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Obstetrical & Gynecological Survey
Issue: Volume 51(9), September 1996, pp 568-574
Copyright: © Williams & Wilkins 1996. All Rights Reserved.
Publication Type: [CME Review Article]
ISSN: 0029-7828
Accession: 00006254-199609000-00024
[CME Review Article]
Obstructed Labor Injury Complex: Obstetric Fistula Formation and the Multifaceted
Morbidity of Maternal Birth Trauma in the Developing World
Arrowsmith, Steven; Hamlin, E. Catherine; Wall, L. Lewis
Author Information
The Addis Ababa Fistula Hospital, Addis Ababa, Ethiopia.
Reprint requests to: L. Lewis Wall, MD, DPhil, Department of Obstetrics and Gynecology, LSU Medical Center, 1542 Tulane
Avenue, New Orleans, LA 70112.
(L. Lewis Wall) Authors whose names are accompanied by an asterisk (*) have indicated, in accordance with the Accreditation
Council for Continuing Medical Education (ACCME) Standards, that they have a relationship which could be perceived by some people
as a real or apparent conflict of interest, but do not feel it has influenced their participation.
Abstract
Prolonged obstructed labor may produce injuries to multiple organ systems. The best known, and most common, of these
injuries is obstetric fistula formation. When obstructed labor is unrelieved, the presenting fetal part is impacted against the soft
tissues of the pelvis and a widespread ischemic vascular injury develops that results in tissue necrosis and subsequent fistula
formation. Unlike the postsurgical vesicovaginal fistula, however, which is usually the result of focal trauma to otherwise healthy
tissues, the obstetric fistula is the result of a "field injury" to a broad area. The field injury that is produced by prolonged
obstructed labor may result in multiple birth-related injuries in addition to (or instead of) a vesicovaginal fistula. Focusing simply
on the "hole" between the bladder and the vagina ignores the multifaceted nature of the injury that many of these patients have
sustained. These injuries may include total urethral loss, stress incontinence, hydroureteronephrosis, renal failure, rectovaginal
fistula formation, rectal atresia, anal sphincter incompetence, cervical destruction, amenorrhea, pelvic inflammatory disease,
secondary infertility, vaginal stenosis, osteitis pubis, and foot-drop. In addition to their physical injuries, women who have
experienced prolonged obstructed labor often develop serious social problems, including divorce, exclusion from religious activities,
separation from their families, worsening poverty, malnutrition, and almost unendurable suffering. Isolated almost exclusively to
the developing world, particularly Africa, this problem has not received the international attention that it deserves, from either a
medical or a social standpoint.
Chief Editor's Note: This article is the 27th of 36 that will be published in 1996 for which a total of up to 36 Category 1 CME
credits can be earned.
Obstetric complications are as old as human birth. Among the most catastrophic of obstetric complications is the development
of a vesicovaginal fistula from prolonged obstructed labor. This condition has been known at least since ancient Egyptian times, as
demonstrated by the mummy of Queen Henhenit of the XIth Dynasty (c. 2050 B.C.), who seems to have suffered from a large
vesicovaginal fistula [1]. Obstetric fistulas were common throughout the Western world before the rise of operative obstetrics.
Advances in the management of laboring women since the end of the 19th century have made obstetric fistulas almost unknown in
developed countries today. For example, in their review of 68 cases of genitourinary fistulas seen at University of California, Los
Angeles, over a 25-year period, Goodwin and Scardino [2] were able to locate only four women with fistulas due to obstetric
complications, two of which were caused by direct injuries to the urinary tract sustained at the time of cesarean delivery rather
than by labor itself.
In the developing world the situation is far different. Death in childbirth is common, especially in Africa, which has the highest
maternal mortality rates of any region in the world. Although Africa accounts for only 20 percent of the world's births, it
nonetheless accounts for 40 percent of the world's maternal deaths [3]. Whereas the maternal mortality rate in the United States is
given as 8 maternal deaths per 100,000 live births, the overall maternal mortality in Africa is estimated by the World Health
Organization (WHO) to be at least 640 deaths per 100,000 liver births [4]. In developed areas of the world such as Scandinavia, the
lifetime risk of a woman dying in childbirth is 1 in 25,000; whereas in rural Africa the rate may be as high as 1 in 15 [4]. The scope
of the obstetric fistula problem in the developing world is largely unknown because the areas where the problem is endemic tend to
be hidden behind geographic, political, and cultural barriers that make population surveys difficult or impossible to perform with
any accuracy; however, maternal morbidity from obstructed labor parallels the trends in maternal mortality. In northern Nigeria,
where a maternal mortality rate of 1,050 per 100,000 births was reported from a large university teaching hospital, there was a
concurrent vesicovaginal fistula rate of 350 fistulas per 100,000 deliveries [5]. Ethiopia is generally considered to have one of the
highest maternal mortality rates in the world, and national estimates as high as 2,000 deaths per 100,000 live births have been
suggested [4]. The obstetric fistula problem in Ethiopia mirrors these statistics. Because the problem of untreated, prolonged
obstructed labor is so prevalent throughout the continent, we believe that the obstetric fistula rate approaches the maternal
mortality rate in many parts of Africa.
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In 1959 Drs. Reginald and Catherine Hamlin arrived in Addis Ababa to establish a midwifery training program at Princess Tsehai
Hospital, named after a daughter of Emperor Haile Selassie who had died in rural Ethiopia from a hemorrhage due to a placenta
previa. The Hamlins soon came to appreciate the magnitude of the obstetric fistula problem in Ethiopia and began efforts to deal
with the unique problems presented by these patients. After repairing nearly 5,000 fistulas at the Princess Tsehai Hospital, the
Hamlins opened the Addis Ababa Fistula Hospital for Poor Women with Childbirth Injuries in 1975, an institution dedicated
exclusively to the care of women with obstetric fistulas. Since that time nearly 13,000 additional fistulas have been repaired, and
the work continues at the rate of 1,000 new patients per year. The perspective we wish to advance is based on the records of this
institution, supplemented by our own clinical experience in dealing with obstetric fistulas in Ethiopia, Ghana, and Nigeria.
Obstetric fistulas result from untreated prolonged obstructed labor. The average patient seen at our institution has been in
labor for 3.9 days. In such cases, the presenting fetal part impacts on the soft tissues of the pelvis shutting off the blood supply to
the affected tissues. This process produces an extensive vascular injury that leads to tissue necrosis and subsequent fistula
formation. Although the vesicovaginal fistula that results from this process usually dominates the clinical picture, focusing solely on
the "hole in the bladder" ignores the other injuries that are caused by obstructed labor. Inasmuch as obstructed labor in rural Africa
may go unrelieved for more than a week, labeling these women simply as "fistula patients" neglects the wide spectrum of pathology
that these women endure. In fact, most women with obstetric fistulas from prolonged labor have sustained injuries to multiple
organ systems and these concurrent injuries may be just as significant from a social, cultural, or even medical point of view, as the
problem of total urinary incontinence Table 1.
Table 1. Spectrum of Trauma Occurring in the Obstructed Labor Injury Complex
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The purpose of this review, therefore, is to emphasize that the injuries resulting from prolonged obstructed labor represent a
syndrome that often involves multiple organ systems. Caring for these patients requires much more than simply "repairing" a
vesicovaginal fistula. The process of carefully collecting and tabulating clinical data from the major fistula repair centers around
the world has only just begun, so the picture presented here is only preliminary. Complete understanding of this syndrome, which
we have chosen to call "obstructed labor injury complex" lies some distance in the future; however, by emphasizing the
multidimensional pathology from which these patients suffer, we appeal to fistula surgeons around the world to broaden their
perspective to include treatment of the "whole-person" when that person has been a victim of unrelieved obstructed labor.
PATHOPHYSIOLOGY OF PROLONGED OBSTRUCTED LABOR AND URINARY TRACT INJURY
Although vesicovaginal fistula formation is the dominant injury among patients who have experienced prolonged obstructed
labor, two things are critical to an understanding of this condition: 1) the pathophysiology that leads to obstetric fistula formation
can lead to injuries in other organ systems; and 2) the injury that leads to fistula formation in obstructed labor is completely
different from the injury that leads to fistula formation as a result of a surgical injury (the most common cause of vesicovaginal
fistula formation in the developed world). A vesicovaginal fistula that occurs as the result of an operative complication is a focal
injury due to direct trauma, such as improper placement of a clamp during a hysterectomy. By contrast, postobstetric vesicovaginal
fistula is a field injury caused by direct pressure over a wide area for a prolonged period of time by the presenting part of the fetus
that has become trapped during labor. This results in a large area of tissue ischemia. Postsurgical fistulas tend to be small and
isolated, and are surrounded by healthy tissue. Obstetric fistulas, on the other hand, tend to be much larger: the average fistula
treated in Addis Ababa is 2.3 cm long (range 0.1-8 cm) and 2.5 cm wide (range 0.1-10 cm). The pathophysiology that leads to
obstetric fistula formation means that obstetric fistulas are surrounded by grossly abnormal tissues that have suffered a near-lethal
episode of hypoxic ischemia Figure 1. This difference in pathophysiology means that drastically different techniques of surgical
repair must be used in obstetric fistula surgery. The distortion and scarring that are found around an obstetric fistula mandate
extremely aggressive dissection with wide mobilization of tissues, virtually detaching the bladder from its location in the pelvis in
order to close the defect without tension on the suture line. Because the fistula has resulted from devascularization of a wide area,
a new blood supply must be brought in to the surgical site to maximize wound healing through the use of pedicled tissue flaps in
virtually all cases [6,7].
Figure 1. Moderate-sized obstetric vesicovaginal fistula. The entire bladder base has been destroyed, with partial loss of the
bladder neck and proximal urethra. The ureteric orifices lie on the edges of the fistula, with complete loss of tissues in between.
The location of the ureters is marked by ureteral catheters that have been brought out through the fistula itself.
The level of injury in the lower urinary tract is determined by the point at which descent of the presenting fetal part is
obstructed during labor. As a result, fistulas may form between the urethra and vagina, the bladder and vagina, or even between
the bladder and the uterus. Ureterovaginal fistulas tend to form as the result of injuries sustained during surgery, but they are also
sometimes seen as the result of obstructed labor alone. The same is true for uterovesical fistulas. The urethra is damaged at least
partially in 28.6 percent of the cases seen in Addis Ababa. Total loss of the urethra, which occurs in about 5 percent of cases,
presents a special technical challenge, because there is usually little viable tissue available with which to perform a neourethral
reconstruction [7].
The high prevalence of urethral injury also leads to a high rate of persistent stress incontinence in patients whose fistulas have
been closed successfully [8]. This fact has not been properly appreciated by the medical community; however, stress incontinence
occurs in 26 percent of our patients after fistula repair. The exact urodynamic reasons for this are unknown, but it is clear that the
pathophysiology that leads to fistula formation can effect bladder function adversely for many reasons. Bladder fistulas are the
result of damage to a wide area of the bladder base. Some fistulas occur at the level of the bladder neck and urethra, with
resultant damage to the sphincteric mechanism. The trigone, through which most of the innervation of the bladder passes, is nearly
always involved. It is likely, therefore, that many of these patients have complex neuropathic bladder dysfunction in addition to
sphincteric incompetence. The extensive scarring that develops as a result of the obstructed labor not infrequently leads to a
marked decrease in bladder volume after the bladder has been mobilized and the defect closed. Functional bladder capacities of 50
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ml or less are not uncommon in these patients after fistula closure. Bladder compliance must also be affected by the large areas of
scar tissue present in obstetric fistulas. Whatever the exact pathophysiology, the urinary incontinence seen in these women even
after successful fistula closure is extremely difficult to manage.
The percentage of patients who have sustained secondary injury to the upper urinary tract is also unknown. Upper tract
damage could result from chronic ascending infection, obstruction from distal ureteral scarring, or even from reflux in very young
patients. In the developing world, hospitals such as ours typically have neither the laboratory capability to detect azotemia, nor the
radiographic facilities to diagnose hydroureteronephrosis. As result, we do not know the true incidence of significant renal damage;
however, clinical experience in Africa indicates that renal failure is a common cause of death in women with obstetric fistulas.
GYNECOLOGIC MORBIDITY
The obstetric literature contains a great deal of information about the urologic sequelae of obstructed labor; however, it has
largely been unappreciated that there is nearly as much gynecologic morbidity in these patients. Review of the menstrual histories
of 998 patients with obstetric fistulas has revealed that a staggering 63.1 percent are amenorrheic. Many of these patients
undoubtedly have hypothalamic or pituitary dysfunction [9], but unpublished data from Nigeria suggest that intrauterine scarring
and Asherman's syndrome are also common (H. Ojengbede, personal communication).
The ischemic vascular field injury that produces obstetrics fistulas also results in extensive scarring and widespread destruction
of the vagina. The vaginal pathology that is encountered ranges from focal bands of scar tissue to complete vaginal destruction.
Some form of vaginoplasty is required in 28.5 percent of our patients [10]. The presence of vaginal scarring is a poor prognostic
factor for fistula repair, being correlated with an increased risk of breakdown of the operative site or the development of
postoperative stress incontinence [11]. In a series of 267 fistula patients with severe vaginal scarring from our institution in
Ethiopia, 57.7 percent suffered from stress incontinence after fistula repair, and 23.5 percent had a persistent or recurrent fistula.
In addition to vaginal injury, many patients sustain severe cervical damage. Until recently we have not collected data on the status
of the cervix in these patients, but a "normal" appearing cervix is rarely seen when patients with obstetric fistulas are examined.
Cervical injury may also be related to the high prevalence of pelvic inflammatory disease encountered among this patient
population. Prolonged obstructed labor may result in complete loss of the cervix. In many patients there is no identifiable cervical
tissue at all. Although long-term patient follow-up is generally impossible in an African setting, the combination of widespread
amenorrhea, vaginal scarring, and cervical destruction leads to a tremendous problem of secondary infertility among these patients
--a significant problem when it is realized that the "social safety net" in most African countries consists almost exclusively of family
and kinship obligations.
RECTAL INJURIES
Although vesicovaginal fistula is the most common fistula seen as a result of obstructed labor, rectovaginal fistulas occur in
17.4 percent of our patient population. In general, rectovaginal fistula repair is less successful than vesicovaginal fistula repair.
Because the injury implies a very wide area of ischemic injury, the presence of a "double fistula" (a combined rectovaginal and
vesicovaginal fistula) might be thought to represent a special treatment challenge; however, the rate of successful fistula closure is
the same for both isolated rectovaginal fistulas and rectovaginal fistulas combined with vesicovaginal fistulas (78 percent). In
contrast, vesicovaginal fistulas can be closed successfully in over 90 percent of cases. The routine use of diverting colostomy might
improve the success rate in repairing rectovaginal fistulas, but there are significant problems with the cultural acceptance of
colostomy in Ethiopia, as well as insurmountable problems with procuring colostomy bags and related supplies which has made this
relatively simple surgical option impractical in most cases. Additional work should be done to compare simple closure of
rectovaginal fistulas with more complex repair techniques such as colo-anal pull-through procedures.
Exceptionally severe rectal injuries are occasionally seen in patients with obstetric fistulas. Approximately twice per year we
see an unusual situation in which the rectal lumen is totally obliterated above the level of the rectal fistula. Inasmuch as the
performance of a preoperative barium enema or endoscopic evaluation of the distal colon is not possible in our setting, this
puzzling condition is generally recognized only after surgical repair of a high rectovaginal fistula. We are unsure if this merely
represents an error in technique that has led to compromise of the rectal lumen at the time of surgery, or if it is another
manifestation of the global ischemia of obstructed labor. Although patients with rectovaginal fistulas commonly have fecal
incontinence, there may also be an as yet unrecognized problem with occult anal sphincter injury in patients who have only
developed an overt vesicovaginal fistula. Although persistent stress incontinence continues to be a problem after successful closure
of a vesicovaginal fistula, it does not appear that patients who have undergone successful closure of a rectovaginal fistula continue
to have persistent fecal loss due to a defective anal sphincter.
ORTHOPAEDIC TRAUMA
In addition to soft tissue injury, patients with obstetric fistulas may suffer direct trauma to the pelvic bones. In a study of 312
Nigerian women with obstetric vesicovaginal fistulas, Cockshott [12] noted bony abnormalities in 32 percent of plain pelvic
radiographs. The findings included bone resorption, marginal fractures and bone spurs, bony obliteration of the symphysis, and wide
(greater than 1 cm) symphyseal separation. In very severe cases of vesicovaginal fistulas where large amounts of bladder tissue are
lost, the periosteum of the pubic bone can often be palpated directly through the fistula defect. It should, therefore, not be
surprising that direct ischemic damage to the pelvic bones could occur, because the pubic symphysis is often the point at which
labor obstructs. The clinical significance of the bony pathology associated with obstetric fistulas is not understood. It may well
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represent avascular necrosis of the symphysis itself. Certainly a very large percentage of patients with severe fistula injuries have
gait disorders, which are a common problem in cases of symphyseal separation.
NEUROLOGIC INJURIES
One of the most tragic injuries associated with obstetric fistula formation is foot-drop [13]. A visitor to any fistula center will
find many patients walking with a serious limp, dragging one foot, and using a stick for support Figure 2. An informal survey of
patients on hand in Addis Ababa recently revealed that almost 20 percent of our patients had some degree of foot drop. Clinically,
these patients have neurologic deficits similar to those seen in leprosy patients with this condition. In some cases anesthesia of the
lower extremity is also present. Whether this problem is the result of impaction of the presenting fetal part on the sacral nerve
plexus, or if it is related to peroneal nerve injury sustained by laboring for days in the squatting position [14] is unknown. It is also
unknown which injuries are permanent and which will resolve over time. We have begun a program of physiotherapy and the use of
posterior splints in patients with significant neurological disability. The use of posterior tibialis tendon transfer is a well-established
procedure for patients with foot-drop from other causes, and it may be that this method will be useful in treating foot-drop
associated with obstetric fistulas.
Figure 2. Foot-drop as a result of prolonged obstructed labor. The patient has lost the ability to dorsiflex and evert the foot due to
damage to the sacral nerve plexus and/or the common peroneal nerve. This results in a characteristic "high-stepping" or "slapping"
gait. Walking must be aided by a stick or crutch, and patients will frequently lose their toes from progressive damage to the distal
areas of the foot as it is dragged or bumped along the ground.
SOCIAL CONSEQUENCES OF PROLONGED OBSTRUCTED LABOR
Although physicians tend to think in terms of clinically definable injuries, much of the suffering that fistula patients endure is a
result of the condition's social consequences. In many rural African cultures, women have a lower social status than men. In
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addition, the division of labor is often such that women are required to perform much of the heavy domestic labor such as carrying
water and firewood or cultivating the fields. Foot drop and pelvic injuries often make performance of these tasks impossible.
Although obstetric fistula formation is most common as a complication of a first pregnancy, 11.7 percent of our patients have had
six or more children. What happens to the surviving children when their mother's life is ruined in this fashion? The impact of an
obstetric fistula on the surviving children of a mother with this condition is an important public health issue about which there are
no data.
In cultures where women's roles are defined largely in terms of reproductive functioning, a woman's obligation to satisfy her
husband's sexual needs is often intimately intertwined with her own sense of self-worth. Vaginal injuries often make intercourse
impossible, and the constant stream of urine makes it otherwise unpleasant. Although infertility is a devastating problem to couples
in any culture, in Africa this is a problem of tremendous significance. Large families may be the only source of help for agricultural
labor, and since governmental social welfare programs are nonexistent in most African countries, children are the only hope one
has for security in old age. The fetal mortality in obstructed labor is staggering. According to our records, 7882 of 8543 fetuses
involved in prolonged obstructed labor died in the process (92.3 percent). Of 9196 patients on whom data are available, 6283 (68
percent) had no living children. The widespread problems of amenorrhea, cervical injury, and postfistula pelvic inflammatory
disease in women with obstetric fistulas mean that many women will never have another chance at childbirth. Furthermore, almost
50 percent of our patients are divorced or separated from their husbands. This compounds an already disastrous social situation
even further.
Many African religious groups, especially Muslims, require personal cleanliness as a prerequisite for worship. Fistula patients
are obviously unclean, and this often excludes them from participation in religious activities. This further diminishes their sense of
self-worth. Their odor is offensive and they cannot control the constant stream of urine that runs from their vaginas, down their
thighs and legs. In order to deal with this never-ending problem, the families of these patients often remove them from the main
family dwelling into a peripheral hut, sometimes forcing them to live out doors. Not uncommonly, they are forced out of the family
compound altogether. Unskilled, illiterate, impoverished, socially isolated, and reeking of urine and (sometimes of feces) these
women truly are the wretched of the earth. Yet these are young women, with most of their lives ahead of them. The average age
at which a fistula develops in our patient population is 18.9 years (range 12-50 years); however, the typical patient who presents at
the Addis Ababa Fistula Hospital for care has suffered from her condition for at least 5 years. The average age at which patients
present for treatment is 24.2 years (range 12-76 years). Those women still sequestered in the villages and shantytowns throughout
Africa may suffer for decades, if not for the rest of their lives. In some cases, those with this condition resort to suicide in order to
end a life that no longer seems worth living.
CONCLUSIONS
The obstetric fistula problem demands an organized international and interdisciplinary effort on several levels. Accurate data
on the prevalence of the problem are lacking, but the number of women who have been injured in this way worldwide are
undoubtedly in the millions. The "syndrome concept" of obstructed labor injury needs additional discussion. Fistula centers in other
countries may be seeing other associated injuries that should be added to this list of complications. The injuries that we have
discussed here must be understood better if treatment and prevention strategies for obstetric fistulae are to be improved.
Fundamental scientific questions such as the exact neurologic lesions involved in the footdrop associated with prolonged obstructed
labor or the development of amenorrhea in patients who develop obstetric fistulas need to be answered. Our understanding of such
problems remains in its infancy. Cooperation among existing fistula centers could speed our understanding of these issues
dramatically.
Fistula centers must also broaden their thinking and their capabilities to deal with the wide-ranging spectrum of clinical
disorders seen in these patients. Fistula surgeons need the assistance of orthopaedists, neurologists, colorectal surgeons, and other
experts to develop the capabilities they need to treat the multifaceted complications of obstructed labor that involve the entire
pelvic floor and its associated organ systems, not just an isolated "compartment" in the pelvis [15]. Finally, the international
medical community must publicize the problem of untreated obstructed labor in order to mobilize the resources needed to treat
those women who have suffered its consequences, and to prevent this from happening to future generations. As it now stands, this
is one of the greatest unaddressed health care needs for the women of this planet. It should not be allowed to remain so.
Acknowledgments--This work was supported in part by The Worldwide Fund for Mothers Injured in Childbirth, 7200 Sears
Tower, Chicago, IL 60606.
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