obstetric fistula an overview brad r. mackinnon university of vermont

Obstetric FistulaObstetric FistulaAn OverviewAn Overview

Brad R. MacKinnonBrad R. MacKinnon

University of VermontUniversity of Vermont

22

ContentsContents What is obstetric fistula?What is obstetric fistula? EpidemiologyEpidemiology Vesicovaginal FistulaVesicovaginal Fistula Why do fistulas occur in young girls?Why do fistulas occur in young girls? The obstructed labor injury complexThe obstructed labor injury complex The obstetric fistula pathwayThe obstetric fistula pathway TreatmentTreatment Surgical management of urinary incontinence after obstetric Surgical management of urinary incontinence after obstetric

fistula repairfistula repair Campaign to end fistulaCampaign to end fistula

ReferencesReferences

33

““ My name is Telanish Shabera. I My name is Telanish Shabera. I am 14 years old. I was promised am 14 years old. I was promised

in marriage when I was 3, in marriage when I was 3, betrothed at 10, and pregnant at betrothed at 10, and pregnant at 12. After 3 days of labor, I was 12. After 3 days of labor, I was

carried on a stretcher to a carried on a stretcher to a hospital, where my baby died 2 hospital, where my baby died 2

hours later. The obstructed labor hours later. The obstructed labor left me incontinent. I smell, and I left me incontinent. I smell, and I

feel so ashamed.”feel so ashamed.” Source: McKenna N. Fistula pilgrims.Source: McKenna N. Fistula pilgrims.

Federation International Gynecologists Obstetricians Federation International Gynecologists Obstetricians

Source: G. Lewis, WHO Press.Source: G. Lewis, WHO Press. 44

““Every minute, a woman Every minute, a woman dies in pregnancy or dies in pregnancy or

childbirth, and for every childbirth, and for every woman who dies, 20-30 woman who dies, 20-30 others will survive but others will survive but with morbidity, one of with morbidity, one of

which is obstetric fistula” which is obstetric fistula” 1313

Source: Campaign to End Fistula Source: Campaign to End Fistula Printed MaterialsPrinted Materials 55

What is obstetric fistula?What is obstetric fistula?

Injury of childbearing from prolonged obstructed Injury of childbearing from prolonged obstructed labor w/o timely medical intervention – typically a labor w/o timely medical intervention – typically a caesarean section to relieve the pressure.caesarean section to relieve the pressure.

The baby usually dies.The baby usually dies. The women is left with chronic incontinence.The women is left with chronic incontinence. Women often abandoned by husband and Women often abandoned by husband and

family, and ostracized by her community.family, and ostracized by her community. Prospects for work and family life greatly Prospects for work and family life greatly

diminished.diminished.

Source: The Lancet 2006; 368: Source: The Lancet 2006; 368: 1201-12091201-1209 66

EpidemeologyEpidemeology11

1818thth Century Century obstetrical drawing of obstetrical drawing of obstructed labor from obstructed labor from absolute absolute cephalopelvic cephalopelvic disproportion.disproportion.

From William From William Smellie’s Smellie’s Sett of Sett of Anatomical Tables, Anatomical Tables, 1752.1752.

Source: Aust N Z J Surg 2000; Source: Aust N Z J Surg 2000; 70: 851–854 70: 851–854 77

How big a problem is this?How big a problem is this? Estimates of 2-7 million women affected.Estimates of 2-7 million women affected. Estimates of >75,000 new cases each year.Estimates of >75,000 new cases each year. Estimates of 3-5 cases per 1000 pregnancies.Estimates of 3-5 cases per 1000 pregnancies. Limited indigenous surgical repair capability.Limited indigenous surgical repair capability. Cultural and religious worldviews serve to perpetuate the Cultural and religious worldviews serve to perpetuate the

status quo:status quo: ““whatever will be, will be”whatever will be, will be” ““the will of God (Allah)”the will of God (Allah)”

Women currently have neither the education, resources, Women currently have neither the education, resources, nor rights to change the underlying causes of fistula.nor rights to change the underlying causes of fistula.

Note: the occurrence in the western world approaches 0.Note: the occurrence in the western world approaches 0.

Source: Lancet 2006; 368: 1201-Source: Lancet 2006; 368: 1201-1209.1209. 88

Socioeconomic factors in obstetric Socioeconomic factors in obstetric fistula formation.fistula formation.

African women predisposed to dystocia due to narrow African women predisposed to dystocia due to narrow pelvic architecture.pelvic architecture.

Marriage at early age, before pelvis growth is complete.Marriage at early age, before pelvis growth is complete. Malnourishment retards maturation.Malnourishment retards maturation. Lack of access to emergency obstetric services.Lack of access to emergency obstetric services. Poverty, illiteracy and limited educational opportunities.Poverty, illiteracy and limited educational opportunities.

Note: Maternal mortality rates in Western Europe and Note: Maternal mortality rates in Western Europe and the USA at the beginning of the 20the USA at the beginning of the 20thth century were similar century were similar to those in the developing world today…dramatically to those in the developing world today…dramatically reduced between 1935 and 1950 due to access to reduced between 1935 and 1950 due to access to emergency obstetric services.emergency obstetric services.

Source: Source: The Lancet Source: Source: The Lancet 2006; 368: 1201-12092006; 368: 1201-1209 99

Vesicovaginal FistulaVesicovaginal Fistula11

Moderate-sized Moderate-sized vesicovaginal fistula vesicovaginal fistula from obstructed labor.from obstructed labor.

Metal catheter passed Metal catheter passed through the urethra is through the urethra is clearly visible through clearly visible through the bladder base, the bladder base, which is missing.which is missing.

1010

Why do fistulas occur in young Why do fistulas occur in young girls?girls?

Increased incidence of cephalopelvic Increased incidence of cephalopelvic disproportion.disproportion.

Pelvic bone immaturity.Pelvic bone immaturity. Reduced birth canal size before age 18.Reduced birth canal size before age 18. Reduced inlet, midplane, outlet dimensions.Reduced inlet, midplane, outlet dimensions. Late onset of puberty. Late onset of puberty. Malnutrition.Malnutrition.

Net = “Low” gynecological age.Net = “Low” gynecological age. Chronological age – age at menarche.Chronological age – age at menarche.

Younger age at marriage.Younger age at marriage.

Source: Am J Obstet Gynecol Source: Am J Obstet Gynecol 2004; 190: 1011-10192004; 190: 1011-1019 1111

The Typical PatientThe Typical Patient1414

Small (44Kg)Small (44Kg) Short (<150 cm)Short (<150 cm) Married Early (mean age Married Early (mean age

= 15.5 years)= 15.5 years) Now Divorced 49%Now Divorced 49% Separated 22%Separated 22% Uneducated 78%Uneducated 78% Poor/Rural (>95%)Poor/Rural (>95%) Developed fistula as Developed fistula as

primagavida 46%primagavida 46%

824/899 fetal deaths824/899 fetal deaths 75/899 live births75/899 live births

14 died in first month14 died in first month

>50% of these women >50% of these women endured fistula for 1-9 endured fistula for 1-9 years before seeking years before seeking treatment.treatment.

Avg. fistula 3.5 cmAvg. fistula 3.5 cm 92% repair success92% repair success 71% fetuses were 71% fetuses were ♂♂

Source: J Midwife Womans Source: J Midwife Womans Health 2005; 50: 286-294.Health 2005; 50: 286-294. 1212

Articles on Association of Age, Gynecologic Age, Articles on Association of Age, Gynecologic Age, Cephalopelvic Disproportion, and Obstructed LaborCephalopelvic Disproportion, and Obstructed Labor15 15

AuthorsAuthors DescriptionDescription Key FindingsKey Findings

Chumlea et Chumlea et al., 2003al., 2003

USA: Cross-sectional study of USA: Cross-sectional study of 2510 females age 8–202510 females age 8–20

Median age at menarche: 12.43Median age at menarche: 12.43

Moerman, Moerman, 19821982

USA: Longitudinal study of USA: Longitudinal study of clinical, laboratory, and x-rays of clinical, laboratory, and x-rays of 90 adolescent girls90 adolescent girls

Pelvic inlet, midplane, and outlet clinically contracted during Pelvic inlet, midplane, and outlet clinically contracted during early adolescence (<17); growth of pelvis continues for 3 y early adolescence (<17); growth of pelvis continues for 3 y after menarcheafter menarche

Treffers, 2002Treffers, 2002 Global: Literature reviewGlobal: Literature review Obstructed labor a major health problem for young adolescent Obstructed labor a major health problem for young adolescent girls, particularly in specific geographic regions girls, particularly in specific geographic regions

Zlatnik and Zlatnik and Burmeister, Burmeister, 19771977

USA: Records review of 1005 USA: Records review of 1005 girls <17girls <17

Gynecologic age is the chronologic age minus age at Gynecologic age is the chronologic age minus age at menarche; Patients with low gynecologic age (<2 y) have an menarche; Patients with low gynecologic age (<2 y) have an increased likelihood of delivering a low birth weight baby increased likelihood of delivering a low birth weight baby compared to those with gynecologic age >2 y; independent of compared to those with gynecologic age >2 y; independent of chronologic agechronologic age


The obstructed labor injury The obstructed labor injury complexcomplex1010

Urological injuryUrological injury Vesicovaginal fistula Vesicovaginal fistula Urethrovaginal fistula Urethrovaginal fistula Ureterovaginal fistula Ureterovaginal fistula Uterovaginal fistula Uterovaginal fistula Complex combined fistulas Complex combined fistulas Urethral damage, including complete Urethral damage, including complete

urethral destruction urethral destruction Bladder stones Bladder stones Stress incontinence Stress incontinence Marked loss of bladder tissue from Marked loss of bladder tissue from

extensive pressure necrosis extensive pressure necrosis Secondary hydroureteronephrosis Secondary hydroureteronephrosis Chronic pyelonephritis Chronic pyelonephritis Renal failure Renal failure

Gynecological injuryGynecological injury Amenorrhoea Amenorrhoea Vaginal stenosis Vaginal stenosis Cervical injury, including complete Cervical injury, including complete

cervical destruction cervical destruction Secondary pelvic inflammatory disease Secondary pelvic inflammatory disease Secondary infertilitySecondary infertility

Gastrointestinal injuryGastrointestinal injury Rectovaginal fistula formation Rectovaginal fistula formation Rectal stenosis or complete rectal Rectal stenosis or complete rectal

atresia atresia Anal sphincter incompetence Anal sphincter incompetence

Musculoskeletal injuryMusculoskeletal injury Osteitis pubis Osteitis pubis

Neurological injuryNeurological injury Foot-drop from lumbosacral or Foot-drop from lumbosacral or

common peroneal nerve injury common peroneal nerve injury Complex neuropathic bladder Complex neuropathic bladder

dysfunction dysfunction Dermatological injuryDermatological injury

Chronic excoriation of the skin from Chronic excoriation of the skin from maceration by urine or faeces maceration by urine or faeces

Fetal injuryFetal injury Fetal case-fatality rate of about 95% Fetal case-fatality rate of about 95%

Social injurySocial injury Social isolation Social isolation Divorce Divorce Worsening poverty Worsening poverty Malnutrition Malnutrition Depression (sometimes with suicide) Depression (sometimes with suicide) Premature deathPremature death

Source: The Lancet 2006;368: Source: The Lancet 2006;368: 12101210 1414

Complications of obstructed labor: Complications of obstructed labor: pressure necrosis of neonatal scalppressure necrosis of neonatal scalp22

>90% of neonates >90% of neonates stillborn, another 3% stillborn, another 3% died the first week died the first week postpartum.postpartum.

Cause of death Cause of death usually asphyxia or usually asphyxia or septicemia.septicemia.

After intrauterine fetal After intrauterine fetal death, the head death, the head collapses, which collapses, which facilitates vaginal birthfacilitates vaginal birth

Source: Source: The Lancet Source: Source: The Lancet 2006; 368: 1201-12092006; 368: 1201-1209 1515

The obstetric fistula pathwayThe obstetric fistula pathway11

Factors include:Factors include: Socio-economicSocio-economic NutritionNutrition Education/literacyEducation/literacy Early marriageEarly marriage Harmful traditional Harmful traditional

practices.practices. Psychosocial damagePsychosocial damage

Result:Result: Suffering ,illness, and Suffering ,illness, and

premature death.premature death.


Common comorbitities associated Common comorbitities associated with Fistulawith Fistula

GynecologicGynecologic AmenorrheaAmenorrhea PIDPID

Musculo-SkeletalMusculo-Skeletal Lower limb contracture 2Lower limb contracture 200 to nerve damage. to nerve damage.

NeurologicalNeurological Foot drop from sacral and perineal nerve compressionFoot drop from sacral and perineal nerve compression Neurogenic bladder dysfunctionNeurogenic bladder dysfunction

DermatologicDermatologic Ammmonical dermatitisAmmmonical dermatitis Vulvar excoriationVulvar excoriation

Source: Lancet 2006; 368: 1201-Source: Lancet 2006; 368: 1201-1209.1209. 1717

Psychosocial damage resulting Psychosocial damage resulting from obstetric with fistulafrom obstetric with fistula

More devastating than the physical injury.More devastating than the physical injury. Divorce and abandonment. Divorce and abandonment. Cast out by their families.Cast out by their families. Social Pariahs.Social Pariahs. Many treated as having received a Many treated as having received a

punishment from God for sexual punishment from God for sexual misbehavior.misbehavior.

Depression, anxiety and other forms of Depression, anxiety and other forms of mental health dysfunction common.mental health dysfunction common.

1818

Early Detection and Treatment.Early Detection and Treatment.

CatheterizationCatheterization Viable treatment during first 90 days +/-.Viable treatment during first 90 days +/-. Avoid urine flowing through fistula.Avoid urine flowing through fistula. Promotes spontaneous closure of fistula.Promotes spontaneous closure of fistula. Foley for 6-8 weeks.Foley for 6-8 weeks.

PreventionPrevention For women in prolonged labor.For women in prolonged labor. Continuous catheterization.Continuous catheterization. Administration of antibiotics postpartum.Administration of antibiotics postpartum.

Reprinted with permission from Reprinted with permission from the WHO (H. Rochat) the WHO (H. Rochat) 1919

Fistula ExaminationFistula Examination

. .

Source: Am J Obstet Gynecol Source: Am J Obstet Gynecol 2006; 195: 1748-1752.2006; 195: 1748-1752. 2020

Simple vs. complicated Simple vs. complicated vesicovaginal fistula.vesicovaginal fistula.55

2121

TreatmentTreatment Surgery to repair the fistula.Surgery to repair the fistula.

At cost of $250+/- plus transport costs.At cost of $250+/- plus transport costs. Few hospitals with few trained surgeons. Few hospitals with few trained surgeons.

RehabilitationRehabilitation Stretching and mobilizing limbs.Stretching and mobilizing limbs. Physiotherapy of lower limbs, foot.Physiotherapy of lower limbs, foot. Psychological and emotional counseling.Psychological and emotional counseling. Employment skill building.Employment skill building.

OutreachOutreach Crucial to recruiting women for treatment.Crucial to recruiting women for treatment. Locate, educate, and transport. Locate, educate, and transport. Treated women as role models.Treated women as role models.

2222

Preoperative CarePreoperative Care Early detection/treatment of fistula is rare.Early detection/treatment of fistula is rare.

Fistulas in patients exist for months to years.Fistulas in patients exist for months to years. Malnutrition and AnemiaMalnutrition and Anemia Physical TherapyPhysical Therapy

Lower limb weakness.Lower limb weakness. Muscular contractures.Muscular contractures.

Complete physical examinationComplete physical examination Fistula location with Foley and Dye.Fistula location with Foley and Dye. Rectovaginal fistula rule out.Rectovaginal fistula rule out. CBC and STD Labs.CBC and STD Labs.

Source: European Urology 2006; Source: European Urology 2006; 50: 1000-1005.50: 1000-1005. 2323

Urethrovaginal fistula before (A) Urethrovaginal fistula before (A) and after (B) surgical repair.and after (B) surgical repair.44

Surgery performed in the Surgery performed in the in dorsal lithtomy position.in dorsal lithtomy position.

Careful vaginal Careful vaginal examination essential to examination essential to ensure no other fistulas ensure no other fistulas present.present.

16-18F Foley placed in 16-18F Foley placed in bladder.bladder.

Success Rate >90% Success Rate >90% reported in multiple reported in multiple studies.studies.

2424

Postoperative CarePostoperative Care

Catheters left in place.Catheters left in place. Urethral 1 week.Urethral 1 week. Urinary 2 weeks.Urinary 2 weeks. Clamped for short periods to accustom the bladder to Clamped for short periods to accustom the bladder to

distention.distention. Confined to bed rest for 2 weeks.Confined to bed rest for 2 weeks.

Bedsore preventative steps.Bedsore preventative steps. Abstain from intercourse for >3 month.Abstain from intercourse for >3 month.

Family planning education.Family planning education. Advise future deliveries be cesarean.Advise future deliveries be cesarean.

Source: BJOG 2006; 113: 475-Source: BJOG 2006; 113: 475-478478 2525

Surgical management of urinary Surgical management of urinary incontinence after obstetric fistula repairincontinence after obstetric fistula repair1212

>25% of women still >25% of women still incontinent after fistula incontinent after fistula repair.repair.

Most common in women Most common in women who had a urethral-who had a urethral-vaginal fistula. vaginal fistula.

Second operation can be Second operation can be done to repair using a done to repair using a combination of combination of uretheralisation (urethral uretheralisation (urethral lengthening), plus lengthening), plus fibromuscular sling of fibromuscular sling of rectus fascia.rectus fascia.

Reprinted with permission from Reprinted with permission from the WHO. (P. Virot) the WHO. (P. Virot) 2626

Addis Ababa Fistula Hospital Fistula Ward.Addis Ababa Fistula Hospital Fistula Ward.

Source:Int J Gynecol Obstet Source:Int J Gynecol Obstet 2006; 94: 254-261.2006; 94: 254-261. 2727

The forgotten fistula patients.The forgotten fistula patients.

Helping women to Helping women to reintegrate into societyreintegrate into society

Education and training in Education and training in work skills.work skills.

Health education Health education sessions and family sessions and family counseling servicescounseling services

Raising awareness of Raising awareness of obstetric fistula locally obstetric fistula locally and globally.and globally.

Gaining agreement and Gaining agreement and resources for change.resources for change.


Obstetric fistula and stigmaObstetric fistula and stigma99

Women’s Dignity Project (WDP) work on Women’s Dignity Project (WDP) work on obstetric fistula in eastern Africa has two main obstetric fistula in eastern Africa has two main themes:themes: Poverty, which precludes access to care, andPoverty, which precludes access to care, and Power of society to reject, banish and isolatePower of society to reject, banish and isolate

Three types of engagement by WDP:Three types of engagement by WDP: Action-oriented researchAction-oriented research Partnerships of people and institutions committed to Partnerships of people and institutions committed to

equitable treatment of womenequitable treatment of women Challenging underlying policies that create and Challenging underlying policies that create and

perpetuate stigmatizing conditions and povertyperpetuate stigmatizing conditions and poverty


Campaign to end fistulaCampaign to end fistula

A part of the United Nations Population Fund (UNFPA), goals include:A part of the United Nations Population Fund (UNFPA), goals include: Universal access to reproductive health services by 2015 Universal access to reproductive health services by 2015 Universal primary education and closing the gender gap in education by 2015 Universal primary education and closing the gender gap in education by 2015 Reducing maternal mortality by 75 per cent by 2015 Reducing maternal mortality by 75 per cent by 2015 Reducing infant mortality Reducing infant mortality Increasing life expectancy Increasing life expectancy Reducing HIV infection rates Reducing HIV infection rates Universal access to reproductive health services by 2015 Universal access to reproductive health services by 2015 Universal primary education and closing the gender gap in education by 2015 Universal primary education and closing the gender gap in education by 2015 Reducing maternal mortality by 75 per cent by 2015 Reducing maternal mortality by 75 per cent by 2015 Reducing infant mortality Reducing infant mortality Increasing life expectancy Increasing life expectancy Reducing HIV infection rates Reducing HIV infection rates

Campaign launched in 2003, and performing detailed needs Campaign launched in 2003, and performing detailed needs assessment.assessment.

3030

Campaign to end fistulaCampaign to end fistula

Click on flash player link below or go to web address listed to start video

http://www.endfistula.org/movie/wm_english.htm

UNFPA Video Player - Flash Player Installation.url

3131

SummarySummary A very real problem with an annual rate of new cases > indigenous A very real problem with an annual rate of new cases > indigenous

repair capability.repair capability. The pool of affected women is growing faster then the ability to effect The pool of affected women is growing faster then the ability to effect

surgical repair, even if it was freely available to all who needed it.surgical repair, even if it was freely available to all who needed it. The surgery repair is uncomplicated and inexpensive, but the real The surgery repair is uncomplicated and inexpensive, but the real

need is to avoid the occurrence of obstetric fistula in the first place.need is to avoid the occurrence of obstetric fistula in the first place. Under WHO leadership, an organized needs assessment and Under WHO leadership, an organized needs assessment and

awareness campaign has started…to soon to evaluate results.awareness campaign has started…to soon to evaluate results. Success will require fundamental changes:Success will require fundamental changes:

in the availability of emergency obstetric treatmentin the availability of emergency obstetric treatment in tradition and cultural mores regarding early marriage,in tradition and cultural mores regarding early marriage, and an elevation in the respect for the human rights of women in and an elevation in the respect for the human rights of women in

general, and young girls in particular, in the developing world.general, and young girls in particular, in the developing world. My take is that this is a monumental effort, and will only occur if My take is that this is a monumental effort, and will only occur if

piggybacked with other, broader programs related to human piggybacked with other, broader programs related to human reproductive rights.reproductive rights.

3232

ReferencesReferences

1.1. Wall LL. Obstetric vesicovaginal fistula as an international public-health problem. Wall LL. Obstetric vesicovaginal fistula as an international public-health problem. LancetLancet 2006; 2006; 368368: 1201-1209.: 1201-1209.

2.2. Van Beekhuizen HJ, Unkels R, Mmuni NS, Kaiser M. Complications of obstructed labour: Van Beekhuizen HJ, Unkels R, Mmuni NS, Kaiser M. Complications of obstructed labour: pressure necrosis on neonatal scalp and vesicovaginal fistula. pressure necrosis on neonatal scalp and vesicovaginal fistula. LancetLancet 2006; 2006; 368368: 1210.: 1210.

3.3. Norman AM, Breen M, Richter HE. Prevention of obstetric urogenital fistulae: some thoughts Norman AM, Breen M, Richter HE. Prevention of obstetric urogenital fistulae: some thoughts on a daunting task. on a daunting task. Int Urogynecol JInt Urogynecol J 2006; (Epub ahead of print). 2006; (Epub ahead of print).

4.4. Pushkar DY, Dyakov VV, Kosko JW, Kasyan GR. Management of urethrovaginal fisyulas. Pushkar DY, Dyakov VV, Kosko JW, Kasyan GR. Management of urethrovaginal fisyulas. European UrologyEuropean Urology 2006; 2006; 5050: 1000-1005.: 1000-1005.

5.5. Roenneburg ML, Genadry R, Wheeless CR. Repair of obstetric vesicovaginal fistulas in Roenneburg ML, Genadry R, Wheeless CR. Repair of obstetric vesicovaginal fistulas in Africa. Africa. Am J Obstet GynecolAm J Obstet Gynecol 2006; 2006; 195195: 1748-1752.: 1748-1752.

6.6. Mishra SK, Morris N, Uprety DK. Uterine rupture: preventable obstetric tragedies? Mishra SK, Morris N, Uprety DK. Uterine rupture: preventable obstetric tragedies? Aus and Aus and NZ J of Obstet and GynecolNZ J of Obstet and Gynecol 2006; 2006; 4646: 541-545.: 541-545.

7.7. Jokhio AH, Kelly J. Obstetric fistulas in rural Pakistan. Jokhio AH, Kelly J. Obstetric fistulas in rural Pakistan. Int J Gynecol ObstetInt J Gynecol Obstet 2006; 2006; 9595: 288-: 288-289.289.

8.8. Serour GI, (FIGO Committee Report). Ethical guidelines on obstetric fistula.Serour GI, (FIGO Committee Report). Ethical guidelines on obstetric fistula. Int J Gynecol Int J Gynecol ObstetObstet 2006; 2006; 9494: 174-175.: 174-175.

9.9. Bangser M. Obstetric fistula and stigma. Bangser M. Obstetric fistula and stigma. Lancet 2006Lancet 2006; ; 367367: 535-536.: 535-536.10.10. Donnay F, Ramsey K. Eliminating obstetric fistula: Progress in partnerships. Donnay F, Ramsey K. Eliminating obstetric fistula: Progress in partnerships. Int J Gynecol Int J Gynecol

ObstetObstet 2006; 2006; 9494: 254-261.: 254-261.11.11. Ramphal S, Moodley J. Vesicovaginal fistula: obstetric causes. Ramphal S, Moodley J. Vesicovaginal fistula: obstetric causes. Curr Opin Obstet GynecolCurr Opin Obstet Gynecol

2006; 2006; 1818: 147-151.: 147-151.12.12. Browning A. A new technique for the surgical management of urinary incontinence after Browning A. A new technique for the surgical management of urinary incontinence after

obstetric fistula repair. obstetric fistula repair. BJOGBJOG 2006; 2006; 113113: 475-478: 475-47813.13. WHO. In: Lewis G, de Bernis L, editors. Obstetric fistula: guiding principles for clinical WHO. In: Lewis G, de Bernis L, editors. Obstetric fistula: guiding principles for clinical

management and program development. Geneva: WHO Press; 2005.management and program development. Geneva: WHO Press; 2005.14.14. Wall LL, Karshima JA, Kirshner C, Arrowsmith SD. The Obstetric vesicovaginal fistula: Wall LL, Karshima JA, Kirshner C, Arrowsmith SD. The Obstetric vesicovaginal fistula:

characteristics of 899 patients from Jos, Nigeria. characteristics of 899 patients from Jos, Nigeria. Am J Obstet GynecolAm J Obstet Gynecol 2004; 2004; 190190: 1011-1019.: 1011-1019.15.15. Miller S, Lester F, Webster M, and Cowan B. Obstetric fistula: A preventative tradegy. J Miller S, Lester F, Webster M, and Cowan B. Obstetric fistula: A preventative tradegy. J

Midwife Womans Health 2005; 50: 286-294.Midwife Womans Health 2005; 50: 286-294.16.16. R.F. Zacharin, A history of obstetric vesicovaginal fistula, R.F. Zacharin, A history of obstetric vesicovaginal fistula, Aust N Z J SurgAust N Z J Surg 2000; 2000; 70:70: 851–854 851–854

obstetric fistula an overview brad r. mackinnon university of vermont

Documents