10-10-10: The FIGO Obstetric Fistula action plan

OBG-Speculum:    2024                       ISSN no.

Vol -2, Issue -1  

Dr. Priyanka Singh

The development of obstetrical fistula is directly linked with obstructed uncared labour. As per WHO, approx. 2 million young females live with the obstetrical fistula in Asia and sub-Saharan Africa. [1] Obstructed labour accounts not only for the morbidity in the form of Fistula but also responsible for 6% of all maternal deaths [1]

Obstetrical Fistulas (OF) are completely preventable by following simple measures of labour care, 1.) timely access to delivery services under the supervision of a trained team,  2.) avoiding teenage pregnancies, 3.) timely referral from smaller peripheral & remote health centres to a facility where 24 hourly caesarean facility is there.

With so much advancement in the medical field, we still come across suffering in the form of Obstetrical Fistulas, especially in low-income developing countries. Preventing fistula and Managing it once it has occurred are the two sections where we need to focus on achieving the sustainable development goal 3 (SDG -3) of improving maternal health. Fistulas make the women isolated not only in the community but also in their families, with difficulty in pursuing jobs and a lot more untold suffering. 

It’s high time to end this global treatment gap and suffering and FIGO has taken it up as an 10 step program to reach such women entitled as “10-10-10 FIGO Obstetrical Fistula Action Plan”- 10 steps, 10 years, 10Million $ to reach 100,000 women.[2]

Step-1: Recruit and train new fistula surgeons with teams for giving holistic care.

Step-2: Continued coaching and supervision by FIGO team of trainers.

Step-3: development of the FIGO Fistula training centre & supporting them.

Step-4: Providing the Fistula surgery-related instruments, equipment and kits.

Step-5: provision of training material and their access.

Step-6: measures to make the program further effective.

Step-7: Generate the true evidence to improvise the practice further.

Step-8: developing the collaboration in between

Step-9: Make the public aware, about the fistula treatment and its impact.

Step-10: Last but not the least to support the program & the team in comprehensive manner to deliver the expected outcome.

As per present scenario it is expected that 10 years with $10 Million will be substantial to cover the whole plan to cover this fistula treatment gap and impact the lives of affected women. Texas Children’s Hospital is partnering with this concept plan for FIGO.

Fistula repair facilities can be made available at stand-alone fistula centres, or developing special wings in current maternity or tertiary care hospitals, Urological departments. Satellite fistula repair units, camps, can be developed linked with Fistula centres where simple fistulas can be repaired and more complicated ones can be referred. [3, 4]

Here we mention the fundamental principles of Obstetrical fistula repair

v  OF can be prevented by immediate bladder catheterization, cleaning, a healthy diet, sitz bath and antibiotics for any existing infection, to those who survived prolonged or obstructed labour.

v  Take proper history (detailed), gentle pelvic and anal examination to identify the other pelvic injuries and weakness and classify them as Simple or Complex based on operative difficulty. Basic lab tests should be within normal limits for planning surgery as it is an elective surgery and the patient party should be counselled about the prognosis and complications before consent.

v  The prognosis of the repair outcome should be assessed based roughly on urethral involvement, defect size, bladder capacity, previous repair attempts (abdominal or vaginal). Women should be informed that despite the proper defect closure in case of VVF some amount of incontinence as stress, urge or mixed can remain.

v  Commonly associated problems like uterine ruputure, scarring, infertility, skin excoriation by urine, foot drop, infections, etc can be there and should be specifically analysed on examination.

v  One dictum for OF management is first repair attempt offers best success rates.

v  Skilled pre & post operative care including physiotherapy be ensured for successful recovery. Malnutrition, anaemia, local infection, urinary tract infection be treated pre-operatively

v  Very small VVF can heal spontaneously if bladder is drained with large size foley’s catheter for 4-6 weeks and avoiding infection in 20-25% cases, especially those with fresh margins.

v  Primary surgery should be delayed min 6 -12weeks  or until there is no inflammation.

v  An exaggerated lithotomy position with Trendelenburg tilt and buttocks protruding out is best for surgery.

v  Various methods & routes of surgical repair has been defined and the best approach is a standard layered method.

v  Dissection as per normal anatomy. Adequate tissue mobilisation and separation of the bladder from the vagina (in VVF) and rectum from the vagina (in RVF). Once the area of the fistula is exposed a circumferential incision is given all around 3 mm away.

v  Tissue handling should be very gentle during surgery

v  Bladder and rectal muscles should be properly approximated preferably in double layer starting 2-3 mm away from the incised margin.

v  Tension-free repair/closure taking all asepsis measures.

v  For larger size RVF better to go for diverting colostomy.

v  In VVF repair high fluid intake (4-5 liters/day) and continuous drainage of urine is advised. Even one urethral and another suprapubic drain be placed in larger size cases. The colour of urine is the best indicator of adequate hydration. Transurethral catheters should be kept for 21 days and should be removed without clamping.

v  Sexual activity in such repair cases should be avoided for 3 -4 months post repair.

WHO recommends that all developing countries should have a OF strategy committee under the maternal health care system. The INTERNATIONAL DAY TO END OBSTETRIC FISTULA is observed 23rd May every year to create awareness in public, strengthen partnership and mobilize the global support for this life devastating injury.

References:

1.               https://www.who.int/news-room/facts-in-pictures/detail/10-facts-on-obstetric-fistula

2.               https://www.figo.org/what-we-do/obstetric-fistula/fistula-surgery-training-initiative/action-plan

3.               Polan ML, Sleemi A, Bedane MM, et al. Obstetric Fistula. In: Debas HT, Donkor P, Gawande A, et al., editors. Essential Surgery: Disease Control Priorities, Third Edition (Volume 1). Washington (DC): The International Bank for Reconstruction and Development / The World Bank; 2015 Apr 2. Chapter 6. Available from: https://www.ncbi.nlm.nih.gov/books/NBK333495/doi: 10.1596/978-1-4648-0346-8_ch6a

4.               L. de Bernis, Obstetric fistula: Guiding principles for clinical management and programme development, a new WHO guideline. International Journal of Gynecology & Obstetrics, 2007: 99(1); S117-121