Policy Title: Executive Summary: Guideline for the Care of a Woman with Female Genital Mutilation Female Genital Mutilation (FGM) constitutes all the procedures that involve partial or total removal of the external female genitalia or other injury to the female organs whether cultural or any non-therapeutic reasons. This guideline provides information for the care of women who have experienced the procedure and are now pregnant Supersedes: New Guideline Description of N/A Amendment(s): This policy will impact on: Women and Children s Business Unit Financial Implications: Non Known Policy Area: Women and Children s Business Unit Document Reference: Guideline for the Care of a Woman with Female Genital Mutilation Version Number: 1 Effective Date: Sept 2009 Issued By: Women and Children s Business Unit Review Date: Aug 2012 Author: E Alston M/W /SoM Impact Assessment Date: Consultation Phase: Obstetric Director Women & Children s Business Unit Mr V Hall. Date Associate Director Mrs G Hopps APPROVAL RECORD Committees / Group Labour Ward Forum, Educational Link Tutor and MSLC. Obstetricians and Midwives ANC Staff, Safe Guarding Nurse, Neonatal unit, Paediatricians Date August Sept 2009 Re consultation October 2009 Date Received for information: IT Dept & Legal Services December 2009 1
Rationale Guideline for the Care of a Woman with Female Genital Mutilation Female Genital Mutilation (FGM) constitutes all the procedures that involve partial or total removal of the external female genitalia or other injury to the female organs whether cultural or any non-therapeutic reasons (WHO, 1996, RCOG 2009). Legal Perspective It is illegal to practice FGM in the United Kingdom (UK) and to assist in its practice on UK nationals or permanent residents abroad. FGM is typically performed on girls between the age of 4 and 13, although in some cases it is performed on new born babies or young women prior to marriage or pregnancy. It is considered child abuse and a grave violation of the human rights of girls and women. In all circumstances where FGM is practised on a child it is a violation of the child s right to life, their right to their bodily integrity as well as their right to health. Incidence Between 100-140 million girls and women worldwide are estimated to have undergone FGM In the UK it is estimated that up to 74,000 women in the UK have undergone the procedure with approximately 20,000 girls under the age of 16 at risk (RCOG 2009) This estimate is based on the number of women and girls living in the UK who originate from countries where FGM is traditionally practised such as Yemen, Oman, Malaysia, Indonesia, the United Arab Emirates as well as 26 countries in Africa from Gambia to Somalia. Classification of FGM Type 1 Excision of the prepuce with or without excision of part or all of the clitoris. This is the mildest form of FGM Type 2 Excision of the prepuce and the clitoris together with partial or total excision of the labia minora. This is the most widespread type of mutilation constituting up to 805 of all FGM. Type 3 Excision of part or all of the external genitalia and stitching/narrowing of the vaginal opening (infibulation). 5-20% of FGM affected women in Africa have been infibulated and the rest have undergone less extreme procedures. Type 4 Unclassified, includes pricking, piercing or incision of the clitoris and/or labia stretching of the clitoris and surrounding tissue, scraping of the vaginal opening or cutting of the vagina: introduction of corrosive substances into the vagina to cause bleeding or herbs into the vagina with the aim of tightening or narrowing the vagina: any other procedures which falls under the definition of FGM given above. 2
Risk Factors Childbearing Complications Fear of childbirth Difficulty in catheterising the bladder Increased risk of candidasis Reduced vaginal opening which makes vaginal procedures difficult or impossible and painful Difficulty in performing fetal bloods sampling or applying a fetal scalp electrode Increased risk of uterine rupture Increased risk of severe vaginal lacerations. (including fistula formation) Increased risk of episiotomy Increased risk of caesarean section Increased risk of postpartum haemorrhage Increased risk of fetal asphyxia or death Extended hospital stay Identification Midwives must discuss FGM as an integral part of the booking interview for those women born in (or with recent ancestry of) those parts of the world associated with FGM. This can be based on the family origin questionnaire used for haemoglobinopathy screening. Discussions must take into account language difficulties, psychological vulnerability and cultural differences. Classify the type of FGM to assess potential risk factors concerning the physical and psychological problems in the pregnancy and labour. A preformatted sheet, including a predrawn diagram, should be considered for the identification of the type of genital mutilation, the need for antenatal defibulation and for planning of Intrapartum care (see RCOG Female Genital Mutilation and its Management Green top Guideline No 53 for the diagrams) Examination must be done only if the woman gives consent and the midwife /obstetrician has the knowledge and skills to undertake the examination Healthcare workers must be aware that internal examination might be impossible without general anaesthesia Referral A culturally sensitive approach must be used at all times as the practice of FGM is embedded in communities who may resent the imposition of western values on them. Healthcare workers should actively demonstrate knowledge and respect. At the initial consultation, the midwife must consider whether the woman needs an early appointment with the Consultant Obstetrician for further assessment and possible de-infibulation A female interpreter must be arranged if required. A list of interpreters is available via the Language Line. The telephone number is available in the ANC Physical examination should also be recommended by an obstetrician to reassess women who have had a previous defibulation, as some may have undergone the procedure again. 3
The woman must be assessed by the Consultant Obstetrician in the absence of students, unless the woman has given her permission for their presence. Counselling must be offered and organised if required. Following referral to the Consultant Obstetrician it may be appropriate to consult with a tertiary centre that has developed expertise in the assessment and management of affected women. Inform the Safeguarding Nurse if a woman has undergone FGM because of the increased risk of FGM with the newborn girl. FGM differs from other forms of child abuse in two important ways 1. Despite the severe consequences, parents genuinely believe it is in the best interests of the child to conform to prevailing custom 2. There is no element of repetition it is a one off act of abuse. Management Defibulation Defibulation involves cutting the scar tissue upwards until the urethral meatus is visible which has formed where the remnants of the labia majora have been stitched together, thus exposing the vaginal opening. This will allow enough room for the tissue to stretch over the baby s head. (Newman 1996 & Eaton 1994). The raw edges on either side are then over-sewn with an absorbable suture material such as fine 3.0 vicryl, which dissolves quickly (Forward 1997, McCaffrey 1995). Antepartum Defibulation must be performed between 20 and 32 weeks gestation to allow for the scar to be fully healed prior to delivery. Local anaesthetic should be offered for the procedure, although a spinal anaesthetic or general anaesthetic should be considered. Women who prefer defibulation in labour must have her request respected and granted. Decisions about delivery must take into account the psychological needs of the woman. Genital mutilation is not an absolute indication for caesarean section unless the woman has such an extreme form of mutilation with anatomical dysfunction that makes defibulation impossible Intrapartum If female genital mutilation is identified in labour: de-infibulation should be performed by an experienced Obstetrician in the first stage of labour rather than the second stage. In such cases delivery of the baby must be by a qualified midwife and not a student. Women with genital mutilation should usually be strongly recommended to deliver in a maternity unit with immediate access to facilities for emergency obstetric care Intravenous access and group and save serum should be strongly recommended Local anaesthesia/epidural can be offered. Epidural is also recommended for those women who find difficulty in tolerating vaginal examination Epidural anesthesia should be offered to women who find When de-infibulation has been performed an intact perineum must be aimed for at delivery 4
When an episiotomy is indicated, a medial lateral episiotomy should be performed. If an anterior episiotomy is needed in labour an epidural should be is recommended. Postpartum Re-infibulation is against the law and must never be performed Care of the perineum must be observed and advised Discuss with the woman and family the potential of female genital mutilation for the female child and the legal consequences should this be considered. The Health Visitor and Safeguarding Nurse must be informed that a female child has been born and this may increase the risk of female genital mutilation in the newborn Information leaflets for support groups can be obtained from such organisations as BWHFS (Black Women s Health & family support groups). A list of useful contacts is enclosed within this Guideline. These guidelines cannot anticipate all possible circumstances and exist only to provide general guidance on clinical management to clinicians. This guideline has been assessed using the Equality and Human Rights Policy Screening Tool This guideline will be reviewed within the three years. References Azadeh, H (1997) Female Circumcision/Genital Mutilation and childbirth A mother and child tragedy. British Journal of Theatre Nursing. Vol.7. No. 7. October. pp 5-10. DOH (2009) Government Equalities Office Fact Sheet. Putting equality at the heart government DOH (2007) Statistical Study to Estimate the Prevalence of Female Genital Mutilation in England and Wales. Eaton, L (1993) Going forward. Nursing Times. Vol.89. No.46. 17 th November. pp 14-15. FORWARD (1999) A report on the conference on Female Genital Mutilation (Moving Forward). London. Foundation for Women s Health Research and Development (FORWARD). 5
McCaffrey, M (1995) Management of Female Genital Mutilation: The Northwick Park Hospital Experience. British Journal of Obstetrics and Gynaecology. Vol. 102. No.10. October. pp. 787-790. Newman, M (1996) Midwifery Care for Genitally Mutilated Women. Modern Midwife. Vol.6. No.6. June. pp 20-22. Read, D (1998) The Report of a Survey into Inter-Agency Policies and Procedures Relating to Female Genital Mutilation (FGM) in England and Wales. (Out of sight, out of mind?) London. FORWARD. pp 1-7. WHO (1996) Female Genital Mutilation Information Pack. World Health Organisation (WHO). August http://www.who.int/frh-whd/fgm/infopack/english/fgm-infopack.htm Useful Contacts Agent for Culture and Change Management UK (ACCM UK) info@accmuk.com Foundation for Women s Health Research and Development (FORWARD) Website www.forward.uk.org.uk National Society for the Prevention of Cruelty to Children (NSPCC) www.nspcc.org.uk Child Protection Helpline 0808 800 5000 (advice for adults worried about a child) Specialist African Well Women Clinic s http://www.forwarduk.org.uk/resources /support/well-woman-clinics Support Groups www.forwarduk.ork.uk The Female Genital Cutting Education and Networking Project: www.fgmnetwork.org Medconsumer.info. Female Genital: mutilation: www.medconsumer.info/topics/fgm.htm 6
Appendix 1 Equality and Human Rights Policy Screening Tool Policy Title: Guideline for the Care of a Woman with Female Genital Mutilation Directorate: Women and Children Name of person/s auditing / authoring policy: M/W E Alston Policy Content: For each of the following check whether the policy under consideration is sensitive to people of a different age, ethnicity, gender, disability, religion or belief, and sexual orientation? The checklist below will help you to identify any strengths and weaknesses of the policy and to check whether it is compliant with equality legislation. 1. Check for DIRECT discrimination against any minority group of PATIENTS: Question: Does the policy contain any statements which may disadvantage people from the following groups? Response Action required Resource implication Yes No Yes No Yes No 1.0 Age? x x x 1.1 Gender (Male, Female and Transsexual)? x x x 1.2 Learning Difficulties / Disability or Cognitive x x x Impairment? 1.3 Mental Health Need? x x x 1.4 Sensory Impairment? x x x 1.5 Physical Disability? x x x 1.6 Race or Ethnicity? x x x 1.7 Religious Belief? x x x 1.8 Sexual Orientation? x x x 2. Check for DIRECT discrimination against any minority group relating to EMPLOYEES: Question: Does the policy contain any statements which may disadvantage employees or potential employees from any of the following groups? 7 Response Action required Resource implication Yes No Yes No Yes No 2.0 Age? x x x 2.1 Gender (Male, Female and Transsexual)? x x x 2.2 Learning Difficulties / Disability or Cognitive x x x Impairment? 2.3 Mental Health Need? x x x 2.4 Sensory Impairment? x x x
2.5 Physical Disability? x x x 2.6 Race or Ethnicity? x x x 2.7 Religious Belief? x x x 2.8 Sexual Orientation? x x x TOTAL NUMBER OF ITEMS ANSWERED YES INDICATING DIRECT DISCRIMINATION = 3. Check for INDIRECT discrimination against any minority group of PATIENTS: Question: Does the policy contain any conditions or requirements which are applied equally to everyone, but disadvantage particular people because they cannot comply due to: Response Action required Resource implication Yes No Yes No Yes No 3.0 Age? x x x 3.1 Gender (Male, Female and Transsexual)? x x x 3.2 Learning Difficulties / Disability or Cognitive x x x Impairment? 3.3 Mental Health Need? x x x 3.4 Sensory Impairment? x x x 3.5 Physical Disability? x x x 3.6 Race or Ethnicity? x x x 3.7 Religious, Spiritual belief (including other belief)? x x x 3.8 Sexual Orientation? x x x 4. Check for INDIRECT discrimination against any minority group relating to EMPLOYEES: Question: Does the policy contain any statements which may disadvantage employees or potential employees from any of the following groups? Response Action required Resource implication Yes No Yes No Yes No 4.0 Age? x x x 4.1 Gender (Male, Female and Transsexual)? x x x 4.2 Learning Difficulties / Disability or Cognitive x x x Impairment? 4.3 Mental Health Need? x x x 4.4 Sensory Impairment? x x x 4.5 Physical Disability? x x x 4.6 Race or Ethnicity? x x x 4.7 Religious, Spiritual belief (including other belief)? x x x 4.8 Sexual Orientation? x x xx TOTAL NUMBER OF ITEMS ANSWERED YES INDICATING INDIRECT DISCRIMINATION = 0 8
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