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Discussion Starter · #1 ·
I just watched a documentary on PBS about women in Afghanistan. It was about different maternal health issues as well. One of the women had a serious fistula from her bladder to vagina as a result of childbirth and had to be operated on to fix it. The doctor in the movie told her that if she got pregnant again, she would need to go to a big city during her 8th month to get a c/s. He told her that if she tried to deliver vaginally, the fistula would open up again and could never be healed. Is this medically true?
 

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A fistula can be very difficult to repair. I have had a few women with them and mosts OB's will refer them to a specialist in urogynacology. The problem is that the surgeries require special expertise to avoid problems later on, like genital prolapse and incontinence....there are a lot of anatomical parts crowded into a small space - with a lot of nerve endings. Perhaps it was a difficult repair for this doctor and maybe not one he was comfortable with - hence he thought the referral would be the best for this women.<br>
I was wondering if it was her first birth, and how traumatic it was....or was it a huge baby? Was she a multip with repeated trauma to the vaginal wall, causing it to be very thin, and difficult to repair?<br>
It could also be that she had some congential defect that was made worse by birthing.<br>
Unfortunately, pelvic floor disruption/dysfunction can be a serious consequence of birth, and sometimes needs to be surgically repaired.<br>
Must have been an interesting documentary.<br>
Carla
 

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That same recommendation is made in the US as well. It's way easier to arrange a c-section than to arrange reconstruction and aftercare again, in the US or Afghanistan.<br>
The rate of recurrance would depend on the reason for the first fistula. If the woman had a malformed pelvis due to injury or malnutrition in childhood, the rate would be higher than if she had a child with a malformation that caused the fistula (hydrocephalus) and that wouldn't happen again.
 

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Did the woman undergo female genital mutilation (clitorectomy) as a child? Many women end up with fistulas because of this terrible practice. According to what I have read, the clitoris is cut off, and the vagina sewed up, sometimes to the size of a matchhead. So when she gets married(can you say ouch!) and then gets pregnant, she tears from stem to stern, because she is so small outside, and the tissues that were supposed to stretch, can't. So cesarean is the preferred method of delivery. Nice for the hospital, huh? If she can get to a hospital, that is...Afghanistan has such a need for midwives who can help the moms during birth!They have one of the highest infant/mother mortality rates in the world right now...
 

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I was going to write what Cathi wrote -<br><br>
all this attention about fistulas being caused by childbirth is totally missing the true reason for the injury.<br><br>
FGM is the reason. Not vaginal birth. A true fistula in a spontaneous birth (no forceps, no episiotomy, etc) is very, very rare.<br><br>
These women are victims of routine sexual violence. We are doing them a grave disservice by continuing to boast the lies that it is all about their lack of access to cesarean sections.
 

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<div>Originally Posted by <strong>mendomidwife</strong> <a href="/community/forum/post/7338804"><img alt="View Post" class="inlineimg" src="/community/img/forum/go_quote.gif" style="border:0px solid;"></a></div>
<div style="font-style:italic;">A fistula can be very difficult to repair. I have had a few women with them and mosts OB's will refer them to a specialist in urogynacology. The problem is that the surgeries require special expertise to avoid problems later on, like genital prolapse and incontinence....there are a lot of anatomical parts crowded into a small space - with a lot of nerve endings. Perhaps it was a difficult repair for this doctor and maybe not one he was comfortable with - hence he thought the referral would be the best for this women.<br>
I was wondering if it was her first birth, and how traumatic it was....or was it a huge baby? Was she a multip with repeated trauma to the vaginal wall, causing it to be very thin, and difficult to repair?<br>
It could also be that she had some congential defect that was made worse by birthing.<br>
Unfortunately, pelvic floor disruption/dysfunction can be a serious consequence of birth, and sometimes needs to be surgically repaired.<br>
Must have been an interesting documentary.<br>
Carla</div>
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do you have any experience with women who subsequently gave birth after fistula repair?<br><br>
i had a vesicovaginal fistula that was caused by (imo) incompetent use of forceps (they were training a resident on me <img alt="" class="inlineimg" src="http://www.mothering.com/discussions/images/smilies/irked.gif" style="border:0px solid;" title="irked"><img alt="" class="inlineimg" src="http://www.mothering.com/discussions/images/smilies/smile.gif" style="border:0px solid;" title="smile">. i was a homebirth transport and they didn't treat me very well.<br><br>
i had a catheter in for 5 weeks and it almost healed on it's own, a little pinprick hole was left and they surgically repaired it. it was a very minor surgery. i have been receiving physical therapy to address these postpartum issues (i also have a prolapsed bladder that is very much improving), and my pt also does internal work on the scar tissue from the birth and surgery. according to her, my vaginal walls feel almost normal now, i just have a small residual scar tissue from the episiotomy <img alt="" class="inlineimg" src="http://www.mothering.com/discussions/images/smilies/greensad.gif" style="border:0px solid;" title="greensad"> but that is also improving with time.<br><br>
the urogyn mentioned that she wants me to have a c-sec for subsequent births, and this just breaks my heart. i am a natural birthing mama and i know in my heart and body that there is no real medical indication for me to have a c-section given my history. but the things that you've written make me think that there may be something else that i haven't considered.<br><br>
this documentary that the op mentioned sounds really interesting, what channel was it on?
 

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I saw the film- and I am going to have to agree- causes are being skipped over- remember that woman had a very very small set of premature twins- tiny babies-- she had urine leakage before birth and those were her first babies-- so what happened before hand to cause her to have constant urine leakage and have a fistula?<br>
I think for some it would be poor- medicalized care during birth, things that someone saw done once or thought should be done ( old medical procedures in many places have become "folk remedy/care")<br>
Female Genital Mutilation most likely accounts for the majority of the cases-
 

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Terrible damage can be caused by both FGM and also rape, especially if the the woman is a child at the time.
 

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Some diseases such as Crohn's (though that is uncommon in Afghanistan) can cause also spontaneous fistulae (w/o a birth) or make women susceptible to them-- in that case C/S can be necessary also.
 

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<div style="margin:20px;margin-top:5px;">
<div class="smallfont" style="margin-bottom:2px;">Quote:</div>
<table border="0" cellpadding="6" cellspacing="0" width="99%"><tr><td class="alt2" style="border:1px inset;">
<div>Originally Posted by <strong>lolar2</strong> <a href="/community/forum/post/7351525"><img alt="View Post" class="inlineimg" src="/community/img/forum/go_quote.gif" style="border:0px solid;"></a></div>
<div style="font-style:italic;">Some diseases such as Crohn's (though that is uncommon in Afghanistan) can cause also spontaneous fistulae (w/o a birth) or make women susceptible to them-- in that case C/S can be necessary also.</div>
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I would be thinking rectal fistulae would be the more common problem with Chrohn's --- and certainly there are things that impact the overall health of these women like war and food availability, water/clean water. In the areas of the world where FGM are prevalent then you also see a higher number of fistula problems-
 

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Recto-vaginal fistulae are more common with Crohn's but they can also go from the rectum to the bladder or urethra, and in some of those cases the vagina is also affected. Any of these are considered by GI's to be a contraindication for vaginal birth.
 

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Discussion Starter · #12 ·

I saw the film- and I am going to have to agree- causes are being skipped over- remember that woman had a very very small set of premature twins- tiny babies-- she had urine leakage before birth and those were her first babies-- so what happened before hand to cause her to have constant urine leakage and have a fistula?<br>
QUOTE]<br><br>
I thought that was a different woman, because the woman with the fistula had given birth 8 months before she appeared at the hospital in the film. And to answer the question about what network it was on, it was on a show called Independent Lens on PBS.
 

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NPR just recently had a story about this too. Malnutrition was mentioned, but not FGM. Seems that this is because the medical establishment doubts that FGM is a cause of fistula. Figures.
 

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A few years ago there was a woman on Oprah raising money for fistula repairs in Africa. She said that many of the fistulas were caused because the women were getting married and pregnant before they were full grown, some of them as young as 13 years old. Then they had no help giving birth and a full term baby can't pass through a child's pelvis without some help, and the women would labor and labor until they got a fistula and ended up with a still birth baby. Then their families would reject them because of the fistula. It was one of the saddest things I have ever seen.
 

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I saw that show on Oprah too and it haunted me. I had no idea the fistulas were causd by FGM because they never mentioned it!!
 

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I saw that Oprah espisode and have also been haunted by it. I am saddened that FGM was not even mentioned as a possible reason for fistulas.
 

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I wanted to add this info because there are probably people who still wonder if this is really a problem or not-- I know this won't be conclusive the trouble is that we are dealing with a cultural practice, if you are doing repairs and want to continue to work with these people in the countries they live in how strong of an anti-cultural statement would you dare make? --<br><br><br>
Am J Obstet Gynecol. 1993 Dec;169(6):1616-8.<br>
Female circumcision: obstetric issues.<br>
Baker CA, Gilson GJ, Vill MD, Curet LB.<br>
Department of Obstetrics and Gynecology, University of New Mexico School of<br>
Medicine, Albuquerque.<br><br>
--------------------abstract altered by me for copy right purposes the bigger part of this has been trimmed off------------<br><br>
The major obstetric problem associated with this profile is prolongation<br>
of the 2nd stage of labor due to scar or soft tissue dystocia and the consequent<br>
need for deinfibulation. Women who labor unattended with an obstructed<br>
introitus are at risk of vesicovaginal and rectovaginal fistulas, laceration of<br>
scar tissue with hemorrhage, and fetal asphyxia or death. Incision of the<br>
fibrous tissue in this patient allowed sufficient widening of the introitus for<br>
expulsion of the fetal head. Delivery was uneventful and occurred after 19<br>
hours. Although some women may desire reinfibulation, this patient sought less<br>
discomfort in future vaginal examinations, so the vulvar scars were not<br>
reapproximated. The raw surfaces were oversewn loosely after delivery.<br><br>
PMID: 8267074 [PubMed - indexed for MEDLINE]
 

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These girls also looked *very* young, especially for a country like Afghanistan where women age rapidly. Remember that picture of that young girl from the early 80's, from National Geographic? They followed up with her sometime around 2000, and even though she was only about 30 or so, she looked 60. And the woman with the fistula hadn't gotten immediate medical care of any kind, it had been left completely untreated for a very long time.<br><br>
There was also a woman brought to that doctor with eclampsia, and her own mother had first brought her to the mullah when she began having seizures. The mullah announced that she had become posessed, and beat the living hell out of her. The baby died, and I think the mother died too (I don't remember for sure). The doctor was totally disgusted but seemed afraid to push it too far. I think he didn't want to offend the mullah and get kicked out, and then be unable to help any of the women.
 
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