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Obstetric fistula

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VOL: 102, ISSUE: 29, PAGE NO: 27



- Obstetric fistula is a severe condition where a fistula develops between a woman’s vagina and rectum (rectovaginal fistula) or vagina and bladder (vesicovaginal fistula) as a result of prolonged or failed childbirth.



- It is predominately a problem in developing countries with poor medical services and a resulting inability to provide Caesarean section.



- Obstetric fistula gains little attention, mainly as it affects the most marginalised sections of society, principally young, poor, illiterate women in remote areas.



- Many of these women never seek treatment because of the stigma, resulting in injuries that may be ignored or misunderstood and chronic conditions associated with incontinence.



- A fistula usually develops during prolonged obstructed labour, although in rare cases it can also be caused by accidental injury at Caesarean section, forceps delivery, foetal craniotomy or symphysiotomy.



- Without medical facilities, obstructed labour can last up to a week, although the foetus usually dies after two or three days.



- During labour, the base of the bladder, anterior vaginal wall and urethra are pushed upward and become compressed between the head of the descending foetus and the posterior pubis. This results in ischaemia.



- These delicate tissues recover after normal childbirth, the ischaemia only lasts a short time and blood flow is restored when the baby is born.



- However, when labour and the resultant ischaemia continue for days, it causes permanent injury as tissue becomes necrotic and begins to slough away. This loss of tissue causes the fistula.



- The risk of tissue injury is proportional to the length of compression and ischaemia.



- At particular risk are women:



- In their first pregnancy;



- Who use traditional maternity care and have home births;



- Whose physical development has been restricted due to poor nutrition or childhood illness;



- Who are teenagers;



- Living in rural areas.



- Symptoms are complex due to the delicate nature of the tissues involved. They include:



- Faecal incontinence;



- Urinary incontinence;



- Complex urological injury;



- Vaginal scarring;



- Vaginal stenosis;



- Secondary infertility;



- Musculoskeletal injury;



- Chronic dermatological irritation;



- Offensive odour.



- The emotional cost of obstetric fistula is hard to gauge but the stigma of incontinence can result in deep feelings of shame.



- Allied to this, women may be ostracised due to the offensive odour, incontinence and damaged fertility.



- This can worsen poverty and malnutrition, resulting in illness and premature death.



- Reconstructive surgery can be used to repair the fistula.



- Counselling is also vital to address any emotional trauma caused by the stigma attached to the condition.



- Unfortunately, the condition is prevalent in developing countries where these kinds of facilities are not available. In these countries the focus should be on providing obstetric services in order to prevent the vast majority of obstetric fistula cases from occurring in the first place.

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