Clinical:Case Study: Childbirth Injuries Epidemic

Original materials created in June 1999 by Steven D. Arrowsmith, M.D.

History

Yeshi is a 15 yo Ethiopian woman who presented with total urinary and fecal incontinence. Three years earlier, her first pregnancy had ended in disaster. Married at 10, she had become pregnant soon after menarche, and, living in a remote village in an extremely mountainous area, she had received no prenatal care. Labor occurred in her hut, attended by an older woman from the village. After 72 hours of unsuccessful labor, she was carried by relatives more than 15 km to the nearest road, eventually reaching a district hospital by bus. Her initial examination was consistent with prolonged obstructed labor, maternal sepsis, and fetal demise. A destructive delivery was performed. On the second post-operative day, she became incontinent of urine and passed a large amount of necrotic tissue from the vagina. By the third day, she began to pass stool per vagina as well. Re-examination revealed a 3 x 4 cm defect in the anterior vaginal wall with total loss of the floor of the bladder. Posteriorly, there was a 4 x 5 cm defect near the vaginal apex contiguous with the rectum. After receiving IV antibiotics, her sepsis resolved, and she was discharged.

In the intervening three years, she had remained totally incontinent of both urine and stool, leading to a subsequent divorce. Examination now revealed the same recto-vaginal and vesico-vaginal fistulae noted at the time of delivery. However, both of these defects were now densely encased in scar. The cervix was no longer present, and the vagina ended as a blind pouch. Vaginal length was now only about 4 cm, and vaginal caliber was reduced by about 70%. The perineum was markedly excoriated from the chronic presence of urine and stool.

Discussion

Although unfamiliar to many western health professions, obstetric fistula is epidemic in the developing world. Very conservative estimates put the worldwide maternal death toll at 1,650 women daily. The government of West African nation of Nigeria admits to more than 75,000 maternal deaths per year; this is more deaths than the total number of Americans killed in action in the Vietnam War. For each death, it is estimated that 20 women sustain childbirth injuries such as those described in our case. Untold thousands, perhaps even millions of women like Yeshi suffer today behind cultural, political, and economic barriers that have left the world unaware of their plight.

The pathophysiology of the injuries described in this case is global ischemia of pelvic organs caused by the pressure of the presenting fetal part in obstructed labor. In wealthier nations, such injuries are obviated by the universal availability of a timely Cesarean section. For women in the developing world, basic obstetrical services are a dream, not a reality. Interruption to pelvic blood flow during obstructed labor leads to a spectrum of injuries involving many organ systems. While vesicovaginal fistula (VVF) is the most common injury, about 15% of patients sustain a rectovaginal fistula (RVF). Five percent suffer total loss of the urethra, and in nearly one in four women, damage to the bladder neck is severe enough that even after successful fistula closure, type III stress urinary incontinence ensues. Renal damage from chronic infection and distal ureteral scarring make renal failure the most common cause of death. About two-thirds experience permanent amenorrhea, most sustain ischemic injury to the cervix, and in about 5% the vagina is lost to ischemic necrosis. One in five sustains some degree of nerve injury to the lower extremities leading to foot-drop. The obstructed labor proves fatal to the fetus in 93% of cases.

Prevention of maternal morbidity and mortality seems a nearly impossible task in the developing world. Establish a network of wellequipped, well-staffed facilities where women have access to Cesarean section, improve transportation systems to bring women rapidly to medical attention, remove financial, political, and cultural barriers to health care for women, improve the status of women in society, and abolish harmful traditional practices, such as female circumcision, that can lead to obstructed labor - all these elements are needed so that childbirth injuries will disappear as they have done in the United States. transportation systems to bring women rapidly to medical attention, remove financial, political, and cultural barriers to health care for women, improve the status of women in society, and abolish harmful traditional practices, such as female circumcision, that can lead to obstructed labor - all these elements are needed so that childbirth injuries will disappear as they have done in the United States.

For now, we have a disaster on our hands that will not go away. But, we can help. The Worldwide Fund for Mothers Injured in Childbirth has established a web site for concerned health care providers at www.wfmic.org. Here you can find resources from medical bibliography information to personal stories of women who have survived this ordeal. The site also maps out ways to become involved in fighting this massive humanitarian catastrophe.

How does one respond to a tragedy so huge, but yet so far away? Donate to organizations such as the Worldwide fund for Mothers Injured in Childbirth, or the Hamlin Churchill Childbirth Injury Trust. These organizations can channel your money and/or your skills to the areas of deepest need. Be an advocate. Learn all that you can about this tragedy (see “Suggested Reading” as a place to start), and then speak out. Put your status as a health professional to work by bringing this disaster out into the open. Finally, network. In the age of the Internet, it has never been easier for people to gather around an issue. Log onto the WFMIC web site and develop ties with other concerned individuals.

And what if you see a patient with VVF or RVF in your practice? Childbirth injuries do occur in the U.S., and people relocate from other countries more frequently than ever. The key to success in fistula repair is experience, and very few practitioners in the U.S. will ever see sufficient numbers of injured women to become proficient in the evaluation and surgical repair of these injuries. Contact WFMIC for help in matching your patient with an experienced surgeon.

Suggested Reading

Wall, L.L. “Dead mothers and injured wives: The social context of maternal morbidity and mortality among the Hausa of northern Nigeria: Studies in Family Planning , 1998; 29:341-359.

Arrowsmith, S., et. al. “Obstructed Labor Injury Complex: Obstetric fistula formation and the multifaceted morbidity of maternal birth trauma in the developing world.” Obstetrical and Gynecological Survey , 1996; 55:568-574.

Wall, L.L. “Obstetric fistulas in African and the developing world: New efforts to solve an ageold problem.” Women’s Health Issues, 1996; 6:229-234.