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Background An obstetric fistula is a traumatic childbirth injury that occurs when labor is obstructed and delivery is delayed. Prolonged obstructed labor leads to the destruction of the tissues that normally separate the bladder from the vagina and creates a passageway (fistula) through which urine leaks continuously. Women with a fistula become social outcasts. Universal high-quality maternity care has eliminated the obstetric fistula in wealthy countries, but millions of women in resource-poor nations still experience prolonged labor and tens of thousands of new fistula sufferers are added to the millions of pre-existing cases each year. This article discusses fistula prevention in developing countries, focusing on the factors which delay treatment of prolonged labor. Discussion Obstetric fistulas can be prevented through contraception, avoiding obstructed labor, or improving outcomes for women who develop obstructed labor. Contraception is of little use to women who are already pregnant and there is no reliable screening test to predict obstruction in advance of labor. Improving the outcome of obstructed labor depends on prompt diagnosis and timely intervention (usually by cesarean section). Because obstetric fistulas are caused by tissue compression, the time interval from obstruction to delivery is critical. This time interval is often extended by delays in deciding to seek care, delays in arriving at a hospital, and delays in accessing treatment after arrival. Communities can reasonably demand that governments and healthcare institutions improve the second (transportation) and third (treatment) phases of delay. Initial delays in seeking hospital care are caused by failure to recognize that labor is prolonged, confusion concerning what should be done (often the result of competing therapeutic pathways), lack of women’s agency, unfamiliarity with and fear of hospitals and the treatments they offer (especially surgery), and economic constraints on access to care. Summary Women in resource-poor countries will use institutional obstetric care when the services provided are valued more than the competing choices offered by a pluralistic medical system. The key to obstetric fistula prevention is competent obstetrical care delivered respectfully, promptly, and at affordable cost. The utilization of these services is driven largely by trust.

Background Obstetric fistula is a debilitating birth injury that affects an estimated 2–3 million women globally, most in sub-Saharan Africa and Asia. The urinary and/or fecal incontinence associated with fistula affects women physically, psychologically and socioeconomically. Surgical management of fistula is available with clinical success rates ranging from 65–95 %. Previous research on fistula repair outcomes has focused primarily on clinical outcomes without considering the broader goal of successful reintegration into family and community. The objectives for this study are to understand the process of family and community reintegration post fistula surgery and develop a measurement tool to assess long-term success of post-surgical family and community reintegration. Methods This study is an exploratory sequential mixed-methods design including a preliminary qualitative component comprising in-depth interviews and focus group discussions to explore reintegration to family and community after fistula surgery. These results will be used to develop a reintegration tool, and the tool will be validated within a small longitudinal cohort (n = 60) that will follow women for 12 months after obstetric fistula surgery. Medical record abstraction will be conducted for patients managed within the fistula unit. Ethical approval for the study has been granted. Discussion This study will provide information regarding the success of family and community reintegration among women returning home after obstetric fistula surgery. The clinical and research community can utilize the standardized measurement tool in future studies of this patient population.

Conjoined twins in a triplet pregnancy are very rare. Failure to diagnose a thoracopagus in a case of known triplet pregnancy resulted in obstructed labor which necessitated an emergency cesarean section. The single infant survived, but the thoracopagus died apparently from asphyxia.

It has long been recognized that the risk of cesarean section rises rapidly the longer the patient has been in labor, and the longer the membranes have been ruptured. The mortality of cesarean section in the ideal case, when the patient is operated on before labor, is negligible. In the patient in labor for a considerable time, the mortality becomes a factor to be reckoned with and in the neglected case it becomes formidable. In the preantiseptic days, in an insuperably obstructed labor, the only alternative was to destroy the living child, and the obstetrician sought methods to deliver the child by operation and yet avoid the opening of the peritoneum. The original extraperitoneal operation, with incision parallel to Poupart's ligament, blunt dissection under the peritoneum to the cervix and vagina and delivery through the flank, was suggested by Joerg in 1809 but done first by Ritgen in 1821. The

Spontaneous intraperitoneal rupture of the uterus during labor is, very fortunately, of rare occurrence. Contrary to early teaching, it occurs most frequently in multiparas. An impaired integrity of the uterine wall from repeated pregnancies is more frequently a causative factor than obstructed labor. This may well be borne in mind as, I believe, the popular notion would lead us to suspect this calamity more particularly in the presence of obstruction. The vulnerable scar, following a cesarean section, operates strongly as a predisposing cause of uterine rupture. Indeed, the likelihood of a tear through the old scar has found expression in the dictum, "Once a cesarean, always a cesarean." Recently, a surgical procedure, known as anterior hysterotomy, has been brought forward as an easy, safe and sane method of inspecting the interior of the uterus. To me it seems only easy. The following case report is convincing argument in favor of