| Normal female genitalia with clitoris, labia minora and labia majora intact.
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| Type 1 FGM can be subtle and hard to identify, as genitalia may look intact.
Even in cases where minimal tissue damage has occurred, there may still be sensory nerve damage, and psychological sequelae.
Type 1 FGM usually involves excision of the clitoral hood (prepuce), with or without excision of part or all of the clitoris.
In some cultures it may involve a ritual pricking or nicking of the clitoral hood, without removal of any tissue.
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| Type 2 FGM is the form of female circumcision most commonly seen.
It involves excision of the clitoris with partial or total excision of the labia minora. The tissue is joined in the midline above, or just over urethra.
A Type 2 presentation can be quite subtle and may be missed by some practitioners when undertaking an examination.
There may be general or periurethral scarring or nerve damage, which makes penetrative procedures uncomfortable.
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| Type 3 FGM is the most extreme presentation. It involves excision of part or all of the external genitalia and stitching/ narrowing of the vaginal opening. (Infibulation) There will be obvious anterior midline scar tissue.
The infibulation may obscure underlying dermatological problems such as abscesses, dermoid and sebaceous cysts, and other scarring. It may predispose to both short and long term health consequences for women.
The Type 3 FGM, the extent to which genital tissue has been removed varies with the individual.
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| Elective deinfibulation may be performed as a non-pregnant procedure, after 20 weeks of pregnancy or as part of the birth process.
The choice and timing of the procedure may be mediated by clinical requirements, cultural factors and psychological issues.
If performed as a non-pregnant procedure, a General Anaesthetic may be appropriate to avoid the potential for psychological stress or "flashbacks".
Spinal Anaesthesia may also be recommended in pregnancy.
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| Preparation for deinfibulation should be that of a minor surgical procedure.
Adequate anaesthesia is essential. Even when using a General Anaesthetic infiltrate the midline area along the original scar line with local anaesthesia to decrease post-operative discomfort.
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| Insert 1 or 2 fingers under the anterior scar tissue to protect the baby's head and to avoid damage to underlying tissue, including the urethral meatus.
Use your fingers to feel how far up to cut as you divide the old scar tissue.
Aim for the anterior episiotomy to extend just above the urethral meatus to allow for unobstructed voiding.
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| Once deinfibulation is complete it is possible to identify the extent of the remaining genital tissue.
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| Suture retracted tissue to promote haemostasis and prevent re-anastamosis of the raw wound edges.
Use a fine, rapidly absorbed suture such as a 2/0 or 3/0 Vicryl Rapide on a small suture needle.
A small number of interrupted or a continuous suture will be adequate.
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| When undertaking a deinfibulation in labour, the steps are the same as for the elective procedure.
Some adjustment is required to compensate for the distension of the perineum as the baby's head descends.
Provide an explanation of the procedure to the woman and elicit her co-operation as you work between and during contractions.
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| If possible, administer a Local Anaesthetic along the anterior scar tissue.
Place 1 or 2 fingers underneath and to your left of the anterior scar tissue.
Infiltrate the scar using a very superficial angle on the needle to protect both the baby's head and yourself.
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| Use 1 or 2 fingers to create clearance from the emerging head prior to inserting the scissors.
Make the anterior incision up the midline scar to just above the urethral meatus.
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| The raw edges will retract and the head will begin crowning.
Check that the perineal area is stretching adequately.
Note that post infective vaginal scarring from the original infibulation , and fibrous tissue of the anterior scar may not stretch under pressure.
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| Control the birth of the emerging head with light downward pressure.
Monitor perineal stretching throughout as occasionally corrosive substances may have been inserted into the vagina to induce scarring that is not evident externally.
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| If there is any degree of tightness, or evidence of severe scarring, perform an early medio-lateral episiotomy. (A bilateral episiotomy is rarely needed nor recommended).
Avoid downward midline incisions as these have the potential to extend to a 3rd or 4th degree tear.
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| Post Birth: Repair the anterior incision as per antenatal management. If not sutured or repaired correctly the raw edges can form an uneven re-infibulation.
Any extension of the anterior incision above the urethra may also be repaired at this time.
Repair of the episiotomy or other genital tract trauma follows the procedures outlined in the CPG: Perineal Trauma: Assessment and Repair.
Ensure that adequate analgesia is prescribed and provided and appropriate advice on wound management and body changes given to the woman.
If you have any questions or would like to make a referral please contact FGM Liaison Officer/s (Refer: medical staff list or nursing & allied health staff list) and/or Female and Reproductive Rights Education Program (FARREP) Tel: (03) 9344 2211.
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