Delivery mode for prolonged, obstructed labour resulting in obstetric fistula in East and Central Africa (3)

13 January, 2020

Dear Julitta,

"This study was the obstructed labour the cause of the fistula or had the fistula occurred earlier and repaired and then a repeat obstruction?"

The full text specifies that 'They had developed fistula during childbirth in an unknown, larger number of facilities some time before seeking fistula repair.'

"I am interested in this study and what the international standards are for delivery practices post obstetric fistula repair in developing countries. One would think it should be by CS irrespective of whether the baby is still born (fresh or macerated) or alive."

The full text says: 'Over 25 years CS rates rose dramatically in this population of 4396 East and Central African women seeking obstetric fistula repair, even though most babies were stillborn. Increases in CS have been documented in diverse contexts around the world, but this analysis is the first to shed light on the frequency of CS with obstructed labour and stillbirth. It indicates widespread disrespect for international guidelines on how to manage obstructed labour with a dead fetus'. The latter leads to the following reference:

World Health Organization, UNICEF, United Nations Population Fund. Managing Complications in Pregnancy and Childbirth: A Guide for Midwives and Doctors, 2nd edn. Geneva: World Health Organization, editor. 2017.

I reviewed the above, which is actually not a formal WHO guideline but a practical manual 'in line with WHO’s current recommendations for emergency obstetric and newborn care'. There are 20 mentions of 'fetal death' in the manual, none of which discuss the management of fetal death following obstructed labour. Most of the mentions of fetal death describe diagnosis of fetal death, and not management. There is one mention of craniotomy as an option: 'In certain cases of obstructed labour with fetal death, reduction in the size of the fetal head by craniotomy makes vaginal birth possible and avoids the risks associated with caesarean'.

A quick google search on 'management of fetal death following obstructed labour' led me to this 2008 WHO/ICM publication (not included in the references of the above paper): Managing prolonged and obstructed labour, Midwifery education module 3.

Again, I could not find guidance here on the management of fetal death following obstructed labour. Nor could I find such guidance after 30 minutes of internet searching. Specifically, I was unable to find a WHO guideline on obstructed labour or fetal death.

Can anyone help clarify this issue? I have written to the lead author C Ngongo to see if he/she can help.

Best wishes, Neil

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