TRAUMATIC COMPLICATION

It is comprised of the following;

1. Cystocele
2. Rectocele
3. Uterine prolapse
4. Retroverted uterus
5. Inversion of the uterus
6. Fistulae
 1. CYSTOCELE :
 It occurs when the walls between a woman’s bladder and her vagina
weakens and allows the bladder to bulge into the vagina.
 It is a hernia of the bladder through the anterior wall of the vagina after
childbirth. This occurs when the tough wall (puboversical fascia) between
the bladder and the vaginan is torn or weaken by child birth allowing the
bladder to herniate into the vagina.
 A bladder that has dropped from its normal position may cause two kinds
of problems, unwanted urine leakage and incomplete emptying of the
bladder.
Incidence : It is common in grand multiparous women due to extreme stretching
of the pelvic floor and the perineum

CAUSES OF CYSTOCELE:
 Loss of muscular support that may occur while giving birth.
 Heavy lifting
 Violent coughing
 History of Prolong labour and obstructed labour
 Premature bearing down
 Instrumental delivery
 Repeated straining during bowel movements.
 After menopause, a decrease in oestrogen to the vagina causes weakening
of the vagina support to the bladder.

CLASSIFICATION/ GRADES OF CYSTOCELE

 Mild cystocele (grade 1) : when the bladder drops only a short way
into the vagina.
 Severe cystocele (grade II) : the bladder extends to the vaginal
opening.
 Advanced cystocele (grade III) : Occurs when the bladder bulges out
through the opening of the vagina.
SIGNS AND SYMPTOMS OF CYSTOCELE
 Discomfort when coughing, bearing down or lifting an object.
 Protruding of the bladder into the vagina
 Feeling like sitting on something which often goes away when lying down.
 Pain or leakage of urine during sexual intercourse.
 A feeling of incomplete emptying of the bladder.
 Feeling of fullness or pressure in the pelvis or vagina especially when
standing.
 Lower abdominal pains
 Frequency of micturating.
 Repeated bladder infection
 Urinary leakages during sexual intercourse

DIAGNOSIS
 Signs and symptoms through history taking.
 Vulva examination
 Vaginal speculum examination using simm’s speculum which will confirm
the prolapse.
 Voiding cystourethrogram, a test that involves taking x-ray of the bladder
during urination.

RISK FACTORS OF CYSTOCELE

 Genetic some women are born with weaker connective tissues.
 Hysterectomy leading to loss of support
 Aging
 Parity.

MANAGEMENT OF CYSTOCELE
 Taking of history on the condition.
 Conduct physical examination to know the extent of the condition
 Reassure and explain condition to the client
 Treatment depends of the grade, age and desire to have more children.
 Treatment range from no treatment for mild cystocele to surgery for an
advanced cystocele i.e anterior colporrhaphy.
 A pessary , a device is placed in the vagina to hold the bladder in place in
severe cases.
 Pessaries must be removed regularly to avoid ulcers and infection.
 A midstream urine is taken for urine routine examination to exclude
bacteruria. Culture and sensitivity test of the urine is also done to know
appropriate antibiotics to give for treatment.
 Teach the woman of pelvic floor exercise
 Educate client on good personal hygiene especially perineal care
 Vulva inspection should be done during general examination.
 Educate client on weight control to help take stress off the pelvic organs.

COMPLICATION OF CYSTOCELE
 Stress incontinence
 Urinary retention
 Painful intercourse
 Recurrent bladder infections

PREVENTION OF CYSTOCELE
 Avoid heavy lifting or correct lifting technique.
 Treat and prevent constipation, drinking plenty fluids and eating of high
fibre diets.
 Weight control
 Exercise to strengthen the pelvic floor muscles
 Early treatment of infections especially upper respiratory tract infections.
 Encourage client to eat nutritious diet to build the immune system.

Labour :
 The use of partogragh to prevent prolong labour
 Giving of timely episiotomy
 Active management of all stages of labour and skillful delivery during
second stage.
 Proper suturing of tears and lacerations.

Puerperium
 Teach level exercise after delivery to strengthen the pelvic floor muscles
 Control coughing and avoid smoking
 Early treatment of upper respiratory tract infections
 Oestrogen therapy during menopause to help kelp pelvic muscles strong

2. RECTOCELE/ PROCTOCELE
  Rectocele occurs when the thin walls of fibrous tissues (fascia) that
separates the rectum from the vagina weakens, allowing the rectum to
bulge into the vagina.
 It can also be explained as a bulge of the rectum wall that protrudes out of
the vagina. This happens when the levator muscles, para rectal muscles and
prerectal muscles becomes lax.

Incidence:
It is common in grand multiparous women due to extreme stretching of the
pelvic floor and the perineum.

GRADES OF RECTOCELE/ CLASSIFICATION

The rectocele is graded according to the degree of it’s inclination into the vagina
of the woman. The three (3) grades of rectocele are as follows ;
 Grade 1 (mild rectocele) : when the rectum drops a short way into the
vagina.
 Grade 2 ( Moderate rectocele) : when the rectum sinks far enough to reach
the opening of the vagina.
 Grade 3 ( Severe rectocele) : when the rectum bulges out through the
opening of the vagina.

CAUSES OF RECTOCELE
 Premature bearing down/ precipitate labour
 Heavy lifting
 Chronic constipation
 Big baby
 Hysterectomy
 Overweight/ obesity
 Untimely giving of episiotomy
 Unskillful delivery
 Instrumental delivery
 History of Prolong and obstructed labour
 History of perineal tear or episiotomy into the rectum or anal
sphincter.

SIGNS AND SYMPTOMS

In mild cases ;
 Feeling of fullness of the rectum even after emptying it
 Protrusion within the vagina
 Pressure in the vagina

In moderate cases:
 Dyspareunia
 Constipation/ difficulty in defecation
 Feeling that something is falling out /down within the pelvis
 Pain or discomfort during evacuation

In severe cases ;
 Vaginal bleeding
 Intermittent fecal incontinence
 Prolapse of the rectum through the anus
 Rectum tissues protrude out of the vaginal opening
 Rectal pressure is always felt by the patient.
 Difficulty in passing out stool as it pushes the stool into rectocele
instead of passing it out through the anus.

DIAGNOSIS
 A rectal examination is done to differentiate a rectocele from
prolapse of the intestines i.e enterocele.
 Ultrasound scan
 M.R.I
 Pelvic floor fluoroscopy
 Digital rectal test
 MANAGEMENT OF RECTOCELE
Treatment of rectocele is determined by the severity or grade
 Reassure client and explain condition to allay anxiety.
 Treatment depends on its severity, non surgical methods is give for mild
cases such as changes in diet like increased high fibre diets and water
intake to avoid constipation.
 Level exercise and insertion of pessary
 A surgery is done to correct the defect i.e posterior colporrhaphy when
symptoms continues despite the use of non surgical methods and are
significant to interfere with the activities of daily living.
 Avoid heavy lifting to prevent pressure on the organs.
 Encourage exercise to strengthen the pelvic floor muscles.
 Weight control
 Personal hygiene
 Encourage regular check up.
 Serving of antibiotics to combat infection

COMPLICATION OF RECTOCELE
o Nerves in the reproductive system can be affected during surgery which can
leads to sexual dysfunction
o Ulcers
o Prolapse of other reproductive organs

NB: Prevention of rectocele is the same as cystocele.

 UTERINE PROLAPSE
 It is a downward displacement of the uterus from its original position.
 Uterine prolapse occurs when the uterus sags or slips from its normal
position and into the vagina.
 The uterus which is a muscular structure is normally held in place by pelvic
muscles and ligaments. If these muscles and ligaments becomes weak, they
are no longer able to support the uterus causing prolapse.

Incidence:
it is more common in latter reproductive years and after menopause.

CLASSIFICATION/ GRADES OF UTERINE PROLAPSE

  1st Degree: This is where the cervix has descended into the vagina.
 2nd Degree: The cervix comes down to the opening of the vagina.
 3rd Degree: The cervix is outside the vagina
 4th Degree : The entire uterus is outside the vagina. This condition is also
called PROCIDENTIA. This is caused by weakness in all of the supporting
ligaments.

CAUSES OF UTERINE PROLAPSE

 Poor management of third stage of labour
 Chronic constipation which leads to straining to evacuate stool
 High parity causing the supports of the vagina and uterus to become weak.
 Congenital weakness of the ligaments in some women
 Trauma during childbirth
 Damage to pelvic floor muscles and tissues during pregnancy and childbirth
 It usually results from childbirth, particularly if the baby is big.
 Prolong labour
 Major surgeries in the pelvic area leading to loss of external support
 Weakening and loss of tissues tone after menopause and loss of natural
oestrogen.

SIGNS AND SYMPTOM OF UTERINE PROLAPSE

 Pressure or heaviness in the pelvis or vagina
 Painful sexual intercourse
 Feeling like you sitting on a ball
 Disturbance in micturition such as frequent micturition ,leaking of urine
when coughing or sneezing.
 Complains of backache when standing
 Bleeding dud to ulcerated protruding uterus
 Difficulty in defecation
 Offensive vaginal discharge
 Pain in the vagina
 Recurrent bladder and bowel infection.
 Protruding of the uterus or cervix from the vagina
 DIAGNOSIS
 History
 Pelvic examination
 Ultrasound scan
 MRI
 Speculum examination

MANAGEMENT OF UTERINE PROLAPSE

 Explain condition and reassure
 Encourage young women to do exercise to strengthen the muscles e.g
levator muscles.
 Mechanical treatment is done by the use of vaginal pessaries are inserted
into the vagina.
 Faradization(electrical currents): treatment by application of an induced or
faradic current is done to help contract the muscles.
 Manchester operation / Fothergill’s operation: amputation of the cervix
with anterior and posterior corporrhaphy is done to correct the prolapse.
 Hysterectomy is also a surgical option.
 Education on self care or personal hygiene
 Oestrogen therapy replacement
 Good nutrition to build the immune system
 Avoid lifting heavy loads
 Avoid constipation by taking high fibre diets and fluids.

PREVENTION OF UTERINE PROLAPSE

Same as Prevention of cystocele
 3. RETROVERTED UTERUS

 A retroverted uterus is also known as tipped or tilted womb,occurs when

the uterus tilts backwards toward the spine.
 CAUSES OF RETROVERTED UTERUS
 Parity
 Fibroids
 Pre mature bearing down
 Big baby
 Breech extraction before full dilation
 Unskillful delivery
 Subinvolution
 Congenital malformation
 Pelvic surgery
 Scar tissues in the pelvis can also hold the uterus in a retroverted position.
 Endometriosis
 Pelvic inflammatory disease
 Weakening of the pelvic ligaments at the time of menopause.

SIGNS AND SYMPTOMS OF RETROVERTED UTERUS

 Low backache
 Menstrual disorders e.g dysmenorrhea
 Dyspareunia
 Fertility problem
 Loss of bladder control
 Urinary tract infection increases
 Cervix is displaced
 Fundus displaced in pouch of douglas

DIAGNOSIS OF RETROVERTED UTERUS

 Ultrasound
 Pelvic examination
 Hysterectomy
 Laparoscopy
 A rectovaginal examination
 Presenting signs and symptoms
 MANAGEMENT OF RETROVERTED UTERUS
The most important retroverted uterus treatment is done by identifying the root
cause of the problem and treating the condition like endometriosis, adhesions,
fibroids etc.
 Reassure the client.
 Hormonal therapy for endometriosis
 Vaginal pessaries
 Patient positioning exercises such as intermittent knee-chest or all fours
position , level exercise.
 Insertion of a urinary catheter to empty the bladder.
 Laparoscopy (keyhole) surgery techniques; the uterus can be repositioned
so that it’s sit over the bladder.
 Colonoscopic manipulation of the uterine fundus under anesthesia.
 Manual anteversion and bladder drainage.
 In some cases, the surgical removal of the uterus (hysterectomy) maybe
considered.

COMPLICATION OF RETROVERTED UTERUS

 Kinking of the uterine vessel
 Urinary retention due to pain.
 Abortion
 Menorrhagia
 Anovulation
 Infertility
 Uterine prolapse
 Prolapse of tubes and ovaries
 Acute retention of urine because the bladder is nipped between the
symphysis pubis and the enlarged uterus.
 PREVENTION
 Skillful delivery during the second stage of labor
 Encourage client not to bear down till cervix is fully dilated in both breech
and cephalic presentation.
 Active diagnosis of big babies for caesarian section.
 Family planning to control parity.

INVERSION OF THE UTERUS

 It is serious condition but rare during childbirth in which the uterus literally
turns inside out after delivery either partial or complete.
 When this happens the top of the uterus (fundus) comes through the cervix
or even outside the vagina.
 It is a life threatening complication requiring prompt diagnosis and
definitive management.
 It is more common in multiple gestations than singleton pregnancies.
 CLASSIFICATION OF UTERINE INVERSION
 First degree inversion: The inverted fundus extends to , but not through the
internal os.
 Second degree inversion: The inverted fundus extends through the internal
os but remains inside the vagina.
 Third degree inversion: The uterus, cervix and vagina are inverted and are
visible at the vulva.

CLASSIFICATION ACCORDING TO TIMING OF EVENTS :

 Acute inversion : occurs within 24hours of delivery.
 Subacute inversion : occurs between 24hours and one month after
delivery.
 Chronic inversion : occurs more than one month after delivery.

CAUSES OF UTERINE INVERSION

 The most common cause is mismanagement of 3rd stage of labour, such as
fundal pressure, excess cord traction during 3rd stage of labour.
 Precipitate labour
 Short umbilical cord
 Prolong labour
 Multiparty can cause uterine muscles to become weak
 Previous uterine inversion
 Fundal implantation of the placenta
 Placenta accreta, in which the placenta is deeply embedded in the uterine
wall
 Uterine fibroids
 Retained placenta
 Uterine atony
 Fetal macrosomia
 Polyhydramnious
 Structural anomaly of the uterus such as unicornuate uterus.
  Connective tissue disorders such as Marfan’s syndrome (genetic disorder
that affect the connective tissue which holds all body cells).

SIGNS AND SYMPTOMS OF UTERINE INVERSION

 Acute lower abdominal pain as a results of stretching of the peritoneal
nerves and ovaries being pulled as the fundus invert.
 Profound shock of neurogenic or haemorrhagic origin
 Protruding of the uterus through the vagina
 Visible inverted fundus
 A mass may be felt on vaginal examination
 On abdominal examination the fundus is not palpable
 Vaginal bleeding
 Backache

DIAGNOSIS OF UTERINE INVERSION

 Ultrasound may be required to confirm diagnosis
 Signs and symptoms

MANAGEMENT OF UTERINE INVERSION

 Admit client and reassure her.
 Inform doctor and call for help from other medical teams.
 Check vital signs every 15mins till condition improves.
 Secure intravenous access with large bore cannula and start IV fluids eg.
Ringers lactate, normal saline.
 Take blood sample for HB, grouping and cross matching, clotting time for
possible blood transfusion.
 Mobilize donors for possible transfusion if HB is low.
 Insert urethral catheter and monitor intake and output chart.
 If placental is in position do not attempt to deliver it until the uterus is
replaced.
  Cover the inverted fundus or uterus with a warm sterile gauze moistened
with sterile normal saline.
 Administer analgesia for relief of pain such as injection pethidine 50mg.
 Immediate uterine repositioning can be done using the following;
 Johnson’s manoeuvre
 Hydrostatic replacement

Measures to reposition the uterus may include;

 Caustious administration of tocolytics to allow uterine relaxation
 Nitroglycerin (0.25-0.5mg) intravenously over 20minutes or terbutaline
0.1-0.25mg slowly intravenously, or magnesium sulfate 4-6g intravenously
over 20minutes.

JOHNSON’S METHOD :
Attempting prompt repositioning of the uterus is best done manually and quickly,
as delay can render repositioning progressively more difficult.
 With the palm of the hands push the fundus along the direction of the
vagina, towards the posterior fornix.
 Then lift the uterus towards the umbilicus and returned to position with a
steady pressure.
 Maintain bimanual uterine compression and massage until the uterus is
well contracted and bleeding has stopped.
 Give injection oxytocin to maintain uterine contractions
 If this fails, hydrostatic replacement should be attempted under spinal or
general anaesthesia.
 HYDROSTATIC REPLACEMENT
 This involves an infusion of warm saline into the vagina through a giving
set, and sealing off the introitus with the operator’s hand inserted into the
vagina.
 As the fluid pressure within the vagina rises, the uterus returns to it’s
normal position. OR
 There is a newer technique to correct a uterine inversion using a balloon
device and water pressure. A balloon is placed inside the uterine cavity and
filled with a saline solution to push the uterus back into position
  If a tight babe of contracted tissue in the uterus prevents it from being
repositioned, an incision may be made along the back portion of the uterus
(laparotomy) . The uterus can then be replaced and incision repaired.
 If placenta is still Insitu, perform manual removal and conduct careful
examination to rule out retained product.
 General anaesthetic of uterine relaxant is then stopped and replaced with
oxytocin or prostaglandins to contract the uterus.
 Uterine massage is done till the uterus contracts fully and bleeding stops.
 Antibiotics prophylaxis are started for at least 24hrs after replacement eg.
Amoxiclav 2g
 Client should be monitored closely after the depositioning , in order to
avoid re-inversion.
 Surgical intervention if repositioning is unsuccessful, hysterectomy which
may be life saving , is the final option if placenta can’t be separated from
the uterus.

COMPLICATION OF UTERINE INVERSION

 Severe haemorrhage
 Genital tract infection
 Shock resulting in maternal death
 Fertility problems

PREVENTION OF UTERINE INVERSION

 Active management of third stage of labor
 Avoid fundal pressure

VAGINAL FISTULA
 A fistula is a passage or hole that is formed between two organs in the body
or an organ in the body and the skin.
 A fistula that has formed in the wall of the vagina is called vaginal fistula.
 A vaginal fistula that opens into the rectum is called a rectovaginal fistula
 A vaginal fistula that opens into the colon is called a colovaginal fistula.
  A vaginal fistula that opens into the small bowel is called an enterovaginal
fistula.
 Urethrovaginal fistula, is the opening between the vagina and the tube
that carries urine out of the body (urethral).
 Ureterovaginal fistula, this happens when abnormal opening develops
between the vagina and the ureters.

VESICO-VAGINAL FISTULA (VVF) :

 It is an abnormal communication between the bladder and the vagina that

allows a continuous involuntary discharge of urine into vaginal vault. It is a
real cause of urinary incontinence.
 In addition to the medical sequel from these fistulas, they have a profound
effect on the client’s emotional well being.G

PREDISPOSING FACTORS OF VESICO-VAGINAL FISTULA

  Conception at a younger age
 Pelvic outlet obstruction due to female circumcision.k
 Insertion of caustic substances/ corcortion into the vagina with the
intent to treat a gynaecological condition or to help the vagina to
return to it’s nulliparous state.
 Pelvic infection such as syphilis.

CAUSES OF VESICO-VAGINAL FISTULA

 A deep tear in the perineum or an infected episiotomy after
childbirth when neglected.
 It can also happens often after radiation treatment for pelvic cancer.
 It can also be associated with hysterectomy
 Cone biopsy
 Surgery of the back wall of the vagina and the perineum, anus or
rectum.
 It can also occur after a violent rape
 Full bladder during labor
 Poorly performed dilatation and curettage; perforation can occur
leaving opening between either the rectum , urethra or bladder.
 Female genital mutilation; the clitoris can be cut through the urethra
into vagina
 Foetal head causing pressure upon the urethra and the base of the
bladder due to prolong obstructed labour. This leads to bruising and
oedema which can cause necrosis in the internal sphincter of the
bladder .

SIGNS AND SYMPTOMS

 It is usually painless but client complains of involuntary passage of urine
into the vagina.
 Chronic urinary incontinence h
 Irrigation of the vagina.
 Dyspareunia
 Haematuria
  Recurrent bladder and vagina infections.
 Signs of infection such as fever, chills, headache.
 Swelling of the vaginal walls.
 Redness and pain in the vaginal or vulva area.

DIAGNOSIS
 Signs and symptoms through history taking .
 Physical examination, using speculum to inspect the vaginal walls
 Sterile dye can be inserted into the bladder via a catheter so that the dye is
looked in the vaginal vault.
 Pelvic x-ray
 Cystoscopy
 Urinalysis to check for infectio

MANAGEMENT OF VESICO-VAGINAL FISTULA

 Take history on the condition from client
 Conduct physical examination on the client to know the extent of the
condition.
 Explain condition to the client and reassure her
 For conservative management, pass and retain a folley’s catheter. It may be
left in situ for 6weeks . This may help resolve the condition.
 Care for the catheter at least twice a day.
 Administer about three (3) litres of IV fluid in 24hrs or encourage client to
take copious fluids for rehydration.
 Give antibiotics to prevent infection.
 The fistulae usually heals without operation when it is small. But if it
persists after 6weeks, then surgery is required to heal the fistula. Examples
include transvaginal or laproscopical surgery.
 Prepare client for surgery if indicated.
 Prior to surgery oestrogen replacement therapy should be given to enhance
successful closure of the hole
 After the operation the indwelling urethral catheter is left in situ for 14-30
days
 Anti spasms can be given to prevent bladder spasm and damage of the
repair.
 Educated on well nourishing diet rich in vitamins and protein to help boost
immunity.
 Educate on proper personal hygiene especially, vulva toileting to prevent
ascending infections.
 Note: the client should not have sex for the next 3months after repair to
prevent gaping
 The next mode of delivery should be via C/S.

COMPLICATIONS OF VESICO-VAGINAL FISTULA

 Repairs shortens the vaginal walls
 Reoccurrence of fistula following SVD
 Infections of the kidney and bladder
 Haemorrhage
 Dyspareunia
 Injury to the ureters, bowel or intestines
 Abdominal approach procedures carry additional risks of abdominal and
pelvic adhesions.

PREVENTION OF VESICO- VAGINAL FISTULA

 If there is urinary retention, the midwife should pass catheter during
labour.
 Appropriate and right catherization practices should be done.
 Advice woman to urinate frequently to prevent retention.
 Manage labour with a partogragh for early detection of prolong/
obstructed labour
 When prolonged labour is noticed, call for immediate intervention.
 Early screening should be done for early detection of ulcerative cells as in
carcinoma of the cervix and managed promptly.
 Advice women to go for regular antenatal check visit
 Advice women to report early when in labour
 Educate the public on pelvic exercise and good nutrition to improve muscle
tone.
 Female genital mutilation should be discouraged and if possible abolished.
 Early intervention of obstructed labour
 Skillful delivery
 Educating the public on the importance of hospital delivery.

RECTO-VAGINAL FISTULA
 A rectovaginal fistula is an abnormal opening between the lower portion of
the large intestine (rectum) and the vagina.
 It is an opening between the vagina and the rectum leading to expulsion of
faeces per vaginum.
 The severity of the symptoms will depend on the size of fistula. Most often,
it appears after about a week after delivery.
 CAUSES OF RECTO-VAGINAL FISTULA
 Trauma during childbirth
 Severe and neglected laceration of the perineal body.
 Unintended results of a surgical procedure like episiotomy
 Prolong and obstructed labour
 Bruising of the rectum during instrumental delivery
 Infections in the anus or rectum
 Cancer or radiation treatment in the pelvic area.
 Crohn’s disease: is a type of inflammatory bowel disease in which the
lining of the digestive tract becomes inflamed, but having Crohn’s
disease increases the risk of the condition.

SIGNS AND SYMPTOMS OF RECTO-VAGINAL FISTULA

  Passage of gas, stool or pus from the vagina
 A foul smelling vaginal discharge
 Inability to control bowel movement
 Recurrent vaginal or urinary tract infections
 Irrigation or pain in the vulva, vagina and perineum.
 Pain during sexual intercourse.
 Persistent pain in the pelvic area.

DIAGNOSIS
 History taking
 A physical examination to locate the rectovaginal fistula
 Speculum examination
 Endoscopy
 Blue dye test
 Computerized tomography (CT) scan of the abdomen and pelvis
 Magnetic Resonance Imagine: it creates images of soft tissues in the
body and MRI can show location of the fistula
 Anorectal ultrasound
 Urinalysis to check for infection
 Signs and symptoms

MANAGEMENT OF RECTO-VAGINAL FISTULA

NB : Fistula is extremely difficult to heal and causes distress to the woman . In
certain cultures , it may leads to her rejection and isolation. Surgery is required to
correct the fistula. After diagnosing rectovaginal fistula , it is best to wait for
months to allow for inflammation to subside before repair. If fistula is small, it will
heal spontaneously during the time interval.
 Reassure client and support person
 Educate client and family on the condition.
 Client and support person should be assisted to sign a consent form for the
repair of the fistula.
 Educate client and assist her on personal hygiene eg. Frequent changing of
pads.
 Any infections should be treated before the surgery
 Give a lukewarm enema a night before the surgery for complete emptying
if the colon and rectum.
 Educate them on drugs and the need to adhere to treatment given.
 Offer psychological support which includes family involvement in the care
of the baby
 Educate client on rest and sleep
 A well nourishing diet should be served to boost client immune system.
 Prescribe antibiotics should be served to combat infection.
 Counseling on family planning should be given , client and partner should
make a choice to prevent pregnancy before treatment.
 Client should be referred appropriately to a specialist and booking done for
repair if necessary.
 Follow up should be encouraged.
 The midwife should embark on home visit to give emotional support to
client and family.

COMPLICATION OF RECTO-VAGINAL FISTULA

 Incontinence of faeces
 Recurrent vaginal and urinary tract infection
 Irrigation or infka of the vagina, perineum or the skin around the anus
 Infected fistula that forms an abscess
 Fistula reoccurrence

PREVENTION OF RECTO-VAGINAL FISTULA

 The general public should be educated on the condition and it’s effect.
 Delay in seeking health care should be avoided as much as possible
 Early screening of anaemia and other infections should be done.
 Treat all anemia and infection antenatally
 Pregnant and labouring women should be educated to avoid premature
bearing down to prevent tears.
 Maintain personal hygiene after delivery especially when the perineum is
sutured due to tears.
 Tears and lacerations should be well sutured especially 3rd degree tears.
 Client should be monitored on partogragh to prevent prolong labour.
 Good infection Prevention should be practised
 Care should be taken during instrumental delivery
 Women who had 3rd degree tears should be given a low residue diet for
the first few days in order to prevent further damage due to straining to
pass stool.
 In case of constipation, mild laxatives should be given.
 Re- suture 3red degree tears under general anesthesia if not healed by 1st
intention.