OBSTETRICS AND MIDWIFERY CARE

1. OBSTETRIC FISTULAS
BY C.C MUMBA

2. OBSTETRIC FISTULA
INTRODUCTION
• Obstetric fistula (OF) occurs in
women who are young whose pelvic
bones are not developed, poor and
uneducated in low resource
constraint settings (rural, high
density areas).
• Women lack the means to access
obstetric emergency care.

3. INTRODUCTION CONT....
• Insufficient nutrition due to repeated
infections result in pelvic bone
deformities, stunted growth and the
culture of early marriages predispose
women to risk of obstructed labour
leading to the occurrence of fistulas.

4. INTRODUCTION CONT....
• According to WHO, 2million women
live with OF in the developing world.
• About 50 000 to 100 000 women
are diagnosed with OF each year
(WHO,2018).
• In Zambia, little has been done to
tackle the problem of fistulas. A
situation analysis was done to draw
attention to the prevalence of
obstetric fistulas.

5. INTRODUCTION CONT....
• The analysis was unable to produce a
national prevalence rate.
• However, based on a number of
factors such as hospital deliveries,
home deliveries and distances from
health facilities, it was possible to
estimate the national prevalence of
approximately 500 cases per year
(Langmead and Baker, 2006-2007).

6. OBJECTIVES
At the end of the presentation, the
students should be able to:
• Define fistula and obstetric fistula
• Mention the types of obstetric
fistulas
• State the predisposing factors to
obstetric fistula

7. • Discuss the causes of obstetric
fistulas
• State the clinical presentation of
obstetric fistulas
• Discuss the management of obstetric
fistulas

8. DEFINITION OF KEY TERMS
• FISTULA
• A fistula is a small tunnel or tract
that connects one surface of the
body to another (Cook, 2008).
• VESICO -VAGINAL FISTULA
a. This is the presence of unnatural
opening between the bladder or
urethra and vagina (Sellers, 2010).

9. DEFINITION OF KEY TERMS CONT..
b. It is an abnormal communication
between the bladder and the vagina
(Brooker, 2008).
• RECTO-VAGINAL FISTULA
This is a condition in which an
abnormal opening occurs between
the rectum and the vagina (Fraser
and cooper, 2006).

10. ANATOMICAL RELATIONS OF FEMALE
PELVIC ORGANS
• The structures of importance in
obstetric fistulas are the vagina, the
uterus, the urethra, the urinary
bladder, the ureters, the sigmoid
colon and the rectum.

11. • The vagina is a passage that allows
the escape of the menstrual flow,
receives the penis during intercourse
and provides an exit for the fetus
during delivery. It runs from the
vestibule to the cervix.

12. ANATOMICAL POSITIONS OF THE
FEMALE REPRODUCTIVE ORGANS

13. ANATOMICAL RELATIONS CONT..
• Anteriorly to the vagina lies the
bladder and the urethra which are
closely connected to the anterior
vaginal wall.
• Posteriorly to the vagina lies the
pouch of Douglas, the rectum and
the perineal body, each occupying
approximately one-third of the
posterior vaginal wall.

14. ANATOMICAL RELATIONS CONT...
• Laterally, on either side of the upper
two-thirds are the pelvic fascia and
the ureters, which pass behind the
cervix, on either side of the lower
third are the muscles of the pelvic
floor.

15. • Inferiorly to the vagina lies the
external genitalia while, superiorly to
the vagina lies the uterus.
• Excessive pressure or trauma to any
of these organs lying adjacent to
each other may affect the other
(Hacker and Moore, 1999).

16. TYPES OF OBSTETRIC FISTULA
• The following are some of the types
of obstetric fistulas:
• Vesico-uterine fistula- between the
bladder and the uterus (womb).
• Vesico-vaginal fistula (VVF),
between the bladder and vagina.

17. TYPES OF OBSTETRIC FISTULA CONT...
• Urethro-vaginal fistula (UVF)-
between the urethra (bladder outlet)
and the vagina.
• Recto-vaginal fistula (RVF)- between
the rectum and vagina.
• Ureterovaginal fistula- between the
ureters (kidney tubes) and the
vagina.

18. TYPES OF OBSTETRIC FISTULA

19. PREDISPOSING FACTORS
• Early or closely spaced pregnancies
• lack of access to emergency obstetric
care
• Physical barriers such as poor road
network, limited transportation and
transport costs.
• Contracted pelvis
• Poverty
• Ritual circumcision (genital mutilation)

20. CAUSES OF OBSTETRIC FISTULAS
• INFECTIONS
-anal abscess
-Inflammatory bowel disease such
as diverticulitis and colitis
• TRAUMA
-Injury to the perineum during
child birth, radiation treatment and
sexual violence (rape).

21. CAUSES OF OBSTETRIC FISTULAS
-Forceps delivery
-Ruptured uterus
- Abortions
• Prolonged labour
-Allowing a woman to go into second
stage of labour with a full bladder.
-

22. CAUSES CONT...
• SURGERY
-Hysterectomy
-Caesarean section
-Vaginal and rectal surgery
• OTHERS
-Malignancy
-HIV/AIDS

23. AETIOLOGY
• Obstetric fistulas result from tissue
ischemia and subsequent necrosis during
labour.
• During normal labour, the bladder is
displaced upwards in the abdomen so the
anterior vaginal wall, bladder base, and
urethra are compressed between the
foetal head and the posterior pubis. If
this occurs for a short period of time,
there is no tissue damage.

24. AETIOLOGY CONT...
• If, however, there is prolonged
pressure, the intervening soft tissues
become ischemic.
• This area undergoes pressure
necrosis, and within 3-10 days
postpartum, the tissues slough off
thereby causing an artificial opening
between the bladder and the vagina
or the rectum.

25. AETIOLOGY CONT...
• This therefore results in incontinence
of urine
and or faecal matter.
• Typically, the length of pressure
without relief is more important than
the magnitude of pressure.

26. CLINICAL PRESENTATION
• Urine trickles continuously into the
vagina or it may happen at night.
• Smell of ammonia or urine in the
vagina
• Irritation or excoriation of the skin
around the vulva due to the
continuous presence of urine.

27. CLINICAL PRESENTATION CONT..
• Passage of bowel contents (gas and/or
stool) through the vagina. This is the
most common symptom
• Inflammation of the vagina which
results in burning, itching and
discharge
• Inflammation of the bladder which
causes frequent and sometimes painful
urination
• Fever (38 degrees celsius), chills,
fatigue or weakness

28. MANAGEMENT OF FISTULA
DIAGNOSIS
• History of painless and continuous
vaginal leakage of urine soon after
pelvic surgery
• History of prolonged labour (exceeding
18hours)
• The patient can also give a history of
fecal matter in the vagina
• Vaginal examination will reveal glove
stained with faecal matter

29. MGT CONT....
• Installation of methylene blue dye into
the bladder will discolour a vaginal pack
if VVF is present.
• Cysto-urethroscopy is performed to
determine the site and number of
fistulae. Endoscopic examination of the
rectum and the lower part of the colon
using a thin, flexible tube with a light
and a camera lens (Sellers, 2010).

30. MGT CONT...
• Recto-vaginal fistulas arising from
childbirth may heal on their own
within a period of 6-12weeks.
• Those that do not heal within this
time frame may require some form
of repair.
• Common approaches include:

31. MGT CONT...
TRANSANAL ADVANCEMENT
FLAP
• This approach involves dissecting
and lifting a portion or flap of the
rectal wall adjacent to the fistula
opening.
• The Doctor will then pull the flap
down over the opening and suture it
to close the opening. This in turn will
allow the fistula to heal

32. MGT CONT....
Transabdominal repair is usually
done for those fistulas located high
in the rectum or vagina which may
not be locally repaired.
• The repair is done by the surgeon
making an incision in the abdomen in
order to gain access to the fistula.

33. • This may be facilitated by
cystoscopically guided placement of
a catheter through the fistulous tract
to assist in subsequent identification
and dissection

34. MGT CONT...
Transabdominal
-An incision that divides the fistula
tract is then made. The idea behind
this is to allow the tissues to grow
together and in the long run
eliminate the fistula (ibid).

35. FIBRIN GLUE
• A recto-vaginal fistula may be closed
by injecting it with fibrin glue. Fibrin
glue is a solution of clotting factors
of fibrinogen and thrombin. From this
glue, a clot will be formed within the
fistula which will promote healing of
the tract.

36. MGT CONT...
Surgisis Biodesign Recto-vaginal
Fistula Plug
• This is a conical-shaped device made
from an advanced tissue repair graft
that communicates with the body
which signals surrounding tissue to
grow across and into the plug
allowing the body to restore itself

37. MGT CONT...
• The placement of the Recto-Vaginal
Fistula Plug does not require cutting
the sphincters, therefore,
incontinence is unlikely.
• Once the healing process is
complete, the plug is completely
incorporated into the patient’s own
tissue leaving a permanent repair
without a permanent implant.

38. MGT CONT...
Fistulectomy
-Repair of the fistula is done with a
resection of the fistulous tract to
expose healthy tissue after which the
defect is closed in the multi layer
fashion beginning with the bladder
mucosa, bladder serosa, pubo-
cervical fascia and vaginal mucosa. A
fascia flap is created to prevent
opposition of the incision planes and
reduce risk of recurrence.

39. PRE-OPERATIVE CARE
• Pre- operative preparation is as for
any other major surgery.
• History & general examination by
ward physician
• Baseline Investigations:

40. PRE-OP CONT....
-Hemoglobin estimation to rule out
anemia, grouping and x-match in case
of need for blood transfusion, Urine for
microscopy culture and sensitivity to
rule out any urinary tract infection that
can interfere with wound healing after
surgery, HIV test and cystoscopy to
locate the fistula site.
• Inform the patient about operation

41. PRE-OP CONT...
–Length of post op stay that is 14
days or more
–Duration of catheterization which
can be 14 days or 4 weeks if the
fistula leaks

42. –Cure rate, risk of stress
incontinence: 95% of defects can
be closed but only,85 – 90% dry
after surgery (some may require
2nd or 3rd operation).
–15% may leak after surgery if the
urethra and bladder were
extensively damaged.

43. PRE-OP CONT...
• Fluid diet in order to keep the rectum
free of fecal matter. The patient
should take at least 6liters of fluid
per day for bladder washout to
prevent infection as urine is a good
media for infection.
• An indwelling catheter is inserted
and left in situ for 2-3 weeks to
encourage the fistula to heal
spontaneously.

44. PRE-OP CONT...
• Barrier cream is applied on the vulval
skin to prevent skin excoriation.
• The patient’s nutritional status must
be improved to promote healing.
Ensure intake of foods rich in
proteins such as beans, chicken,
meat and kapenta as well as fruits
such as oranges, apples, mangoes
and also green leafy vegetables like
amaranthus, cassava leaves among
others.

45. PRE-OP CONT...
• Antibiotics are given to prevent or
treat any urinary tract infection. For
example; Nitrofurantoin 100mg tds
or Nalidixic acid 500mg
• Documentation of all the pre-
operative

46. • preparation in the patients file should
be done and ensure that consent for
the operation is obtained before
surgery.
• Psychological care is given in order
to allay anxiety.

47. PRE-OP CONT...
• Pre anaesthetic evaluation and
choice of anaesthesia
• Give enema early in the morning on
the day of the operation to rid the
rectum of any fecal matter.
• Nil per mouth from midnight

48. POST OPERATIVE CARE
• After surgery, an indwelling catheter
is inserted for 14 days. The
indwelling Foley catheter drains urine
from the bladder.
This decompresses the bladder wall
so that the wounded edges come
together and stay together giving it a
greater chance of closing naturally,
at least in the smaller fistulas.

49. POST-OP CONT...
• Care after surgery will include the
following:
-Maintain a liquid diet for two days
after the procedure for continuous
bladder drainage.
- Monitor urine output hourly in order
to detect any bleeding or blockage
from the repair site.

50. POST-OP CONT...
- Give triple antibiotics which are;
Benzyl penicillin 4 mega units
6hourly, Gentamycin 80mg 8hourly
intravenously (tds) and
Metronidazole 400mg 8hourly
intravenously for 5 days. Give
analgesia Pethidine 50-100mg
intramuscularly for 3 doses
thereafter paracetamol 1gm tds until
when the pain subsides.

51. POST-OP CONT...
• Use stool softeners for two weeks to
avoid straining at stool which can cause
damage to the repair site for example;
Liquid paraffin once a day.
-Bath at least once a day: shower
standing up to promote drainage of
urine and promote circulation.
Additionally, clean the vulva with soap
and water to promote cleanliness and
prevent infection.

52. POST-OP CONT...
• Do not lift heavy things within six (6)
weeks of healing. That is, avoiding
strenuous work which can lead to
breakdown of the repair site.
-Abstain from sexual intercourse and
other forms of insertion such as
tampons for at least six weeks to
promote healing.

53. POST-OP CONT...
• Some drainage may be expected for
two to four weeks after the
procedure or up to twelve weeks
after the procedure as the plug is
incorporated and the fistula is closed.
• Complications following surgery
include the following: haemorrhage,
infection due to poor hygiene, clot
retention due to haemorrhage,
catheter blockage due to clot
formation and occlusion of the
ureters by the blood clot.

54. POST-OP CONT...
• If the plug falls off, it could be that
the suture holding it in place has
broken or dissolved.
• It is important to return to the
Doctor to discuss the situation.
• The doctor may decide to put
another surgisis bio design fistula
plug in place (Cook, 2008).

55. POST-OP CONT...
• Some women are not candidates for
this surgery, but can seek out
alternative treatment called a
urostomy and a bag for the collection
of urine is worn on a daily basis. For
example women with extensive
injuries with loss of most of the
bladder, severe vaginal stenosis,
total incontinence following failed
repair and operation for stress
incontinence.

56. PREVENTION OF OBSTETRIC FISTULAS
• Prevention comes in the form of:
access to obstetrical care,
-support from trained health care
professionals throughout pregnancy,
-providing access to family planning,
- promoting the practice of spacing
between births, and supporting
women in education and postponing
early marriages.

57. PREVENTION CONT....
• Strategies to educate local
communities about the cultural,
social, and physiological factors that
contribute to the risk for fistula such
as:
-organizing community level
awareness campaigns about
obstetric fistulas.

58. PREVENTION CONT....
• Strategies :
-seek antenatal care for early
detection of abnormalities such as
contracted pelvis which can lead to
prolonged labour and subsequently
fistula formation.
-Prevention of prolonged obstructed
labour and fistula should preferably
begin as early as possible in each
female’s life

59. PREVENTION CONT....
-For example, improved outreach
programs to raise awareness about
the nutritional needs of female
children to prevent malnutrition as
well as improve the physical maturity
of young mothers, are important
fistula prevention strategies.

60. PREVENTION CONT...
• Midwives located in the local
communities where fistula is
prevalent that is, Eastern and
Southern provinces of Zambia can
also contribute to promoting healthy
practices that help prevent future
development of obstetric fistulas.
For example early seeking of
treatment for sexually transmitted
infections (STIs) and avoid delays
when seeking obstetric care.

61. PREVENTION CONT...
• Promoting education for girls is also a
key factor to preventing fistula in the
long term.
This is to avoid early marriages and
prevent early pregnancies that can lead
to prolonged labour and cephalo-pelvic
disproportion (CPD) with subsequent
fistula formation.

62. PREVENTION CONT....
• Train traditional birth attendants for
sensitization of women to seek
antenatal care early to avoid obstetric
complications.
• It is also important to ensure access to
timely and safe delivery during
childbirth; measures include availability
and provision of emergency obstetric
care as well as quick referral and safe
caesarean sections for women in
obstructed labour

63. PREVENTION CONT...
• The patient must be counselled
regarding future pregnancies. She
should seek medical attention as
soon as she knows she is pregnant to
prevent further complications.
• Future deliveries should be by
caesarean section if the patient has
had a successful vesico-vaginal
repair.

64. COMPLICATIONS OF OBSTETRIC
FISTULA
• Recurrent recto-vaginal and vesico-
vaginal fistulas due to post
operative infection.
• Extensive scarring of vaginal,
bladder and rectal walls with poor
blood supply.
• Injuries to the bladder and the
genital tract following surgery
(Sellers, 2010).
•

65. • Urine / ammoniac dermatitis due to
continuous leakage of urine
• Urinary stones due to stasis of urine
• Renal complications (Infections and
renal failure ).

66. PHYSICAL CONSEQUENCES OF
O/FISTULA
• The most direct consequence of an
obstetric fistula is the constant leaking of
urine, faeces, and blood as a result of a
hole that forms between the vagina and
bladder or rectum.
• This endless leaking has both physical and
societal penalties.
• Nerve damage that can result from the
leaking of urine can cause women to
struggle with walking and eventually lose
mobility.

67. PHYSICAL CONSEQUENCES CONT...
• In an attempt to avoid the leaking of
urine, women limit their intake of
water and liquid which can ultimately
lead to dehydration
• Ulcerations and infections can persist
as well as kidney disease and kidney
failure which can each lead to death.

68. SOCIO-CULTURAL CONSEQUENCES OF
O/FISTULA
• These physical consequences of
obstetric fistula lead to severe socio-
cultural stigmatization.
• Most women are divorced or
abandoned by their husbands and
partners, disowned by family,
ridiculed by friends, and even
isolated by health workers.

69. SOCIO-CULTURAL CONSE CONT...
• Women with obstetric fistula become
worthless in the eyes of society
because of the harsh odour.
• Now marginalized members of
society, women are pushed to the
brims of their villages and towns,
often to live in isolation in a hut
where they will likely die from
starvation or an infection in the birth
canal.

70. SOCIO-CULTURAL CONSE CONT...
• Further, women are sometimes
forced to turn to commercial sex
work as a means of survival because
the extreme poverty and social
isolation that results from obstetric
fistula eliminates all other income
opportunities.

71. SUMMARY
• There are many types of obstetric
fistula that occur in women. The
commonest being Recto and Vesico
vaginal fistulas.The largest challenge
that stands between women and
fistula treatment is information. Most
women have no idea that treatment
is available. Because this is a
condition of shame and
embarrassment, most women hide
themselves and they may suffer in
silence with no relief.

72. SUMMARY CONT…….
• The key is prevention with good
surgical technique, identification and
repair of the injury at the time of
index surgery to avoid recurrence.
The midwife needs to be aware of
these fistulas their prevention,
treatment and give appropriate
information antenatally, intrapartum
and postpartum in order to preserve
the integrity of the women.

73. REFERENCES
• Bennet R.V and Brown L.K (1993),
Myles Textbook for Midwives,
Twelfth Edition. London.
• Brooker C. (2008), Medical
Dictionary, 16th edition, Elsevier
limited, Churchill, Livingstone
• Cook (2008), A Patients Guide-
Fistula, Causes, Symptoms and
Treatment Options, Ontario. Canada.

74. REFERENCES CONT...
• Cooper A.M, Fraser D.M, Nolte G.W,
(2006), Myles Textbook for
Midwives, African Edition. London.
• John R.M and Neeraj K (2012),
www.womenshealthsection.com/cont
ent/urogvvf/articles.php3. United
States of America. Accessed on
11.12.2012 at 17: 30hours.