A Fistula Update

It’s been one year from today that I had surgery for my fistula. Most people probably don’t remember the days of their surgeries. This one was memorable. Mostly because I thought it was going to fix something that was wrong.

But it didn’t.

I journaled the details of my fistula recovery through eight weeks. (You can read all about how the fistula was diagnosed and the surgery/recovery in the prior posts.) I mainly journaled through those first few months after surgery because that was the information I wanted as a post-op patient but couldn’t find anywhere on the internet. And although fistulas are uncommon, that was a really lonely place to be for a few months.

One year out, I wanted to offer a couple reflections I didn’t have a year ago. Last month, I had the opportunity to lecture some midwife students on obstetric fistula. It was a great opportunity and I think it’s a lecture they’ll never forgot. After the lecture, I realized there was a little more to say…so here it goes!

The size suture you use matters.

Bless midwifery faculty. They’re always teaching you even 8 years after midwifery school. One of the points made during my presentation was about the size of the suture used to repair my laceration when the fistula was created. She asked: Why was a 2-0 used on a small 2nd degree laceration when a 3-0 suture might have been more appropriate? The difference in the size of the suture needle could have made all the difference.

The other side to this important point is that fistulas form from the rectum/sphincter side – not from the vagina side. In other words, there has to be trauma to the sphincter complex for the fistula to have a tract to start. In hindsight, I don’t know if a different suture size would have changed anything for me. But for students and practicing midwives, this is a really important point to take to heart in your practice. Use an appropriately sized suture to the laceration and the amount of tissue you are repairing.

Anatomy matters too.

I see this a lot in midwifery students. They are so excited to catch the baby, but when we’re looking at a non-intact vagina to repair it, they’re completely overwhelmed at how to repair the laceration(s). And that’s normal, but we have to be diligent about teaching the anatomy and emphasizing why it matters. When I have a student and we are beginning a laceration repair, I go through the anatomy every single time. It’s the only way to enforce the education and build confidence.

Like any skill, it takes a number of vaginal lacerations to get a baseline of what each laceration looks like. But after that baseline is achieved, beware of confidence and continue to hone your suturing skills. Repairing vaginal lacerations really is an art – every midwife learns it. But you can continue to learn. I personally like to watch the surgeons in surgery or while repairing an extensive laceration. You’ll learn new ways to assess the tissue, throw a stitch and tie a knot.

If you’re not sure where to start, go back to the anatomy and try to imagine the vaginal and rectum anatomy in 3D. When you’re sewing a 2nd degree laceration, be aware of what you are sewing on top of (the rectum or sphincter complex). Or, if you have deep sidewalls, be aware how deep you throw those stitches. And if you’re ever just not sure, call in a second set of eyes for an opinion, guidance or help.

Educate before discharge.

This last one isn’t really pertinent to me. Who thinks a mama that births a baby without an epidural and has a small second degree is going to have a fistula? Not many would say yes to that questions.

But I work at a hospital where enough babes are birthed, that 3rd and 4th degree lacerations are more common. I was looking for a patient handout one night on how to care for a 3rd or 4th degree laceration for one of the patients that sustained a laceration…but I also wanted a handout that noted abnormal healing signs or signs of a fistula.

I found just the handout from Royal College of Obstetricians & Gynaecologists.

It has some beautiful pictures to show what part of the anatomy was damaged and how it is repaired. The handout mentions how to support healing and how to use a squatty potty.

And it ends with the risk of another significant vaginal tear in subsequent births.

It’s a dream handout. And I think it’s appropriate to offer this to someone while they are on the postpartum unit. Check it out yourselves…but it’s something I’ve changed in my practice to help women recover well from a significant laceration and to have a good resource for information if something is not healing as expected.

Those are my tips! Otherwise, my fistula is exactly the same as it was prior to and after surgery. At this point in my life, I don’t think I’ll have it repaired. And I have a lot of peace with that.

As always, if you have a fistula and have any questions at all, I am always happy to answer or just listen. Send me an email at amidwifenation@gmail.com.



1 year ago on the blog…The State of Midwifery (Part 2): How to Bolster the Force

2 years ago on the blog…What is shared decision making?

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