Lessons From the Developing World: Obstructed Labor and the Vesico-Vaginal Fistula

Julia Cron, MD

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In This Article

History of Obstructed Labor and the Vesico-Vaginal Fistula

Obstructed labor has been a topic in the medical literature for hundreds of years. The oldest evidence of obstructed labor can be found in the remains of Queen Henhenit, the wife of Egypt's ruler around the time of 2050 BC. The Queen's mummy was originally sent to the Metropolitan Museum of Art in 1909. It was then returned to Cairo in 1923, where an extensive anatomical review found a defect in the bladder communicating directly with the vagina (Figure 1). It has been hypothesized that severe damage to Queen Henhenit's bladder and vagina occurred at the time of parturition, likely resulting in her death. As it has been noted, "to Queen Henhenit belongs the dubious honor of having suffered the most antique vesico-vaginal fistula documented."[2]

Figure 1.

The pelvis of Queen Henhenit. From Zacharin RF. Obstetric Fistula. New York, NY: Springer-Verlag; 1988. Reprinted with permission from Springer-Verlag.

In the 11th century, the Persian physician Avicenna made the connection between obstructed labor and vesico-vaginal fistulas. He noted, "In cases which women are married too young, and in patients who have weak bladders, the physician should instruct the patient in ways of prevention of pregnancy. In these patients the fetus may cause a tear in the bladder that results in incontinence of urine. The condition is incurable and remains so until death."[2] In the first book of operative gynecology, published in 1663, the Dutch physician, Hendrik Van Roonhuyse, gave a clear description of the vesico-vaginal fistula and proposed a method of repair using stitching needles made of stiff swans' quill. It wasn't until almost 200 years later, however, that the first vesico-vaginal fistula was closed in the United States.[2]

In 1838, Dr. John Peter Mettauer of Virginia wrote a letter to the Boston Medical and Surgical Journal confirming the relationship between obstructed labor and vesico-vaginal fistulas. This letter reported that he had successfully closed a vesico-vaginal fistula with wire sutures. Despite Mettauer's important accomplishment, the honor of being the first American surgeon to close a vesico-vaginal fistula is most often given, erroneously, to Dr. James Marion Sims (Figure 2). Dr. J. Marion Sims was born in South Carolina in 1813. He has been called "the father of American gynecology," and as the British Medical Journal noted at the time of his death, he "must be considered as the establisher of that branch of medical science (gynecology) which before his day had been looked upon as a mere accessory of obstetrics."[2] Although he was not the first American to close a vesico-vaginal fistula, he significantly improved the surgical techniques of fistula repair, and to this day many of his techniques remain the standard.

Figure 2.

James Marion Sims, 1813-1883. From Zacharin RF. Obstetric Fistula. New York, NY: Springer-Verlag; 1988. Reprinted with permission from Springer-Verlag.

In 1845, Dr. Sims encountered his first vesico-vaginal fistula when a colleague introduced him to Anarcha, a 17-year-old slave who had been in labor for 3 days. After discovering silver wire suture, on June 21, 1849, Sims completely closed the enormous fistula of Anarcha. (This was her 30th surgery.) In January 1852, Sims published "The Treatment of Vesico-Vaginal Fistula" in the American Journal of Medical Sciences, which detailed the surgical principles used to close vesico-vaginal fistulas -- principles that continue to guide fistula surgeons around the world today. In 1853, Sims moved to New York to establish a hospital that would be devoted to the treatment of diseases unique to women. He is lauded for recognizing that women's health problems deserved particular medical and surgical attention; before the middle of the 19th century, many physicians refused to treat female patients, so sick women suffered in isolation.[2] On May 4, 1855, the first fistula hospital was opened as a result of Dr. Sims' determination. Soon the hospital became too small to accommodate the growing patient population, and in 1857 the hospital moved to a more prestigious Park Avenue location. The location has maintained its prestige over the years, and today it is the site of another famous New York City landmark -- the Waldorf Astoria Hotel!

With improvements in obstetric care and the surgical advances of Dr. Sims and his colleagues, the problems of obstructed labor and vesico-vaginal fistulas were rare occurrences in the developed world during the 20th century. This, however, was not the case in the developing world. In 1959, Catherine and Reginald Hamlin (Figure 3) left their jobs as obstetricians in Australia to establish a midwifery training school in Addis Ababa, the capital of Ethiopia. Quickly, they recognized the problem of obstructed labor and began to focus their efforts on the treatment of women with obstetric fistulas. They wrote, "The high Ethiopian mountains make it one of the most spectacularly beautiful countries in the world; but mothers who live in such remote areas, cut off from access to medical help, must, when childbirth becomes difficult, endure the torture of unrelieved obstructed labor. Those who survive find themselves afflicted with the most appalling damage and mourning the still-birth of their only child ...ashamed of a tragic injury suffered in their first, only experience of childbirth."[2] Their exposure to this tragedy prompted the Hamlins to open the second fistula hospital in the world on May 24, 1975. The hospital is still open today, treating about 700 patients per year. It is estimated that the Hamlins have treated more than 15,000 women since first opening the fistula hospital.[3] As noted by Zacharin,[2] "The Hamlins' wish for the future is that, like the first fistula hospital in New York, the second in Addis Ababa should continue to function until no longer required ...until that time arrives and obstetric fistula has vanished as it did, 100 years ago in the United States."

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