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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.
Episiotomy
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/Resuturing
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. |
