1. Prenatal Care of Patients with Female Circumcision: Planning for Labor and Delivery
Grace Alfonsi MD
Katherine Miller MD
Department of Family Medicine University of Colorado
Department of Community Health
Denver Health Medical Center

2. Learning Objectives Define the anatomy
Formulate a plan for prenatal management
Describe intrapartum care including complications
Discuss special considerations when caring for circumcised women
not discussing legal, ethical , womens and childrens rights issues. Need to care for the patient and put these aside.

3. BACKGROUND 130-200 million females world-wide
About 200,000 women in the US are circumcised
About 22,000 are arriving in the US each year
Customary in many African nations, not limited to a particular religion or country

4. Terminology Female Genital Mutilation Female Genital Cutting
Female Circumcision
Sunna

5. Female Circumcision Type I (WHO classification)
Normal Anatomy
Excision of prepuce
and clitoris
Female Genital Mutilation: Integrating the Prevention and Management of Health
Complications into the curriculum of nursing and midwifery. Teachers Guide. World Health Organization.

6. Type II (WHO Classification)
Female Circumcision
Type II (WHO Classification)
Excisicion of prepuce, clitoris and all or part of labia minora
Normal Female Anatomy
Female Genital Mutilation: Integrating the Prevention and Management of Health
Complications into the curriculum of nursing and midwifery. Teachers Guide. World Health Organization

7. Female Circumcision Type III
(Infibulation)
Excision of part or all of external genitalia with stitching/narrowing of the vaginal opening
Picture on Left from Female Genital Mutilation: Integrating the Prevention and Management of Health
Complications into the curriculum of nursing and midwifery. Teachers Guide. World Health Organization

8. Obstetric Complications
Difficult intrapartum vaginal exams and urinary catheterization
Second stage soft tissue dystocia
Need for anterior episiotomy
Increased risk of hemorrhage and infection
Risk of poor healing
Increased risk of maternal and neonatal morbidity and mortality
Increased C section rate

9. Evidence based approach
No randomized trials
Large prospective observational trial
Qualitative studies on immigrants
Recommendations based on Expert Consensus statements from the World Health Organization
Customary and generally accepted medical practice

10. Lancet article
Prospective observational study of 28,393 women presenting for singleton delivery between Nov 2001 and March 2003
28 obstetrical centers in Burkina Faso (5), Ghana (3), Kenya (3), Nigeria (6), Senegal (8) and Sudan (3)
Management of labor based on standard practice in that community. Rural sites and tertiary care sites included
Approached women presenting for labor eval. Excluded plan C sections. Singleton pregnancies only
Eval by local midwife accepted and categorized type of circumcision
Study sponsored by WHO
Delivery practice for that community not altered by study, only observed
Who Study group on female genital mutilation and obstetric outcome,
Female genital mutilation and obstetric outcome: WHO collaborative prospective study in Six
African Countries. Lancet 2006:367:

11. Who Study group on female genital mutilation and obstetric outcome,
Wide range of type FC from different areas and wide range of how common the practice is
Who Study group on female genital mutilation and obstetric outcome,
Female genital mutilation and obstetric outcome: WHO collaborative prospective study in Six
African Countries. Lancet 2006:367:

12. Maternal Outcomes
Shows that with increased rate of C sec, pp blood loss and number of hospital days with more extensive FC/FGM
Who Study group on female genital mutilation and obstetric outcome,
Female genital mutilation and obstetric outcome: WHO collaborative prospective study in Six
African Countries. Lancet 2006:367:

13. Infant outcomes
Shows no effect on birth weight , but significant effect on need for resusction and perinatal death
WHO Study group on female genital mutilation and obstetric outcome,
Female genital mutilation and obstetric outcome: WHO collaborative prospective study in Six
African Countries. Lancet 2006:367:

14. Lancet Conclusions
Women with FGM are more likely to have adverse obstetric outcomes
Risks are greater with more extensive FGM
Parity did not affect these risks
Study done with high background rates of adverse maternal/infant outcomes
Limitation: Hospital based study
Lifetme risk of maternal death is 1 in 35 in Ghana, 1 in 12 in Burkina Faso and perinatal mortality ranging from 44 per 1000 in Sudan to 88 per 1000.
WHO Study group on female genital mutilation and obstetric outcome,
Female genital mutilation and obstetric outcome: WHO collaborative prospective study in Six
African Countries. Lancet 2006:367:

15. Stangers in a Strange land
Qualitative study of Somali women in Norway.
Snowball sample of patients
Interviewed patients and providers about their prenatal and labor experiences
23 Somali immigrants and 36 health professionals interviewed
Vange S, Johanse RE, et al. Qualitative study of perinatal cae experiences among Somali women and local health care
Professionals in Norway. Eur J Obstet Gynecol Reprod Biol.2004 Jan 15: 112 (1): 29-35

16. The Patient
“Childbirth is like going into a tunnel and you never know whether you are coming out alive.”
Vange S, Johanse RE, et al. Qualitative study of perinatal cae experiences among Somali women and local health care
Professionals in Norway. Eur J Obstet Gynecol Reprod Biol.2004 Jan 15: 112 (1): 29-35

17. Outpatient Provider
“I didn’t study her genitals very carefully as I think that would have been intrusive and I don’t think it is necessary…it is the hospital’s job to take care of the delivery and they will do whatever they think is necessary”
Vange S, Johanse RE, et al. Qualitative study of perinatal cae experiences among Somali women and local health care
Professionals in Norway. Eur J Obstet Gynecol Reprod Biol.2004 Jan 15: 112 (1): 29-35

18. Inpatient Midwife
“The women come here to deliver their child and not to discuss circumcision…you can’t discuss with a woman when she is in labor pain.”
Vange S, Johanse RE, et al. Qualitative study of perinatal cae experiences among Somali women and local
health care professionals in Norway. Eur J Obstet Gynecol Reprod Biol.2004 Jan 15: 112 (1): 29-35

19. Physician on L and D
“When you don’t recognize the anatomy, you are sort of taken aback.”
Vange S, Johanse RE, et al. Qualitative study of perinatal cae experiences among Somali women and local health care
Professionals in Norway. Eur J Obstet Gynecol Reprod Biol.2004 Jan 15: 112 (1): 29-35

20. Post Partum Patient
“ I felt so lonely and lost…if I had stayed at home in Somalia,there would have been people around me, people who cared. Here I was alone, helpless…and then it ended in a C-section…I don’t think it was necessary.”
Vange S, Johanse RE, et al. Qualitative study of perinatal cae experiences among Somali women and local health care
Professionals in Norway. Eur J Obstet Gynecol Reprod Biol.2004 Jan 15: 112 (1): 29-35

21. WHO Guidelines
Prevention of FGM/FC and management of its complications should be included in antenatal care
Provide information to couples about timing of opening of the scar tissue of type III circumcisions and discuss complications
Develop rapport before attempting a PE
Carefully examine introitus and document anatomy

22. WHO Guidelines
Establish local guidelines for opening up the type III introitus taking into account traveling distance and availability of anesthesia
Midwives and doctors should receive adequate training in safe techniques for opening the scar tissue of type III circ.
Couples should be offered education and counseling requarding the health consequences of female circumcision

23. Antenatal Care Detailed physical exam noting anatomy including :
- Visibility of Urethra
- Extent of opening
- Description of external genitalia
Can’t always do on the first PE
Take your time
Look at a picture if you need to

24. Prenatal Assessment: Sample notes
Sample notes: Circumcised with the absence of clitoris, ant labia minora missing; no fusion of labia, urethral meatus visible, opening greater than 2 cm.
Circumcised with 2 cm vaginal opening; labia majora fused; no urethra visualized but can be palpated under fused labia; speculum exam difficult; os not seen; bimanual exam not attempted.

25. Formulating a Birth Plan
Develop rapport with the patient and her family including language considerations
Discussion and exams over several visits
Expect need to call or consult with other family members
Diagrams are very helpful
Discuss provider preference and possibilities

26. Formulating a Birth Plan
Discussion of anterior episiotomy and subsequent repair
Emphasize unpredictability of delivery and appearance of perineum post partum
Review risks of labor and delivery including poor healing, breakdown of repair, hemorrhage and infection

27. Document and Discuss Document discussions
Discuss with obstetrical back-up
Discuss with labor and delivery nursing
Don’t wait until the delivery room to make this plan

28. Delivery Room Management
Identify urethra
Adequate anesthesia
Anterior episiotomy: cut only to urethra.
If unable to do digital vaginal checks may need to do anterior episiotomy prior to second stage.
Consider need for earlier episiotomy (scar tissue on perineum does not stretch in the usual way)

29. Technique of Anterior episiotomy
From ACOG handout prepared by
RAINBO original author N Toubia MD
Ilustrators: J. Thorpe and S. Gilbert

30. REPAIR OPTIONS
Repair anterior episiotomy by reapproximating labial edge
---as before
---more open than before
Complete open repair (Deinfibulation)
Both options have increased risk for infection and breakdown of suture line

31. Technique For Repair (Deinfibulation)
From ACOG handout prepared by RAINBO
Author N.Toubia MD, Illustrators J.Thorpe and S.Gilbert

32. SUMMARY
Female circumcision patients can present a challenge in the labor suite if encountered there for the first time
Good birth planning and documentation can help the patient , her family and the care provider effectively manage these physical and social issues. This starts in our family practice office.
Family doctors are well equipped to care for this immigrant population.

33. Bibliography
1.Female Genital Mutilation: Integrating the Prevention and Management of Health Complications into the curriculum of nursing and midwifery. Teachers Guide. World Health Organization. Department of Gender and Women’s Health, Department of Reproductive Health and Research. World Health Organization. Geneva 2001
WHO/FCH/GWH/01.3
2. Management of pregnancy, childbirth and the postpartum period in the presence of female genital mutilation. Report of the WHO Technical Consultation. October 15-17, 1997, World Health Organization, Department of Gender and Womens Health, Department of Reproductive Health and Research. World Health Organization. Geneva WHO/FCH/GWH/01.2
3. Rushwan H. Female genital mutilation(FGM) management during pregnancy,
childbirth and the postpartum period. International Journal of Gynecology and
Obstetrics 70(2000)
4. Toubia, Nahid. Female Circumcision as a Public Health Issue. NEJM (1994)
Volume 31:
5 Vangen S, Johansen RE, Sundby J, Traeen B, Stray-Pedersen B. Qualitative study
of perinatal care experiences among Somali women and local health care
professionals in Norway. Eur J Obstet Gynecol Reprod Biol. 2004
Jan 15;112(1):
6. Who Study group on female genital mutilation and obstetric outcome,
Female genital mutilation and obstetric outcome: WHO collaborative prospective study
in Six African Countries. Lancet 2006:367: