Does the timing of deinfibulation for women with type 3 female genital mutilation affect labour outcomes?

Deinfibulation

Deinfibulation (sometimes called ‘reversal’) is the surgical procedure to open up the covered vagina in type 3 FGM. This can be carried out prior to conception, during pregnancy or during labour. An anterior incision is made through the scar tissue, facilitating a clear view of the vagina opening and urinary meatus below, and the resulting edges are then over sewn so that the skin cannot re-appose and thus re-fuse.

In 1995, McCaffrey published a review of the UK's first FGM specialist clinic and concluded that antenatal deinfibulation is preferable because staff are unaccustomed to FGM; to allow for vaginal examination and other interventions during labour; and to reduce blood loss (McCaffrey et al, 1995). Subsequent to this, the Royal College of Nursing (2015) recommended antenatal deinfibulation.

However, several authors have noted that antenatal deinfibulation may be less acceptable because women may fear two episodes of pain (one antenatally and one during childbirth); deinfibulation rarely takes place during pregnancy in Africa; and there may be negative psychological consequences as deinfibulation can trigger flashbacks to the original procedure (McCaffrey et al, 1995, Chalmers and Hashi, 2000; Momoh et al; 2001; Norman et al, 2009).

A benefit of antenatal deinfibulation is that it can be performed under local anaesthetic by a specialist midwife or doctor in an outpatient setting, at low cost and reducing the need for emergency procedures when the woman is in labour. In the author's clinic, many women, such as those with type 3 FGM or women who had a caesarean section with their first child which they believe to be a consequence of not being ‘opened’ prior to labour, actually seek out antenatal deinfibulation.

The current Royal College of Obstetricians and Gynaecologists (RCOG, 2009) Green-top Guideline falls short of recommending a specific optimal timing for deinfibulation. It states that ‘defibulation can be carried out in the antenatal period or intrapartum.’ They recommend the decision be ‘made by a senior obstetrician with adequate experience in this field … if vaginal access is adequate then intrapartum defibulation is appropriate … defibulation can be carried out in the first stage of labour … or during the second stage at the time of crowning of the head’ (RCOG, 2009: 8). Adopting a policy of intrapartum deinfibulation has its problems. Raouf et al (2011) reported that intrapartum deinfibulation may not be possible if the fetal head is advancing too quickly, or if the birth attendant is unclear as to when/whether it needs doing thus delaying deinfibulation until it is too late and the head has been delivered. This can result in severe perineal trauma.

With guidance non-specific on optimal timing and in consideration of what may be preferable to women, this work aimed to provide evidence on which to base an informed discussion with women with type 3 FGM to enable them to decide the timing of their deinfibulation.

Methods

Between 2008 and 2012, 158 pregnant women identified as having type 3 FGM were seen in a specialist midwifery-led clinic. They were offered a perineal examination and, if found to have type 3 FGM, offered deinfibulation in the second trimester at around 20 weeks' gestation in line with the RCOG Green-top Guidelines (2009). For women who declined, a plan for intrapartum deinfibulation labour was discussed and documented. Following local study approval (Joint Research Compliance Office Reference Number: 13HH0423—a retrospective data collection study of anonymised data), medical records were requested and records for 94 women were included in the review. A data collection sheet was completed for each set of casenotes. After initial primary analysis of the findings, a secondary analysis of 63 datasets (excluding women who had caesarean sections) were entered onto IBM SPSS Statistical Version 21.0 for analysis. Chi-square test was used to determine P values. Risk ratios, confidence intervals and significance at P=<0.05 were calculated for risk of adverse outcome according to timing of deinfibulation.

Results

Secondary analysis

The 31 women who had a caesarean section were excluded from further analysis.

The remaining 63 datasets were divided into two groups: ‘previous/antenatal deinfibulation’ (n=42) and ‘not deinfibulated before labour’ (n=21).

Rates of episiotomy and perineal tears; length of second stage; estimated blood loss, haemoglobin levels; neonatal Apgar scores; duration of maternal stay; and complications (identified as a combination of either intravenous syntocinon and/or a blood transfusion, and/or intravenous antibiotics) were analysed. Of the 21 ‘not deinfibulated before labour’, 13 were deinfibulated during labour by a senior registrar, one by an obstetric consultant, one by a labour ward midwife, one by a junior doctor (senior house officer) and five were not deinfibulated. Only one deinfibulation in labour was performed in the first stage of labour (by a consultant), the reason recorded for this was to facilitate vaginal examination.

A summary of compared outcomes between the two groups can be found in Table 2. There were no significant differences in outcomes between the two groups using Chi-square analysis. However, when risk ratios were applied to risk of adverse outcome, those deinfibulated in labour were at increased risk of having an episiotomy and of increased length of stay (Table 3).

Table 3. Risk ratios, confidence intervals and significance according to timing of deinfibulation

	Previous/antenatal deinfibulation	Not deinfibulated before labour	Total	Relative Risk	95% CI	P-value
	n (%)	n (%)	n (%)
	42 (66)	21 (34)	63 (100)
Length of stay
<2 days	15 (36)	3 (14)	18 (29)	1.33	1.00–1.77	P=0.048*
2 or more days	27 (64)	18 (86)	45 (71)
Episiotomy
No	18 (43)	6 (29)	24 (38)	1.67	1.07–2.59	P=0.023*
Yes	24 (57)	15 (71)	39 (62)
EBL
< 500 ml	23 (55)	10 (48)	33 (52)	1.15	0.68–1.96	P=0.58
> 500 ml (PPH)	19 (45)	11 (52)	30 (48)
Haemoglobin
Hb < 70g/L	2 (11)	2 (22)	4 (15)	0.87	0.59–12.28	P=0.49
Hb > 70g/L	16 (89)	7 (78)	23 (85)
Second stage duration
Up to 120 minutes	33 (79)	13 (62)	46 (73)	1.77	0.80–3.93	P=0.16
>120 minutes	9 (21)	8 (38)	17 (27)
Vagina packed in theatre
No	39 (93)	17 (81)	56 (89)	2.6	0.65–10.83	P=0.17
Yes	3 (7)	4 (19)	7 (11)

SVB—spontaneous vaginal birth; EBL—estimated blood loss; PPH—post-partum haemmorhage; Hb—haemoglobin

* —statistically significant

The frequency of perineal tears in the two groups were compared (Table 4). In total, 58 women (92%) were deinfibulated (whether before or during labour) and 39 women (62%) had a medio-lateral episiotomy. A large number of women had deinfibulation, a medio-lateral episiotomy and a tear. Frequency of perineal trauma was analysed further (Figure 1). Most women had either deinfibulation with an episiotomy (37%), deinfibulation with a tear (27%), or deinfibulation with an episiotomy and a tear (21%). In total there were 25 assisted births and 39 episiotomies. Fourteen of 63 women who had a spontaneous vaginal birth received an episiotomy (22%).

Table 4. Frequency of perineal tears

	Previous/antenatal deinfibulation	Not deinfibulated before labour	Total
Type of tears	n (%)	n (%)	n (%)
	42 (66)	21 (34)	63 (100)
No tear	14 (33)	8 (38)	22 (35)
First-degree tear	6 (14)	6 (29)	12 (19)
Second-degree tear	21 (50)	6 (29)	27 (43)
Third-degree tear	1 (2)	0 (0)	1 (2)
Fourth-degree tear	0 (0)	1 (5)	1 (2)

The following are examples of the different descriptions used to report perineal damage entered in the notes by the senior registrar or senior house officer that carried out the repair. This reflects the complex and varied nature of the tears suffered by women with type 3 FGM:

‘1 cm laceration above urethra’, ‘anal fissure’, ‘anterior vaginal wall lacerations and cervical tear’, ‘small extension on upper vulval incision’, ‘bilateral vaginal wall tears’, ‘extended tear’, ‘anal sphincter exposed but not injured’, ‘2nd-degree tear and lacerations’, ‘labial (para-urethral) tear’, ‘clitoral lacerations packed in theatre’, ‘peri-urethral tear and perineal tear’, ‘vagina packed in theatre’, ‘episiotomy extended had to go to theatre 8 days later for perineal refashioning’.

Discussion

Several factors affect outcomes in labour for women who have type 3 FGM. The severity of type 3 FGM impacts on the amount of scar tissue as well as the elasticity of the perineum. As FGM is an unregulated and unskilled (illegal) procedure, sequelae of FGM may leave one woman anatomically different to another and experiential knowledge shows that some women have very thin anterior scar tissue while others have a dense fibrotic thick scar. The level of scarring (i.e. thickness of the anterior scar tissue layer) is determined by the degree, and therefore, the depth of the mutilation. This is different to keloid scarring, which is excessive over-scarring of an area. This may have a substantial effect on how easily the perineum stretches during childbirth and increased likelihood of tearing.

Current research and literature does not mention the phenomenon of women with type 3 FGM who have fused anterior scar tissue. Sometimes the layer of scar tissue that has formed above the vaginal opening and urinary meatus cannot be lifted and incised because it has fused with the wall of the urinary meatus. These women can only be ‘opened’ a couple of millimetres and it is likely that these women are at greater risk of tearing, especially if this is not discovered until the woman is in labour.

In 2006, the WHO (Banks et al, 2006) undertook a multicentre study that provided conclusive evidence that women with FGM are significantly more likely to have caesarean sections, postpartum haemorrhage, episiotomy, extended hospital stay, need infant resuscitation and experience perinatal death. Furthermore, women with type 3 FGM are more likely to have adverse outcomes than the other types of FGM for both primiparous and multiparous women (Banks et al, 2006).

The primary analyses of this study are in agreement with these findings. The overall caesarean section rate was 33% (30% emergency and 3% elective). The national rate of caesarean sections for 2010–11 was 24.8%, of which 10% were elective caesarean sections (Health and Social Care Information Centre (HSCIC), 2011). At the local hospital in 2011, the caesarean section rate was 29.3% (15% emergency caesareans). Therefore, the rate of emergency caesarean sections in this group was higher than both the national average and local hospital average. To what extent this is explainable in terms of socioeconomic, demographic and other factors is not clear but must be considered as possible confounding factors due to known effects on birth outcomes (Essex et al, 2013). Women from FGM practising communities may be fearful of choosing an elective caesarean section even if it is recommended (Vangen et al, 2004). Other studies have similarly noted that FGM is rarely given as a direct indication for caesarean birth, which makes it difficult to quantify how many caesareans sections are due to FGM, as opposed to other complex factors that may apply to this population (Rouzi et al, 2001; Wuest et al, 2009; Paliwal et al, 2013).

The national rate of instrumental births for 2010–2011 was 12.5%, of which 6% were forcep deliveries (HSCIC, 2011). At this hospital, the rate of instrumental births in 2011 was 18.1% (12.1% ventouse; 6% forceps). In this study 27% of all births were instrumental births (19% ventouse; 7% forceps); more than double the national average. Similarly, the rate of episiotomy at spontaneous vaginal birth was 22% compared to 8.2% in England in 2010–11 (HSCIC, 2011). In this study, the rate did not differ according to timing of deinfibulation.

Evidence surrounding FGM and perineal trauma appears contradictory. Two studies undertaken in Saudi Arabia by Rouzi et al (2001; 2012), did not find significantly higher rates of episiotomy, vaginal laceration or blood loss for women with FGM when compared with a group of women without FGM.

This contrasts with research from the UK, which has reported higher levels of perineal trauma, in agreement with our findings (McCaffrey et al, 1995; Bikoo et al, 2006; Raouf et al, 2011; Paliwal et al, 2013). A retrospective audit undertaken in the West Midlands compared outcomes for 102 women with previous/antenatal deinfibulation with 18 women with intrapartum deinfibulation. They found that mothers who commenced labour without prior deinfibulation were significantly more likely to have an episiotomy and more blood loss at birth. However, there was no difference in Apgar scores of babies, or late-stage caesarean section between the two groups. (Paliwal et al, 2013). Several other studies have reported similar findings (Penna et al, 2002; Bikoo et al, 2006; Nour et al, 2006) but the sample sizes are insufficient for results to be conclusive. A recent systematic review into interventions to improve birth outcomes in women who have undergone FGM failed to identify any trials that met the review criteria, indicating further research and discussion on optimal and feasible trial design is essential in the future to provide quality evidence on management (Balogun et al, 2013).

The intrapartum clinical situation for women who are ‘not deinfibulated before labour’ is unpredictable, as there may be an attendant with little experience of when the optimum time to deinfibulate is, or whether a medio-lateral episiotomy is also required. In this study, women rarely required deinfibulation alone. The high rates of neonatal adverse outcomes found in Africa, as reported by the WHO (Banks et al, 2006), seem to be avoided by strategies of intervention before the newborn is affected. This may explain the high rates of caesarean section found in studies carried out in Europe and the US highlighting the different trend in obstetric management from that of Africa (Essén et al, 2001; Nour et al, 2006; Wuest et al, 2009).

Several qualitative studies refer to instances of doctors and/or midwives waiting to see whether the perineum stretches adequately, and, in some cases, this resulting in deinfibulation not being performed in time (Chalmers and Hashi, 2000; Lundberg and Gerezgiher, 2008, Norman et al, 2009). There should be additional focus placed on the training of midwifery and obstetric staff so that they can provide women with informed choice including all the risk factors which have been described: an increased risk of tearing as well as episiotomy associated with FGM (and hopefully further discourage the continuation of the practice); and to recognise that antenatal deinfibulation means possibly avoiding the risk that this will be carried out too late (and perhaps excessive additional tearing).

It should be noted that 12 women were identified in the records as having type 3 FGM despite this following previous vaginal birth, eight of whom said that they lived in the UK at the time. Further research is needed to clarify the experience of childbirth for women with type 3 FGM in the UK and the nature of the care management during, and after, labour. Was the type 3 FGM left intact at birth and managed by episiotomy only, and to what extent were tears or incisions over-stitched or repaired? Not all women in the study were clinically assessed by the same person, which may have had an effect on the possible collection and interpretation of this information; nevertheless, these are important issues to consider, mostly for the wellbeing of the woman and her future reproductive health, but also in consideration of potential legal issues regarding any reinfibulation post-delivery. It is essential that services develop protocols and policies for the appropriate reporting and investigation of suspected incidence of reinfibulation post-delivery. It is important to put the future reproductive health of women with FGM at the forefront of care-management, which considers outcomes and birth choices in subsequent pregnancies as well as the immediate one. This study identified women who had type 3 FGM following caesarean section, thus still leaving them in need of deinfibulation. It could be proposed that women are offered deinfibulation at the time of caesarean section while under anaesthetic, thus minimising repeated discomfort in future pregnancies. These issues need multiprofessional debate at a national level. It is essential that further qualitative research is undertaken to ascertain the wishes of women with FGM and to provide support to make evidence-based decisions regarding their own wellbeing. It is worth noting that for those women included in this study, eight of the 10 multiparous women chose to be deinfibulated antenatally because they blamed their previous caesarean section on FGM. This correlates with findings from other studies (Bikoo et al, 2006; Norman et al, 2009) and suggests that women are motivated to seek out options to improve their reproductive outcomes.

Limitations

Women with more severe type 3 FGM are more likely to seek out antenatal deinfibulation (Norman et al, 2009). Therefore, the ‘not deinfibulated before labour’ group may include women with ‘less severe’ type 3 FGM, and consequently may be less likely to have severe perineal trauma, thus skewing any significant findings.

Some women did not attend their appointment in the antenatal FGM clinic so may not have known that deinfibulation was available to them rather than actively declining it. Bikoo et al (2006) reported 38% of women declined antenatal deinfibulation. It is unclear whether women always understand the choices that are available to them as English is rarely their first language.

Retrospective analysis relies on information collected and recorded by others. Some medical records were missing or not available. Despite good access to eligible records, and accessing all known cases attending locally over 4 years, this was a small sample size due to the relatively small sample available. This makes observing statistically significant differences between sub-groups unlikely. In order to achieve greater numbers and therefore achieve more statistically significant findings, it may be appropriate for those in the UK running specialist services to collaborate for future research and to pool service audit data.

Conclusions

In this study all the women, regardless of timing of deinfibulation, had higher than local and national rates of caesarean section, instrumental birth, episiotomy and perineal damage. The rate of perineal trauma is unacceptably high and warrants further investigation into the management of care of women with type 3 FGM. Women in whom deinfibulation was delayed until labour had a significantly greater risk of episiotomy and prolonged hospital stay of >2 days when compared to those who had deinfibulation prior to labour. Antenatal deinfibulation should continue to be offered as an option to women with type 3 FGM as there may be a beneficial effect on labour and birth outcomes.

Key Points