The problem of post-partum fistulas in developing countries

Uncomplicated midvaginal vesico-vaginal fistula repair in ibadan: a comparison of the abdominal and vaginal routes

BACKGROUND

Obstetric fistula is a resultant effect of prolonged obstructed labour. The best surgical management of simple uncomplicated fistula determines the outcome of care.

OBJECTIVE

To compare outcome of uncomplicated mid-vaginal fistula between vaginal and abdominal route of repair.

MATERIALS AND METHOD

This was a hospital based retrospective study conducted at the University College Hospital, Ibadan from January, 2000 till December, 2006.

RESULT

Of the 71 midvaginal fistulae managed, 40.8% had abdominal repair while the remainder were through vaginal approach. The overall repair success rate was 79.2% with comparable outcome in both groups-78.3% for the abdominal and 80% for the vaginal group (p=0.999). The duration of hospital stay did not differ significantly between the groups (p=0.972). Post operative complications were found in 41.4% of the abdominal group compared to none in the vaginal group (p<0.001). The complications were failed repair (20.7%) and urinary tract infection (20.7%). The mean estimated blood loss was 465.5ml in the abdominal group compared to 332.9ml for the vaginal group (p=0.303).

CONCLUSION

Despite the comparable surgical repair outcome of the two methods, the vaginal approach is associated with lesser blood loss and lower risk of post-operative complications. It is recommended that the vaginal route should be employed in the repair of uncomplicated midvaginal fistula unless there are other compelling reasons to the contrary.

Symphysiotomy for feto-pelvic disproportion

BACKGROUND

Symphysiotomy is an operation in which the fibres of the pubic symphysis are partially divided to allow separation of the joint and thus enlargement of the pelvic dimensions during childbirth. It is performed with local analgesia and does not require an operating theatre nor advanced surgical skills. It may be a lifesaving procedure for the mother or the baby, or both, in several clinical situations. These include: failure to progress in labour when caesarean section is unavailable, unsafe or declined by the mother; and obstructed birth of the aftercoming head of a breech presenting baby. Criticism of the operation because of complications, particularly pelvic instability, and as being a 'second best' option has resulted in its decline or disappearance from use in many countries. Several large observational studies have reported high rates of success, low rates of complications and very low mortality rates.

OBJECTIVES

To determine, from the best available evidence, the effectiveness and safety of symphysiotomy versus alternative options for obstructed labour in various clinical situations.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (7 July 2012).

SELECTION CRITERIA

Randomized trials comparing symphysiotomy with alternative management, or alternative techniques of symphysiotomy, for obstructed labour or obstructed aftercoming head during breech birth.

DATA COLLECTION AND ANALYSIS

Planned methods included evaluation of studies against objective quality criteria for inclusion, extraction of data, and analysis of data using risk ratios or mean differences with 95% confidence intervals. The primary outcomes were maternal death or severe morbidity, and perinatal death or severe morbidity.

MAIN RESULTS

We found no randomized trials of symphysiotomy.

AUTHORS' CONCLUSIONS

Because of controversy surrounding the use of symphysiotomy, and the possibility that it may be a life-saving procedure in certain circumstances, professional and global bodies should provide guidelines for the use (or non-use) of symphysiotomy based on the best available evidence (currently evidence from observational studies). Research is needed to provide robust evidence of the effectiveness and safety of symphysiotomy compared with no symphysiotomy or comparisons of alternative symphysiotomy techniques in clinical situations in which caesarean section is not available; and compared with caesarean section in clinical situations in which the relative risks and benefits are uncertain (for example in women at very high risk of complications from caesarean section).

Symphysiotomy for feto-pelvic disproportion

BACKGROUND

Symphysiotomy is an operation in which the fibres of the pubic symphysis are partially divided to allow separation of the joint and thus enlargement of the pelvic dimensions during childbirth. It is performed with local analgesia and does not require an operating theatre nor advanced surgical skills. It may be a lifesaving procedure for the mother or the baby, or both, in several clinical situations. These include: failure to progress in labour when caesarean section is unavailable, unsafe or declined by the mother; and obstructed birth of the aftercoming head of a breech presenting baby. Criticism of the operation because of complications, particularly pelvic instability, and as being a 'second best' option has resulted in its decline or disappearance from use in many countries. Several large observational studies have reported high rates of success, low rates of complications and very low mortality rates.

OBJECTIVES

To determine, from the best available evidence, the effectiveness and safety of symphysiotomy versus alternative options for obstructed labour in various clinical situations.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2010), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2010, Issue 3) and PubMed (1966 to 31 August 2010).

SELECTION CRITERIA

Randomized trials comparing symphysiotomy with alternative management, or alternative techniques of symphysiotomy, for obstructed labour or obstructed aftercoming head during breech birth.

DATA COLLECTION AND ANALYSIS

Planned methods included evaluation of studies against objective quality criteria for inclusion, extraction of data, and analysis of data using risk ratios or mean differences with 95% confidence intervals. The primary outcomes were maternal death or severe morbidity, and perinatal death or severe morbidity.

MAIN RESULTS

We found no randomized trials of symphysiotomy.

AUTHORS' CONCLUSIONS

Because of controversy surrounding the use of symphysiotomy, and the possibility that it may be a life-saving procedure in certain circumstances, professional and global bodies should provide guidelines for the use (or non-use) of symphysiotomy based on the best available evidence (currently evidence from observational studies). Research is needed to provide robust evidence of the effectiveness and safety of symphysiotomy compared with no symphysiotomy or comparisons of alternative symphysiotomy techniques in clinical situations in which caesarean section is not available; and compared with caesarean section in clinical situations in which the relative risks and benefits are uncertain (for example in women at very high risk of complications from caesarean section).

Fecal incontinence related to pregnancy

Fecal incontinence related to pregnancy is an underreported and debilitating physical problem that has psychosocial ramifications. Disruption of the external and internal anal sphincters, which may occur during vaginal delivery, is the most common etiologic factor. Endoanal ultrasound is a minimally invasive, simple, and accurate diagnostic tool used to confirm and guide management of sphincter complex disruption.

Urinary and faecal incontinence following delayed primary repair of obstetric genital fistula

OBJECTIVE

To evaluate: (1) the factors associated with the development of obstetric genitourinary fistula, (2) the incidence of urinary and faecal incontinence following closure of the fistula and (3) the urodynamic findings in women with persistent urinary incontinence.

DESIGN

An observational clinical study.

SETTING

A specialised fistula unit in a developing country.

POPULATION

Women following successful anatomical closure of obstetric genitourinary fistula.

METHODS

Fifty-five women were enrolled from the Fistula Hospital in Ethiopia, following obstetric fistula repair. Their case records were reviewed and details regarding (1) antecedent obstetric factors, (2) the site, size and type of fistula and (3) pre-operative bladder neck mobility and vaginal scarring were recorded. All women were questioned regarding symptoms of faecal and urinary incontinence. Women reporting urinary incontinence following fistula repair underwent urodynamic investigations.

MAIN OUTCOME MEASURES

Clinical and urodynamic assessment.

RESULTS

The mean age of the women was 23 years (range 16-45 years). The fistula in 38 women (69%) followed the first delivery and in 17 women (31%) following a subsequent delivery. The mean duration of labour was four days (range 1-9 days). Forty-four women (80%) had an isolated vesico-vaginal fistula and 11 (20%) had a combined vesico-vaginal and recto-vaginal fistula. The mean diameter of the fistula was 2.9 cm (0.5-6 cm). Successful repair occurred in all women. Thirty women (55%) reported persistent urinary incontinence and 21 (38%) altered faecal continence at follow up. In the former group, urodynamic investigations identified genuine stress incontinence in 17 women (31%), detrusor instability in two (4%) and mixed incontinence in 11 (20%).

CONCLUSION

This study demonstrates the high rate of successful closure of the fistula in a specialised fistula unit, but highlights the problem of persistent urinary incontinence following closure.