What is Obstetric Fistula?

Helai Hesham

Fellow in Female Pelvic Medicine and Reconstructive Surgery

PGY-6

 What is Obstetric Fistula?

The Freedom from Fistula Foundation just celebrated their 10 year anniversary in Lilongwe, Malawi. The facility has become a stand-alone center on the grounds of Bwaila hospital in the center of town.  They do nearly 350 fistula repairs yearly with a infrastructure that has trained local and foreign fistula surgeons throughout the years. While caring for women and training surgeons, they have also built a 10 year database of all their patients including follow up to be able to conduct responsible and much needed research within the field. I have been lucky enough to witness this dedicated group of providers treat countless women from Malawi and surrounding countries whose lives have been devastated by vaginal fistulas for the past month.

My introduction to the fistula center was filled with smiles and warm embraces. Although a relative stranger, the management, nursing and providers all welcomed me as if I was coming back home. The rest of the month continued in the same manner, and time after time, I saw the affection that they so easily extend to me extended to patient after patient. Amidst the smiles that would greet me every morning when entering the ward, I saw the grim reality of obstetric fistula.  Although I had attempted to prepare myself and had read much about the condition prior to my arrival in country, the pathophysiology – how it affects a person mind, body, and soul is not something that comes across the pages of textbooks. I had much to learn. 

Patients arrived to the fistula center in several different ways. Patients living close – within a day of walking, usually arrived on their own by foot. Patients farther away would have the fistula center ambulances bring them to the center in large groups.  After getting checked in, they would then wait to be screened. Initial screening includes a thorough history and physical by nursing staff. A physician or clinical officer would then also see the patients, check physical examination findings and make plans regarding possible repair or preoperative optimization.  All patients would be screened for HIV status and possible anemia. Many patients would have surgery deferred as they would find that they were positive for HIV and would need to obtain treatment first and have optimized viral loads.  Nearly all patients would have malnutrition and be placed on a high protein diet, multivitamins and Fe, especially if they were expected to have larger repairs requiring flaps or abdominal procedures.  Patients would then await their surgical date, often remaining inpatient while being optimized. If they had small children, the children would also stay in the facility.

What was most impressive was that the degree of assault that an obstetric fistula had on the pelvic floor, hearts, minds and bodies of these patients. Obstetric fistula occurs when woman have prolonged, obstructed labor courses.  When labor goes unattended, labor can continue for days – this length of time leads to soft tissue necrosis where the baby’s head lays within the pelvis. This often leads to a hole between the vagina and the bladder or the rectum. While many focus on this hole and treating this assault surgically, it’s important to realize that there is much more damage. Patients would not only be leaking urine or feces constantly; some would also have foot drop. Some patients would have lower extremity contractures so severe that they would require weeks of physical therapy to allow them to bear weight.  Most would also be struggling with depression and decreased self-worth. Many considered fistula to be an affliction that was given to them by a higher power. Others were considered to be witches within their communities and had been ostracized from the communities they were once a part of.  And yet, these women, when they would see us in the morning would smile a greeting in hopes that by the end of their stay with us, their maladies would be treated.