Appendix 3
Female Genital Mutilation (FGM) – Maternity Guidance
1.Indication
1.1 Background
Female genital mutilation (FGM) is defined as all procedures involving partial or total
removal of the external female genitalia or other injury to the female organs, whether for
cultural or other non-therapeutic reasons. [ref: rcog guideline 53]. It is estimated by the
World Health Organisation (WHO) that 130 million women worldwide have undergone FGM.
[ref WHO ref 3 RCOG]
Traditionally FGM was done in Africa, but it is important to note that it is also seen in
Indonesian and Indian populations.[rcog, 2015] The local population of Salisbury includes
women from Ghana (30% prevalence) and Somalia (98-100% prevalence).
The Law
All types of FGM have been illegal in the UK since the 1985 Female Circumcision Prohibition
Act. The new Female Genital Mutilation Act (2003) updates and extends the original act.
The act states that it is
‘an offence to take UK Nationals and those with permanent UK residency overseas for the
purpose of circumcision, to aid and abet, counsel or procure the carrying out of FGM. It is
illegal for anyone to circumcise women or children for cultural or non-medical reasons’
A person convicted of an offence under the FGM act is liable to imprisonment for up to 14
years.
1.2 Aim/purpose
To provide women with opportunity for de-infibulation at the optimum time.
To provide sensitive and appropriate care for women who have experienced FGM
To inform women about the illegality of the procedure in any form
1.3 Patient/client group
Women who have undergone FGM.
Children or young women who may be at risk of FGM
All areas may come into contact with these groups, high risk areas would be ED, Maternity
and sexual health.
According to the World Health Organisation (WHO) Female Genital Mutilation (FGM) is
practiced in approximately 30 countries in Africa and the Middle East.
In the United Kingdom it is often seen among immigrants from:
Somalia, Guinea, Mali, Sudan, Ethiopia, Sierra Leone, Egypt
FGM has also been documented in communities in Yemen, Iraq, Israel, Oman, the United
Arab Emirates, the Occupied Palestinian Territories, India, Indonesia, Malaysia and
Pakistan.
1.4 Exceptions/ contraindications
None.
2. Clinical Management
2.1 Staff & equipment
All Obstetricians and Midwives
2.2 Method/procedure
At booking every women must be sensitively questioned (regardless of race or culture) if they have
undergone any procedures to their genitalia for medical, religious or cultural reasons. Consideration
should be given to the woman’s language and understanding. It is important to ask women at
booking, particularly if they are from a high-risk area, or have ancestry from a high-risk area.
Talking to women and young girls about FGM
It may be difficult for women to talk about the issue, and it's important to ask sensitively. There may
be language barriers, and a trained interpreter may be required during the consultation. Some women
may not understand the term FGM, but know about circumcision. Other ways of asking about it could
be to use words such as "cut", "closed" or "open". Other important factors highlighted in the FGM:
multi-agency practice guidelines (HM Government, 2014) are the following:

Women and girls may prefer to speak to a professional of the same gender.

They may not want to be seen by a professional from their own community.

Alerting the girl’s or woman’s family to the fact that she is disclosing information about FGM
may place her at risk of harm.

Develop a safety and support plan in case they are seen by someone "hostile" at or near the
department, venue or meeting place – e.g. prepare another reason why they are there.

If they insist on being accompanied during the interview – e.g. by a teacher or advocate –
ensure that the accompanying person understands the full implications of confidentiality,
especially with regard to the person’s family.

Do not assume that families from practicing communities will want their girls and women to
undergo FGM.
Ask the questions DOH (2015)
Do you or your partner come from a community where cutting or circumcision is practised?
Have you been cut? It may be appropriate to use other terms or phrases
In all circumstances
The Woman and Family must be informed of the law in the UK and the health consequences of
practising FGM
Ensure all discussion are approached with due sensitivity and are non-judgemental
Discuss the obligation to refer to Social Care and that you will be informing their GP
and Health Visitor.
Emphasise that the family will be offered support around the issue
Safeguarding
It is important to note that as with domestic violence and rape, if an adult woman has had FGM and
this is identified through the delivery of NHS healthcare, the patient’s right to patient confidentiality
MUST be respected if they do not wish any action to be taken. No reports to social services or the
police should be made in these cases, however when a woman becomes pregnant the rights and
safety of the baby and (in the case of FGM a female child) must be considered. Where professionals
believe that an individual has undergone FGM, they must consider risks to other girls or women who
may be related to or living with her and/or her family
AN URGENT REFFERALTO CHILDREN’S SOCIAL CARE SHOULD ALWAYS BE MADE (EVEN IF
OUT OF HOURS) IF A CHILD OR YOUNG ADULT SHOWS SIGNS OF VERY RECENTLY
HAVINGUNDERGONE FGM. THIS MAY ALLOW FOR THE POLICE TO COLECT PHYSICAL
EVIDENCE.
AN URGENT REFERRAL SHOULD ALWAYS BE MADE IF A HEALTH PROFESSIONAL
BELIEVES THAT THERE ARE PLANS TO TRAVEL ABROAD WHICH PRESENT A RISK THAT A
CHILD IS IMENINENTLY LIKELY TO UNDERGO FGM.
Referrals into the MASH (Children’s Social Care) should be followed up in writing within three
days. The Named Nurse for Safeguarding should receive a copy of the referral.
Ensure the Named Midwife for Safeguarding is informed for all women identified as having
undergone FGM.
Antenatal care
The more anatomically destructive the mutilation the greater risk of obstetric sequelae [ref 20 rcog
guideline].
Potential maternal consequences include [RCOG guideline]:

Fear of childbirth

Recurrent UTIs

HIV and Hepatitis

Post traumatic stress disorder

Increased likelihood of caesarean section

Increased likelihood of PPH

Increased likelihood of episiotomy

Increased likelihood of severe vaginal tears

Difficulty in performing vaginal examinations

Difficulty in applying fetal scalp electrodes

Difficulty in performing fetal blood sampling

Difficulty in performing catheterisation
Types of FGM
FGM can be divided into 4 categories [WHO classification]
Normal anatomy
Type 1: Partial or total removal of the
clitoris and/or the prepuce
(clitoroidectomy)
TYPE 2: Partial or total removal of the
clitoris and the labia minora, with or
without excision of the labia majora
(excision)
TYPE 3: Narrowing of the vaginal orifice
with creation of a covering seal by cutting
and appositioning the labia minora and/or
the labia majora, with or without excision
of the clitoris (infibulation)
TYPE 4: All other harmful procedures to
the female genitalia for non-medical
purposes, e.g. pricking, piercing, incising,
scraping and cauterising.
(Images courtesy of Blatant World, Ireland: https://www.flickr.com/people/blatantworld/)
The following should be done in the antenatal period:

These women need to be identified correctly and referred to a consultant led clinic.

The consultation in antenatal clinic should include a psychological assessment and referral to
a psychologist should be discussed with the woman [rcog, 2015]

Physical assessment should be ideally by a consultant obstetrician or senior registrar, firstly
for documentation and secondly to determine whether antenatal surgery is required.

The proforma should be used to assist with identification and to plan intrapartum care.
Patient details/sticker
Antenatal Proforma for FGM
Name:
DOB:
Consultant: KEB/SLD/SAF/SMV/AJK/JBF
Hospital number:
Date:
Gravida:
Parity:
Language spoken:
Antenatal
Interpreter required: Yes/ No
Circle as appropriate
Recurrent UTIs Yes/No
Abnormal Stream Yes/ No
Is the urethra easily visualised Yes/No
Post traumatic stress psychologist referral offered Yes/No
Informed about inability to re-infibulate the FGM after delivery Yes/No
Define FGM: Type 1/ Type 2/ Type 3/ Type 4
Intrapartum Recommendations:
Circle as appropriate
Manage labour as normal Yes/No
Inform consultant of admission (out of hours) Yes/ No
Inform registrar when in labour Yes/No
IV access and G+S in labour Yes/ No
Medio-lateral episiotomy as required Yes/No
Intrapartum care:

FGM is not an absolute indication for caesarean section.

Women with FGM are advised to deliver on labour ward.

Inform the registrar when admitted in labour, the proforma will state whether the
consultant is to be

FGM is not an absolute indication for caesarean section.

Women with FGM are advised to deliver on labour ward.

Inform the registrar when admitted in labour, the proforma will state whether the
consultant is to be informed.

IV access and G+S should be performed when in active labour.

Epidural anaesthesia should be offered to women who have difficulty tolerating
vaginal examinations and if an anterior episiotomy is required in labour.

Episiotomy should be recommended if inelastic scar tissue is preventing progress but
caution should be used regarding placement.
Postpartum care

Seek advice for suturing if unsure of anatomy.

As per UK law the FGM cannot be re-sutured but it is important to stop the bleeding,
this can be done with interrupted sutures either side of the anterior episiotomy.

WHO recommends suturing of the raw edges to prevent spontaneous reinfibulation
[rcog ref 29]
Consider prophylactic antibiotics if large anterior episiotomy.
2.3 Potential complications / Risk Management
Potential safeguarding concerns regarding any female infant born sibling other children in family or
close friends.
3. Patient Information
The NHS Choices website has information about FGM for women, which may be a useful
resource.
http://www.nhs.uk/NHSEngland/AboutNHSservices/sexual-health-services/Pages/fgmhealth-services-for-women.aspx
4. Audit

Documented enquiry and risk assessment completed in hand held maternity notes;

A referral appointment with the lead Consultant for FGM was made by 16 weeks
gestation;

Questions should be asked and documented regarding if they have any problems
with dyspareunia, menstruation or micturition;

Women who have been infibulated should be always be encouraged to have this
reversed before childbirth to prevent complications of FGM. This discussion should
be documented in the maternity hand held notes.

Women should be given an information leaflet.

Any safeguarding issues should be documented and raised with The Named Midwife
for Safeguarding

The FGM proforma was completed.

An appointment was made 3 weeks post natal for a review.
5. Evidence Base
Summary of evidence, review and recommendations
1. DOH (2015) Female Genital Mutilation Risk and Safeguarding- Guidance for
Professionals
2. HM Government (2014) Multi-agency Practice Guidelines: Female Genital Mutilation
3. RCOG (2015) Female Genital Mutilation and it’s management (Green-top Guideline
No.53) https://rcog.org.uk/en/guidelines-research-services/guidelines/gtg53/
4. South West Child Protection Procedures
5. WHO (2014) Female Genital Mutilation- Fact Sheet No 241.
www.who.int/mediacentre/factsheets/fs241/en/