a presentation for postgraduate class

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

8. 2-week mass obstetric fistula treatment project,

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

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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.

33. Treatment of underlying causes: hypothalamic dysfunction, panhypopituitarism, or uterine synaechia.

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