Obstetrics fistula


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Obstetrics fistula

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