Female genital mutilation (FGM) Flashcards
How and when is FGM frequently performed?
Withuout analgesia or adequate sterility
Performed in girls age 8 onwards
Define female genital mutilation.
Any procedure involving partial or total removal of the external genitalia and/or injury to the female genital organs whether for cultural, religious or other non-therapeutic reasons’.
What are the long term complications of FGM?
- urinary (painful urination, urinary tract infections);
- vaginal (discharge, itching, bacterial vaginosis and other infections);
- menstrual (dysmenorrhaea, difficulty in passing menstrual blood, etc.);
- scar tissue and keloid;
- sexual (dyspareunia decreased satisfaction, etc.);
- childbirth complications (difficult delivery, PPH, C/S, need to resuscitate the baby, etc.) and newborn deaths;
- need for later surgeries: e.g. the sealing or narrowing of the vaginal opening (Type 3) may lead to the practice of cutting open the sealed vagina later to allow for sexual intercourse and childbirth (deinfibulation). Sometimes genital tissue is stitched again several times, including after childbirth, hence the woman goes through repeated opening and closing procedures, further increasing both immediate and long-term risks;
- psychological problems (depression, anxiety, post-traumatic stress disorder, low self-esteem, etc.);
What should be done if FGM is encountered in an adult in the UK?
There is now a legal obligation in the UK to document all cases in the medical notes and report all cases through the safeguarding team in NHS Trusts to reduce the incidence of this practice in young girls and women in the UK.
What should be done if FGM is encountered in a minor?
In cases where FGM is suspected in minors, this is classified as child sexual abuse and social services and the police should be involved.
What are the types of FGM?
Type 1: Clitoroidectomy: excision of prepuce (clitoral hood) with or without the removal of the clitoris.
Type 2: Excision of clitoris and partial or total removal of the labia minora.
Type 3: Excision of part or all of the external genitalia and stitching/narrowing of the vagina – infibulation.
Type 4: Piercing the clitoris, cauterization, cutting the vagina, inserting corrosive substances. This also
includes any plastic surgery procedures done as an adult.
Where is FGM most common?
What is the problem with the diffrence between FGM and cosmetic surgery of the vulva?
There is often an extremely fine line between cosmetic surgery on the vulva and FGM and gynaecologists must seek advice before considering such procedures
What has happened with labiopasties in recent years?
Prevalence of requests risen
NHS has withdrawn most funding for it
Increased private practice in this area
Private practice often offers less support after the procedure so pre/post-surgery patients still attent NHS psychosecual clinics to help with sexual dysfunction due to body dysmorphia or SE of surgery
Does FGM affect labour and delivery?
Evidence is unclear but labour may be obstructed in type 3 FGM. Depending on type of FGM it may be appropriate to perform midline episiotomy for safe delivery.
If FGM is altered during labour (or other procedure) can it be resutured?
No, it is illgeal to resutture an FGM but is often requested by women.
What is deinfibulation? When is it indicated?
Reversal of infibulation
Should be identified preconceptually and managed antenatally. If in labour, a senior obbstetrician will need to be present during delivery
How is deinfibulation performed?
- Under adequate analgesia - to avoid flashbacks to FGM procedure; local anaesthetic may be used
- Incision made along vulval incision scar
- Urethra identified before surgery commences to reduce damage
- Fine absorbable suture may be used and prophylactic antibiotics given
- Follow up care and support groups - as emotional distress and sexual dysfunction may not be resolved after this
What are the complications of deinfibulation?
- Bladder obstruction
- UTI
Offer prophylactic antibiotics
Q: A 25-year-old woman has been seen by her community midwife and disclosed previous ‘cutting’. The midwife has urgently referred her to your antenatal clinic. She is now 28 weeks pregnant. What are the next steps that you should take?
- Initial examination to determine the degree of FGM (1–4) as this will affect the management initially and of labour.
- Inform safe guarding team + document, with date and time. These are legal requirements.
- Depending on the type of FGM, midline episiotomy in labour may be necessary.
- Early deinfibulation is preferable. Suturing postdelivery should be performed by a senior obstetrician. In the UK it is illegal to perform restoration of the FGM, even on request.
