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the health worker needs to establish
whether or not the pregnant woman
has undergone this type. Where type
III FGM is common, the vulvar area
must be inspected at the first antena-
tal visit. In women having their first
baby, this will establish the extent of
the damage, and the degree of physical
barrier presented. Women with a tight
introitus following FGM (opening 1 cm
or less) are at greater risk of major pe-
rineal damage during labour than tho-
se who have not been sewn so tightly
or whose mutilation has been partly
reversed (“opened up”) on marriage to
allow the marriage to be consumma-
Figure 4: A urinary catheter can be inserted in presence of FGM even in the severest form, to
As a general guideline, if the urina-
obtain a clear sample of urine using One finger as shown in this diagram.
ry meatus can be observed or if two
fingers can be passed into the vagina
without discomfort, the mutilation is
unlikely to cause major physical pro-
blems at delivery (Gabar I.A. 1985),
wherever this occurs.
Digital assessment is not always ne-
eded, as the visual appearance may
provide all the information required.
Making a record of the appearance of
the vulva may help to avoid unneces-
sary examinations in the future, or to
highlight when specific procedures
may be difficult to carry out.
If the woman has had previous preg-
nancies, the history of the deliveries
will help to indicate whether she is
likely to have persistent problems. It
is important to find out whether resu-
Figure 5: The index finger of the left hand is inserted through the introitus and directed to the
pubis. The anterior skin flap is raised and anterior incision is made.
turing has taken place following deli-
very. In this respect, there are major In those countries where type III is common in women with type III FGM.
variations among communities, even virtually universal, hospital delivery There is, however, clearly a difficulty
in the same country. Repeated cutting is often not an option. However, the in obtaining a clean sample of urine
and resuturing (“de-infibulation” and traditional birth attendants (TBAs) for investigation. A catheter sample
“re-infibulation”) leave extensive scar- are familiar with the practice of FMG cannot be obtained and other urine
ring, which is often unstable. Though, and can reduce the complications di- samples are contaminated by vaginal
if there is any doubt, the perineal area rectly arising form the procedure and secretions. Where the diagnosis can-
should be inspected to assess the ex- give the labouring women comfort and not be established with certainty, whe-
tent of existing damage. physiological support. re urinary infections are recurrent, or
In areas where type III FGM is not Complications of pregnancy, which where there has been an attack of se-
common, a tight introitus (opening pose special problems in the manage- vere pyelonephritis, the introitus sho-
1 cm or less) should be regarded as a ment of FGM. uld be opened up.
major risk factor, especially if the scar 1: Antepartum haemorrhage 3: Pre-eclampsia
is thick. Women with this condition Again the same principles apply - if When hypertension develops in
should be required to deliver in hospi- the FGM interferes with appropriate pregnancy, and the patient is referred
tal where skilled supervision of labour assessment and management, it will be to hospital, important decisions may
should reduce the incidence of major necessary to open up the closed vulva depend on the degree of proteinuria.
perineal trauma - although problems during pregnancy and before labour. In women with type III FGM, the urine
may still arise if the woman presents 2: Urinary tract infection is always contaminated with vaginal
late in labour or if the baby is born on Urinary tract infections are com- secretion and may therefore show fal-
the way to the hospital. mon in pregnancy. They may be more se proteinuria. Where this is a serious
pag. 168 Vol. 4, Nr. 3 /septembrie 2008
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