FGM Flashcards
Definition of FGM
“Female genital mutilation (FGM) comprises all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons.”
Classifications of FGM:
Type 1
Type 1: Often referred to as clitoridectomy, this is the partial or total removal of the clitoris and in very rare cases, only the prepuce (the fold of skin surrounding the clitoris).
Classifications of FGM:
Type 2
Type 2: Often referred to as excision, this is the partial or total removal of the clitoris and the labia minora (the inner folds of the vulva), with or without excision of the labia majora (the outer folds of skin of the vulva ).
Classifications of FGM:
Type 3
Type 3: Often referred to as infibulation, this is the narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and repositioning the labia minora, or labia majora, sometimes through stitching, with or without removal of the clitoris (clitoridectomy).
Classifications of FGM:
Type 4
Type 4: This includes all other harmful procedures to the female genitalia for non-medical purposes, e.g. pricking, piercing, incising, scraping and cauterizing the genital area.
Highest risk countries for FGM
• Ethiopia, Eritrea, Egypt, Somalia, Sudan, some parts of Indonesia
Why does FGM occur?
- Social acceptance
- Part of becoming a woman and preparation for marriage and adulthood
- Necessary for marriage
- Discourage extramarital intercourse and preserve virginity due to reduced sensation and fear of opening scarring/being “found out”
- Cleanliness and feminity
- Some association with religion but not widely practiced in Islam
Immediate health risks:
Pain, Bleeding, Swelling, Urinary retention, Infection (including hepatitis, tetanus etc), Poor wound healing, Injury to surrounding genital tissue, Death
Long term health risks:
- Difficulties with urination:
Dysuria, Recurrent infections, Stasis of urine
causing stones, Damage to the urethra - Vaginal problems:
Abnormal discharge, itching, bacterial vaginosis
and other infections, Difficulty performing
gynaecological procedures - Menstrual problems:
Haematocolpos and Dysmenorrhoea - Scar tissue:
Keloid scarring, Neuroma, Epidermal inclusion
cysts and sebaceous cysts - Sexual dysfunction:
Dyspareunia, Lacerations, Reduced sexual pleasure - Psychological sequelae
Obstetric risks of FGM
• Recognised complications:
Increased rate of caesarean section
PPH
Perineal trauma
anterior episiotomy and mediolateral episiotomy likely to be required
Prolonged labour
Neonatal resuscitation/death and still birth
Difficulty with examinations, applying FSE, catheterisation
• Evidence for most of these risks only for countries where FGM is performed and risk in developed countries is unknown
Describe the process of deinfibulation
Deinfibulation: Minor procedure, Purpose is to restore vaginal introitus,
Pre procedure counselling:
• Explain procedure
o Analgesia- local versus GA
o Psychological support- may cause flash backs.
o Explain physiological changes to menstruation, urination, sexual intercourse
Procedure:
- Identify anterior flap of skin and lift with two fingers, apply local anaesthetic centrally
- Beware of urethra/clitoris which may lie directly below scarred tissue
- Insert fingers and incise tissue centrally. Caution above urethra and do not extend to clitoris as this may cause excessive bleeding (in labour this should be done with scissors)
- Inspect edges for bleeding and other abnormalities such as cysts
- Suture raw edges with absorbable suture
Important things to cover when counselling re antenatal care and delivery
- If deinfibulation required, counselling regarding the sequelae of this. Recommend antenatally, ideally >24/40. Alternatively can be done in labour.
- Discussion that referral to obstetrician during birth may be required
- Gender preference of obstetrician may not be possible
- Explain that episiotomy- RML and superior- may be necessary.
- Reinfibulation is illegal
- Discuss whether an interpreter is necessary (family members are not appropriate)
- Acknowledge cultural resistance to IOL and caesarean section and explore this
- Offer postnatal support- labour may trigger previous traumatic experiences of FGM/other previous experience
