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problem, the scarring should be ope- average, this will leave 4-5 cm of the made an incision along the probe and
ned up. If this is not possible for any old scar unopened as the mutilation excise the scarring tissue [7]. If there is
reason the obstetrician can attempt always extends to the clitoral area. an indication for episiotomy, this may
to obtain clear sample of urine using a also be performed. There is no need to
urinary catheter in presence of type III Assessment of labour incise the circumcision scar before the
FGM. (See figure 4)
progress (pelvic examination)
second stage of labour, as this will ca-
use unnecessarily bleeding.
LABOUR IN THE PRESENCE first stage of labour care after delivery
Pelvic examination to diagnose and After delivery, the raw bleeding ed-
assess progress of labour can be very ges must be secured in some fashion.
Where the introitus is tight, and painful for the infibulated women. Be- A circular stitching around the edges
defibulation was not performed an- fore conducting the pelvic examinati- of the labia majora leaving the vulval
tenatally, it is difficult to assess the on, the health-care provider will need area open [8]. This will allow free flow
degree of cervical dilatation. If there to have the knowledge about the cir- of urine and menstrual blood. This also
is a problem of assessment, the scar cumcision and be willing to talk and to facilitates intercourse and may relieve
can be opened in the mid-line as de- bridge the cultural gap between him or dyspareunia. Individual patients may
scribed previously. Ideally, this should her and the patient. To increase com- elect different degrees of repair after
be performed under local anaesthesia. fort during the pelvic examination, delivery, and this should be discussed
Topical analgesic ointments have so the attending health-care provider can beforehand. Caring for the ritually cir-
far proven ineffective in providing any conduct bimanual examination using cumcised women in labour poses hi-
significant pain relief, although recent a single finger. The use of the epidural ghly specialised problems with which
research by the pharmaceutical indus- analgesia is always encouraged if avai- the contemporary obstetrician needs
try suggests that effective anaesthetic lable. to be familiar [9]. Incision of the ante-
creams may soon be available, provi- second stage of labour rior circumcision in the second stage
ding a useful alternative to local ana- The second stage of labour should of labour and sensitivity to the psycho-
esthesia. Usually there is little bleeding be conducted in the usual manner. logical and cultural needs of the pati-
from the relatively avascular scar tis- However, a specific delivery protocol ent will bring the best results.
sue. In these circumstances, suturing should be used. The main point in medicalisation
should be delayed until after delivery. the second stage of labour is that, the The question of medicalisation of
With a wider opening, normal asses- circumcision scar which consists of a FGM (to carry out the procedure un-
sment is possible, and a decision about flap of skin enclosing the upper part of der hygienic circumstances) is a com-
anterior division of the scar, often com- the vestibule, to be incised during se- mon question, in my view this should
bined with episiotomy, can be delayed cond stage of labour with crowning of not be encouraged. The most common
until the second stage of labour. The the head, before episiotomy allowing argument in favour of medicalisation
second stage of labour may be compli- sufficient widening of the introitus for was that it could be a temporary mea-
cated if the foetal head is held up on expulsion of the foetal head, or bree- sure, as a first step towards eradication
the scar tissue. This is dangerous to ch delivery. The index finger of the of the practice. The argument against
both the mother and baby and this is left hand is inserted through the in- medicalisation was that by medica-
the time when uncontrolled tears can troitus and directed to the pubis. The lisation of the practice is legitimised
occur, as well as foetal asphyxia. There flap of the skin anterior to it is raised. [10].
should be no delay in performing a Using a pair of scissors this cut in the
mid-line cut in the anterior scar to mid - longitudinal line (Figure 5). The Acknowledgment
minimize trauma. To avoid unneces- introitus is thus widened and the ure- I would like to thank Mr Alan Wal-
sary bleeding, the incision should not thral opening exposed3. In women ler, Audiovisual centre. University of
be extended beyond the urethra – no with more sever stenosis insert a pro- Newcastle, for helping me to develop
extra space is created by doing so. On be through the pin - hole opening and these figures for forward 1997.
1. WHO ( July 1995) Female genital mutilation, the practice. women in Sudan. 1985. Am J Nurses; 85(6):687
WHO Techniqual Bulletin, Geneva. 7. Lightfoot - Klein H. Shaw E. Special needs of the ritually
2. Abu Shama, A.O., et al. (1949). Female Circumcision in the circumcised women patients. Joon Principles & Practice.
Sudan. Lancet, 1:544-5 Vol 20, nr 2(1991), 102 -107.
3. Proceeding of the female Genital multilation expert meet- 1. Nahid Toubia. Female circumcision as a public issue. The
ing, November 1998 New England Journal of Medicine. Sept 1994. No 11, Pag 712
4. Report of a WHO Technical Consultation Geneva, 15-17 Oc- -716.
tober 1997 1. Ahmed B. Management of women who are circumcised
5. H. Gordon. Female genital mutilation. The diplomate, the during pregnancy and childbirth. Journal of Obstetrics and
journal of the diplomates of the Royal College of Obstetri- Gynaecology. May 2000, vol 20, Nr 3:280-281.
cans and Gynaecologists. August 1998, Page 86 - 90. 10. RCOG statement No 3. May 2003. The Royal College of Ob-
6. Gabar, I.A. Medical protocol for delivery of infibulated stetrician and Gynaecologist.
Vol. 4, Nr. 3/septembrie 2008
pag. 169
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