POST-OPERATIVE CARE:
NIGERIA
OLADAPO SHITTU
OLADOSU OJENGBEDE
HASSAN WARA
1
RELEVANCE TO MEETING
BEFORE NOW, NEED FOR:
• Compilation of Credible Incidence &
Prevalence Statistics
• Classification of Fistulae
• Development of Preoperative & Operative
Treatment Protocols
QUESTIONS:
• What is the current state of postoperative
care of Obstetric Fistula?
• How satisfactory is this?
• What Research Questions are there?
2
1
OBJECTIVES
AIM:
Use Post-operative Treatment of Obstetric
Fistula in Nigeria to illustrate adequacy or
otherwise of this aspect of care.
APPROACH:
• Present National Context,
– Relevant SocioSocio-Economic Profile
– Historic & Current Perspective on Fistula Control
• Current State of Postoperative Care
• Raise Research Questions
3
BIBLIOGRAPHY
1)
2)
3)
4)
5)
6)
7)
8)
National population Commission, Federal
Republic of Nigeria. Nigeria Demography and
Health Survey: 2003. April 2004. 11-7.
Harrison, K.A. and Rossiter,
Rossiter, C.E. Maternal
Mortality.
Mortality. Brit. Journ,
Journ, Obstet.
Obstet. Gynaecol.
Gynaecol. 1985.
suppl.
suppl. (5) 100100-115.
Waaldijk,
Waaldijk, K. and Armiya’
Armiya’u, Y.D. The Obstetric
Fistula: A Major Public Health Problem Still
Unsolved. Int. Urogynaecol.
Urogynaecol. Journ.
Journ. 1993. 4: 126126128.
UNFPA & EngenderHealth.
EngenderHealth. In: Obstetric Fistula
Needs Assessment: Findings from Nine African
.org 2003. 57Countries.
www.unfpa.org
57-76.
Countries. www.unfpa
Lawson, J.B. Sequelae of Obstructed Labour. In:
Obstetrics and Gynaecology in the Tropics and
Developing Countries. Eds. Lawson, J.B. and
Stewart, D.R. London: Edward Arnold. 1967.
203203-218
Murphy, M. Social Cosequencies of VesicoVesicoVaginal Fistula in Northern Nigeria. Journ.
Journ. Of
Biosocial Science. 1981. 13: 139139-150
Harrison, K.A. Obstetric Fistula: One Social
Calamity Too Many.
Many. Br. Journ.
Journ. Obstet.
Obstet. and
Gynaecol.
Gynaecol. 1983. 90: 385385-386
Waaldijk,
Waaldijk, K. The (Surgical) Management of
Bladder Fistula in 775 Women in Northern
Nigeria. Nijmegen,
Nijmegen, Holland. 1989.
•
9) Ejembi,
Ejembi, C.L. (Ed) The VesicoVesico-Vaginal Fistula
Scourge: A Preventable Social Tragedy.
Tragedy.
Proceedings of the National Workshop on
VesicoVesico-Vaginal Fistula. Published by the
National Task Force on VesicoVesico-Vaginal Fistula. .
1995.
10) Sims, J.M. On the Treatment of VesicoVesico-
Vaginal Fistula. Am. J. Med. Sci.
Sci. 1852. 23:59.
•
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11) Lewis Wall, L. Dead Mothers and Injured Wives: The
Social Context of Maternal Morbidity and Mortality Among
the Hausa of Northern Nigeria.
Nigeria. Studies in Family planning.
1998. 29 (4) 341341-359.
12) Ghatak,
Ghatak, D.P. A Study of Urinary Fistulae in Sokoto,
Sokoto,
Nigeria.
Nigeria. J. Indian Med. Assoc. 1992. 90 (11)285(11)285-287.
13) Gharoro,
Gharoro, E.P.; Abedi,
Abedi, H.O. VesicoVesico-vaginal Fistula in
Benin City, Nigeria. Int. Journ.
Journ. Gynaecol.
Gynaecol. Obst.
Obst. 1999. 64.
313313-314
14) Aimakhu,
,
V.E.
Reproductive
Functions
after the
Aimakhu
Repair of Obstetric VesicoVesico-Vaginal Fistulae. Fertility and
Sterility. 1974. 25: 586591.
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15) Harrison, K.A. Mode of Delivery with Notes on
Rupture of the Gravid uterus and VesicoVesico-Vaginal Fistula.
Fistula.
Brit. Journ,
Journ, Obstet.
Obstet. Gynaecol.
Gynaecol. 92. suppl.
suppl. (5) 6161-71.
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2
NIGERIA
• Most populous country in Africa (1-in-5
African is Nigeria).
• Endowed with huge human and natural
resources
• High Prevalence of Poverty
• Has Maternal Mortality Ratio (MMR) of
1,100 per 100,000 live births
• For each death 20 other women
develop morbidities.
5
OBSTETRIC FISTULA:
PREVALENCE IN NIGERIA
• Estimated 250,000 obstetric
fistula patients, in 1993
• 800,000 cases by 2002, with
preponderance in northern
Nigeria
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3
REASONS FOR INCREASED
PREVALENCE
• Worsening MMR (3,200 per
100,000 in some places)
• Fistula repair is new to local
communities
• At rate of 2,000 repairs yearly,
will take 200-400 years to repair
existing cases
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CHRONOLOGY OF FISTULA
CARE IN NIGERIA
• Early 1960ies: Surgical Repair in Teaching
Hospitals
• Late 1970ies: elucidation of social, cultural
and economic determinants of obstetric
fistula (Began strategies for prevention)
• Late 1980ies: concept of “Fistula Centers”
emerged
• Late 1980ies: emergence of Nongovernmental organizations and
partnerships to control fistula
8
4
NIGERIAN FISTULA
REPAIR: CURRENT
APPROACHES
• Teaching Hospitals
• Fistula Centers
• Fistula Campaign
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UNFPA/ENGENDERHEALTH
REVIEW OF FISTULA
FACILITIES
• 2,286 fistula repairs done annually by 11
leading fistula Hospitals in Nigeria
• 33 surgeons currently identified with fistula
repair in the country
• 6.8% (155) of all fistula repairs are performed
in the Teaching Hospitals. Implies each of
the 25 Teaching hospital surgeons performs
average of 6 repairs annually
• 93.2% (2,131) of repairs done in Fistula
Centers, with each of the 8 surgeons in them
performing an annual average of 266 repairs.
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5
UNFPA/ENGENDERHEALTH
REVIEW OF FISTULA
FACILITIES Cont…
• 57.5% of all the repairs done in North-west
zone, in 3 Fistula centers and 3 Teaching
Hospitals located there.
• No report of fistula activities from North-east
and South-east zones.
• Treatment of fistula patients in the Fistula
Centers is essentially free of user-charges.
• But cost of fistula repair in Teaching
hospitals average 166USD, ranging from 90
to 250USD.
250USD
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THE FISTULA CAMPAIGN
APPROACH
• Initiated by the UNFPA in February
2005.
• Assembled 12 volunteer fistula
surgeons (including two each from UK
and USA)
• Operated on patients in four Fistula
Centers over a fortnight.
• 545 patients were treated, with 87.3%
successes
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UNFPA FISTULA CAMPAIGN
SITES
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GENERAL CONSIDERATIONS
FOR FISTULA REPAIR
• Good preoperative preparation of
patient for type of repair;
• Thorough fistula(e) assessment for
optimal planning
• Good surgical skills for
– appropriate selection of right technique for
type of fistula and its successful
implementation
• Good postoperative management.
management
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•
•
PREPARATION FOR
SURGERY
Thorough clinical examination ( including now optional Examination
Examination Under
Anaesthesia)
Most universal of laboratory investigations performed are:
– Hemoglobin estimation and Urinalysis.
– Others (in Teaching hospitals)are
• Serum Electrolytes,
• Urea and Glucose estimations;
• Renal function tests; Urine Microscopy,
• Culture and Sensitivity
• occasional Intravenous Urogram.
•
Improvement of Patient’
Patient’s:
– general health,
– nutrition and
– hygiene
– administration of hematinics
– topical application of petroleum Jelly ( less available Zinc Oxide
Oxide and Castor
Oil cream),
•
Interval before surgey:
surgey:
– Usually threethree-month
– recent “early repair”
repair” approach advocated by Waaldijk
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OPERATIVE
CONSIDERATIONS
•
Choice of anaesthesia
–
–
–
•
Operators are:
–
–
•
•
Depend on intuitional protocol and preferences.
Teaching hospitals often use general anaesthesia, by
Fistula Centers and Fistula Campaigns use spinal block given by the surgeon or his assistant.
gynecologists, and trained Residents and Medical officers.
Urologists and general Surgeons rarely involved, unless in procedures
procedures involving upper Urinary
tract.
Surgical methods and techniques in common use include:
Vaginal Surgery
–
–
–
–
–
Saucerization technique
SingleSingle-layered technique (using nonnon-absorbable suture)
FlapFlap-splitting technique
Urethral reconstruction
Graft use
» Martius graft
» Labial graft
•
Abdominal Surgery
•
Ureteric Surgey
– Transperitoneal technique
– Transvesical,
Transvesical, extraperitoneal technique
–
–
–
–
•
Simple repair
Resection and anastomosis
Reimplantation
Transplantation
Rarely performed include Combined AbdominoAbdomino-Vaginal Repair and Colpoclesis.
Colpoclesis.
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8
POST-OPERATIVE Care:
Marion Sims Principles
•
•
•
•
•
“use of a block tin catheter for
continuous drainage;
bowed to be kept quiescent for 10-15
days;
opium
normal fluid; and
perineum irrigation”
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CATEGORIZATION OF POSTOPERATIVE PERIOD
• Early postoperative care
(catheterization period)
• Late post-operative care (postcauterization period)
• Care of other complications
co-existing with fistula
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9
•
EARLY
CARE: Catheterization
Site:
–
–
•
•
•
Transurethrally in most cases.
Suprupubic in Urethral reconstruction & Transabdominal fistula
repair
Type:
–
“threethree-way”
way” Foley’
Foley’s catheter, prefered but scarce & expensive
–
“twotwo-way”
way” Foleys most commonly used.
Retention:
–
By inflated balloon.
–
Stitch to Labia (inJuxta
(inJuxta--Urethral, Large fistulae or fisulae with
Circumferential tissue loss),
Duration of catheterization:
–
14 days a primary fistula repair
–
Extension of up to additional 14 days if:
•
•
•
–
–
urethral reconstruction or bladderbladder-neck repair was performed or
postoperative leakage was incurred.
Drainage Connection:
Closed urine bags usually
Open receptacles (relative inexpensiveness)
inexpensiveness)
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EARLY CARE Cont…
•
Vaginal Pack;
– Used as tamponade
– Removed within 48 hours.
•
Pain Relief:
– Narcotics (Pethidine
(Pethidine or Morphine)
• Given sixsix-hourly intervals for 24 hours
• then paracetamol,
paracetamol, 1gm thrice daily for
another two days.
days.
– Extended for up to 48 hours for patients who
had abdominal repair
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10
EARLY CARE Cont…
•
Fluid Intake:
– Targets Urine output of at least 100ml per
hour
– Over 4000ml Daily (tropical environment
with daily insensible fluid loss of about
2000 ml)
– Intravenous infusion for the first 24 to 48
hours, depending on when her resumed
oral fluid intake can meet this
requirement.
21
EARLY CARE Cont…
Urine Output Monitoring:
•
Performed:
– hourly or
– 2-4 hourly intervals.
•
Heavy Blood Stains or Clots:
– Increased intravenous or oral fluid administration
until the urine colour clears.
– Persistent passage of clots warrants irrigation of the
bladder with citrated solution.
•
If drainage ceases patient must be promptly examined
to exclude:
– external compression of catheter;
– Catheter kinks;
– internal catheter blockage by clots or sediments;
– ureteric obstruction (by ligation or edema); or 22
– diminished renal urine secretion.
secretion.
11
S Likely Cause of
Reduced
Urine
Outflow
EARLY CARE Cont…
Features
Remedies
1 External
compressio
n of
catheter
system
•
Patient lies in catheter or drainage
tube
•
ReRe-directing drainage system to pass over
patient’
patient’s thighs
2 Catheter kinks
•
Examination of entire drainage system
for any acute angulations
•
Ensurance that no part of drainage system
experiences curvature of less than 1200
3 Internal
catheter
blockage
•
External factors excluded without
resumed urine flow
Percussion over suprapubis suggest
urine within bladder but cough or
gentle suprapubic pressure fail to
move column of urine in catheter
•
Using aseptic means, 50ml syringe is connected
to catheter to ‘suck out’
out’ suspected blockage,
failing which an initial few ml of Saline is gently
instilled to flush back obstruction
Once patency is restored, irrigation of bladder
with saline or sodium citrate is completed.
Surgical repair that involved Trigone
or any of the ureters
Loin pain
Vomiting
Persistent fever
Abdominal distention
(increased creatinine)
creatinine)
•
•
•
•
•
•
•
•
•
Circulatory shock
Increased Creatinine
Increased Urea
•
•
4 Ureteric
obstructio
n
5 Diminished
Renal
Secretion
of Urine
•
•
•
•
•
•
Referral if no facilities for imaging and or
laparatomy
Renal tract imaging: ultrasonography,
Intravenous Urogram, CT Scan of MRI (if
available)
Strong clinical or radiologic suspicion mandates
rere-laparatomy to identify and free obstruction
(Prevention by routine catheterization of ureters
if repair is proximal to them)
Resuscitation
Dialysis (or referral for one)
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EARLY CARE Cont…
Antimicrobial use:
•
Indication:
–
None use
–
Prophylactic use
–
urine cultureculture-based use
–
continued during the postpost-operative period.
–
Postoperative urine cultures repeated every 22-3 days interval,
the last culture being of the tip of the removed catheter.
•
Types of antimicrobial in common use:
–
have broadspectrum
–
relatively inexpensive
–
Include: CoCo-trimoxazole,
trimoxazole, Nitrofurantoin,
Nitrofurantoin, Ampicillin and
Ampiclox.
Ampiclox.
–
Parenteral preparations are used on the more intricate and
extensive repairs or to address obvious sepsis.
•
Duration of antimicrobial therapy:
–
five to ten days period
–
Entire duration of catheterization
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EARLY CARE Cont…
•
Patient Ambulation:
– Customized to patient’
patient’s situation,
– As early as the day after repair
– Later for patients with transabdominal repairs
and urethral reconstructions
•
VulvoVulvo-Vaginal Toileting:
Toileting:
– Nurses trained in fistula care employ irrigation
techniques, using warm water or dilute
antiseptic solution to clean vulva and perineum
of blood stains, menstrual effluent, discharges
and other debris each day and after bowel
movements.
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LATE POSTOPERATIVE
CARE:
•
•
•
•
•
•
•
Outcome Determination: At the expiration of the intended period of continous bladder
drainage, the catheter is removed and the patient examined to confirm
confirm outcome of
repair. Following an interval of about two hours of removing the catheter, the
vestibule is inspected for normality, stress incontinence or introital urine leakage.
–
If there is introital leakage, the patient is reassured and rere-catheterization for a
further 77-10 days is done.
–
If stress incontinence, the repair is regarded as partially successful
successful and the
patient is counseled and encouraged to void urine at hourly intervals
intervals until
reviewed each day.
–
If no leak or stress incontinence, adjudged successful repairs, undergoes bladder
training to improve the bladder capacity urine storage and voidance
voidance capability:
they initially void urine at hourly intervals and progressively have the voidance
interval extended until a convenient schedule to her is attained.
attained.
Patients with partial or complete success at repair, before discharge
discharge are given
complete counseling on:
Resumption of coitus after three months
Contraceptives should be used unless pregnancy is desired
When pregenant,
pregenant, antenatal care should be sought as early as possible and her detail
detail
history told to the clinic attendants.
Subsequent deliveries should be by elective caesarean section but
but never at home.
At this stage, the patient is discharged to her relatives if they
they are available and
supportive, otherwise, she is transferred to the adjacent rehabilitation
rehabilitation center for the
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requisite care.
13
LATE POSTOPERATIVE
CARE Cont…
Rehabilitation: All the Nigerian Fistula Centers
and few teaching hospitals like ABUTH have
active rehabilitation Centers where fistula
patients are given:
–
–
–
elementary educational skills and
trainings in cooking, tailoring, knitting, and other
craftmaking that will empower them to earn
subsistence when discharged home.
Social workers attached to these centers finally
assist each patient to link up and rere-integrate with
their immediate relatives and families. (Some
achieve restoration to their husbands).
27
MANGEMENT OF OTHER
PROBLEMS THAT CO-EXISTED
WITH FISTULA
a. Obstetric Palsy:
• The footfoot-drop complicates over 15% of obstetric
fistulae from obstructed labour,
• most are unilateral but are occasionally bilateral
• Only Teaching hospitals are adequately equipped
with physiotherapy facilities for the necessary
physical and electroelectro-therapy.
therapy.
• Shoe calipers and foot elevators required for passive
treatment of this problem are generally unavailable
and unaffordable to fistula patients.
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MANGEMENT OF OTHER
PROBLEMS THAT CO-EXISTED
WITH FISTULA Cont…
a. Secondary Amenorrhea:
• CoCo-exists with up to 2/3 of fistula patients
• Investigation and treatment of this is beyond the
scope of the services of the Fistula Centers,
• Teaching hospitals investigate for the following:
• underlying causes:
• hypothalamic dysfunction,
• panhypopituitarism,
panhypopituitarism, or
• uterine synaechia.
synaechia.
• Few of the patients are however able to afford
the treatment.
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MANGEMENT OF OTHER
PROBLEMS THAT CO-EXISTED
WITH FISTULA Cont…
a. Sexual Dysfunction:
• Gynaetresia complicates about 10% of
obstetric fistulae.
• All the fistula treatment facilities are
capable of treating with:
•
•
counseling and
use of lubricants during sexual intercourse
(from inert Aqueous Jelly to Xylocaine
cream).
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CONCLUSION:
• Nigeria has one of the highest prevalences of obstetric
fistulae in the World, and this will worsen unless her
current obstetric standards of obstetric care are
improved and the current rate of repair of fistulae
overhauled.
• More Fistula Centers need to be established and more
fistula campaigns organized to harness the underunder-utilized
expertise that abound in the country’
country’ Teaching hospitals.
• The currently ‘highhigh-tech’
tech’, expensive and unaffordable
management protocol being offered at the Teaching
hospitals to fistula patients need to be reviewed.
Development of a minimum but safe standard of care that
will give the multitude of fistula patients access to their
care is urgently desirable.
• It is needless to emphasis that improved funding is
necessary for the provision of resources that will make a
difference in the lives of these indigent fistula patients31
who are hugely disadvantaged.
disadvantaged
THANK YOU!
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