FGM

Question 1

What is the classification of types of FGM according to the WHO

Answer 1

1 Partial or total removal of the clitoris and/or the prepuce (clitoridectomy)
2 Partial or total removal of the clitoris and the labia minora, with or without excision of the labia
majora (excision)
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 clitoris (infibulation)
4 All other harmful procedures to the female genitalia for non-medical purposes, e.g. pricking,
piercing, a incising, scraping and cauterising

Question 2

What is the WHO definition for FGM

Answer 2

Female Genital Mutilation (FGM) is defined as all procedures involving partial or total removal of the
external female genitalia or other injury to the female genital organs whether for cultural or other nontherapeutic reasons (WHO).

Question 3

Do you talk to woman about their genital mutilation?

Answer 3

No

Try cutting. circumcision

Question 4

What is the law in Australia and New Zealand

Answer 4

it may not be performed in New Zealand or Australia
It is illegal to give advice on how to procure it or facilitating FGM
(either in Aus/NZ or for a Aus/NZ resident or citizen overseas)

Question 5

Who is at risk?

Answer 5

Strongest risk factor country of origin, specifically where she was in childhood
Most commonly north east Africa, Somalia, Sudan, Ethiopia, Egypt. In Somalia and Sudan 80% have undergone type 3
It is also practiced in Asia and the Middle East

Question 6

What are the positive benefits of FGM?

Answer 6

There are none

Question 7

What are the long term negative consequences of FGM?

Answer 7

 Impaired sexual function: apareunia, dyspareunia, anorgasmia, reduced sexual pleasure
 Urinary tract: recurrent urinary tract infections, prolonged voiding time, difficulty obtaining a
mid-stream urine specimen for analysis
 Recurrent vaginal infections, infertility
 Menstrual problems: haematocolpos, retained menstrual clots, dysmenorrhoea
 Local scar complications: keloid, dermal cysts
 Local pain: chronic neuropathic pain
 Difficulty with minor gynaecological procedures: eg Pap smear, bladder catheterisation
 Psychological: post-traumatic stress disorder, anxiety, and depression

Question 8

What are the impacts of FGM on intrapartum events

Answer 8

Generally not an indication for caesarean
 difficulty with vaginal examination in pregnancy and labour
 difficulty with intrapartum procedures (eg amniotomy, placement of a fetal scalp
electrode)
 difficulty with urethral catheterisation if required
 increased likelihood of severe perineal trauma and vaginal laceration
 increased likelihood of episiotomy
 increased risk of caesarean section
 fear of childbirth

Question 9

How to manage someone antenatally

Answer 9

1. identification
2. exam findings should be documented clearly so repeat examinations aren’t needed
3. In women where antenatal assessment indicates that adequate vaginal examination is unlikely to be
   possible due to introital narrowing, it is advisable to offer antenatal deinfibulation. This is most commonly performed during the second trimester but can be carried out at any time during pregnancy or the first stage of labour

Question 10

how does FGM relate to obstetric outcomes?

Answer 10

In low income countries, FGM is associated with an increased risk of perinatal death. It is not clear
whether this association persists in high income countries with optimal obstetric care.

Question 11

how to manage FGM and episiotomy

Answer 11

In women with a history of FGM who have not required antenatal deinfibulation (and even in some who have), anterior episiotomy may be required at the time of delivery, and as such a birth attendant with appropriate knowledge and expertise should be available
It is not necessary to routinely perform a mediolateral episiotomy in women with a history of FGM,
whether or not deinfibulation has been performed, but it will frequently be required due to increased
scarring and lack of normal skin elasticity at the vaginal introitus.

Question 12

If it is the womans request to reinfibulate, can you do it?

Answer 12

nope, it is illegal

Question 13

Deinfibulation

What is it and how is it done

Answer 13

Minor surgical procedure undertaken to separate the fused midline structures and restore a vaginal introitus
that is adequate for normal sexual function, voiding, menstruation, facilitate vaginal examinations, smears and intrapartum care.
It can be done with local, but depending on the woman IV sedation is also used,
THhe iincision should extend anteriorly enough to allow visualization of the external urethral meatus but not to injury the buried clitoris or clitoral stump. The skin edges are approximated with a fine absorb able suture
There is not enough evidence for restoring clitoral sensation currently

Question 14

How can we prevent FGM

Answer 14

Explain the legal status of FGM to woman and their families esp those with daughters
measures that are community based / give out information and support
Referral on if ongoing concern for the child

Question 15

What international documents condem FGM ? (3)

Answer 15

The Universal Declaration of Human Rights (Article 25).
The Convention on the Elimination of all Forms of Discrimination against Women (Articles 2f, 5a,12).
The Convention on the Rights of the Child (Articles 2, 19.2, 24.1, 37a, 24.3).

Question 16

In NZ we wont often see the short term complications of FGM as it is illegal here
What are the short term complications

Answer 16

Haemorrhage (clitoral artery)
Shock - blood loss / infection / pain
Pain
Urinary retention -Urinary Retention is very common and may last for hours or days. It is commonly due to pain, tissue swelling, inflammation, injury to the urethra, and fear of passing urine on the raw wound.
Injury to adjacent tissue - Injury to the urethra, vagina, perineum and rectum can result from the use of crude instruments, poor light, careless techniques, or from the struggles of the girl.
Infection - Infection commonly occurs for a number of reasons; unhygenic conditions, the use of unsterilized instruments, applications of traditional herbs or ashes to the wound, contamination of the wound with urine and/or faeces, or binding of the legs following infibulation which prevents wound drainage. Septicaemia and tetanus may also develop.

Fracture or dislocation - Fracture of the clavicle, femur, humerus or hip joint can occur if heavy pressure is applied to a struggling girl during the procedure - as often occurs when several adults hold her down.

Failure to heal - Wounds may fail to heal quickly because of infection, irritation from urine, underlying anaemia or malnutrition