie ... 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 effectsurgical repair even if it was freely available to all who needed it The surgery repair is uncomplicated and inexpensive but the realneed is to avoid the occurrence of obstetric fistula in the first place .
Under WHO leadership an organized needs assessment andawareness campaign has started to soon to evaluate results Success will require fundamental changes in the availability of emergency obstetric treatmentin tradition and cultural mores regarding early marriage .
and an elevation in the respect for the human rights of women ingeneral and young girls in particular in the developing world My take is that this is a monumental effort and will only occur ifpiggybacked with other broader programs related to human.
The Typical Patient14 Articles on Association of Age, Gynecologic Age, Cephalopelvic Disproportion, and Obstructed Labor15 The obstructed labor injury complex10 Complications of obstructed labor: pressure necrosis of neonatal scalp2 The obstetric fistula pathway1 Common comorbitities associated with Fistula Psychosocial damage resulting from ...

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