ANTENATAL, INTRAPARTUM AND

POSTPARTUM CARE OF WOMEN LIVING

WITH FGM

04/01/2024
 Outcomes
By the end of this chapter, you should be able to:

1. Describe the management of women living with

FGM during pregnancy, labour, childbirth and the
postnatal period.

2. Identify complications due to FGM that may affect

pregnancy

3. Discuss the management of complications

associated with FGM that may occur during
pregnancy, labour, childbirth and the postnatal
period.
 INTRODUCTION
• Women with FGM should be assessed as early as
possible, preferably during the antenatal period.
– Allows appropriate and timely management including
referral for skilled assistance.

• Type I, II, and IV FGM without any associated

complications
 Pregnancy, labour and delivery is unlikely to be
affected by FGM

• Type III FGM

 Associated with the highest risk of complications
during delivery.
 OBSTETRIC RISKS ASSOCIATED WITH FGM
• Caesarean section

• Postpartum haemorrhage

• Episiotomy

• Perineal tears and lacerations

• Prolonged/obstructed labour

• Instrumental delivery

• Postpartum genital wound infection

• Maternal mortality

• Extended maternal hospital stay

For the neonate, there is an increased risk of:

• Stillbirth and early neonatal death

• Asphyxia and resuscitation at birth

• Injuries due to difficult delivery

Management of certain conditions may be

hindered by the anatomical distortions
resulting from FGM.
 Why the higher risk of obstetric complications?

• Tight vaginal introitus due to scarring

• Recurrent reproductive and urinary tract

infections (RTIs and UTIs)

• Epidermal inclusion cysts and keloids

 ANTENATAL CARE OF WOMEN LIVING WITH FGM

• The antenatal period may be the only time

the woman comes into contact with the health
care system.

• When providing care to women living with

FGM, it is important to be sensitive and
respectful towards their cultural beliefs,
values and attitudes.
 Initial Prenatal Evaluation
• During history taking and physical
examination:

 Determine the FGM status of the client

 Complications associated with FGM

 History Taking
• Do not start by asking the client questions on FGM. First take
routine history.
• A good time to ask about her FGM status is when taking her surgical or
reproductive history. This can be asked in the following way:
“I know many women from your community have experienced some form of
genital cutting. Do you know whether this was done to you?”

• If the answer to the above question is ‘Yes’, ask about type

• Enquire whether she has experienced any complications associated
with FGM.
• Complications during previous delivery
• Prior history of de-infibulation, and re-infibulation
• Any concerns she may have.
 Physical Examination
• Confirm the presence of FGM and identify type

• Check for any conditions that may complicate

pregnancy and delivery or interfere with future
vaginal examinations.

• In the presence of type III FGM, assess the

elasticity of the surrounding tissues with your
index and middle fingers or a cotton swab/bud.
 If the urethral meatus is visible or if the index and
middle fingers can be passed into the vagina without
difficulty, it is unlikely that there will be mechanical
barrier to delivery due to FGM.
• Carefully record the findings to avoid
repeated examinations (should include a
simple drawing).

• Discuss the information learnt from the

examination with the woman and her
husband/partner, if appropriate.

• If the woman has a tight vaginal opening

due to her infibulation, discuss the need for
deinfibulation.
 At the End of the Clinical Evaluation:
• Discuss the findings with the client and
jointly agree on follow up and a birth plan

• Ask the client whether she has any

questions and address her concerns

• Clearly record the findings from the clinical

evaluation
 MANAGEMENT OF COMPLICATIONS ASSOCIATED
WITH FGM DURING PREGNANCY
• RTIs
• UTIs
• Obstruction of the vaginal opening
• Epidermal inclusion cysts and keloids
• Vulvar abscesses
• RVF, VVF and incontinence

 Keep in mind other complications, not related to FGM, that

may occur in pregnancy and manage appropriately.
MANAGEMENT OF LABOUR AND DELIVERY
• Women with type I, II and IV FGM and
those with type III FGM but have
undergone deinfibulation, are unlikely to
have FGM-related complications during
delivery.

• Note that this might the first time the

woman is coming into contact with a
health care provider for the particular
pregnancy.
 Initial Evaluation of Women in Labour
• Find out her FGM status

• Ask her whether she experienced any FGM-related complications in the

previous pregnancies
• Assess her FGM status, type of FGM, presence of complications
and elasticity of perineal tissues
– Assessing elasticity of perineal tissues - Try slowly and carefully to introduce
first one finger into the vagina to measure the tightness of the introitus. If it
allows one finger, try to move the finger upward and downward, and left to
right. If there is space for a second finger, try to widen the two fingers and
check the resistance.

• If the vaginal introitus is tight, explain to the woman that an

episiotomy may be required during delivery

• In women with type III FGM, discuss the need for deinfibulation at the
earliest opportunity and obtain consent
 Monitoring Progress of Labour
• Monitoring of labour in women living with
FGM is the same as those without FGM.

• However, vaginal examinations may be

difficult in women with a tight vaginal
opening or those with type III FGM.
 POSTPARTUM CARE OF WOMEN LIVING WITH FGM
In the postpartum period, there is an increased risk off:

1. Postpartum haemorrhage

2. Injury to the urethra, bladder and rectum.

3. RVF and VVF.
4. Urine retention as a result of injury to the urethra
5. Genital wound infection, which may lead to wound
breakdown or even septicaemia
6. Psychological problems
• For the baby:

1. Asphyxia

2. Death

3. Injuries due to a difficult delivery

4. Severe brain injury

 Advice Post-Delivery
• Women living with FGM should receive
counselling similar to those without FGM.

• Do not lose the opportunity to counsel

against FGM
 Thank
You!

04/01/2024