Arrowsmith S, Hamlin E C, Wall L L
Addis Ababa Fistula Hospital, Ethiopia.
Obstet Gynecol Surv. 1996 Sep;51(9):568-74. doi: 10.1097/00006254-199609000-00024.
Prolonged obstructed labor may produce injuries to multiple organ systems. The best known, and most common, of these injuries is obstetric fistula formation. When obstructed labor is unrelieved, the presenting fetal part is impacted against the soft tissues of the pelvis and a widespread ischemic vascular injury develops that results in tissue necrosis and subsequent fistula formation. Unlike the postsurgical vesicovaginal fistula, however, which is usually the result of focal trauma to otherwise healthy tissues, the obstetric fistula is the result of a "field injury" to a broad area. The field injury that is produced by prolonged obstructed labor may result in multiple birth-related injuries in addition to (or instead of) a vesicovaginal fistula. Focusing simply on the "hole" between the bladder and the vagina ignores the multifaceted nature of the injury that many of these patients have sustained. These injuries may include total urethral loss, stress incontinence, hydroureteronephrosis, renal failure, rectovaginal fistula formation, rectal atresia, anal sphincter incompetence, cervical destruction, amenorrhea, pelvic inflammatory disease, secondary infertility, vaginal stenosis, osteitis pubis, and foot-drop. In addition to their physical injuries, women who have experienced prolonged obstructed labor often develop serious social problems, including divorce, exclusion from religious activities, separation from their families, worsening poverty, malnutrition, and almost unendurable suffering. Isolated almost exclusively to the developing world, particularly Africa, this problem has not received the international attention that it deserves, from either a medical or a social standpoint.
产程延长导致的梗阻性难产可能会对多个器官系统造成损伤。其中最广为人知且最为常见的损伤是产科瘘的形成。当梗阻性难产得不到缓解时，先露胎儿部分会压迫骨盆软组织，进而引发广泛的缺血性血管损伤，导致组织坏死及随后的瘘管形成。然而，与通常由对原本健康组织的局部创伤导致的术后膀胱阴道瘘不同，产科瘘是大面积“区域损伤”的结果。产程延长导致的梗阻性难产所造成的区域损伤，除膀胱阴道瘘外（或取而代之），还可能导致多种与分娩相关的损伤。仅仅关注膀胱与阴道之间的“孔洞”，忽视了许多此类患者所遭受损伤的多面性。这些损伤可能包括全尿道缺失、压力性尿失禁、输尿管肾盂积水、肾衰竭、直肠阴道瘘形成、直肠闭锁、肛门括约肌功能不全、宫颈破坏、闭经、盆腔炎、继发性不孕、阴道狭窄、耻骨炎和足下垂。除了身体上的损伤，经历产程延长导致的梗阻性难产的女性还常常会出现严重的社会问题，包括离婚、被排除在宗教活动之外、与家人分离、贫困加剧、营养不良以及几乎无法忍受的痛苦。这个问题几乎只存在于发展中世界，尤其是非洲，无论从医学还是社会角度来看，都没有得到应有的国际关注。
