This practice refers to medically unnecessary vulvar and perineal modification. In the United States, it is a federal crime to perform unnecessary genital surgery on a girl younger than 18 years. That said, forms of female genital mutilation are practiced in countries throughout Africa, the Middle East, and Asia. As many as 200 million women worldwide have undergone one of these procedures, and approximately 513,000 girls in the United States were at risk for this practice in 2012 (Goldberg, 2016; UNICEF, 2016). Cultural sensitivity is imperative, because many women may be ofended by the suggestion that they have been assaulted or mutilated (merican College of Obstetricians and Gynecologists, 2014).
The World Health Organization (2008) classifies genital mutilations into four types (Table 27-1). Long-term complications from surgery and its associated scarring include infertility, genital pain, diminished sexual quality of life, and propensity for urogenital infection (Almroth, 2005; Andersson, 2012; Nour, 2015). In general, women with significant symptoms following type III procedures are candidates for corrective surgery. Specifically, division of midline scar tissue to reopen the vulva is termed deinibulation.
Female genital mutilation has been associated with some adverse maternal and neonatal complications. The World
TABLE 27-1. World Health Organization Classification of Female Genital Mutilation
Type I Partial or total removal of the clitoris and/or prepuce
Type II Partial or total removal of the clitoris and the labia minora, with or without labia majora excision
Type III Partial or total labial minora and/or majora excision, followed by fusion of the wound, termed infibulation, to cover and narrow the vagina. With or without clitoridectomy
Type IV Pricking, piercing, incising, scraping, cautery, or other injury to female genitalia
Adapted from the World Health Organization, 2008.
Health Organization (2006, 2008) estimated that these proce dures increased perinatal morbidity rates by 10 to 20 per 1000.
Small increased risks for prolonged labor, cesarean delivery, and postpartum hemorrhage are also found (Berg, 2014; Chibber, 2011; Wuest, 2009). Importantly, the psychiatric consequences can be profound.
To prevent obstetrical complications, deinibulation can be performed either antepartum or intrapartum (Fig. 27-9) (Esu, 2017). In women not undergoing deinibulation, anal sphincter tear rates with vaginal delivery may be increased (Berggren, 2013; Rodriguez, 2016). In our experiences, intrapartum deinibulation in many cases allows successful vaginal delivery without major complications.
hese surgeries are performed with increasing frequency in reproductive-aged women, and thus pregnancy following these procedures is not uncommon. Logically, there are concerns for symptom recurrence following vaginal delivery, and high-quality data to aid evidenced-based decisions are limited. For women with prior stress urinary incontinence surgery, slightly greater protection against postpartum incontinence is gained by elective cesarean delivery (Pollard, 2012; Pradhan, 2013). Stated another way, most women with prior corrective surgery for incontinence can be delivered vaginally without symptom recurrence. Also, cesarean delivery is not always protective. Obviously, symptom recurrence and the need for additional vaginal surgery should be weighed against the surgical risk of cesarean delivery (Groenen, 2008). In those with prior surgeries for anal incontinence or pelvic organ prolapse, only scant information regarding outcomes is available. Such cases require individualization.