Female genital mutilation types ,complications and mangment

2.  Dr Awad

3.  The World Health Organisation estimates that
worldwide over 125 million women and girls
have undergone FGM .
 FGM is a is recognised as a form of “Honour
Based Abuse” .
 The agreed definition of the word
infibulation is that it is ‘a stitching together
of the labia.’


4.  FGM is a potentially life threatening
initiation ritual which can leave young
victims in agony and with physical and
psychological problems that can continue
into adulthood .

5.  Type 1 - Clitoridectomy : Excision of the prepuce,
with or without excision of part or all of the
clitoris
 Type 2 - Excision: partial or total removal of the
clitoris and labia minor, with or without excision of
the labia majora (the labia are the “lips” that
surround the vagina)
 Type 3 - Infibulation: narrowing of the vaginal
opening through the creation of a covering seal,
The Seal is formed by cutting and repositioning the
inner, or outer, labia with or without removal of
the clitoris. Excision of part or all of the external

6.  genitalia and stitching/narrowing of the vaginal opening (infibulation).
Infibulation is strongly linked to virginity and chastity, and used to
safeguard girls from sex outside marriage and from having sexual
feelings. In some cultures it is considered necessary at marriage for
the husband and his family to see her “closed” and, in some
instances, both mothers will take the girl to be cut open enough to be
able to have sex.
 Type 4 - Unclassified: which includes: pricking, piercing or incising
of the clitoris and/or labia for cultural/non-therapeutic reasons;
stretching of the clitoris and/or labia; cauterisation by burning of the
clitoris and surrounding tissue; scraping of the tissue surrounding the
vaginal orifice (angurya cuts) or cutting the vagina (gishiri cuts);
introduction of corrosive substances or herbs into the vagina to cause
bleeding or for the purposes of tightening or narrowing it; and any
other procedure that falls under the definition of female genital
mutilation given above

7.  Complications of Female Genital Mutilation
 The procedure is often performed in the
girl’s home by a traditional birth attendant
or a family member and without anaesthesia.
 Acute Complications
The most common immediate complications
from FGM were pain, haemorrhage (5–62%),
urinary retention (8–53%) and genital swelling
(2–27%), although there were additional
studies reporting infection and fever, and
three deaths directly attributed to FGM.

8.  The most common complication is severe pain,
infection, including tetanus and blood born viruses
(including HIV and Hepatitis B and C) as well as
potential for abscess formation which may lead to
septicaemia.
 There is concern that some type 4 FGM
procedures, where a small cut is made adjacent to
the clitoris, may now be performed more
frequently. This may leave little in the way of long-
term scarring and so contemporaneous recording of
all findings is crucial.
 Where reversal is required to treat early
complications, repeat infibulation may be carried
out at a later date (But it is Illegal) .

9.  Late Complications
 Reported long-term complications of FGM are listed
below. The systematic review by Berg demonstrated
an association of FGM with urinary tract infection,
dyspareunia and bacterial vaginosis ) .
 Genital scarring after FGM can be unsightly and
painful. Keloid scarring has been reported in up to 3%
of women. Epidermoid inclusion cysts and sebaceous
cysts may need surgical excision (retention cysts
occur with type 1,2 and 3 and may reach a large size
or become infected, presenting with pain, urinary
retention and dyspareunia) . Neuroma of the clitoris
causing pain has been described


10.  Sexual difficulties with anorgasmia reported
in 80% of cases (removal of sexually sensitive
tissue such as the clitoris and labia minora
may reduce sexual sensation, while scarring
over the clitoris may be painful. Numerous
reports exist of various sexual consequences
of FGM, including a reduction in desire and
arousal, reduced frequency of orgasm or
anorgasmia, decreased lubrication and
poorer sexual satisfaction

11.  Dyspareunia if the vaginal opening is sufficient to allow
penetration
 Penetration may cause lacerations and haematoma, requiring
medical intervention
 Chronic local irritation and inflammation may lead to further
narrowing, resulting in deteriorating flow, retention of urine and
haematocolpos
 Variable degrees of urinary outflow obstruction are common,
leading to poor flow beneath the infibulation scar may result in
symptoms of urinary obstruction, and stasis of urine may lead to
painful micturition and recurrent urinary tract infection (UTI).
Rarely, vaginal or urinary calculi may form

12.  It is accepted that FGM has psychological
effects, and flashbacks, anxiety and post-
traumatic stress disorder have been
reported. FGM has been linked to an
increased incidence of domestic violence in
Africa.
 Dysmenorrhoea is commonly reported and is
not only related to the inhibition of
menstrual outflow

13.  FGM has been associated with an increased
risk of bacterial vaginosis and herpes simplex
virus type 2.
 Fistula is rare, but can result in injury at the
initial procedure or at defibulation or
following laceration in labour
 Infertilty

14.  Complication in pregnancy and delay in the second stage
of childbirth (meta-analysis reported an increased risk of
prolonged labour, postpartum haemorrhage and perineal
trauma. The WHO study also found an increased risk of
caesarean section and demonstrated an increased need for
neonatal resuscitation and risk of stillbirth and early
neonatal death).
 Many FGM-practising countries are hepatitis B endemic
and some have a high prevalence of HIV. Although
mechanisms by which FGM may increase the risk of
transmission of hepatitis B, hepatitis C and HIV have been
proposed (i.e. sharing of non-sterile instruments and
cutting in groups), there is currently no conclusive
epidemiological evidence to support this

15.  Short Term Consequences
 Pain
 Emotional and psychological shock
(exacerbated by having to reconsider being
subjected to the trauma by loving partners,
extended family and friends)
 Fracture or dislocation as a result of
restraint

16.  The mechanical barrier posed by infibulation in
type 3 leads to prolonged or obstructed labour.
 Caesarean section for fear of laceration and
difficult birth
 Difficulty in intrapartum monitoring (including
application of fetal scalp electrodes and fetal
blood sampling and in performing vaginal
examination).
 Retention of urine and difficulty in catheterizing
the urethra in labour and prior to caesarean
section.
 Difficulty in gynaecological examination and
evacuation of the uterus following miscarriage

17.  Prolonged Labour
 Defibulation in the first stage of labour or
at delivery, the incision should be made
 with scissors (rather than a scalpel) just
before crowning of the fetal head.
Lidocaine without adrenaline (epinephrine)
should be used. Once the procedure has
been 10

18.  performed, the need for episiotomy should be
assessed; this is commonly required (irrespective
of FGM type) due to scarring and reduced skin
elasticity of the introitus
 Lacerations in the scar tissue may cause
postpartum haemorrhage (PPH); more severe
 lacerations rarely extend to involve the urethra,
bladder or rectum.
 Wound infection and retention of lochia, leading to
puerperal sepsi
 Re-infibulation causing more dense scar tissue with
implications for sexual function and
 later obstetric complications- this should not be
performed as it is illegal

19.  performed, the need for episiotomy should be
assessed; this is commonly required (irrespective
of FGM type) due to scarring and reduced skin
elasticity of the introitus
 Lacerations in the scar tissue may cause
postpartum haemorrhage (PPH); more severe
 lacerations rarely extend to involve the urethra,
bladder or rectum.
 Wound infection and retention of lochia, leading to
puerperal sepsi
 Re-infibulation causing more dense scar tissue with
implications for sexual function and
 later obstetric complications- this should not be
performed as it is illegal

20.  An increased risk of urinary tract infection
 Difficulty in performing vaginal
examination antenatally, in the assessment
of the cervix prior to induction of labour,
carrying out induction of labour and in
assessing progress in labour.


21.  Catheterising the bladder
 Application of a fetal scalp electrode
 Delay in the second stage
 The risk of spontaneous laceration
 The need for an anterior midline episiotomy
 Increased risk of post-partum haemorrhage due to perineal
trauma
 Increased risk for Caesarean section, still-birth and early
neonatal death

22.  The question of re-infibulation following childbirth
should also be raised. The legal position should be
explained as re-infibullation is illegal.
 The patient should be offered elective defibulation
at around 20 weeks of gestation, once it has been
explained that this will reduce most of the
difficulties and increase the likelihood of an
uncomplicated, joyful birth. Ideally de-infibulation
should be offered before the first intercourse, by
trained health care professionals. This will only be
the case for those patients diagnosed in
gynaecological clinics or those who actively seek
medical advice prior to pregnancy

23.  When the patient presents in late
pregnancy or even in labour, defibulation
may be
 carried out in the first stage. Bleeding
from the cut edges can be limited by
opening the fused labia strictly in the
midline with scissors and stopping as soon
as the urethral meatus is exposed. De-
infibulation can also be carried out after
the Caesarean section .

24.  In the second stage, the procedure should be carried
out as the fetal head distends the
 vulva, care being taken to protect the head from
laceration. Stretching of the fused labia allows a good
view of the line of fusion and reduces blood loss; the
external urethral meatus tends to be displaced away
from the incision line by the fetal head.
 Defibulation service - It is vital that a defibulation
service be available so that women
 have easy access and is requested by women when they
marry. Defibulation before pregnancy is the ideal but
unfortunately many women only come to the attention
of doctors and midwives when they are already pregnant

25.  Elective defibulation during the antenatal
period (ideally around 20 weeks) reduces
 lacerations and avoids defibulation or anterior
episiotomy in labour.
 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.
 Clitoridian reconstruction is not indicated as
the complications overweight the benefits

26.  Elective defibulation during the antenatal
period (ideally around 20 weeks) reduces
 lacerations and avoids defibulation or anterior
episiotomy in labour.
 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.
 Clitoridian reconstruction is not indicated as
the complications overweight the benefits