• Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Be the first to comment
    Be the first to like this
No Downloads

Views

Total Views
2,917
On Slideshare
0
From Embeds
0
Number of Embeds
1

Actions

Shares
Downloads
147
Comments
0
Likes
0

Embeds 0

No embeds

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
    No notes for slide

Transcript

  • 1. Dr. Swati Singh
    Department of Obstetrics & Gynaecology
    UDUTH
    1
    OBSTETRIC FISTULA
  • 2. OUTLINE OF PRESENTATION
    2
    An Overview
    Principles of fistula management
    Treatment options
    Post-operative care
    Recto-vaginal fistula: features & management
    Prevention
    conclusion
  • 3. Source: G. Lewis, WHO Press.
    3
    “Every minute, a woman dies in pregnancy or childbirth, and for every woman who dies, 20-30 others will survive but with morbidity, one of which is obstetric fistula”
    An Overview
  • 4. An Overview
    4
    Millions of girls and young women in resource-poor countries are living in shame and isolation, often abandoned by their husbands and excluded by their families and communities.
    They usually live in abject poverty, shunned or blamed by society and, unable to earn money, many fall deeper into poverty and further despair.
  • 5. An Overview
    5
    The reason for this suffering is that these young girls or women are living with an obstetric fistula (OF) due to complications which arose during childbirth.
    Their babies are also probably dead, which adds to their depression, pain and suffering.
  • 6. Nigeria Program
    Fistula Care supports six hospitals:
    FaridatYakubu General Hospital, Zamfara State
    MaryamAbacha Women and Children’s Hospital, Sokoto State
    BirninKebbi Specialist Fistula Center, Kebbi State
    Laure Fistula Center at Murtala Mohammed Specialist Hospital, Kano State
    BabbarRuga Hospital, Katsina State
    The South East VVF Center, Ebonyi State
  • 7. RESULT OF FISTULA TREATMENT: The UNFPA Fistula fortnight - 2005
    7
    • As part of the global Campaign to End Fistula
    • 8. 2-week mass obstetric fistula treatment project,
    • 9. reducing the backlog of untreated fistulas and raise awareness regarding obstetric fistulas and safe motherhood.
  • 8
    PRINCIPLES OF FISTULA MANAGEMENT
    Preparation of patient for surgery
    Improve nutrition
    Treat infections
    Treat other existing complications
    Perform operation
    By trained surgeon
    Hospital admission up to 2 weeks after
    Scrupulous postoperative care
  • 10. PREOPERATIVE CARE
    9
    Rx infection – appropriate antibiotics
    Frequent pad change – to minimize inflammation, oedema and vulvar irritation
    Zinc oxide + lanolin – for perineal and vulvar dermatitis
    Divertion of urinary stream –
    By passing folleyscather
    by gluing pezzer catheter to a fitted contraceptive diaphragm with rubber cement
    Medical therapy
    Haematinics
    Steroid /estrogen
  • 11. TIMING OF REPAIR
    10
    Controvercial
    Traditional belief – to wait for 3 to 6 months
    Allows the inflammation and oedema to resolve
    prevention of the woman from becoming an outcast is very well feasible by the immediate management by: catheter and/or early closure
    waiting 3 months is malpractice since one allows the woman to become an outcast by neglect of the fistula
    keeswaaldijk, Colins and associates, persky and associates and cruikshanks
  • 12. INSTRUMENTS
    11
  • 13. CHOICE OF ANAESTHESIA
    12
    General anesthesia
    complicated and expensive needing an anesthetic machine,
    anesthetic fluids (ether or halothane), oxygen, a variety of drugs
    special skill, for intubation
    Also for safety reasons intensive monitoring is necessary intra- and postoperatively
    Regional anesthesia
    does not require special equipment,
    is easy to learn,
    does not need intensive intra- and/or postoperative monitoring,
    is as effective as general anesthesia,
    does not require electricity, and is safe and cheap.
    Therefore spinal anesthesia with a long-acting anesthetic drug seems to be the method of choice.
  • 14. Principles of fistula repair (intraoperatively)
    13
    Good exposure
    Position of the patient
    Episiotomy
    Wide mobilisation of the vaginal epithelium to expose the bladder
    Excision of scared tissue
    A tension- free closure of bladder and vagina
    Good haemostasis
  • 15. OPERATIVE CONSIDERATIONS
    14
    Vaginal Surgery
    Single-layered technique (using non-absorbable suture)
    Saucerization technique
    Flap-splitting technique
    Urethral reconstruction
    Graft use
    Martius graft
    Labial graft
  • 16. 15
  • 17. 16
  • 18. 17
  • 19. OPERATIVE CONSIDERATIONS
    18
    Abdominal Surgery
    Transperitoneal technique
    Transvesical, extraperitoneal technique
    Combined Abdomino-Vaginal Repair
    Ureteric Surgery
    Simple repair
    Resection and anastomosis
    Reimplantation
  • 20. POST-OP. (EARLY) CARE: Catheterization
    19
    Site:
    Transurethrally in most cases.
    Suprupubic in Urethral reconstruction & Transabdominal fistula repair
    Type:
    “three-way” Foley’s catheter is preferred
    Retention:
    By inflated balloon.
    Stitch to Labia (in Juxta-Urethral, Large fistulae or fisulae with Circumferential tissue loss),
    Duration for primary repair is 14 days (but longer if urethral reconstruction or bladder-neck repair was performed or a postoperative leakage was noticed
  • 21. EARLY CARE Cont…
    20
    Drainage:
    Connected to closed urine bags usually
    Into open receptacles (relative inexpensiveness
    Vaginal Pack;
    Used as tamponade
    Removed within 48 hours.
    Pain Relief:
    Narcotics (Pethidine or Morphine)
    Given six-hourly intervals for 24 hours
    paracetamol.
  • 22. EARLY CARE Cont…
    21
    Fluid Intake:
    Target Urine output of at least 100ml per hour
    Over 4000ml Daily (tropical environment with daily insensible fluid loss of about 2000 ml)
    Intravenous infusion for the first 24 to 48 hours, depending on when her resumed oral fluid intake can meet this requirement.
  • 23. EARLY CARE Cont…
    22
    Urine Output Monitoring:
    Performed hourly or
    2-4 hourly intervals.
    If Heavy Blood Stains or Clots in Urine:
    Increased intravenous or oral fluid administration until the urine color clears.
    Persistent passage of clots warrants irrigation of the bladder.
  • 24. EARLY CARE Cont…
    23
    If Urine Drainage Ceases:
    external compression of catheter;
    Catheter kinks;
    internal catheter blockage by clots or sediments;
    diminished renal urine secretion.
  • 25. EARLY CARE Cont…
    24
    Antimicrobial use:
    Prophylactical use / treatment as mcs result
    Postoperative urine cultures repeated every 2-3 days interval, the last culture being of the tip of the removed catheter.
    Types of antimicrobial in common use:
    Options include: Co-trimoxazole, Nitrofurantoin, Ampicillin and Ampiclox.
    Parenteral preparations are used on the more extensive repairs or to address obvious sepsis.
  • 26. EARLY CARE Cont…
    25
    Patient Ambulation:
    As early as the day after repair
    Late for patients with transabdominal repairs and urethral reconstructions
    Vulvo-Vaginal Toileting:
    Nurses trained in the care of obstetric fistula employ irrigation techniques, using warm water or dilute antiseptic solution to clean the vulva and perineum each day and after bowel movements.
  • 27. POSTOPERATIVE CARE: Concluding Early Care
    26
    Outcome Determination:
    2 hours after catheter removal, the vestibule is inspected for normality, stress incontinence or introital urine leakage.
    If there is introital leakage: patient is reassured and re-catheterization for further 7-10 days.
    If stress incontinence: repair is regarded as partially successful and patient is counseled and encouraged to void urine at hourly intervals until reviewed each day.
  • 28. Outcome Determination
    27
    If no leak or stress incontinence:
    adjudged successful repair,
    undergoes bladder training to improve the bladder capacity, urine storage and voidance capability
  • 29. POSTOPERATIVE CARE: Concluding Early Care
    28
    Patients with partial or complete success be counseled on:
    Resumption of coitus after three months
    Contraceptives use unless pregnancy is desired
    Early antenatal care when pregnant and her detail history told to clinic attendants.
    Subsequent deliveries should be by elective caesarean section but never deliver at home.
  • 30. Rehabilitation/ reintegration
    Social workers ensure vocational training in tailoring and basket weaving, dyeing to earn an income.
    Counseling (the need for a lot of encouragement, support and someone simply to talk to about their lives)
  • 31. MANGEMENT OF OTHER PROBLEMS THAT CO-EXISTED WITH FISTULA
    30
    Obstetric Palsy:
    complicates over 15% of obstetric fistulae from obstructed labour
    Mostly unilateral but occasionally bilateral
    physiotherapy facilities for the necessary physical and electro-therapy
    Shoe calipers and foot elevators required for passive treatment of this problem are generally unavailable and unaffordable to fistula patients.
  • 32. MANGEMENT OF OTHER PROBLEMS THAT CO-EXISTED WITH FISTULA Cont…
    31
    Secondary Amenorrhea:
    • Co-exists with up to 2/3 of fistula patients
    • 33. Treatment of underlying causes:
    hypothalamic dysfunction,
    panhypopituitarism, or
    uterine synaechia.
  • 34. MANGEMENT OF OTHER PROBLEMS THAT CO-EXISTED WITH FISTULA Cont…
    32
    Sexual Dysfunction:
    • Gynaetresia complicates about 10% of obstetric fistulae.
    • 35. Treatment is with:
    counseling and
    use of lubricants during sexual intercourse (from inert Aqueous Jelly to Xylocaine cream).
  • 36. PRE-OPERATIVE CARE FOR RVF
    Improve nutritional status
    Treat infections
    Correct anaemia
    Treat other complications
    - Bed sores
    Ammoniacal dermatitis
    - Foot drop – physiotherapy
  • 37. PRE-OPERATIVE CARE (Low RVF)
    Counsel patient on her condition & proposed surgery
    Obtain consent
    Low residue diet
    3-day Bowel preparation
    Neomycin tablet 1g twice daily – 72hrs
    Enema saponis (preceding night & morning of operation
    Nil per os – at least 8hours before surgery
  • 38. PRE-OPERATIVE CARE (High RVF)
    35
    5-day bowel preparation
    Initial Descending colon colostomy
    Closure of fistula
    Colostomy closure after 2-3 months
  • 39. TECHNIQUE OF REPAIR
    Same principle for fixing VVF (flap-splitting):
    Adequate exposure
    Tissue dissection to separate vagina from rectum
    Independent repair of rectum and then vagina using 2/0 polyglactin (Vicryl) suture on 25mm heavy taper-cut needle, making sure mucosal edges are inverted
  • 40. Post Operative Care
    Fluid diet for 5days
    Low residue diet for further 3-5 days in high fistula
    Liquid paraffin after 48hrs daily for 3-5 days
    Intestinal anti microbial – Neomycin or Thalazole 500mg 6hrly for 5 day
  • 41. At Discharge
    Avoid intercourse or vaginal object insertion for 3months
    All subsequent pregnancies be booked & full history volunteered
    Delivery by CS in subsequent pregnancy.
  • 42. PREVENTION – Always better than cure!
    STRATEGIES
    39
    Alleviate: poverty, illiteracy and harmful traditional practices
    Improve health systems and social infrastructure
  • 43. - Promote & improve EmOC
    services in remote rural areas !!
  • 44. - Help rural population understand and better implement this proverb:
    “The sun should not rise or set twice on a labouring woman”
    —African proverb
  • 45. 42
    Advocacy to policy makers and governments
    Information, Education & Counseling of the public
    Fundraising to support prevention and treatment of obstetric fistula
    To increase collaboration between institutions providing repairs
    Launch public awarenesscampaign on issues
    surroundingsafedeliveries.
  • 46. The UNFPA's Key Strategies to Address Fistula
    43
    ‘Postpone marriage and pregnancy for young girls
    ‘Increase access to education and family planning services for women and men
    ‘Provide access to adequate medical care for all pregnant women and emergency obstetric care for all who develop complications
    ‘Repair physical damage through medical intervention and emotional damage through counselling'
    Source: UNFPA Campaign to End Fistula: “Fast Facts” (www.unfpa.org/fistula/facts.htm).
  • 47. CONCLUSION
    44
    A very real problem with an annual rate of new cases > indigenous repair capability.
    Preventionthroughsafemotherhoodis the waytowardselimination of obstetricalfistula
    Success will require fundamental changes:
    In tradition and cultural more so regarding early marriage,
    An elevation in the respect for the human rights of women in general, and young girls in particular.
    Further progress is best made by apprenticeship with one of the master surgeons
  • 48. Cured Fistula Patient
    What a smile for a new life !!
  • 49. Cured Fistula Patient
    Life with restored dignity
    THANK YOU
  • 50. 47
    References
    Wall LL. Obstetric vesicovaginal fistula as an international public-health problem. Lancet 2006; 368: 1201-1209.
    Roenneburg ML, Genadry R, Wheeless CR. Repair of obstetric vesicovaginal fistulas in Africa. Am J ObstetGynecol 2006; 195: 1748-1752
    3. WHO. In: Lewis G, de Bernis L, editors. Obstetric fistula: guiding principles for clinical management and program development. Geneva: WHO Press; 2005.
    Wall LL, Karshima JA, Kirshner C, Arrowsmith SD. The Obstetric vesicovaginal fistula: characteristics of 899 patients from Jos, Nigeria. Am J ObstetGynecol 2004; 190: 1011-1019.
    John A, Howard W. Vesicovaginal fistula In: Te Linds’s OPERATIVE GYNAECOLOGY Tenth ed Walter Kluwer India pvt Ltd 2009. p973-993
  • 51. 48
    6. Christopher NH,Marcus ES. Genital fistula In: Shaw’s Textbook of Operative Gynaecology 6thed Reed Elsevier India pvt ltd 2006 p237-270
    7. Waaldjik K. Katsina (Nigeria): BabbarRuga Fistula Hospital; 1998. Evaluation report XIV on VVF projects in northern Nigeria and Niger; 27 pp.
    8. United Nations Population Fund. The second meeting of the working group for the prevention and treatment of obstetric fistula. Addis Ababa, 30 October-1 November, 2002. New York (NY): United Nations Population Fund, 2003.
    9. Waaldijk K. The immediate management of fresh obstetric fistula. American Journal of Obstetrics and Gynecology, 2004, 191: 795-799.
    10. Kelly J. Repair of obstetrics fistula. A review. ObstetGynaecol .2002:205-11