Health Tips

A tragic childbirth injury

Obstetric fistula is one of the most serious and tragic childbirth injuries. It is an abnormal connection between the birth canal and bladder and/or rectum, usually from prolonged, obstructed labour without access to timely, high-quality medical treatment. It leaves women and girls to have abnormal leakage of the contents of one organ (urine, faeces or both) into another organ or to the outside of the body. This often leads to chronic medical problems, depression, social isolation and deepening poverty.

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But the good news is, fistula is almost entirely preventable.

How it happens

Obstetric fistulas is caused by an extensive crush injury of pelvic tissues due to obstructed labour during the second stage that is not diagnosed and treated in a timely fashion.

Note:
The first stage of labour: Cervix is opening and your baby is moving down the birth canal. 
The second stage of labour: The baby is being born.
The third stage of labour: When the placenta is delivered.

As a result of prolonged compression of the fetal head on blood vessels supplying the tissues of the vagina, bladder and rectum; the blood supply to the particular tissue gets cut off. Hence, the tissue does not get enough oxygen (ischemia)  and eventually dies off (necrosis). The dead tissue sloughs away, leaving a gap between nearby organs, most commonly between the vagina and bladder or rectum. .  The hole is called an obstetric fistula, in medical terms.

Without immediate intervention, obstructed labour can last for days, resulting in death or severe disability of the baby and mother. 

Obstetric fistula has been virtually eliminated in industrialized countries through the availability of timely, high-quality medical treatment for prolonged and obstructed  –namely, Caesarean section (C-section). However, this may not be the case in developing countries.

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Factors that contribute to a high prevalence of obstetric fistula include:

• Low social, economic, and political status of women resulting in poor maternal health service

• Delivery at home without proper medically trained  birth attendants

• Limited or no access to emergency obstetric services

• Infrastructure and economic barriers to healthcare access 

• Lack and  poor quality of secondary and tertiary health care services

• Low quality healthcare in general. 

An obstetric fistula should be suspected in women who present with a complaint of continuous urine or faeces leakage, with unpleasant odour beginning immediately following childbirth, particularly after a long labour. 

Consequences for women

Obstetric fistula is associated with devastating lifelong morbidity with severe medical, social, psychological and economic consequences.

Left untreated, obstetric fistula can cause chronic incontinence and can lead to a range of other physical ailments including frequent infections, kidney disease, painful sores and infertility. The physical injuries combined with misconception about the cause of fistula often result in stigma and discrimination, leading to social isolation, psychological harm and mental health issues. 

Women and girls with fistula are often unable to work, and many are abandoned by husbands and families and ostracized by their communities, driving them further into poverty,  vulnerability and decreasing their quality of life. 

Reconstructive surgery can usually repair a fistula. Unfortunately, women and girls affected by this injury often do not know that treatment is possible for this condition, they are unable to  afford it or cannot reach the facilities where the treatment option is made available due to various reasons. There is also a shortage of highly trained and skilled surgeons to perform these repairs. Tragically, at the current rate of progress, many women and girls living with fistula today die due to complications before being treated in underdeveloped countries.

Beyond surgery, a holistic approach that addresses the psychosocial and socioeconomic needs of fistula survivors is required to ensure full recovery and healing. 

Counseling and other forms of support – such as livelihood skills, literacy, job training and health education – may also be necessary to help women reintegrate back into their communities, rebuild their lives, and regain their dignity and hope after surviving fistula.

Follow-up is also crucial for all women and girls who have had fistula repair surgery, helping to ensure they do not develop the injury again during subsequent births and to protect the survival and health of both mother and baby. Women and girls who have been deemed inoperable or incurable also require special and sustained attention and support.

Prevention is key

Prevention is the key to ending fistula. Fistula is an indicator of poor quality of maternal care. Ensuring skilled birth care during all births and providing timely and high quality emergency obstetric care for all women and girls who develop complications during delivery would make this tragic condition as rare in developing countries as it is in the industrialized world. 

Additionally, providing family planning to those who want it could significantly reduce maternal disability and death.

Medically reviewed by Ashwini Nair, MB BCh BAO.

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References:

1. UpToDate. Obstetric fistulas in resource-limiting settings.

2. Obstetric fistula. United Nations Population Fund. Accessed May 21, 2022. https://www.unfpa.org/obstetric-fistula

Written by

DOC2US Editorial Team