Managing pregnancy, labour and birth, and postnatal care

Care for women with FGM during pregnancy, labour and birth, and postnatal care should always be provided by a LMC who is familiar with the FGM Clinical Care Antenatal, Labour & Birth and Postnatal Guidelines and experienced in the management of women with FGM. Women affected by FGM Type 3 may require specialised pregnancy care, which can include deinfibulation before or during labour (New Zealand FGM Education Programme, 2009a).

In addition to routine antenatal education, LMCs should discuss the following areas to prepare the woman for pregnancy, labour and birth and what to expect in the postnatal period:

• The anatomy and physiology of unaltered genitalia compared with FGM.
• The potential for referral to a registrar/obstetrician during labour or birth, and the possible need for deinfibulation during birth.
• Women may request a female registrar/obstetrician. Where possible, this should be arranged. However, it should be explained that this is dependent on availability.
• The process of suturing the scar site after deinfibulation (restoring the scar site to a state of infibulation is illegal in New Zealand).
• The physiological changes that follow deinfibulation during labour, including changes in menstruation, urination and sexual intercourse.
• Gender preferences for interpreters.
• Cultural resistance to induction of labour, and relevant DHB induction of labour practices for post term pregnancies (Note: Where there is opposition to induction of labour or other interventions this should be clearly documented in the women’s notes).
• Cultural resistance to caesarean section, and relevant DHB indications for performing caesareans.
• Postnatal support – note that some women may experience psychological trauma or flashbacks during childbirth related to FGM and/or the refugee experience. If necessary, refer for psychological support.

Genital assessment is recommended during the antenatal period, once a trusting relationship has been established between a woman and her LMC. It is important to determine early in the pregnancy the degree to which a woman’s FGM is likely to impact on her labour and birth. The New Zealand Female Genital Mutilation 2008 Health Care Survey showed that only 20% of women affected by FGM had undergone a genital assessment prior to labour (Denholm & Powell, 2009). Lack of assessment places a woman and her baby at unnecessary risk of complications during labour and birth.

It is important to note that health literacy varies greatly across the range of women affected by FGM. Women who have come from urban areas commonly have higher levels of health knowledge than those from rural backgrounds. It should not be assumed that all women are literate, even in their mother tongue (Ministry of Health, 2001). Provide antenatal health education that is clear, concise and highly visual.

Additionally, be aware that for most women affected by FGM, pregnancy and childbirth are considered normal events in their homelands. In many traditional societies the childbirth process is viewed as a collective experience, largely involving closely-related women. Family members are intimately involved in supporting the pregnant mother, helping with birth, caring for the newborn and influencing any health decisions. LMCs therefore need to be aware that decisions about issues such as induction of labour, caesarean section and choices for labour may need to be made in consultation with a number of family members.

The Female Genital Mutilation Resource Kit contains a number of tools and resources to assist service providers to communicate effectively with women affected by FGM: see www.fgm.co.nz.