female genital mutilation

Question 1

Complications of female genital mutilation (FGM)

Answer 1

Clinicians should be aware of the short- and long-term complications of FGM.

Question 2

The legal and regulatory responsibilities of health professionals

Answer 2

FGM and UK law
All health professionals must be aware of the Female Genital Mutilation Act 2003 in England, Wales and Northern Ireland and the Prohibition of Female Genital Mutilation (Scotland) Act 2005
in Scotland. Both Acts provide that:

1. FGM is illegal unless it is a surgical operation on a girl or woman irrespective of her age:
   (a) which is necessary for her physical or mental health; or
   (b) she is in any stage of labour, or has just given birth, for purposes connected with the labour or birth.
2. It is illegal to arrange, or assist in arranging, for a UK national or UK resident to be taken overseas for the purpose of FGM.
3. It is an offence for those with parental responsibility to fail to protect a girl from the risk
   of FGM.
4. If FGM is confirmed in a girl under 18 years of age (either on examination or because the patient or parent says it has been done), reporting to the police is mandatory and this must be within 1 month of confirmation. [New 2015]

Female genital cosmetic surgery (FGCS) may be prohibited unless it is necessary for the patient’s physical or mental health. All surgeons who undertake FGCS must take appropriate measures to ensure compliance with the FGM Acts. [New 2015]

Re-infibulation is illegal; there is no clinical justification for re-infibulation and it should not be undertaken under any circumstances. [New

Question 3

What are the legal and regulatory responsibilities of health professionals in their evaluation of women
with FGM?

Answer 3

When a woman with FGM is identified:
- The health professional must explain the UK law on FGM. [New 2015]
- The health professional must understand the difference between recording (documenting FGM in the medical records for data collection) and reporting (making a referral to police and/or social services) and their responsibilities with regards to these (Appendix I). [New 2015]
- The health professional must be familiar with the requirements of the Health and Social Care Information Centre (HSCIC) FGM Enhanced Dataset and explain its purpose to the woman. The requirement for her personal data to be submitted without anonymisation to the HSCIC, in order to prevent duplication of data, should be explained. However, she should also be told that all personal data are anonymised at the point of statistical analysis and publication. [New 2015]
- The health professional should be aware that it is not mandatory to report all pregnant women to social services or the police. An individual risk assessment should be made by a member of the clinical team (midwife or obstetrician) using an FGM safeguarding risk assessment tool (an example
of such a tool can be found at https://www.gov.uk/government/publications/safeguarding-womenand-girls-at-risk-of-fgm).
If the unborn child, or any related child, is considered at risk then a report should be made. [New 2015]

Question 4

What are the principles of FGM management in obstetric and gynaecological practice?

Answer 4

• All acute trusts/health boards should have a designated consultant and midwife responsible for the care of women with FGM (Appendix II).
• All gynaecologists, obstetricians and midwives should receive mandatory training on FGM and its management, including the technique of de-infibulation. They should complete the programme of
  FGM e-modules developed by Health Education England. [New 2015]
• Specialist multidisciplinary FGM services should be led by a consultant obstetrician and/or gynaecologist and be accessible through self-referral. These services should offer: information and advice about FGM; child safeguarding risk assessment; gynaecological assessment; de-infibulation; and access to other services.
• Health professionals should ensure that, in consultations with women affected by FGM, the
  consultation and examination environment is safe and private, their approach is sensitive and nonjudgemental and professional interpreters are used where necessary. Family members should not be used as interpreters.

Question 5

How should recent FGM be managed?

Answer 5

• Healthcare professionals should be vigilant and aware of the clinical signs and symptoms of recent FGM, which include pain, haemorrhage, infection and urinary retention. [New 2015]
• Examination findings should be accurately recorded in the clinical records. Some type 4 FGM, where a small incision or cut is made adjacent to or on the clitoris, can leave few, if any, visible signs when healed. Consideration should be given to photographic documentation of the findings at acute presentation. [New 2015]
• Legal and regulatory procedures must be followed (Appendix I); all women and girls with acute or recent FGM require police and social services referral. [New 2015]

Question 6

How should FGM be managed in gynaecological practice?

What should the referral pathway be for women with FGM?

Answer 6

• Women may be referred by their general practitioner (GP) to a hospital gynaecology clinic. The referral should be directed to FGM services, if available, or to the designated consultant obstetrician and/or gynaecologist responsible for the care of women and girls with FGM.
• Women should be able to self-refer. [New 2015]
• All children with FGM or suspected FGM should be seen within child safeguarding services. [New 2015]

Question 7

How should women with FGM be assessed in gynaecological practice?

Answer 7

• Women with FGM may present with symptoms directly attributable to their FGM or with co-existing gynaecological morbidity. Gynaecologists should ask all women from communities that traditionally practise FGM whether they have had the procedure. [New 2015]
• Clinicians should be aware that psychological sequelae and impaired sexual function can occur
  with all types of FGM.
• Examination should include inspection of the vulva to determine the type of FGM and whether de-infibulation is indicated, as well as to identify any other FGM-related morbidities, e.g. epidermoid inclusion cysts. [New 2015]
• All women should be offered referral for psychological assessment and treatment, testing for HIV, hepatitis B and C and sexual health screening. Where appropriate, women should be referred to gynaecological subspecialties, e.g. psychosexual services, urogynaecology, infertility. [New 2015]
• Gynaecologists should be aware that narrowing of the vagina due to type 3 FGM can preclude vaginal examination for cervical smears and genital infection screens. De-infibulation may be required prior to gynaecological procedures such as surgical management of miscarriage (SMM) or termination of pregnancy (TOP).

Question 8

What is the role of de-infibulation in gynaecological practice?

Answer 8

• Women who are likely to benefit from de-infibulation should be counselled and offered the procedure before pregnancy, ideally before first sexual intercourse.
• Women offered de-infibulation should have the option of having the procedure performed under local anaesthetic in the clinic setting in a suitable outpatient procedures room (Appendix III).

Question 9

What is the role of clitoral reconstruction?

Answer 9

Clitoral reconstruction should not be performed because current evidence suggests unacceptable
complication rates without conclusive evidence of benefit. [New 2015]

Question 10

What level of care do women with FGM require?

Answer 10

Women with FGM are more likely to have obstetric complications and consultant-led care is
generally recommended. However, some women with previous uncomplicated vaginal deliveries
may be suitable for midwifery-led care in labour.

Question 11

How should women with FGM be identified in pregnancy?

Answer 11

• All women, irrespective of country of origin, should be asked for a history of FGM at their booking antenatal visit so that FGM can be identified early in pregnancy. This should be documented in the maternity record. [New 2015]
• Women identified as having FGM should be referred to the designated consultant obstetrician or midwife with responsibility for FGM patients. Local protocols will determine which elements of care should be undertaken by these individuals and which may be undertaken by other appropriately trained midwives or obstetricians (Appendix IV).

Question 12

What antenatal documentation is required to demonstrate that legal and regulatory processes have been adhered to?

Answer 12

The midwife or obstetrician should ensure that all relevant information is documented in the clinical records (Appendix I). [New 2015]

Question 13

How should antenatal care be managed?

Answer 13

• Referral for psychological assessment and treatment should be offered.
• The vulva should be inspected to determine the type of FGM and whether de-infibulation is indicated. If the introitus is sufficiently open to permit vaginal examination and if the urethral meatus is visible, then de-infibulation is unlikely to be necessary.
• Screening for hepatitis C should be offered in addition to the other routine antenatal screening tests (hepatitis B, HIV and syphilis). [New 2015]
• De-infibulation may be performed antenatally, in the first stage of labour or at the time of delivery and can usually be performed under local anaesthetic in a delivery suite room. It can also be performed perioperatively after caesarean section (Appendix III).
• The midwife or obstetrician should discuss, agree and record a plan of care (see Appendix IV). This may be documented in a preformatted sheet.
• Women should be informed that re-infibulation will not be undertaken under any circumstances. [New 2015]

Question 14

How should intrapartum care be managed?

Answer 14

• If a woman requires intrapartum de-infibulation, the midwife and obstetrician caring for her should have completed training in de-infibulation or should be supervised appropriately.
• If de-infibulation planned for the time of delivery is not undertaken because of recourse to caesarean section, then the option of perioperative de-infibulation (i.e. just after caesarean section) should be considered and discussed with the woman. [New 2015]
• Labial tears in women with FGM should be managed in the same manner as in women without FGM. Repairs should be performed where clinically indicated, after discussion with the woman and using appropriate materials and techniques.

Question 15

How should intrapartum care be managed for women identified as having FGM in pregnancy for whom
there has been no agreed documented plan of care?

Answer 15

The impact of FGM on labour and delivery should be sensitively discussed and a plan of care agreed. [New 2015]

Question 16

How should postnatal care be managed?

Answer 16

• A woman whose planned de-infibulation was not performed because of delivery by caesarean section should have follow-up in a gynaecology outpatient or FGM clinic so that de-infibulation can be offered before a subsequent pregnancy. [New 2015]
• The discharging midwife should ensure that all legal and regulatory processes have been adhered to prior to discharge (Appendix I). [New 2015]

Question 17

Legal and regulatory responsibilities of health professionals

Answer 17

1. Data recording (http://www.hscic.gov.uk/fgm)
   - Data recording is mandatory for all women identified as having FGM.
   - Document FGM diagnosis in medical records (even if FGM is not the reason for presentation).
   - If genital examination is performed and type of FGM is identified, record FGM type (WHO classification).*
   - Document further details in accordance with the HSCIC FGM Enhanced Dataset.
   - Explain to woman that her personal data will be transmitted to the HSCIC for the purpose of FGM prevalence monitoring and that the data will not be anonymised.
2. Reporting to police and/or social services in the event of risk to a child (https://www.gov.uk/government/publications/safeguarding-women-and-girls-at-risk-of-fgm)

Children under 18:

 - If FGM is confirmed (on examination or if the patient or parent says it has been done), refer as a matter of urgency to the police and this should be done within 1 month of confirmation.
 - If FGM is suspected (but not confirmed) or the girl is at risk (but has not had FGM), refer to social services or the police. The urgency of the referral depends on the degree of risk.

Nonpregnant women with FGM: no requirement to report unless a related child is at risk.

Pregnant women:

 - A member of the clinical team (midwife or obstetrician) must make an individual risk assessment using an FGM safeguarding risk assessment tool and if the unborn child, or any other child in the family, is considered to be at risk of FGM then reporting to social services or the police must occur.
 - Document maternal history of FGM in the personal child health record (‘Red Book’) prior to postnatal discharge.
 - If delivery of a baby girl, notify the designated child protection midwife, who should inform the GP and health visitor.

*Genital piercings should be classified as type 4 FGM in accordance with the WHO FGM classification.

Question 18

Clinical management of adult women with FGM in obstetric and gynaecological practice

Answer 18

1. All acute trusts/health boards should have a designated consultant and midwife responsible for the care of women with FGM
2. All women in obstetric and gynaecological practice
   l Explain law on FGM, documenting the discussion and referring her to information provided in the Health Passport (https://www.gov.uk/government/publications/statement-opposing-female-genitalmutilation).
   l Provide interpreter if required (not a family member).
   l Offer referral for psychological assessment and treatment.
   l Offer specialist referral as appropriate, e.g. sexual health, urology.
   l Make a clinical assessment of FGM (symptoms, examination) and need for de-infibulation.
   l Record data in accordance with the HSCIC FGM Enhanced Dataset. These include age at FGM,
   country where FGM was performed, date of entry to UK (if applicable) and past history of
   de-infibulation and/or re-infibulation.
   l If de-infibulation is indicated, offer before pregnancy – it can usually be performed on an
   outpatient basis.
   l Reporting to social services or the police is only required if a related child is considered to be at
   risk.
3. Additional management in pregnant women
   - Refer to designated consultant obstetrician or specialist midwife with responsibility for women with FGM.
   - Local protocols will determine which elements of care (child safeguarding risk assessment, data recording, clinical management) should be undertaken by the designated midwife or obstetrician and which may be undertaken by other appropriately trained midwives or obstetricians.
   - Discuss and clearly document a plan of care – preformatted pro formas may be used.
   - Make an individual risk assessment using an FGM safeguarding risk assessment tool (an example of such a tool can be found at https://www.gov.uk/government/publications/safeguarding-womenand-girls-at-risk-of-fgm). If the unborn child or any related child is considered to be at risk then reporting to social services or the police must occur.
   - Offer screening for hepatitis C in addition to routine screening for hepatitis B, HIV and syphilis.
   - If de-infibulation is indicated, discuss, agree and document the timing (antenatal or intrapartum). Inform the woman that re-infibulation after delivery will not be performed under any
   circumstances.
   - Manage as high obstetric risk (increased risk of haemorrhage, perineal trauma and caesarean section), except for women who have had previous pregnancies with uncomplicated vaginal deliveries and no history of post-delivery re-infibulation.
   - Document maternal history of FGM in the personal child health record (‘Red Book’) prior to postnatal discharge.
   - If delivery of a baby girl, notify the designated child protection midwife, who should inform the GP and health visitor.
   - Offer postnatal follow-up if de-infibulation performed intrapartum or if planned de-infibulation did not occur because of delivery by caesarean section.

Question 19

One recommended method of performing de-infibulation

Answer 19

1) Type 3 FGM (infibulation)

2) Infiltration of midline scar with local anaesthetic
- Infiltration of the infibulation scar with local anaesthetic should be undertaken with surgical
forceps placed behind the scar to prevent injury to
underlying tissues.

3) Incision of midline scar
The incision should be made either with scissors or
a knife and extended anteriorly until the external
urethral meatus is visible.

4) Suturing of cut edges with absorbable suture:
The cut edges may be oversewn with a fine
absorbable suture and a paraffin gauze dressing applied.

Question 20

Plan of care for women with FGM in pregnancy

Answer 20

Woman with FGM in pregnancy:

• Referral to designated midwife and/or obstetrician with responsibility for FGM* * Local protocols will determine which elements of care (child safeguarding risk assessment, data recording, clinical management
  plan) should be undertaken by the designated midwife or obstetrician responsible for women with FGM and which may be undertaken by other appropriately trained midwives or obstetricians
• Consultant-led care

1 - Child safeguarding risk assessment by midwife or
obstetrician:
2 - Data recording:
3- Clinical management plan:

Question 21

Child safeguarding risk FGM

Answer 21

assessment by midwife or obstetrician:

• Use risk assessment tool
• Explain law on FGM
• Report to social services or the police if unborn child or related child at risk

Question 22

Data recording:

FGM

Answer 22

• Ensure compliance with HSCIC Enhanced Dataset
• Document FGM diagnosis, including FGM type
  (WHO classification)

Question 23

Clinical management plan:FGM

Answer 23

• Ensure clear documentation
• Preformatted pro formas may be used

1 - Antenatal
2 - Intrapartum
3 - Postpartum

Question 24

Clinical management plan: Antenatal FGM

Answer 24

1. Use professional interpreter if required (not family member) and explain law on FGM
2. Offer referral for psychological assessment and screening for hepatitis C, in addition to routine
   antenatal screening
3. Make clinical assessment of FGM. If de-infibulation is
   required, agree timing and explain that re-infibulation
   will not be performed
4. Assess other obstetric risk factors and action
   appropriately
5. Agree and document plan for antenatal, intrapar

Question 25

Clinical management plan: Intrapartum FGM

Answer 25

1. Generally manage as high risk for caesarean section,
   haemorrhage and perineal trauma
2. Some women may be considered low risk and
   suitable for midwifery-led care if history of previous
   uncomplicated vaginal delivery
3. If de-infibulation is required, ensure that the midwife
   and obstetrician caring for the woman have received
   appropriate training
4. Perineal tears in women with FGM should be managed in the same manner as in women without FGM

Question 26

Clinical management plan: Postpartum FGM

Answer 26

1. Document maternal history of FGM in personal child health record (‘Red Book’)
2. If delivery of baby girl, notify safeguarding midwife who should inform the GP and health visitor
3. Offer postnatal follow-up if de-infibulation performed
   intrapartum or if planned de-infibulation did not occur
   because of delivery by caesarean section
4. Ensure all data required for HSCIC Enhanced Dataset
   have been recorded