Obstetric Complications: The Case of Vesicovaginal Fistula

Q: Obstetric Complications: The Case of Vesicovaginal Fistula

Hello Miss Ting-Ting： Both cesarean sections and vaginal deliveries can potentially lead to complications such as vesicouterine fistulas. <br>For instance, a large fetal head may exert pressure on the cervix, or prolonged labor may cause excessive pressure on the lower uterine se

Postpartum complications? (Forwarded from the Director's mailbox)

Dear Director:
I would like to inquire whether a "vesicouterine fistula" can occur during childbirth, and how it is caused.
In June 2003, I delivered at a large hospital where all my prenatal check-ups were normal (conducted by the same doctor at the same hospital).
The plan was for a natural delivery, and everything was fine in the labor room until I was pushed into the delivery room.
Within less than 20 minutes, I was taken to the operating room.
I have a question regarding an event in the delivery room: a nurse applied significant pressure on my abdomen several times, which was very painful, yet she continued to push down hard.
Subsequently, the fetal heart rate dropped rapidly, and the doctor had to quickly administer general anesthesia and perform a cesarean section to deliver the baby.
Is it normal for nurses to apply such pressure on the abdomen?
In the hospital, I experienced a very noticeable phenomenon; I still had a urinary catheter in place, and there was a significant amount of bright red blood in my urine.
The doctor said this was a normal occurrence and that I could be discharged but needed to return home with the catheter.
I didn’t think much of it at the time, as I didn’t understand the situation and trusted the doctor's expertise, so I went home.
This marked the beginning of my suffering.
On the third day of my postpartum confinement, I developed a persistent fever and urgently went to see a friend’s mother in Taipei County, then rushed to a hospital in Taipei City.
The doctor simply stated, "You need to be hospitalized," which led to multiple visits to the hospital and solitary treatments.
The pain, loneliness, and fear I experienced were overwhelming.
No one was there to care for me at night; my family was busy taking care of our children, and my in-laws had to work for a living.
Having just given birth, I was unable to properly rest during my confinement.
My emotions shifted from the joy of childbirth to fear and depression, with tears flowing daily.
Who will help me bear my pain, fear, and depression? My attending physician simply stated that it was due to "my blood vessels being too small," which seems unprofessional.
Who will take responsibility for the injuries I endured during this time? Who will soothe my spirit? About three months after giving birth, I had to undergo another surgery due to the fistula, leaving my body even weaker.
Who will advocate for me? The doctors keep saying it’s because my abdominal blood vessels are too small.
How exactly does this happen? I beg for your assistance.

Miss Tingting, 30~39 year old female. Ask Date: 2004/07/07

Dr. Li Guanghan reply Obstetrics and Gynecology

Hello Miss Ting-Ting: Both cesarean sections and vaginal deliveries can potentially lead to complications such as vesicouterine fistulas.
For instance, a large fetal head may exert pressure on the cervix, or prolonged labor may cause excessive pressure on the lower uterine segment, leading to ischemic necrosis of the tissue and the formation of a fistula.
Additionally, poor wound healing from the separation of the bladder and lower uterine segment during an emergency cesarean can also result in fistula formation.
Injuries to the bladder during surgery, or negative pressure caused by the baby passing through the birth canal during vaginal delivery, can lead to bladder rupture and subsequently fistula formation.
In most cases of vaginal delivery, inadequate or improper pushing by the mother can result in the fetus becoming lodged, which may pose a risk to the fetus's life or cause distress.
To facilitate the progression of labor, applying moderate pressure to the abdomen is a reasonable approach.
Dr.
Cheng Jin-He, Department of Obstetrics and Gynecology, Hsinchu City Hospital.

Reply Date: 2004/07/07

More Info

Vesicovaginal fistula (VVF) is a serious obstetric complication that can occur during childbirth, particularly in cases of prolonged labor, obstructed labor, or surgical interventions such as cesarean sections. It is characterized by an abnormal connection between the bladder and the vagina, leading to involuntary leakage of urine through the vagina. Understanding the causes, risk factors, and implications of VVF is crucial for both patients and healthcare providers.

In your case, it seems that you experienced a traumatic delivery that may have contributed to the development of a vesicovaginal fistula. The pressure applied to your abdomen by the nursing staff during labor, combined with the rapid decision to perform a cesarean section due to fetal distress, could have increased the risk of injury to the surrounding tissues, including the bladder and vagina. Such injuries can occur if the baby is too large, if there are abnormal presentations, or if the labor is prolonged, leading to tissue ischemia and necrosis.

The symptoms of VVF typically include continuous leakage of urine, which can lead to significant physical and emotional distress. Patients often experience social isolation, embarrassment, and depression due to the condition. In your situation, the initial signs of blood in the urine and the subsequent development of fever and other complications suggest that there may have been underlying issues that were not adequately addressed during your postpartum care.

It is essential to recognize that VVF can be a result of multiple factors, including:
1. Obstructed Labor: When the baby cannot pass through the birth canal, prolonged pressure can damage the surrounding tissues.

2. Surgical Complications: Cesarean sections, especially if performed under emergency conditions, can lead to inadvertent injury to the bladder or vagina.

3. Infection: Postpartum infections can weaken tissue integrity, making it more susceptible to fistula formation.

4. Poor Prenatal Care: Lack of proper monitoring during pregnancy can lead to undiagnosed conditions that complicate delivery.

Regarding your emotional and psychological distress, it is vital to seek support. The trauma of childbirth and the subsequent complications can lead to feelings of helplessness and depression. Counseling or therapy can provide a safe space to express your feelings and begin the healing process. Additionally, support groups for women who have experienced similar complications can be incredibly beneficial.

As for the treatment of VVF, surgical intervention is often required to repair the fistula. This typically involves a procedure to close the abnormal connection between the bladder and vagina. The success of surgery can depend on various factors, including the size and location of the fistula, the presence of scar tissue, and the overall health of the patient.

In conclusion, while the experience of developing a vesicovaginal fistula can be devastating, it is important to understand that you are not alone, and there are medical professionals who can help you navigate this condition. Seeking a second opinion from a specialist in obstetrics and gynecology, particularly one who has experience with fistula repair, can provide you with more options and a clearer understanding of your situation. Remember, your health—both physical and emotional—is paramount, and addressing these issues is the first step toward recovery.

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