Women and girls from the FGM practising communities have the same right of access to National Health services as everyone other resident in the United Kingdom, these women must be treated sympathetically.

Currently there are several specialist clinics in the United Kingdom, however in today's society it is becoming increasingly more likely that women will not live close to a specialised centre.

The proceeding tabs aim to provide advice and guidance on what to do should you come into contact with a woman who has undergone FGM.
Identification of the woman at risk of FGM

It is essential to identify women who have undergone FGM at the booking visit. The antenatal period may be the first contact that she and her partner will have with the health care system and she may feel quite unsure and frightened about what to expect.

Who is at risk?

Patients attending UCH with a past history of FGM are most commonly from Somalia and Sudan. In Somalia 95% of women will have FGM and the majority will have had the most extensive Type III FGM. All women from these countries must be asked about FGM.

The other countries of origin with high rates of FGM and who are likely to come to the UK include Eritrea, Gambia, Ghana, Kenya, Nigeria, Sierra Leone and Yemen. Rates of FGM in these countries are variable and many will have a Type I or II FGM which may not cause obstetric complications.

How to ask?

Women may not volunteer this information and the booking midwife will need to ask sensitively. A trained interpreter may be necessary. Women will not understand the terminology female genital mutilation although may use the word circumcision. Other ways of phrasing this difficult question include asking if the women is “cut” or “closed” or “open”.

What to do if the woman has had FGM?

Once identified it is important to explain to her about how FGM may affect labour and delivery. She may already be aware that some kind of “opening/cutting” may be necessary and have strong views on this. She may however have very little information on what has happened to her and what needs to happen next. The possible problems must be explained sensitively. She must also be made aware that she does need a vaginal assessment to see whether the vagina is adequate for delivery. This assessment must be done by a midwife or obstetrician experienced in FGM and able to make that decision.
What is deinfibulation?

Deinfibulation (or defibulation) opens up the scar tissue to restore the normal vaginal opening. It is commonly called “reversal” although is not accurate at this does imply that the procedure can be undone and tissue replaced which is of course not the case.

When is it necessary?

An experienced midwife can usually tell whether deinfibulation is needed by perineal inspection and an internal vaginal examination is not necessary. On inspection the vagina should be adequate to allow a vaginal examination in labour. The urethral opening should be visible to allow catheterisation if necessary. If neither of these are the case, then deinfibulation is required.

Timing of Deinfibulation

The RCOG guidelines recommend deinfibulation in the mid-trimester at around 20 weeks gestation. However many women present much later for booking and thus have later deinfibulation. Women also may be reluctant to undergo deinfibulation until labour as this would be what happens in their country of origin. The problem with this is that a midwife familiar with FGM may not be on duty at the time of delivery. These issues should be explained sensitively to the women. If she still declines antenatal deinfibulation then it should be clearly documented in her hand held obstetric notes that she requires deinfibulation on admission in labour.


Women may still need a standard episiotomy during labour for fetal distress or delay in second stage whether or not they have had deinfibulation and this must also be explained to them.

The Procedure of Deinfibulation

Deinfibulation is usually performed under local anaesthetic. This means it is essential to be very gentle and also to explain carefully what you are doing at each stage. Flash-backs to the original procedure have been reported.

The woman is placed in the lithotomy position and the vulva is washed with antiseptic solution. It may not be possible to clean inside the vagina as the opening can be just a few millimetres diameter. You can then insert a finger under the anterior band or scar tissue. If the opening is too small to allow your finger, then you can use the closed points of an artery forcep or small Spencer-Wells forceps. Once the forceps is under the scar tissue you can open them up and infiltrate the scar tissue with local anaesthetic (e.g. 1% Xylocaine and adrenaline). This may be painful and the woman should be warned about this. Once the area is numb, a straight incision is then made anteriorly with either scalpel or scissors through the scar tissue (Figure 1). This may be thick and quite difficult to cut. In pregnancy it is adequate to excise the scar tissue until the urethra is visible. A more extensive excision can be done but should be discussed with the woman and is more usual in non-pregnant women. The cut ends of the incised skin will usually now retract outwards to reveal a normal vaginal introitus beneath. If there is no bleeding then suturing is not necessary. However if there is bleeding the raw edges should be sutured either with continuous or interrupted sutures. Suturing will also decrease the chance of raw edges sticking together in the midline (3.0 Vicryl rapide).

Post-operative care

The woman should be given advice about bathing the area twice a day and gently checking that the suture lines are not healing together across the midline. Gelonet (vaseline gauze) can be applied immediately after the procedures. Intercourse should be until healing is complete and the woman feels comfortable and confident. She should be warned that her urine flow may be faster – and noisier!


Reinfibulation is illegal in the UK. The midwife may be asked by the woman or her husband to reclose the vagina after delivery. It is very important not to do this and to explain to the woman that it is against the law and that you cannot do it.
Coming Soon.
The first time that the FGM bill was presented to Parliament in 1982 it was defeated, the reason being that it would alienate minority groups, and that action taken against individuals would be construed as being racist, and also the numbers affected by FGM were not known at this time.

In 1985 the Government introduced the Prohibition of Female Circumcision Act making FGM illegal in England Ireland and Wales. The law made it illegal to:

“Excise, infibulate or otherwise mutilate the whole or any part of the labia majora or minora or clitoris of another person or to aid abet counsel or procure the performance by another person of any of those acts on that other person own body” (Para 1a).

The penalty was £1000 fine or a term of imprisonment not exceeding 6 months or both.

The Children Act 1989

The government passed the Children Act 1989 to protect children. This act was an attempt to amalgamate existing laws into one comprehensive law. The act did not specifically mention FGM.

Working together to Safeguard Children

In 1999, Working together to safeguard children was produced this document sets out guidelines on how all agencies and professionals should work together to promote children’s welfare and protect them from abuse and neglect. The guidelines provide a framework for local authorities which will help deal with issues of child protection. FGM is specifically mentioned in the chapter “Child protection in specific circumstances” It states that Local authorities may exercise their powers under Section 47 of the Children act if they believe that a child is likely to be or has been the subject of FGM.

Female Genital Mutilation Act 2003

Due to a loophole in the 1985 bill it soon became clear that this would allow communities to take daughters home ‘on holiday’ to have FGM performed there.

In 2003, a private members bill supported by the Government was legislated, it was enacted in March 2004. The amended Law is called the Female Genital Mutilation Act 2003. This made it illegal to take girls who are UK nationals or UK permanent residents out of the UK for the sole purpose of FGM.

This protection applies irrespective of the legislation in the country to which the girl maybe removed to. The maximum prison sentence was increased to 14 years.
The primary focus for safeguarding children is to prevent FGM taking place. It is acknowledged that some families see FGM as an act of love rather than cruelty; however FGM causes considerable harm both in the short and long term and constitutes physical and emotional abuse to children.

Wherever possible the aim of prevention is to work in partnership with parents, families and communities to protect children through raising awareness of the harmful effects of the practice and the UK legislation (FGM Act 2003).

FGM must always be considered as causing significant harm therefore, if you believe that a girl or her younger siblings may be at risk you must act and contact your local child protection co-ordinator. The document Working Together To Safeguard Children (1999) highlights that a local authority may exercise its powers under s.47 of the Children Act 1989 if it has reason to believe that a girl is likely to be or has been the subject of FGM. Professionals must work together to safeguard children and be vigilant at all times to the potential risk.

Thresholds for Referral/Risk Assessment

Professionals need to be aware of the possibility of FGM. The following are possible indicators that FGM may take place:

● The family comes from a community that is known to practise FGM. E.g. Somalia, Sudan and other African
countries. It may be possible that they will practice FGM if a female family elder is present in the family network.

● Antenatal booking provides an opportunity for recognition of risk and preventative work with parents/carers. Any
female child born to a woman who has been subjected to FGM must be considered to be at risk, as must other
female children in the extended family.

● Parents state that they or a relative will take the child out of the country for a prolonged period.

● A child may talk about a long holiday to her country of origin or another country where the practice is prevalent,
including African countries and the Middle East. Of other European Countries.

● The child may confide to a professional that she is to have a ‘special procedure’ or to attend a special occasion.

● Reference to FGM/Circumcision is heard in conversation, for example a child may request help from a teacher
or another adult.

(Ref: Waltham Forest Local Safeguarding Children Board FGM Protocol for Children and Young People 2006). ***London Procedures

Indications that Female Genital Mutilation may have already taken place include:

● A child may spend long periods of time away from the classroom during the day with bladder or
menstrual problems.

● There may be prolonged absences from school.

● A prolonged absence from school with noticeable behaviour changes on the girl’s return could be an indication
that a girl has recently undergone FGM.

● At antenatal booking the holistic assessment may identify women who have undergone FGM. Midwives and
Obstetricians should then plan appropriate care for pregnancy and delivery.

Professionals also need to be vigilant to the needs of children who may/are suffering the adverse consequence of the practice.

Child who has already undergone FGM

If a child has already undergone FGM and this comes to the attention of any professional, a referral should be made to social services. A strategy meeting must be convened within two days. The strategy meeting will consider how, where and when the procedure was performed and the legal implication of this.

● If the child has already undergone FGM the strategy meeting will need to consider carefully whether to continue
enquiries or whether to assess the need for support services. Particular attention should be given to assessing
the needs of any other girls in the family. If any legal action is being considered, legal advice must be sought.

● A second strategy meeting should take place within ten working days of the referral, with the same chair. This
meeting must evaluate the information collected in the enquiry and recommend whether a child protection
conference is necessary. (LCPC 2003).

● Any girl who has undergone FGM may be offered counselling and medical help as required. Consideration must be
give to any other female siblings at risk.

● A child protection conference should only be considered necessary if there are unresolved child
protection issues once the initial investigation and assessment have been completed.