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This chapter should be cited as follows:
Shahid U, Rane A, Glob. libr. women's med.,
ISSN: 1756-2228; DOI 10.3843/GLOWM.415693

The Continuous Textbook of Women’s Medicine SeriesObstetrics Module

Volume 6

Pregnancy complaints and complications: clinical presentations

Volume Editor: Professor Gian Carlo Di Renzo, University of Perugia, Italy

Chapter

Genital Mutilation

First published: August 2021

AUTHORS

Usama Shahid
Royal Australian College of Obstetricians and Gynecologists trainee. James Cook University, Townsville, Australia
Ajay Rane
Head of Department of Obstetrics and Gynecology. James Cook University, Australia. FIGO Committee for Fistula and Genital Trauma

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INTRODUCTION

Female genital mutilation (FGM) is a traditional practice where female genital organs are altered for non-medical reasons.1 FGM is usually performed with the unconsented restraint of minors by untrained personnel in unsterile environments.2

The practice exposes these girls to a lifetime of potential gynecological, obstetric, and psychiatric complications (Table 1).2,3,4,5

1

FGM complications.

Gynecological

Obstetric

Psychiatric

Acute hemorrhage

Prolonged labor

Post-traumatic stress disorder

Dyspareunia

Increased perineal trauma rates

Anxiety

Dysmenorrhea

Increased episiotomy rates

Affective disorders

Chronic pelvic pain

Inconclusive data currently regarding cesarean section and instrumental rates with FGM


Wound infections



Recurrent urinary tract infections



FGM is undertaken for numerous motives, including initiation into womanhood, religious beliefs, as a form of aesthetic appeal, and as a means of suppressing sexual desires.3,4 Despite the medical complications of FGM and increased legal ramifications, FGM prevalence rates have only marginally declined over the past two decades.6 The United Nations International Children’s Emergency Fund (UNICEF) estimates that over 200 million girls and women alive today have undergone FGM.7 Although FGM is practiced across a multitude of cultures, the highest prevalence remains across Sub-Saharan African communities, with 11 countries in the region having prevalence rates greater than 70%.1

In a recent study looking at the economic burden of FGM across 27 countries, it was estimated that 1.4 billion US dollars were spent in 2018 on managing the complications of FGM.7

DEFINITION AND TYPES OF FGM

FGM is defined as all procedures involving partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons.1 The World Health Organization has described FGM in four different types, allowing for the standardization of assessment and documentation (Table 2).1

2

Types of FGM.

Type

Description

1


Partial or total removal of the clitoris and/or the prepuce (clitoridectomy).

1a: Removal of the clitoral hood or prepuce only.

1b: Removal of the clitoris with the prepuce.

2

Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora.

2a: Removal of the labia minora only.

2b: Partial or total removal of the clitoris and labia minora.

2c: Partial or total removal of the clitoris, labia minora and labia majora.

3

Narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoria (infibulation). Re-infibulation is included in this definition.

3a: Removal and apposition of the labia minora.

3b: Removal and apposition of the labia majora.

4

Unclassified – all other harmful procedures to the female genitalia for non-medical purposes, for example, pricking, piercing, incising, scraping, and cauterization

Type 3 FGM or infibulation remains of the most concerning type of FGM. The increased frequency and severity of medical complications associated with infibulation, along with the increased likelihood of requiring medical intervention makes its recognition and appropriate management vital. This is particularly relevant in the obstetric context.

SOCIAL AND MEDICO-LEGAL CONSIDERATIONS

An important aspect of managing FGM is to appreciate the deep-rooted socio-cultural pressures fuelling the practice. In societies where FGM is a social norm, the practice is self-perpetuating secondary to a desire to conform to this behavioral rule.8 Despite the medical and legal consequences of FGM, individuals and families alike fear marginalization and loss of social status if they were to abandon the practice.8 In addition, women in patriarchal societies gain recognition through marriage and childbirth and this process is challenged when FGM is abandoned. As males in some cultures prefer females with FGM when considering partners.9

Thus, any blame towards the patient or their culture does not aid the process of abandonment or management of the individual. Considering the taboo nature of a socio-culturally delicate topic like FGM, an appreciation of these behavioral pressures is important when consulting patients. With this in mind, the legal aspects of FGM should be made clear to the patient. FGM is illegal and constitutes criminal assault.10 It is illegal to arrange or assist in arranging for an individual to go overseas for the purpose of FGM.11 Where de-infibulation is required, re-infibulation following delivery is illegal and should not be performed under any circumstance.11

The International Federation of Gynecology and Obstetrics, Royal College of Obstetricians and Gynecologists, Royal Australian and New Zealand College of Obstetricians and Gynecologists have all barred their members from performing FGM in any capacity.1,11,12

EARLY PREGNANCY ASSESSMENT

History

  • Every woman regardless of ethnicity should be asked about FGM at her booking in visit.11
  • Enquire about complications of FGM and particularly psychiatric symptoms.
  • Ensure all other investigations (pap smears, STD screening, antenatal serology) are up to date. Women with FGM may be less likely to present to healthcare professionals, particularly if from a low socio-economic status or a minority demographic.

Examination

  • Explain the need for examination to assess the FGM type and whether any further intervention may be required. As with all pelvic examinations this needs to be done respectfully, understanding the potential distress this may cause the patient. If there is concern for significant distress being caused, then the examination can be re-scheduled with a support person present.
  • The main purpose of the pelvic examination is to determine whether the patient has type 3 FGM (infibulation) or not.
  • With a chaperone present, examine the anatomical level of tissue closure, degree of fibrosis, presence of inclusion cysts, any tenderness and vaginal patency at the level of introitus.
  • Document findings clearly and classify the FGM type.

Management

  • FGM is best managed in specialized referral clinics.11 These clinics offer a streamlined hub of patient access to culturally appropriate liaison officers, interpreters, and social workers.
  • Counsel the patient on the risks of FGM in pregnancy.
  • Respectfully explain the legal aspects of FGM. Particular emphasis should be made to explain that if de-infibulation is required, under no circumstance will re-infibulation be performed post-partum. In addition, if the baby is female performing FGM is illegal and constitutes criminal assault.
  • Reporting of FGM to the police, child protection services, and social services is not mandatory for adults. The decision to report FGM should be assessed on a case-to-case basis. Reporting should be undertaken if the patient is deemed to be vulnerable or there is clinical concern of the FGM being performed recently. In addition, if the patient voices intention of performing FGM or has a previous history of doing so then reporting should be undertaken. Finally, if the patient is a minor (less than 18 years old) then reporting is mandatory.13
  • Mental-health referral: if the patient is suffering from psychiatric symptoms or remains high risk for exacerbation in pregnancy then ensure appropriate referrals are made to psychiatric services.
  • Ensure that no routine pregnancy cares are missed.
  • Document plan of care for pregnancy. More frequent visits may be required.

De-infibulation

De-infibulation is a minor surgical procedure to divide the scar tissue sealing the vaginal introitus in type 3 FGM.11 In the obstetric context, de-infibulation is indicated to allow for adequate intrapartum vaginal examination and facilitate a safe vaginal delivery. There are no randomized controlled trials looking at pregnancy outcomes associated with de-infibulation but it still remains routine practice for women with type 3 FGM.11 De-infibulation is best performed in the second trimester but can be done in the first stage of labor and at the time of a cesarean section (for subsequent pregnancies and gynecological indications).11 The steps of the de-infibulation process are provided below:14

  • Pre-operative preparation:
    • Ensure the patient is adequately consented and understands that re-infibulation will not be performed.
    • Discuss anesthesia with the patient. Most de-infibulation procedures can be done under local anesthetic in theater but for some women psychological distress may warrant neuraxial anesthesia.
  • Positioning and administration of local anesthetic:
    • Place the patient in lithotomy with adequate lighting. De-infibulation is usually performed in the operating theater.
    • Routine betadine preparation and drape.
    • If the infibulation extends anteriorly close to the external urethral meatus an in-dwelling catheter can be sited to help delineate the urethra, thus avoiding inadvertent injury during the procedure.
    • Using 1% xylocaine local anesthetic, infiltrate the infibulation scar tissue at the midline of the vaginal introitus.
  • De-infibulation:
    • Lift the infibulation scar tissue and gently insert one or two fingers past the introitus. Similarly, surgical forceps can also be inserted to avoid inadvertent tissue damage.
    • Using either a scalpel or scissors incise the infibulation scar tissue thereby dividing it anteriorly up to the level of the external urethral meatus.
    • If the de-infibulation is being performed intra-partum use scissors to incise the scar tissue. If vaginal examination is possible with the infibulation then it can be performed at the crowning of the fetal head but usually de-infibulation is done in the first stage of labor.11
    • Inspect the cut edges for bleeding points and examine the remaining genital tissue.
    • Using 3–0 vicryl rapide apply a heamostatic running suture to oversew the raw vulval edges bilaterally.
  • Post-procedure care:
    • Most women do not require admission to hospital for monitoring and can be safely discharged with antenatal follow up.
    • Advise vulval hygiene.
    • Regular pain relief with paracetamol.
    • No sexual intercourse for 14 days.
    • Counsel on signs of infection and bleeding and when to return to hospital for assessment.

INTRA-PARTUM MANAGEMENT

  • Ideally women with FGM should have already been made aware antenatally of the intra-partum risks associated with FGM with a documented plan in place.
  • Induction of labor and intra-partum monitoring are done for routine obstetric or fetal indications as per local guidelines.
  • Women with FGM may find vaginal examinations quite distressing, an epidural can be offered to help with this process. In addition, ensuring the patient has an appropriate interpreter and support person may help.
  • If the patient has type 3 FGM and had planned to undergo intra-partum de-infibulation, explain the procedure, its timing, and indication (to allow for assessment and safe vaginal delivery).
  • If proceeding ahead with a cesarean section (for either routine indications or patient distress not allowing for examination even with an epidural) counsel the patient on de-infibulation at the time of the cesarean section. This is for subsequent pregnancies and for gynecological indications.
  • Reduced skin elasticity due to scarring from FGM means that episiotomy is commonly indicated but should be assessed on a case-to-case basis.11
  • Perineal tears should be repaired as per usual.

POST-PARTUM MANAGEMENT

  • Debrief the patient on the process and events. A formal debrief in 6 weeks may need to be booked.
  • If de-infibulation was not performed (at the time of a cesarean section) the patient can be booked for gynecological outpatients' follow up to consider performing de-infibulation as an elective procedure.
  • Ensure the patient has a contraception plan in place.
  • If the newborn is female, re-address FGM being illegal and if there are ongoing concerns report to child protection services.

CONCLUSION

FGM is a multi-faceted, socially taboo topic with a range of implications for obstetric patients. If addressed with understanding, in a culturally appropriate and timely manner, the pregnancy complications can be suitably managed.

PRACTICE RECOMMENDATIONS

  • A robust understanding of the socio-cultural demographics surrounding FGM and promoting the practice are essential towards respectfully addressing the issue in obstetric patients.
  • FGM is illegal and constitutes criminal assault. This needs to be made clear to patients at their first booking-in visit if FGM is noted.
  • FGM is associated with a range of complications and thus best dealt with in specialized clinics.
  • Reporting of FGM is mandatory in the case of a minor, if there is clinical concern of the FGM being performed recently or if there is ongoing concern about the mothers susceptibility of performing FGM on her newborn. The police, social services, and child protection services should be involved in these cases.
  • De-infibulation is best performed in the second trimester but can be undertaken intra-partum as well. Even if the patient is going for a cesarean section, de-infibulation can be opportunistically offered. The patient should be counseled that re-infibulation will not be performed under any circumstance.
  • If a patient in labor with FGM has difficulty tolerating vaginal examinations an epidural anesthetic can be offered.
  • Reduced vaginal and perineal elasticity from FGM means that often an episiotomy is required.
  • A formal post-partum debrief is helpful in ongoing care and engaging patients with FGM in pregnancy about the events surrounding their delivery.

CONFLICTS OF INTEREST

The authors of this chapter declare that they have no interests that conflict with the contents of the chapter.


REFERENCES

1

World Health Organisation: Office of the High Commissioner For Human Rights, Joint United Nations Programme on HIV/AIDS, United Nations Development Programme, et al. Eliminating female genital mutilation: an interagency statement. Geneva: 2008. Website: https://apps.who.int/iris/bitstream/handle/10665/43839/9789241596442_eng.pdf;jsessionid=D71499CA7DEA3497540BAC214EDD2CF3?sequence=1

2

Barstow DG. Female genital mutilation: the penultimate gender abuse. Child Abuse Negl 1999;23:501–10. https://doi.org/10.1016/S0145-2134(99)00017-4

3

Dare FO, Oboro VO, Fadiora SO, et al. Female genital mutilation: an analysis of 522 cases in South-Western Nigeria. Journal of Obstetrics and Gynaecology 2004;24(3):281–3. DOI: 1080/01443610410001660850

4

Behrendt A, Moritz S. Posttraumatic stress disorder and memory problems after female genital mutilation. American Journal of Psychiatry 2005;162(5):1000–2. DOI: 1176/appi.ajp.162.5.1000

5

Lurie JM, Weidman A, Huynh S, et al. Painful gynecologic and obstetric complications of female genital mutilation/cutting: A systematic review and metaanalysis. PLoS Med 2020;17(3):e1003088. https://doi.org/10.1371/journal.pmed.1003088

6

Berg RC, Denison E. Interventions to reduce the prevalence of female genital mutilation/cutting in African countries. Campbell Systematic Reviews 2012:9 https://doi.org/10.4073/csr.2012.9

7

Female Genital Mutilation Cost Calculator. World Health Organization Human Reproduction Programme. 2020. Website: https://srhr.org/fgmcost/

8

Global Strategy to stop health-care providers from performing female genital mutilation. World Health Organisation. Department of Reproductive Health and Research, 2010. https://www.unfpa.org/sites/default/files/pub-pdf/Global_strategy_for_health_providers.pdf

9

Shahid U, Rane, A. African, male attitudes on female genital mutilation: an Australian survey. Journal of Obstetrics and Gynaecology 2017. DOI: 10.1080/01443615.2017.1323196

10

Mathews B. Female Genital Mutilation: Australian law, policy and practical challenges for doctors. Medical Journal of Australia 2011;194:139–41. Doi: 10.5694/j.1326-5377.2011.tb04197.x

11

Female Genital Mutilation and its Management. Royal College of Obstetricians and Gynaecologists, 2015. Greentop Guideline No. 53. https://www.rcog.org.uk/globalassets/documents/guidelines/gtg-53-fgm.pdf

12

Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). No change in peak body view on female genital mutilation [media release]; [cited 2014 April], 2010. Available from: http://www.ranzcog.edu.au/media/pdfs/MR-May-28-2010-College-Postion-on-FGM.pdf

13

FGM safeguarding and risk assessment. Quick guide for health professionals. Department of Health, 2017. Website: available at https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/585083/FGM_safeguarding_and_risk_assessment.pdf

14

Female genital mutilation clinical care. Deinfibulation guidelines. FGM Education Programme for the New Zealand Ministry of Health, 2009. Website: https://fgm.co.nz/wp-content/uploads/2019/10/fgm-deinfibulation-guidelines-2009.pdf

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