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

Julia Cron, MD

In This Article

The Obstructed Labor Complex

The obstructed labor complex was characterized by Arrowsmith, Hamlin, and Wall in 1996. It is described as, "the injuries resulting from prolonged obstructed labor, representing a syndrome that often involves multiple organ systems." Although the vesico-vaginal fistula often dominates the clinical presentation, one should recognize the broad scope of injuries.

Before detailing the multisystem syndrome of the obstructed labor complex, it is important to consider the nature of maternal mortality and morbidity in the developing world, as maternal mortality is directly related to maternal morbidity. In countries where many women die from childbirth, many more women suffer significant morbidity from childbirth. In the developing world, the maternal mortality rate is 1000 deaths per 100,000 live births; compare this with a rate of 21 deaths per 100,000 live births in more developed countries. In the least developed countries, a woman has a lifetime risk of death during childbirth of 1 in 16, or 6.25%. In the United States, this risk is 0.03%, or 1 in 3500 ( Table 1 ).[4] The leading cause of maternal mortality in both the developed and the developing world is hemorrhage. Other contributors are infectious and hypertensive etiologies, and in the developed world, embolic phenomena. Obstructed labor accounts for 8% of all maternal deaths in the developing world, and most notably, plays a negligible role in all US maternal deaths.[5]

Perhaps more important than the role of obstructed labor in maternal mortality is the role that it plays in maternal morbidity. As previously discussed, the obstructed labor complex encompasses a wide range of gynecologic, skeletal, neurologic, and dermatologic injuries. In addition, there are significant consequences of obstructed labor on the fetus and on the psychosocial condition of a woman.

Gynecologic sequelae are often the most noticed sequelae of obstructed labor. Scarring of the genital tract, along with possible pituitary and hypothalamic dysfunction, frequently lead to amenorrhea. One study found that 63.1% of women with obstetric fistula were amenorrheic, and many of these women exhibited dysfunction of the gonadotropin hormonal axis.[6] Traumatic obstructed labor also increases the risk of infections, including pelvic inflammatory disease. The combination of amenorrhea, pelvic inflammatory disease, and genital tract scarring results in a high rate of secondary infertility in these patients -- a significant problem considering the importance placed on childbearing in most societies in the developing world.

Women who experience obstructed labor are also more likely to suffer bony abnormalities. Although the clinical significance is unclear, a study of 312 Nigerian women with vesico-vaginal fistulas found that 32% of the women demonstrated abnormalities on x-ray.[7] These abnormalities included bone resorption, fractures, bone spurs, obliteration of the symphysis, and symphyseal separation.

A study from Nigeria showed that 65% of women with obstetric fistula currently or previously had symptoms of perineal nerve injury, including findings of a foot drop.[8] At the Ethiopian fistula hospital, 20% of patients are reported to have a foot drop.[9] The foot drop is thought to result from excessive compression of the sacral nerve plexus by the fetal head. Damage to the perineal nerve may also result from laboring for days in the squatting position, which may be exacerbated by the application of pressure on the gravid abdomen by traditional labor assistants. In addition to perineal nerve damage, many women suffer nerve damage to the bladder, which results in complex neuropathic bladder dysfunction. Dermatologic injuries in women who have vesico-vaginal fistulas as a result of obstructed labor include most notably vulvar excoriation and ammonical dermatitis from continuous urine leakage.

One of the most tragic consequences of obstructed labor is what it does to the unborn child. As a result of excessive pressure on the placenta from prolonged uterine activity, fetal asphyxia and stillbirth often occur after obstructed labor. Murphy's study[10] from Nigeria showed that 90% of the long-term patients in the fistula ward at the University Teaching Hospital were childless. In Addis Ababa, 92% of fetuses involved in prolonged obstructed labor died in the process.[9] Elkins[11] found that 90% of the patients delivered a stillborn in a review of 82 patients with vesico-vaginal fistulas from West Africa.

The delivery of a stillborn is particularly distressing in societies that place such an emphasis on childbirth. The birth of a baby is celebrated by a woman's family and community, whereas the woman who gives birth to a stillborn typically brings sorrow and shame to her family. These women may be perceived as dirty, and thus are often excluded from participating in community activities, including religious celebrations. The consequences of obstructed labor are misunderstood, and some believe that the problems are the work of evil spirits or the result of sexually transmitted infections. Thus, as noted by Wall,[12] women who have suffered the tragedy of obstructed labor are "the most dispossessed, outcast, powerless group of women in the world."


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