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Female circumcision: Obstetric issues
Female circumcision: Obstetric issues Cathy A. Baker, MD, George J. Gilson, MD, Maggie D. Vill, MD, and Luis B. Curet, MD Albuquerque, New Mexico Female circumcision is a problem unfamiliar to most Western obstetrician-gynecologists. We present a case illustrative of the unique management problems posed by these patients during labor. A method of releasing the anterior vulvar scar tissue to allow vaginal delivery is described. Sensitivity and a nonjudgmental approach as to what is culturally appropriate care for these women are of paramount importance. (AM J OBSTET GYNECOL 1993;169:1616-8.)
Key words: Female circumcision, infibulation, obstetric complications
Female circumcision is a widely practiced ritual in many parts of the world, particularly in countries along the Horn of Africa and in western sub-Saharan Africa. Recent U.S. involvement in Somalia may herald an influx of immigrants from that part of the world where female circumcision is routinely practiced. Most U.S. health care providers have had no experience in dealing with this particular problem. Little is known outside the local area about dealing with the unique obstetric management required by the procedure, as well as coping with the cultural and psychosexual issues involved. Having recently managed a case and finding little in the obstetric and gynecologic literature, we share our experience and offer some intrapartum management suggestions.
Case report A 36-year-old Sudanese woman, gravida 3, para 2, was followed up at the University Prenatal Clinic since 11 weeks' gestation. The patient had undergone "pharaonic circumcision" as a young girl, and since coming to the United States with her husband, a university graduate student, she had been particularly embarrassed about the vulvar scars. She had undergone two previous cesarean sections; the first was for failure to progress while she was being cared for in the United States, and the second was a repeat cesarean section done in Sudan. The patient had two goals for this pregnancy: She was adamant about wanting only a female provider who was comfortable with and knowledgeable about female circumcision, and she desired a vaginal birth, because her family in Sudan had implied that her previous cesarean sections were due to "moral weakness." The patient's vulvar scarring was quite tender and made performing an adequate pelvic examination
From the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of New Mexico School of Medicine. Received for publication April 13, 1993; accepted May 19, 1993. Reprints not available. Copyright © 1993 by Mosby-Year Book, Inc.
0002-9378/93 $1.00 + .20 6/1/48726
1616
and Papanicolaou smear extremely difficult. She received prenatal care from a female obstetrics and gynecology resident (C.A.B.) throughout her pregnancy, which proceeded without complications. At 39 weeks' gestation the patient had spontaneous rupture of the membranes. She was admitted to the labor and delivery suite and begun on a regimen of oxytocin augmentation. Epidural anesthetic was administered to the patient early in her labor to facilitate vaginal examinations and the placement of an intrauterine pressure monitor. Placement of a Foley catheter was difficult because the meatus was obscured by vulvar scar tissue, but catheterization was accomplished after lidocaine spray was administered locally to facilitate location of the meatus by palpation underneath thick bands of scar tissue. After epidural anesthesia was successfully established, it was possible to examine the patient without discomfort. The external genitalia appeared to be missing the labia minora, with the clitoral area and external urinary meatus obscured by two bands of scar tissue. The outer band was approximately 2 em wide and 2 cm long, bridging the inner surfaces of the remaining labial tissue. An inner, thicker band of scar tissue that was approximately 3 em wide and 2 em long obscured the original area of the clitoris and the urinary meatus and impinged on the top one fourth of the vaginal orifice (see Fig. 1, A). With oxytocin augmentation, complete cervical dilatation occurred 19 hours after spontaneous rupture of the membranes. The fetal heart rate rose to 180 beats/min and diminished variability was noted. The scar tissue was injected with 1% lidocaine, the bands were cut (see Fig. 1, Band C), and the urinary catheter was removed. A small midline episiotomy site was cut, and low forceps were applied, with delivery of a 3420 gm male infant having Apgar scores of 8 at 1 minute and 9 at 5 minutes. The midline episiotomy and the incised scar tissue were repaired. The patient had specified that she wanted to have less discomfort with vaginal examinations after her delivery, so the vulvar scars were not reapproximated. Instead, the raw surfaces were oversewn with a running
Baker et al. 1617
Volume 169, Number 6 Am J Obstet Gynecol
/
Fig. 1. Deinfibulation procedure. A, Appearance of vulva at onset of labor; B, insertion of finger behind band of scar tissue before incision; C, appearance of vulva after incision of scar bands; D, postpartum repair completed.
locking stitch of 4-0 chromic suture (see Fig. 1, D). There was minimal bleeding from the scar resection. Post partum, the patient's temperature spiked to 38.7 0 C, and she was started on a regimen of ampicillinsulbactam for endometritis. The fever abated, and she was discharged home on postpartum day 2 without further complications; sitz baths were recommended to promote healing and comfort. An examination 6 weeks post partum revealed complete healing of the vulvar scar site. At this time the labia minora and clitoris appeared to be missing but the external urinary meatus and introitus appeared unscarred and in the midline. The patient reported less dyspareunia and expressed delight with her successful vaginal birth. She planned to visit her family in the Sudan soon, to show off her son who had been born vaginally. Comment
Female circumcision is a popular but medically incorrect term used to describe a variety of ritual surgical procedures performed on the female genitalia. The three most prevalent types are as follows: type 1 (Sunna), excision of the clitoral hood, with preservation of the clitoris itself and the labia minora; type II (excision), removal of the prepuce and glans clitoris together with adjacent parts of the labia minora; type III (infibulation or pharaonic circumcision), removal of the entire clitoris, the labia minora, and the adjacent medial portions of the anterior labia majora, followed by stitching to-
gether (or sticking together with paste or thorns) the two sides of the vulva, obliterating the introitus and leaving only a small opening to allow egress of urine and menses. The type of procedure varies with geographic area and traditional practice. Besides the immediate health risks of these procedures (usually performed without anesthesia under nonsterile conditions on prepubertal girls), which include hemorrhage, sepsis, tetanus, urinary retention, and emotional trauma, there are a number of serious long-term gynecologic and obstetric complications. The gynecologic problems include keloid formation, vulvar dermal inclusion cysts, recurrent urinary tract infections, dysmenorrhea, hematocolpos, dysparenuia, recurrent vaginitis, chronic pelvic infection, pelvic pain, and infertility. The major obstetric problem is prolongation of the second stage of labor because of scar or soft tissue dystocia, with the attendant need for "anterior episiotomy" (deinfibulation). Vesicovaginal and rectovaginal fistulas, laceration of the scar tissue with subsequent hemorrhage, and fetal asphyxia or death are common sequelae in women who labor unattended with an obstructed introitus. Additionally, infibulation makes vaginal examination in labor very difficult and painful, resulting in the inability to effectively monitor the progress of labor. Gabbar, J a Sudanese physician, has outlined a protocol for the management of women who have undergone type III circumcision (Fig. 1). The circumcision scar is
1618 Baker et al.
composed of a band (or bands) of fibrous tissue enclosing the upper part ofthe vestibule. This must be incised during the second stage of labor, before episiotomy, allowing sufficient widening of the introitus for expulsion of the fetal head. To accomplish this, a finger is inserted through whatever introital aperture is present and directed toward the pubis. With adequate local or regional anesthesia this flap of tissue anterior to the pubis is cut in layers in the midline, over the finger, with scissors until the urethral meatus is visualized and the pliable tissues beneath the scar are freed and are able to stretch over the head, allowing delivery. A mediolateral or midline episiotomy mayor may not be necessary in addition. Individual patients may elect different degrees of repair after delivery, and this should be discussed beforehand. The patient's husband may make this decision for her, and rapport with him is critical. Because his perspective is that of protecting his wife and her propriety, application of our own ethical viewpoint may be inappropriate and may even be viewed as sexually abusive." If the patient desires reinfibulation, this can be accomplished at the time of delivery by simply reapproximating the cut edges of the scar with interrupted sutures of absorbable suture material. If a "less tight" repair is desired, as in our patient, the raw surfaces may simply be oversewn with a running locked stitch of absorbable material to obtain hemostasis. Postpartum sitz baths are appropriate, as in any patient who has had an episiotomy. The psychosexual aspects of female circumcision also bear note. Because the standard of propriety in many of the cultures from which these women come is that physical contact with any male other than her husband is strictly forbidden, and because the husband's permis-
December 1993 Am J Obstet Gynecol
sion may be required for the woman to obtain health care at all, every effort should be made to ensure that the health care practitioner is female. As noted above, the husband's rapport is essential and every effort should be made to establish his trust. The issue of whether the woman will want her own infant daughter circumcised also needs to be discussed so that she can make an individual, culturally appropriate, and educated choice. Because circumcision is equated with virtue in these cultures, an uncircumcised woman is essentially unmarriageable within her own society. The decision not to circumcise a daughter thus has a major impact on the girl's future. Our culture would view these issues as inappropriate sexual and economic control of women; however, it is wise to acknowledge that the individuals involved have been strongly socialized and have accepted the practice as the norm defined by their culture. After being exposed to Western culture, other African women may express ambivalence about these issues. Each must be treated with the respect and sensitivity to which she is due, without an attempt to impose our value system. Caring for the ritually circumcised woman in labor poses highly specialized problems with which the contemporary obstetrician-gynecologist needs to be familiar. Incision of the anterior vulvar scar early in the second stage of labor and sensitivity to the psychologic and cultural needs of the patient will bring the best outcome. REFERENCES 1. Cabbar IA. Medical protocol for delivery of infibulated women in Sudan. Am J Nurs 1985;85:687. 2. Lightfoot-Klein H, Shaw E. Special needs of ritually circumcised women patients. J Obstet Gynecol Neonat Nurs 1991; 20:102-7.
Key words: Female circumcision, infibulation, obstetric complications
Female circumcision is a widely practiced ritual in many parts of the world, particularly in countries along the Horn of Africa and in western sub-Saharan Africa. Recent U.S. involvement in Somalia may herald an influx of immigrants from that part of the world where female circumcision is routinely practiced. Most U.S. health care providers have had no experience in dealing with this particular problem. Little is known outside the local area about dealing with the unique obstetric management required by the procedure, as well as coping with the cultural and psychosexual issues involved. Having recently managed a case and finding little in the obstetric and gynecologic literature, we share our experience and offer some intrapartum management suggestions.
Case report A 36-year-old Sudanese woman, gravida 3, para 2, was followed up at the University Prenatal Clinic since 11 weeks' gestation. The patient had undergone "pharaonic circumcision" as a young girl, and since coming to the United States with her husband, a university graduate student, she had been particularly embarrassed about the vulvar scars. She had undergone two previous cesarean sections; the first was for failure to progress while she was being cared for in the United States, and the second was a repeat cesarean section done in Sudan. The patient had two goals for this pregnancy: She was adamant about wanting only a female provider who was comfortable with and knowledgeable about female circumcision, and she desired a vaginal birth, because her family in Sudan had implied that her previous cesarean sections were due to "moral weakness." The patient's vulvar scarring was quite tender and made performing an adequate pelvic examination
From the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of New Mexico School of Medicine. Received for publication April 13, 1993; accepted May 19, 1993. Reprints not available. Copyright © 1993 by Mosby-Year Book, Inc.
0002-9378/93 $1.00 + .20 6/1/48726
1616
and Papanicolaou smear extremely difficult. She received prenatal care from a female obstetrics and gynecology resident (C.A.B.) throughout her pregnancy, which proceeded without complications. At 39 weeks' gestation the patient had spontaneous rupture of the membranes. She was admitted to the labor and delivery suite and begun on a regimen of oxytocin augmentation. Epidural anesthetic was administered to the patient early in her labor to facilitate vaginal examinations and the placement of an intrauterine pressure monitor. Placement of a Foley catheter was difficult because the meatus was obscured by vulvar scar tissue, but catheterization was accomplished after lidocaine spray was administered locally to facilitate location of the meatus by palpation underneath thick bands of scar tissue. After epidural anesthesia was successfully established, it was possible to examine the patient without discomfort. The external genitalia appeared to be missing the labia minora, with the clitoral area and external urinary meatus obscured by two bands of scar tissue. The outer band was approximately 2 em wide and 2 cm long, bridging the inner surfaces of the remaining labial tissue. An inner, thicker band of scar tissue that was approximately 3 em wide and 2 em long obscured the original area of the clitoris and the urinary meatus and impinged on the top one fourth of the vaginal orifice (see Fig. 1, A). With oxytocin augmentation, complete cervical dilatation occurred 19 hours after spontaneous rupture of the membranes. The fetal heart rate rose to 180 beats/min and diminished variability was noted. The scar tissue was injected with 1% lidocaine, the bands were cut (see Fig. 1, Band C), and the urinary catheter was removed. A small midline episiotomy site was cut, and low forceps were applied, with delivery of a 3420 gm male infant having Apgar scores of 8 at 1 minute and 9 at 5 minutes. The midline episiotomy and the incised scar tissue were repaired. The patient had specified that she wanted to have less discomfort with vaginal examinations after her delivery, so the vulvar scars were not reapproximated. Instead, the raw surfaces were oversewn with a running
Baker et al. 1617
Volume 169, Number 6 Am J Obstet Gynecol
/
Fig. 1. Deinfibulation procedure. A, Appearance of vulva at onset of labor; B, insertion of finger behind band of scar tissue before incision; C, appearance of vulva after incision of scar bands; D, postpartum repair completed.
locking stitch of 4-0 chromic suture (see Fig. 1, D). There was minimal bleeding from the scar resection. Post partum, the patient's temperature spiked to 38.7 0 C, and she was started on a regimen of ampicillinsulbactam for endometritis. The fever abated, and she was discharged home on postpartum day 2 without further complications; sitz baths were recommended to promote healing and comfort. An examination 6 weeks post partum revealed complete healing of the vulvar scar site. At this time the labia minora and clitoris appeared to be missing but the external urinary meatus and introitus appeared unscarred and in the midline. The patient reported less dyspareunia and expressed delight with her successful vaginal birth. She planned to visit her family in the Sudan soon, to show off her son who had been born vaginally. Comment
Female circumcision is a popular but medically incorrect term used to describe a variety of ritual surgical procedures performed on the female genitalia. The three most prevalent types are as follows: type 1 (Sunna), excision of the clitoral hood, with preservation of the clitoris itself and the labia minora; type II (excision), removal of the prepuce and glans clitoris together with adjacent parts of the labia minora; type III (infibulation or pharaonic circumcision), removal of the entire clitoris, the labia minora, and the adjacent medial portions of the anterior labia majora, followed by stitching to-
gether (or sticking together with paste or thorns) the two sides of the vulva, obliterating the introitus and leaving only a small opening to allow egress of urine and menses. The type of procedure varies with geographic area and traditional practice. Besides the immediate health risks of these procedures (usually performed without anesthesia under nonsterile conditions on prepubertal girls), which include hemorrhage, sepsis, tetanus, urinary retention, and emotional trauma, there are a number of serious long-term gynecologic and obstetric complications. The gynecologic problems include keloid formation, vulvar dermal inclusion cysts, recurrent urinary tract infections, dysmenorrhea, hematocolpos, dysparenuia, recurrent vaginitis, chronic pelvic infection, pelvic pain, and infertility. The major obstetric problem is prolongation of the second stage of labor because of scar or soft tissue dystocia, with the attendant need for "anterior episiotomy" (deinfibulation). Vesicovaginal and rectovaginal fistulas, laceration of the scar tissue with subsequent hemorrhage, and fetal asphyxia or death are common sequelae in women who labor unattended with an obstructed introitus. Additionally, infibulation makes vaginal examination in labor very difficult and painful, resulting in the inability to effectively monitor the progress of labor. Gabbar, J a Sudanese physician, has outlined a protocol for the management of women who have undergone type III circumcision (Fig. 1). The circumcision scar is
1618 Baker et al.
composed of a band (or bands) of fibrous tissue enclosing the upper part ofthe vestibule. This must be incised during the second stage of labor, before episiotomy, allowing sufficient widening of the introitus for expulsion of the fetal head. To accomplish this, a finger is inserted through whatever introital aperture is present and directed toward the pubis. With adequate local or regional anesthesia this flap of tissue anterior to the pubis is cut in layers in the midline, over the finger, with scissors until the urethral meatus is visualized and the pliable tissues beneath the scar are freed and are able to stretch over the head, allowing delivery. A mediolateral or midline episiotomy mayor may not be necessary in addition. Individual patients may elect different degrees of repair after delivery, and this should be discussed beforehand. The patient's husband may make this decision for her, and rapport with him is critical. Because his perspective is that of protecting his wife and her propriety, application of our own ethical viewpoint may be inappropriate and may even be viewed as sexually abusive." If the patient desires reinfibulation, this can be accomplished at the time of delivery by simply reapproximating the cut edges of the scar with interrupted sutures of absorbable suture material. If a "less tight" repair is desired, as in our patient, the raw surfaces may simply be oversewn with a running locked stitch of absorbable material to obtain hemostasis. Postpartum sitz baths are appropriate, as in any patient who has had an episiotomy. The psychosexual aspects of female circumcision also bear note. Because the standard of propriety in many of the cultures from which these women come is that physical contact with any male other than her husband is strictly forbidden, and because the husband's permis-
December 1993 Am J Obstet Gynecol
sion may be required for the woman to obtain health care at all, every effort should be made to ensure that the health care practitioner is female. As noted above, the husband's rapport is essential and every effort should be made to establish his trust. The issue of whether the woman will want her own infant daughter circumcised also needs to be discussed so that she can make an individual, culturally appropriate, and educated choice. Because circumcision is equated with virtue in these cultures, an uncircumcised woman is essentially unmarriageable within her own society. The decision not to circumcise a daughter thus has a major impact on the girl's future. Our culture would view these issues as inappropriate sexual and economic control of women; however, it is wise to acknowledge that the individuals involved have been strongly socialized and have accepted the practice as the norm defined by their culture. After being exposed to Western culture, other African women may express ambivalence about these issues. Each must be treated with the respect and sensitivity to which she is due, without an attempt to impose our value system. Caring for the ritually circumcised woman in labor poses highly specialized problems with which the contemporary obstetrician-gynecologist needs to be familiar. Incision of the anterior vulvar scar early in the second stage of labor and sensitivity to the psychologic and cultural needs of the patient will bring the best outcome. REFERENCES 1. Cabbar IA. Medical protocol for delivery of infibulated women in Sudan. Am J Nurs 1985;85:687. 2. Lightfoot-Klein H, Shaw E. Special needs of ritually circumcised women patients. J Obstet Gynecol Neonat Nurs 1991; 20:102-7.