Female circumcision is a problem unfamiliar to most Western obstetrician-gynecologists. We present a case illustrative of the unique management problems posed by these patients during labor. A method of releasing the anterior vulvar scar tissue to allow vaginal delivery is described. Sensitivity and a nonjudgmental approach as to what is culturally appropriate care for these women are of paramount importance.
PIP: Although female circumcision is a health condition unfamiliar to most Western obstetrician-gynecologists, immigrants from parts of the world where this procedure is routinely practiced may be encountered. Such women pose unique management problems during labor and delivery. Presented is the case of a 36-year-old Sudanese woman who had undergone pharaonic circumcision, with substantial vulvar scarring, as a young girl in her country of origin. After emigration to the US, she had 2 Cesarean section deliveries. When she presented to the University of New Mexico with a 3rd pregnancy, she requested vaginal birth (to overcome the stigma of moral weakness her family associated with cesarean section) and a female obstetrician familiar with female circumcision. The patient had spontaneous membrane rupture at 39 weeks' gestation. Epidural anesthesia was necessary to examine the patient without severe discomfort. The external genitalia were missing the labia minora, and the clitoral area and external urinary meatus were obscured by bands of scar tissue that had to be cut. The major obstetric problem associated with this profile is prolongation of the 2nd stage of labor due to scar or soft tissue dystocia and the consequent need for deinfibulation. Women who labor unattended with an obstructed introitus are at risk of vesicovaginal and rectovaginal fistulas, laceration of scar tissue with hemorrhage, and fetal asphyxia or death. Incision of the fibrous tissue in this patient allowed sufficient widening of the introitus for expulsion of the fetal head. Delivery was uneventful and occurred after 19 hours. Although some women may desire reinfibulation, this patient sought less discomfort in future vaginal examinations, so the vulvar scars were not reapproximated. The raw surfaces were oversewn loosely after delivery.