Obstetric Fistula

Obstetric fistula is a serious and debilitating complication of childbirth affecting millions of women in the developing world. A gynecologic fistula refers to an abnormal communication between the urinary tract or the gastrointestinal tract and the genital tract, produced by obstetric causes, usually prolonged and obstructed labor. The earliest example of obstetric fistula was found in 2050 BC in Egypt, where an Eleventh Dynasty mummy, Henhenit, appears to have had a vesico-vaginal fistula (VVF). The relationship between obstructed labor and fistula development was recognized and described by the Persian physician, Avicenna, in 1037 AD (Zacharin 2000). Before the twentieth century, both urinary and rectal fistulas were a common result of deliveries throughout the world. The unfortunate women who endure such obstructed labors and resulting incontinence are often young, undernourished, uneducated, and married early (Wall and others 2004). They are usually from rural, poor areas, often with an early first pregnancy. However, a Tanzanian survey by the Women’s Dignity Project and Engender Health (2006) has shown that fewer than half of the fistulas in that country resulted from a first birth, suggesting that many fistulas occur in subsequent pregnancies as well. The woman labors at home, without the benefit of a trained birth attendant and far from medical care capable of providing surgical intervention. In the absence of adequate communication or transportation services, labor continues for several days; if delivery does not follow, the baby dies and the mother often endures the longterm complications of an obstetric fistula (IMPAC 2006). Figure 6.1 describes the clinical implications of obstetric fistula. The advent of anesthesia and safe, effective surgical procedures for cesarean sections have made the occurrence of obstetric fistula a rare event in the developed world; when they do occur, they are typically due to a congenital anomaly, surgical complication, malignancy, or radiation damage. However, in the lowand middle-income regions of Asia and Sub-Saharan Africa, the overwhelming cause of fistulas between the bladder and the vagina (vesico-vaginal fistula, VVF) and between the rectum and vagina (recto-vaginal fistula, RVF) is prolonged and obstructed labor. This is also the situation, although less well documented, in Latin America and the Caribbean. In prolonged labor, which frequently results in delivery of a stillborn, the bladder and/or rectal tissue is compressed between the pelvic bones and the fetal head, cutting off blood flow and causing ischemic pressure necrosis (Husain and others 2005). In the hours or days following such a prolonged labor, the fistula forms and leakage of urine, stool, or both appears.