Female circumcision: a risk factor in postpartum haemorrhage.MM McSwiney, PR Saunders
Sir Humpry Davy Dept of Anaesthesia, Bristol Royal Infirmary.
A major postpartum haemorrhage occurred in a patient with a previous history of female circumcision. Following assisted vaginal delivery 6 litre blood loss occurred as a result of tears to the vagina and perineum. The tears were sutured, followed by insertion of vaginal packs. Replacement fluid therapy was given. To reduce the incidence of tears and accompanying haemorrhage, it is advisable to perform two episiotomies viz. anterior and midline posterior or mediolateral.
Keywords: Adult, Case Report, Circumcision, Culture, Episiotomy, Female, Human, Male, Perineum, injuries,Postpartum Hemorrhage, etiology,therapy,Pregnancy, Risk Factors, Vagina, injuries,
Female circumcision is performed more widely than is generally recognized. Though the incidence is more in Third World Countries, health care workers in the Western World also encounter it due to immigration and increased world travel from these continents. We present here our experience of vaginal delivery of a female who had undergone pharonic circumcision.
A 22 year old, 45 kg Somalian patient, gravida 1 para 0 was admitted to the maternity hospital at 39 weeks of gestation. The patient was unable to speak English. The history from her husband included a previous infibulation.
On examination she was found to have a longitudinal lie with a cephalic presentation and spontaneous rupture of membranes. Vulval examination demonstrated a pharonic circumcision. Syntocinon was commenced to augment her contractions. Analgesia was provided with an intramuscular injection of pethidine (75 mg).
After 6 hrs, the cervix was found to be fully dilated, with the fetal head in the occipitoanterior position. The cardiotocograph demonstrated persistent type II decelerations. The patient was taken to the theatre for instrumental delivery with an anaesthetist present.
A moderate haemorrhage was noted from perineal tears around the fetal head, which had reached the perineum. Forceps were applied at this stage following a posterior episiotomy. A healthy male child was delivered followed by an intact placenta with satisfactory uterine contraction.
Immediately after delivery a rapid haemorrhage occurred. Inspection by the obstetrician demonstrated numerous vaginal and perineal tears.
At this stage, anaesthesia was induced and the patient was intubated and ventilated. A total blood loss of 6 litres occurred. Replacement fluid consisted of 2,500 ml of gelatin colloid, 7 units of blood and 5 units of fresh frozen plasma.
The numerous vaginal and perineal lacerations were sutured and the vagina was packed with proflavine hemisulphate pads. The patient was transferred to the intensive care unit where intermittent positive pressure ventilation with sedation was continued overnight until the patient was extubated the following morning.
Forty-eight hrs later the vaginal pack was removed under anaesthesia. Satisfactory surgical repair and good haemostasis was evident. The patient was discharged a week later with instruction for future deliveries by Caesarean section.
Though some observers believe female circumcision was originally a means of suppressing female sexuality and attempting to ensure chaste or monogamous behaviour, others believe that it started long ago among herders as a protection against rape of the young girls who took the animals out to pasture. In fact the origins have proved impossible to trace,.
It is performed more widely than is generally recognised and no continent is exempt. It is usually performed by the local 'Dayah' or 'Midwife' at a time varying between eight days and puberty. It is estimated that more than 74 million women and children are circumcised in Africa alone. The operations are also practiced in many parts of the Middle East and with Moslennization were introduced into Indonesia and Malaysia. Reports that the operation is being performed in London led to the introduction of a bill in the House of Lords to prohibit excision or infibulation of the female sexual parts, unless two doctors agree that it is necessary for the physical health of the patient.
There are three main types of female circumcisions:,
1. Circumcision proper - known in Muslim countries as sunna (traditional) is the mildest but also the rarest form. It involves the removal only of the clitora prepuce.
2. Excise - this involves amputation of the whole of the clitoris and all or part of the labia minora.
3. Infibulation - also known as pharonic circumcision. This involves amputation of the clitoris, the whole of the labia minora and at least the anterior two-thirds and often the whole of the medial part of the labia majora. The two sides of the vulva are then stitched together with silk, catgut or thorns, and a tiny silver of wood or a reed is inserted to preserve an opening for urine and menstrual blood. The girl's legs are usually bound together until the wound has healed which may take up to 40 days. In societies where pharonic circumcision is practiced, women are commonly reinfibiulated after each delivery, divorce and on the death of their husband.
The insertion of rock salt into the vagina after delivery to cause vaginal narrowing is common in the United Arab Emirates. 'Gishri' or vaginal cuts is another method used to achieve the same effect.
Most of the adverse health consequences are associated with the Pharonic circumcision,, and are listed below:
A. Immediate: Haemorrhage; wound infection and urethral damage.
B. Gynaecological and genitourinary: haematocolpos; keloid formation; implantation dermoid cysts and abscesses; chronic pelvic infection; calculus formation; dyspareunia; infertility and urinary tract infection. and
C. Obstetric: perineal lacerations; haemorrhage; bladder, urethral, rectal injury; puerperal sepsis; delay in labour; vesico and rectovaginal fistulae; fetal brain damage and fetal loss.
The splitting of the circumcision skin fold, so called anterior episiotomy or cleinfibulation, is always necessary during labour. If this is not done the rigidity of the circumcision scar may force the fetal head backwards, causing severe perineal lacerations, as occurred in our case. Thus, the patient requires two incisions, an anterior episiotomy and a midline posterior or mediolateral episiotomy.