• April 13, 2018

Presentation On Obstetric Fistula

Definition of obstetric fistula:

Obstetric fistula  is childbirth injury that occurs in a woman when there is  hole created in between the rectum and the urinary bladder  as a result of prolong labour leaving the woman to be incontinent of urine or feces or both mostly through both urinary and anal passages. The abnormal communication between the vagina and either the bladder anteriorly or the rectum tract posteriorly. It is a complication of childbirth and occurs due to prolonged childbirth most especially in teenage expectant mothers.

Symptoms of obstetric fistula include:

• Flatulence, urinary or fecal incontinence, which may be continual or only happen at night.
• Foul-smelling vaginal discharge.
• Repeated vaginal or urinary tract infections.
• Irritation or pain in the vagina or surrounding areas.
• Pain during sexual activity.
• Infection and inflammation of the genital area resulting in irritation or pain
• Intense pain during sexual activity

Classification based on the location of the obstetric fistula:

• Vesico-vaginal fistula: fistula that connects the urinary bladder and vagina which allows urine to keeps leaking out of the vagina
• Recto- vaginal fistula: fistula that connects the rectum and vagina which allows foul smelling discharge leaks out. Gas may also be discharged.

Causes of obstetric fistula:

Obstetric fistula is usually a problem of underdeveloped countries and is commonly caused to due prolonged, unattended labor. Other possible causes of vaginal fistula include:

• Poorly performed abortions
• Use of episiotomy and forceps during labor
• Pelvic fracture, resulting in a difficult labor
• Cervical cancer therapy with radiation
• Inflammatory bowel disease like ulcerative colitis, crohn’s disease
• Sexual abuse or rape
• Trauma during surgery of vagina, perineum, anus or rectum

There are several indirect risk factors that can end up in causing the obstetric fistula. Some of the risk factors are:

• Poverty: most of the impoverished countries can lack adequate medical infrastructure. They lack of proper medical professionals, medical care and infrastructure to take care of a woman in labor.
• Malnutrition: lack of proper nutrition to the mother makes her vulnerable to diseases. Stunted growth during the growing years of the woman is the result of malnutrition and is associated with underdeveloped pelvic bones. The weak and underdeveloped bones can increase the risk of difficult labor and consequently of obstetric fistula.
• Lack of information: lack of information about maternal health, family pressures about waiting for a normal labor and other complications that may arise during home-births can contribute to the risk factors of developing obstetric fistula.
• Early marriages and childbirth: in under-developed countries like sub-Saharan Africa, many girls are married off as soon as they attain menarche. This is due to the socio-economic factors where the girls are “sold” in marriage for a price. This leads to early childbirth when the girl’s tissues are not ready to take in the pressure. The tragic part is that once these girls develop obstetric fistula, they are shunned by the family and society.
• Status of women in under-developed and developing countries: women in certain societies are dominated by their husband and in-laws who decide about the maternal care to be provided. Some even believe that women are supposed to suffer in childbirth and refuse to go for cesarean section even if it is strongly indicated.

Diagnosis of obstetric fistula:

The symptoms of the obstetric fistula are the basis of diagnosis.

• Physical examination is done to look at the vaginal walls.
• A dye is used in the vagina to find the site of leakage.
• Infection of the vagina is confirmed with local swabs and blood and urine tests.
• An x-ray or Magnetic Resonance Imaging can help in identifying the extent of tissue damage.
• Endoscopy is done to find out the type of fistula and its size.

 Treatment of obstetric fistula

Treatment of obstetric fistula depends on the ability of the tissue to heal. It also depends on the size and location of the fistula. About eighty percent of women can be cured by simple vaginal surgery. Topical or oral medicines are given for the wounds to heal before surgical intervention.
Based on the extent of the damage and size and location of the fistula, various types of vaginal surgery may be done.

• Single-layered technique, using non-absorbable suture
• Flap-splitting technique
• Urethral reconstruction or catheterization
• Saucerization technique
• Using grafts

The surgery may be done directly via the vagina, via the bladder or through the abdomen. A combination of abdominal and vaginal repair may also be chosen depending upon the existing fistula. An opening created between the intestine and the skin on the abdomen in case of a large rectovaginal fistula to divert the intestinal contents so that the fistula is kept clean for surgery. Once the surgical wound heals, the opening called colostomy is closed.

Pathophysiology

For women with obstructed labor, labor that goes unattended, the labor can last up to six or seven days. The labor produces contractions that push the baby’s head against the mother’s pelvic bone. The soft tissues between the baby’s head and the pelvic bone are compressed and do not receive adequate blood flow. The lack of blood flow causes this delicate tissue to die and where it dies holes are created between the laboring mother’s bladder and vagina and/or between the rectum and vagina. This is what produces incontinence or uncontrolled urine or feces  in a fistula patient. Obstetric fistula most commonly occurs among women who live in low-resource countries, who give birth without access to medical help. If a woman’s labor becomes obstructed, she could remain in excruciating pain for days before her baby is finally dislodged. Her baby likely dies and she is often left with an obstetric fistula, a small hole created by constant pressure from the fetal head, which renders her incontinent. Mostly young woman are not matured enough to have children especially those given of for marriage immediately after menarche or their first menstrual period do not have adequate space for the fetal head to pass during delivery so are very prone to obstetric fistula.

Complication of obstetric fistula:

Obstetric fistula has a more severe impact on the social, economic and psychological aspects, apart from the physical symptoms. Affected women are often ostracized from the community due to the smell or continuous leakage of urine. There may be

• Severe ulcerations of the vaginal tract
• Kidney damage
• Infection of the fistula turning it into an abscess
• Paralysis of the lower limbs caused by nerve damage
• Amenorrhea, or absence of menstruation
• Depression
• Infertility