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Obstetrics Fistula

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Obstetrics Fistula

  1. 1. Obstetrics Fistula BERHANU M
  2. 2. 2 Contents • INTRODUCTION • Historical Survey • Epidemiology • Etiology • Why do fistulas occur in young girls? • The obstructed labor injury complex • Management of genitourinary fistula • Surgical management of urinary incontinence after obstetric fistula repair • Prevention of fistula • References
  3. 3. INTRODUCTION Definition • An abnormal communication between two epithelial surfaces • Obstetric Fistula: Genitourinary fistula or genito-rectal fistula related to labor and delivery. • VVF abnormal connection between bladder &vagina, leakage of urine via vagina . • RVF abnormal connection between rectum &vagina, leakage of feces via vagina
  4. 4. Historical Survey • The Ebers papyrus from Egypt 1550 BC contains the earliest references to the condition, • while Avicenna the renowned Arabo-Persian physician (1037 AD) first realized the relationship with obstructed labour. • Professor Derry 1935, of the medical faculty University in Egypt, discovered a large VVF in the mummy of Queen Henhenit,2050BC, certainly the oldest fistula discovered • Pelvis was considerably contracted in transverse diameter –large rupture of vagina in to bladder • Death could be obstructed labour
  5. 5. Historical Survey… In1663 Hendrik van Roonhuyse of Amsterdam published what was probably the first text on operative gynaecology. Where in the following innovations were proposed: • (i) proper exposure of the fistula with a speculum; • (ii) denudation exclusive of the bladder wall; and • (iii) approximation of the denuded edges by means of ‘stitching needles’.
  6. 6. Historical Survey… • In 1675 the Swiss physician Johann Fatio successfully closed two fistulas using the van Roonhuyse technique and • 16 79 Christoph Voelter excessive fluid and diet in labour distends the rectum and the vagina- frequent catheterization also sugest immediate repair • In 1766 Levret was first to propose use of the knee–chest position both to view and operate upon the fistula. • Henry Levert of Mobile, Alabama was the first to suggest the use of metal sutures in 1829; and in 1834 Montague Gosset of London first had success using metal sutures
  7. 7. Historical Survey… • In 1834, De Lamballe was the first to emphasize tension-free closures. He also noted that newly acquired fistulae without evidence of induration at the edges might be cured by prolonged catheterization alone. • De Lamballe also made attempts to cure VVF with pedicle flaps from labia, buttocks, and thigh. • In 1836 Peter Mettauer of Virginia was first to close a fistula in the US, followed closely by George Hayward of Massachusetts in 1839. John Peter Mettauer (1787–1875).
  8. 8. James Marion Sims (1813-1883)
  9. 9. Historical Survey… • In 1845, Dr J. Marion Sims of America encountered his first case of obstetric fistula, • on his 30th operation on the same patient in 1849, managed to close the fistula. • In 1852, he published his article on the principles of fistula repair, and he has subsequently been called “the father of American gynecology.” • On May 4, 1855, he opened the world’s first fistula hospital in New York. with 30 beds devoted exclusively to fistula surgery • On the site of the hospital today, however, is the Waldorf Astoria Hotel, as there is now no need for a fistula hospital in America
  10. 10. Historical Survey… • Later noteworthy contributions to fistula surgery were made by Trendelenburg, • who pioneered the transvesical approach in 1890
  11. 11. Historical Survey… • A most important advance was the Martius graft proposed by Heinrich Martius in 1928 • a labial fat graft interposed between the vaginal skin and bladder wall • Martius was endeavouring to improve continence control using the graft, which allegedly contained parts of the bulbocavernosus muscle, but • found that this was not so; yet it greatly improved primary closure success Heinrich Martius
  12. 12. Historical Survey… • In 1974,the 2nd fistula hospital was opened by Drs Rignald and Catherine Hamlin in AA • Largest fistula repair service in the world. • Operated more than 35000 patients • Operates 1200-1300 patients/year • Trains doctors • Decentralized to regional Hospitals, 5
  13. 13. Historical Survey… • Comprehensive holistic care o A village for fistula patients with conduits o Have school and physiotherapy department where they exercise for the crippling injuries o Prevention activities and midwifery school
  14. 14. Epidemiology • Found in all developing countries including South Africa. • The majority of obstetric fistulae are confined to the “fistula belt” across the northern half of sub-Saharan Africa from Mauritania to Eritrea and in the developing countries of the Middle East Asia. • No accurate data on the incidence and prevalence of the condition • Incidence being about 2 in every 1000 deliveries in Sub-Saharan Africa • UNFPA estimates that fistula may occur at a rate as high as 2 or 3 cases per 1,000 pregnancies in areas with high maternal mortality • This incidence rate suggested a worldwide incidence of 50,000 to 100,000 new cases annually • Globally there are at least two million women still waiting treatment, most of whom live in Africa • The unmet need for fistula repair is estimated to be as high as 99%
  15. 15. World Health Organization map of obstetric fistula.
  16. 16. Epidemiology… Ethiopia • Estimated that 9000 women develop an obstetric fistula each year, of which only 1200 are surgically repaired • 2 million women suffer from obstetric fistula around the world, and between 26,000 and 40,000 live in Ethiopia • Incidence of obstetric fistula in rural Ethiopia was found to be 2.2 per 1,000 women of reproductive age • According to EDHS 2005 only 4 percent of the women reported obstetric fistula
  17. 17. Epidemiologic factors Ethiopia… EDHS 2005 • (56.7%) are living in a union, 52 divorced • one-third had OF before reaching the age of 24, • more than two-thirds of the women suffering from OF are residing in rural areas, • 79.6% had their first intercourse before the age of 19 years, • The average age at first marriage among these women is 16.5 years. • 50.9% of them had no formal education.(92%) • Most of them (55.6%) had no pre-natal care • 86% of them had delivered at home
  18. 18. Epidemiologic factors… • on average 22 years old • 82% Of them had to travel at least 700 kilometrs for medical care, walking an average of at least 12 hours and spending an average of 34 hours in a bus • 94% of Ethiopian fistula patients were married • 83.3% of OF had occurred during delivery before the age of 20 • The mean height of the fistula patients was 149 cm • Labor duration an average of 3.8 days • 93% stillbirth • The mean age at first marriage was 14.7 years
  19. 19. Etiology Obstetrics cause: • Prolonged obstructed labor – predominant cause • Other causes include: o Destructive delivery o Instrumental vaginal delivery o Cesarean delivery with or wthout hysterectomy o Traditional practices (defibulation, Gishiri) o Symphysiotomy
  20. 20. Etiology … Non Obstetrics cause • Traumatic (coitus, sexual violence, accidental trauma, FGM) • Infection (Granulomatous infection, TB, HIV) • Congenital • Neglected pessary, or other foreign bodies • Malignancy • Iatrogenic, surgery • Radiotherapy
  21. 21. Source: Lancet 2006; 368: 1201- 1209. 22 Why obstetric fistula common in Africa? • African women predisposed to dystocia due to narrow pelvic architecture ,circumcision ,gishiri • Marriage at early age, before pelvis growth is complete. • Malnourishment retards maturation. • Lack of access to emergency obstetric services. • Poverty, illiteracy and limited educational opportunities • Note: Maternal mortality rates in Western Europe and the USA at the beginning of the 20th century were similar to those in the developing world today…dramatically reduced between 1935 and 1950 due to access to emergency obstetric services.
  22. 22. The obstructed labour injury complex
  23. 23. COMPLICATION OF OLIC l Renal damage l Genital tract injuries l Nerve damage-AAFH 20% l Muscle and fascial damage l Bone damage- AAFH 30% l Psychological trauma
  24. 24. Genital complications • Uterine rupture • Fetal loss • Post-partum Sepsis • Ischemic processes in pelvic organ tissues • Spontaneous symphsiolysis
  25. 25. Complications after vaginal scarring • Dyspareunia, can lead to apareunia • Ammenorrhea: can be secondary to • Infertility: 60% have amenorrhoea after delivery – Severe mental stress of losing a child and a husband, together with the shame of incontinence – Malnutrition may also be a factor. – A small number of patients will have Sheehan’s syndrome, – The resultant decrease in (FSH) and (LH) . – Ashermann’s syndrome – scarring of the endometrium by either repeated infections endometrial cavity • Bladder dysfunction-
  26. 26. Rare associations • Cervical incompetence • Uterine prolapse
  27. 27. Extra-genital damage • GI damage • Anal sphincter damage • Musculoskeletal damage , damage to levator ani & contracture • Neurologic damage 20-65%pts. Can be due to o Lumbosacral injury, o vertebral disc prolapse, o impengement of common peroneal nn
  28. 28. Consequence of incontinence Urine dermatitis • Many patients restrict their drinking and end up with very concentrated urine. • When the patient is incontinent, the phosphates and nitrates contained in the urine • Irritate the skin, causing local hyperkeratosis and secondary ulceration (vulva and skin). • The condition will improve if the patient can drink more and dilute her urine Stone in the bladder or vagina: • Restrict ion of drinking, Concentrated urine, form stone & FB inserted to stem urine
  29. 29. Psycho-Social consequences • Decreased in life expectancy • Social isolation and personal injury- Still birth ,incontinent ,divorce , social outcast • Depression- 100% has psychological disorder AAFH • Suicidal thought - up to 40% thinking seriously of suicide • Even after cure 30% go with their psychological disorder
  30. 30. Psycho-Social consequences … • In this prospective study, 51 consecutive women with obstetric fistula admitted to the Barhirdar Hamlin Fistula Centre in the north of Ethiopia were screened using the General Health Questionnaire (GHQ-28) for potential mental health disorder before and 2 weeks after fistula surgery. Prior to surgery, all women screened positive. By 2 weeks after, this had dropped to 36% (P = 0.005). 27% of the 45 women who were cured of their incontinence screened positive, while all 6 of those with severe residual incontinence continued to screen positive. • We conclude that surgical treatment of obstetric fistula results in marked improvements in mental heath. Browning A, Fentahun W, Goh J. The impact of surgical treatment on the mental health of women with obstetric fistula. BJOG 2007;114:1439–1441.
  31. 31. Malnutrition • In Ethiopia, in particular, neglect and depression lead to malnutrition • one out of five of them have to beg for food to survive. • 62% Of the women had no belonging at home • more than half of them were rejected by their husband after the fistula developed
  32. 32. Reproductive outcomes • Only about 20% of post-repair patients will achieve a term pregnancy. If a patient become pregnant, she has a high chance of miscarriage or prematurity. This is because of an incompetent cervix. • The anterior lip is frequently torn so badly that it will not be strong enough to hold a pregnancy to term. • Others have vaginal stenosis that is severe enough to preclude intercourse.
  33. 33. 1966 and 1976, 148 out 162 patients with obstetrically acquired vVF were successfully repaired in Lagos University Teaching Hospital. The reproductive performance of these patients after repair has been reviewed with special regard to menstruation, satisfactory coitus and childbearing. Before the repair of the fistulae 66 patients (40.6%) had secondary amenorrhoea ranging from 4 months to 15 years. There were 3 cases each of oligomenorrhoea and cryptomenorrhoea. After repair menstruation returned within 6 months in 58 pts. 2ry amenorrhoea is thought to be due to a combination of severe malnutrition, anemia, endometritis, psychological upsets and occasionally endocrine malfunction due to focal anterior pituitary necrosis
  34. 34. Classification • Different classification system • Most based on location of fistula • There is no standardized classification exists
  35. 35. Waaldijk’s system (1995) use for planning treatment for analysis of the out come • Type I: not involving closing mechanism • Type II: involving closing mechanism • A: not involving (sub) total urethra a: with out circumferential defect b: with circumferential defect • B: involving (sub) total urethra a: with out circumferential defect b: with circumferential defect • Type III: miscellaneous, e.g. ureter fistula
  36. 36. High-risk fistulas • > 4 to 5 cm in diameter • Involvement of urethra, ureter(s), or rectum • Juxta cervical location with an inability to visualize the superior edge • Recurrence following a failed repair
  37. 37. DIAGNOSIS By history • young ,primi para ,illiterate ,rural area NO or poor ANC follow up, HX of prolonged labor ,home delivery ,still birth incontinent after 3-10 days of delivery ,weakness of extremities or paralysis ,smell bad ,neglected ,divorced ,malnourished ,psychologically depressed
  38. 38. P/E • inspection
  39. 39. Vaginal stenosis
  40. 40. Pelvic examination • size and depth of vagina? • Can the cervix be felt? • Can a defect be felt in the anterior vaginal wall? • consider the margins carefully. Are they soft , some what rigid or (in the worst cases) stuck to the pubic rami?
  41. 41. Investigation • Even if the diagnosis of fistula from hx and p/e is easy ,investigation is mandatory to R/o coexistent • In a series of 43 patients with VVF, Goodwin and Scardino found 12% to have an associated ureterovaginal fistula
  42. 42. Investigation… • With the patient in the left lateral position, use a Sims speculum to expose the anterior vaginal wall. Ask the patient to cough. A small fistula may be readily visible. • Alternatively, perform a dye test in this position
  43. 43. Investigation… Dye test ( or three-swab test is recommended (Moir, 1973). • Dilute methylene blue (or gentian violet) should be used – if it is too concentrated, it will stain everything, making interpretation of the test difficult. 1. Insert a catheter. 2. Fill the catheter balloon with dye and have two or three moist swabs ready to put into the vagina. 3. Insert the swabs well into the vagina. 4. Slowly instill about 60 ml of dye.
  44. 44. Investigation… 5. After 1 minute, ask the patient to cough. 6. Remove the swabs one by one. 7. If any of the swabs are stained, this indicates the presence of a fistula. 8. If none of the swabs is stained, there could still be a fistula. Repeat the test using up to 200 cm3 of dye. The patient should walk around for 20 minutes while the dye is in the bladder. Sometimes the hole is very small, especially if it is between the cervix and the bladder. It is easy to overlook a tiny fistula. 9. If this second test is negative but the swab is wet with urine, there is a ureteric fistula.
  45. 45. Methylene blue test
  46. 46. Cystourethroscopy • This form of endoscopy is another valuable adjunct to diagnostic evaluation. It allows localization of the fistula, determination of its proximity to the ureteral orifices, and assessment of surrounding bladder mucosa viability. • Probe through fistulous Tract to facilitate Visualization
  47. 47. Ureteral Involvement • IVP and Retrograde pyelography generally has the same diagnostic value to evaluate the upper urinary system • Phenazopyridine hydrochloride
  48. 48. Investigation… • Voiding cystourethrography • Ultrasound with color Doppler flow • CT scan • NB Currently available ultrasonography and CT are unlikely to replace the traditional diagnostic methods of IVP, retrograde pyelograms, and cystoscopy
  49. 49. Management of early case • vaginal examination for assessment • Insert FOLEY catheter Ch18 • Examine patient fistula once a week • If it seems healing leave catheter in situ • If not healing excise slough and prepare for early closure • as soon as wound clean perform an early closure • Mobilize patient at all times
  50. 50. Prevention at caesarean section • The incision in the lower segment should be on the high side and the lateral ends curved upwards to minimize inaccessible tears • When the baby’s head is deeply impacted in the pelvis, it is better to get help to push up the head vaginally than to force a hand down between the head and the lower segment. This may produce vertical tears • The alternative is to extract the baby as a breech birth if possible.
  51. 51. When should we repair ? • The shorter the waiting time the better social and psychological benefit • Most surgeons advise waiting at least 3 months from the injury before operating. • The first repair always has the best chance of success, and this should not be compromised. • The best time to repair a fistula is when the edema and inflammation subside and there is no infection • Some recommend steroid improves tissue quality but rather delays healing • If no contraindication estrogen increase tissue thickness vascularity
  52. 52. When should we repair ?... • Reported series of early repair (few weeks of DX) with steroid therapy do not show superior results, the use of steroids in early repair is no longer accepted • Up to 28% failure rate • Post surgical fistulas if diagnosed within 48 hrs can be repaired as tissue is mobile and less inflamed • 1year- in radiation induced fistula
  53. 53. PREOPERATIVE PREPARATION • Improve the general condition nutrition malaria anemia contracture -2% of pts at AAFH
  54. 54. Neurological damage and physiotherapy • Ischaemia to the lumbar–sacral plexus
  55. 55. PREOPERATIVE PREPARATION… • Explanation • about the procedure , stay ,catheter ,out come of surgery in achieving cure risk of stress incontinence
  56. 56. PREOPERATIVE PREPARATION… • Bowel preparation • Hydration o avoids hypotension during spinal o avoids difficulty in identifying ureteric orifice o catheter blockage
  57. 57. Choice of Anesthesia • Spinal anesthesia is the preferred method for all fistula cases • Bupivacaine 0.5% • Lidocaine 5% • Gynecologist has to have a good hand in spinal
  58. 58. Issue of antibiotics • Most surgeons administer one dose of a broad spectrum antibiotic prophylactically (eg, cefazolin 1 gram intravenously). • Gentamicine 80mg im bid and metronidiazole 500mg iv tid –fecal contamination
  59. 59. Antibiotic prophylaxis… • Objective: To test the hypothesis that intravenous antibiotics given intra- operatively reduce the failure rate of vesico-vaginal fistula repair. • Design: A single blind, randomised controlled trial. • Setting : A district hospital in Benin, West Africa. • Population: Seventy-nine women undergoing repair of an obstetric vesico-vaginal fistula by a single surgeon at Hopital Evangelique; two women had repeat operations. • Methods: Participants in the treatment group (n = 41) received ampicillin 500 mg intra-operatively. Controls (n = 40) received no prophylactic antibiotics. • Main outcome: measures Failure of fistula closure and objective incontinence (a positive pad test) at hospital discharge. Secondary outcomes: included febrile morbidity, other antibiotic use and urinary infection. • Results: Antibiotic prophylaxis did not reduce the odds of failed repair (OR 2.1 95% CI 0.75-6.1) or of objective incontinence (OR 1.9; 95% CI 0.72-51). The women in the antibiotic prophylaxis group received less post-operative antibiotics and had less urinary infections at day 10. • Conclusions : Prophylactic antibiotics should not be used in vesico-vaginal fistulae repair in the developing world outside randomised controlled trials. A . J . TOMLINSON & J . G. THORNTON, A randomised controlled trial of antibiotic prophylaxis for vesico- vaginal fistula repair, British Journal of Obstetrics and Gynaecology April 1998, Vol. 105, pp. 397-399
  60. 60. Instruments
  61. 61. sutures • Never use non absorbable sutures-stones • Vicyl or dexon 0 or 2.0 3.o • The perfect needle for a suture is a ready- mounted 5/8-circle 26 mm needle, but this Is expensive. We reserve it for suturing in difficult corners and deep situations.
  62. 62. Position of the table
  63. 63. Basic principle of fistula repair • Adequate exposure • Protection of the ureters • Separation of vagina from the bladder around the fistula • Mobilization of enough bladder after excision of scar • Tension free closure • Support of the urethra when needed
  64. 64. Transvaginal approach (flap splitting Technique ) • 1-Good exposure –scar may be difficult excision or episiotomy
  65. 65. Getting the correct tissue plane • Some surgeon infiltrate the vagina with haemostatic agents 1:200000 adrenaline thus aiding in dissection • Others prefer saline
  66. 66. Protection of the ureter
  67. 67. Using a curved artery forceps
  68. 68. The distal flap must now be dissected off the proximal urethra and para-urethral
  69. 69. • When the surgeon judges that there has been enough dissection to enable a tension free • The fistula edge is trimmed of any scar tissue or residual vaginal skin. • Corner sutures placed • The fistula is then repaired with interrupted 00 absorbable sutures. • Fish-hook (J) needles or 5/8-circle needles are ideal.
  70. 70. Corner sutures
  71. 71. • Once the repair has been completed, a dye test is performed to ensure sound closure of the bladder . A no. 16 Foley catheter is passed, saline coloured with methylene blue is introduced into the bladder (around 100 ml should suffice) and the suture line is checked for leaks. fig
  72. 72. Repair completed
  73. 73. Checking for the leakage of dye
  74. 74. Vaginal closure • Interrupted suture to avoid infected hematoma • Hemostasis has to be secured by adrenaline soaked swab , head down , vaginal packing
  75. 75. • Gauze soaked in antiseptic solution • May obscure serious bleeding • No need to pack in dry cases • While inserting sims speculum has to protect the site of the repair
  76. 76. Securing the indwelling catheter • Taping or suturing catheter with labia to avoid pressure on repair site in case of fistula involving urethra and bladder neck • Stay for 2 weeks post procedure
  77. 77. SELECTION OF CASES FOR THE BEGINNER • Attempt a case beyond one’s capabilities is not only demoralizing for the surgeon but a disaster for the patient, as the best chance of cure is always the first operation • There are some clues that fistula is complex foot drop ,rectal fistula ,after c/s , following hysterectomy  No vaginal stenosis , easily visible and palpable ,small , minimal scar ,not close to the cervix or EUO
  78. 78. Who are at risk of post repair stress incontinence • Goh’s type 2-4 • Post repair bladder capacity <150cc • Severe vesical fistula • Severe vaginal scarring
  79. 79. Surgery to reduce incidence of stress incontinence • Urethral lengthening procedure -severe post-repair stress incontinence , the average urethral length was 1.4 cm, -To fashion the bladder side of the anastomosis into a tube with a diameter approaching that of the urethra
  80. 80. Repair of the pubo-cervical fascia • It is a fascial sling that supports the urethra, the urethro-vesical junction and bladder base. • Thus supporting and elevating the new urethro-vesical junction
  81. 81. Urethral support with a fibro-muscular sling • A review by Andrew Browning of 318 consecutive patients successfully repaired at the Addis Ababa Fistula Hospital in the year 2000 showed an immediate postoperative incontinence rate of 33%. • Repair was by simple closure, with a fat graft added in most cases. This was a much higher figure for incontinence than had previously been recognized, and he started to use a fibro- muscular sling in high-risk cases, i.e. those with a shortened urethra (<2.5 cm from the external urethral orifice, • Reduced stress incontinence to 18%
  82. 82. Route of repair • There is no randomized controlled trial • When access is good and vaginal tissues are sufficiently mobile ,the vaginal route is usually most appropriate. If access is poor and the fistula cannot be brought down, however, the abdominal approach should be used. Overall, more surgical than obstetric fistulas are likely to require an abdominal repair, although in the author’s series of cases from the UK ,and those reviewed from Nigeria two-thirds of cases were satisfactorily treated by the vaginal route regardless of etiology
  83. 83. The Martius graft • Described by Martius 1928 • Labial fat as interposition graft • Supplied by pudendal artery • The right labia is traditionally used • The landmark for the incision is - lateral to the base of the clitoris, down the prominence of the labia for at least 6 cm • The Martius graft fixed on the repaired site with 5 anchor sutures • Improves closure rate, neovascular pedicle ,fills dead space , mechanical protection
  84. 84. • Birkhoff and colleagues reported a 100% success rate in six patients with transvaginal repairs of VVF using the Martius technique. In a series mostly of post obstetric injuries, Elkins and colleagues reported a successful closure in 96% (24 of 25 procedures).
  85. 85. POSTOPERATIVE NURSING CARE • Equally important as effective surgery • A good operation can be ruined by neglectful aftercare. • Nurses may unfamiliar with post op care • Teach to give the three DS • The patient must at all times be • Drinking • Draining • Dry
  86. 86. Principles of catheter care • Nothing must pull on the catheter. o secured with a suture with a mons pubis o secure the catheter to the abd in the midline • The catheter must not become blocked or fall out.
  87. 87. Pre-discharge advice • Return back if she leaks • Abstinence from sex for at least for 3 month • The surest way of cure is to have no more delivery but once pregnant C/s for future deliveries
  88. 88. Subsequent pregnancy • Fertility returns with in 2 yrs in majority after successful repair • The need for cesarean section in any subsequent pregnancy has been emphasized • Kelly , however, reported 33 patients who became pregnant within 1 year of fistula repair, 12 of whom were delivered vaginally without damage to the repair • But he set criteria o previous cause is non recurring one (contracted pelvis has to be R/O) o interposition graft o experienced obstetrician
  89. 89. The optimal way to deliver • very little written about the optimal way to deliver a patient who previously has had a severe obstructed labour, obstetric fistula and fistula repair. • One article pointed out that only 50% of patients were selected to undergo a trial of vaginal delivery and of those 50% needed a caesarean; of those delivering vaginally, 27% had their fistula reopen during the delivery. • 24 women after successful repair return with repeat fistula after delivery (17 SVD, 6c/s ,1 caesarean hysterectomy after 2 days of labor )
  90. 90. optimal way of managing labor…. • The optimal way of managing labor following obstetric fistula repair is o to provide a waiting area for women as they approach term and o perform a timely caesarean section. At term in those where dates are known with some confidence or otherwise at the onset of labor.
  91. 91. Prevention • Almost all obst. fistulas are preventable. Strategies include 1. Adequate childhood nutrition 2. Delay in child bearing until full pelvic growth is completed. 3. Provision of health education about sexuality child birth and contraception 4. Universal basic education for women 5. Education of men concerning women’s reproductive health 6. Supervision of labor of every pregnant woman by trained birth attendant 7. Monitoring of every labor with partograph 8. provision of emergency obstetric service at the community level
  92. 92. Prevention Education for girls Education for healers Family planning Better transportation
  93. 93. References • Brian Hancock , Practical Obstetric Fistula Surgery, 2005 • FIGO and partners, Global competency-based fistula surgery training manual, 2011 • Brian Hancock , First Steps in VVF Surgery 2005 • Zewdu Gashu Dememew, Obstetric fistula situation in Ethiopia, Johns Hopkins University-Technical Support for the Ethiopian HIV/AIDS Initiative, Hawassa Ethiopia • Browning A, Fentahun W, Goh J. The impact of surgical treatment on the mental health of women with obstetric fistula. BJOG 2007;114:1439–1441 • Mulu Muleta, Obstetric Fistula in Developing Countries: A Review Article, J Obstet Gynaecol Can 2006;28(11):962–966 • Browning A. Pregnancy following obstetric fistula repair, the management of delivery. BJOG 2009;116:1265–1267
  94. 94. References… • ROBERT F. ZACHARIN, A HISTORY OF OBSTETRIC VESICOVAGINAL FISTULA, Aust. N.Z. J. Surg. (2000) 70, 851–854 • Khalil A A. A Review of Obstetric Fistula in Sudan . Webmed Central OBSTETRICS AND GYNAECOLOGY 2011;2(9):WMC002222 • Yashar Najiaghdam M.D, GENITO-URINARY FISTULAS, PPT • Pierre Marie Tebeu, Risk factors for obstetric fistula: a clinical review, Int Urogynecol J (2012) 23:387–394 • Kees waaldijk, immediate management of the obstetricfistula, babbarrugafistulahospital, PPT • Browning et al., The Relationship Between Female Genital Cutting and Obstetric Fistulas, Obstet Gynecol. 2010 March ; 115(3): 578–583. doi:10.1097/AOG.0b013e3181d012cd. • Sunil, Sanga ,Obstetric fistula in Ethiopia , Journal of Family and Reproductive Health, Vol. 3, No.4 , December 2009 ,
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