Self deinfibulation during unassisted home delivery: a hitherto unknown dimension of female genital mutilation?

Introduction

The reproductive health consequences of female genital mutilation (FGM) have been extensively documented [1]. Impaired healing and scar formation is common.

When the healing and scar formation from FGM constitute significant soft tissue obstruction to natural delivery, surgical division of such an obstruction under anesthesia is usually necessary (Deinfibulation). This can be complex and difficult due to distorted anatomy. We recently encountered a new aspect to the problem, where a woman deinfibulated herself to enable a home vaginal delivery.

Presentation

A newly home-delivered woman arrived by ambulance at the Emergency Room of our hospital at 06.40 h. Her baby was well, but she requested attention to what she initially described as genital trauma and moderate bleeding. She had self-delivered her baby at 6:30 am when her uterine contractions suddenly became regular and she was unable to reach the hospital. The placenta was retained.

She confided in the attending physician that she had cut her own perineum with an unsterile razor blade, as the baby’s head was distending her perineum, but would not emerge.

She was a 32-year-old, Sudanese woman (G2 P1) with a history of a previous vaginal delivery, whose pregnancy had just turned 38 weeks. She had no medical training. She had had FGM at birth and re-infibulation by a traditional midwife after delivery of her first baby in the Sudan.

She was not pale. Her vital signs were normal and stable. Blood was sent for crossmatch and hemogram. With an infusion of oxytocin, the urinary bladder was emptied after draping the perineum. The placenta was delivered by controlled umbilical cord traction.

Inspection revealed multiple vulvo-vaginal lacerations, following what was a narrowing of the genital opening, with an introital adhesion in the midline, consistent with a Type III genital mutilation [2]. The self-inflicted cut was in the region of a right medio-lateral episiotomy, but this appeared to have been the point-of-yield, extending anteriorly to the vulval scar.

The patient refused examination under anesthetic in the operating room. Under local infiltration anesthetic, she had a repair of the genital laceration. The 2 cm lateral perineal tear which had been cut by the patient was repaired using interrupted 2.0 Vicryl. The bleeding edges of the vulval adhesion was closed with interrupted 2.0 Vicryl stitches.

She had one dose of Co-Amoxiclav, 1.2 g and tetanus vaccine and toxoid administered after a test dose. She was transferred to the post-natal ward for 12 h observation after which she self-discharged. A de-brief and advice to have a hospital delivery during her next confinement, was offered.

She declined further discussion about her genital mutilation.

Discussion

We are unaware of any previous similar report of what this patient admits to having had done to herself. There has been one report of a self-performed cesarean section from South America [3]. Here, we had a woman who had had a first re-infibulation on demand, and a second ill-advised one, by default.

Unfortunately, female genital mutilation persists to this day, in certain culturally-unique countries of the world.

The Green-top Guideline of the Royal College of Obstetricians and Gynaecologists (RCOG) [2] details the steps and importance of intra-partum deinfibulation, in women who have had significant scarring secondary to FGM.

Even in settings where there are rules and laws against re-infibulation, naïve junior doctors may undertake ‘re-constitution’ of a deinfibulation [4]. We obviously had an identical undertaking in this case, although there are no relevant laws in our practice area. A reflective learning process has been undertaken.

In Sudan from where the patient is originally from, re-infibulation as performed after her first childbirth represented a considerable source of income for some midwives vis-à-vis ‘increase (a woman’s value) by helping her maintain her marriage as well as striving for beautification and completion’ [5].

The bothersome implication of self deinfibulation is that it is probably more widespread than we think, at least in settings where FGM is widely practiced.

In the United Kingdom’s Female Genital Mutilation Act of 2003, re-infibulation was not specifically covered [6]. The World Health Organization [7] and the RCOG [8] state clearly that re-infibulation should not be undertaken under any circumstances. Indeed, the RCOG describes it as: ‘illegal’ in keeping with the direction of many countries who are moving towards FGM-specific clauses in law.

There is no question that more healthcare providers for women need to be educated, sensitized and empowered, to effectively curtail FGM and its consequences. We have locally commenced this initiative already.

We are much more concerned about newly-delivered, self de-infibulated mothers, who may not survive uncontrolled bleeding, genital sepsis or tetanus from de-infibulation practices in home settings.

That is the main intent of this report.

The debate about FGM is culturally-sensitive and may be viewed differently in various parts of the world. It needs considerable socio-cultural engineering, and goes far beyond legislation in settings outside where it is most practiced.