Female Genital Mutilation and Management
Summary of the RCOG Guideline ( GTG 53, July 2015)
Female genital mutilation- refers to ‘all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons.
Practized as a tradition in several countries, FGM is considered a human rights violation and a form of child abuse, breaching the United Nations Convention on the Rights of the Child, and is considered a severe form of violence against women and girls. The type of FGM practized varies in different regions.
WHO Classification of FGM( 2007) –
Type 1: Partial or total removal of the clitoris and/or the prepuce (clitoridectomy).
Type 2: Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision).
Type 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).
Type 4: All other harmful procedures to the female genitalia for non-medical purposes, for example: pricking, piercing, incising, scraping and cauterization.
Is genital piercing a form of FGM? – Yes. it’s type 4 FGM.
Health professionals should ensure that 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.)
When a woman with FGM is identified-
– Explain UK law to her.
– Tell her that her data will be recorded ( without anonymysation- This is done to prevent duplication of data) . The data is anonymized at the time of statistical analysis and publication. Her data should be recorded regardless of whether she presented due to complaints related to FGM or otherwise.
– Record data in accordance with the HSCIC FGM Enhanced Dataset. ( HSCIC Stands for Health and Social Care Information Centre) The data 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
– Where appropriate- educate women on how FGM is illegal in the UK and how the practice has serious long-term physical, psychological and emotional consequences.
– Use appropriate language pertaining to FGM- cut’, ‘closed’ or ‘circumcised may be more acceptable to the woman than ‘Mutilation’.
Responsibility of the Health professional– understand the difference- Recording vs reporting.
Recording- (documenting FGM in the medical records for data collection).
Reporting- making a referral to police and/or social services.
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- If the unborn child, or any related child, is considered at risk then a report should be made.
MANAGEMMENT OF FGM-
Identify the signs of recent FGM– Bleeding( 5-62%) , pain,infection, urinary retention( 8-53% ), genital swelling( 2-27%) .
Record examination findings accurately– ( Important to record examination findings asap- The wound may heal later) . Consider photographic documentation. All women and girls with acute or recent FGM require police and social services referral.
Use the WHO Classification of FGM to document.
REFERRAL PATHWAY-
If seen by GP- Refer to Gyn clinic- to FGM services OR to the named consultant responsible for care of women with FGM. ( e.g some hospitals do not have FGM clinic, but a named consultant who dealss with cases of FGM)
Children should be seen within child safeguarding services.
Women should be able to self refer.
WHEN THEY PRESENT TO GYNECOLOGY CLINIC-
If she belongs to a community which traditionally practise FGM—ask her explicitly whether they have had the procedure. ( some women may not be aware that they have had the procedure) It is good practice to ask this question when the woman is alone. Ideally, this question should be asked of all antenatal women in their booking visit.
Be aware of psychological sequelae.
Examination–
1. Inspection of the vulva to determine the type of FGM
2. Whether de-infibulation is indicated
3. Identify any other FGM-related morbidities, e.g. epidermoid inclusion cysts
Offer – referral for psychological assessment and treatment
– testing for HIV, hepatitis B and C and sexual health screening
– If appropriate- refer to Gyn specialties- psychosexual, urogyn, infertility.
Discuss, agree and record a plan of care.
Inform her that re-infibulation will not be undertaken under any circumstances.
TIME OF DE-INFIBULATION– antenatally/ in the first stage of labour / at the time of delivery
– can usually be performed under local anaesthetic in a delivery suite room
– – can also be performed perioperatively after caesarean section
Intrapartum- De-infibulation to be done by midwife/ physician who is properly trained.
If she delivers by caesarean section– Discuss peri-operative de-infibulation. à If not done post opà Give Gynecology follow up so that it can be done before her next pregnancy.
FGM Identified intrapartum ( No prior documented plan) – The impact of FGM on labour and delivery should be sensitively discussed. + Agree upon a plan of care.
If de-infibulation not done because of caesarean delivery– Give Gyn appointment for possible de-infibulation before next pregnancy.
Before discharge– make sure all legal and regulatory process have been adhered to ( Midwife to do) .
If delivery of a baby girl, notify the designated child protection midwife, who should inform the GP and health visitor.
Short term complications of FGM- Bleeding( 5-62%) , pain,infection, urinary retention
( 8-53% ), genital swelling( 2-27%) .
Long term consequences of FGM–
1. 1. Genital scarring
2. 2. Urinary tract complications
3. 3. Dyspareunia, apareunia, impaired sexual function
4. 4. Psychological sequelae
5. 5. Menstrual problems- Haematocolpos.
6. 6. Obstetric complications- risk of prolonged labour, postpartum haemorrhage and perineal trauma. Higher incidence of stillbirth and neonatal death.
FGM and UK law-
Applicable acts( both acts apply to women as well as children) – 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.
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.
Re-infibulation is illegal; there is no clinical justification for re-infibulation and it should not be undertaken under any circumstances.
In some communities adult women may undergo re-infibulation following childbirth- a patient may ask for re-infibulation after deliivery- under UK law, re-infibulation is illegal.
Recording od=f data has been discussed above.
Reporting of the case depends on whether a child or adult is affected.
If a child is affected– any child with confirmed or suspected FGM, or a child is considered to be at risk of FGM, must be reported, if necessary without the consent of the parents. ( FGM is child abuse) . Also inform GP and health visitor. If in any doubt- contact named lead for safeguarding.
If a pregnant woman with FGM is identified– record in her notes( antenatal notes, screening notes and immunisation returns ; also note if she has been de-infibulated and if she has been referred to other service) . No need to REPORT every case- make an individual risk assessment. If the unborn child, or any related child, is considered to be at risk of FGM, then a report must be made to children’s social care or the police.
After birth, Record the FGM in maternity discharge documentation( so that the GP and health visitor know) . In baby’s ‘red book’– document family history of FGM.
Non pregnant adult woman of age > 18 years with past history of FGM- no legal requirement to report( UNLESS a related child is at risk) . If she does not wish any action to be taken- do not report.
Any woman or girl with Acute or recent FGM— > Police and social services referral is a must.
Role of clitoral recosntruction– The RCOG guideline states that Clitoral reconstruction should not be performed because current evidence suggests unacceptable complication rates without conclusive evidence of benefit.
CARE DURING PREGNANCY– Women with FGM are more likely to have obstetric complications and consultant-led care is generally recommended – i.v access in first stage, FBC , group and save.
However, some women with previous uncomplicated vaginal deliveries may be suitable for midwifery-led care in labour—Provided there is no history of re-infibulation after her last delivery.
Time of de-infibulation-For type 3 FGM( adequate vaginal assessment in labour is unlikely to be possible ) de-infibulation should be recommended antenatally – at around 20 weeks of gestation.
If vaginal examination is not possible or intrapartum procedures and urinary catheterisation are not feasible, then de-infibulation in the first stage of labour should be recommended. An epidural should be offered to cover the procedure and for subsequent examinations and delivery.
If vaginal access is adequate then de-infibulation can be performed at the time of delivery under local anaesthetic.
The full guideline with very useful appendices can be found here-