Oxford Handbook of Midwifery (67 page)

1. • Lidocaine can be injected slowly as the needle is withdrawn. However,
     it is considered to be more effective if 3–4mL are injected initially and
     

     then, before removing the needle, the remaining lidocaine is injected
     

     either side of the initial injection, in a fan shape.
     

   • At least 4–5min must be given for the analgesic to be effective prior to incision (Fig. 14.3).
     
   • Use blunt-ended scissors.
     
   • Insert two fingers into the vagina, as before.
     

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Line of incision Anal sphincter

Fig. 14.3
Episiotomy.

1
Carroli G, Belizan J (2006). Episiotomy for vaginal birth (Cochrane review). In:
Cochrane Library
, Issue 3. Chichester: John Wiley and Sons.

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Female genital mutilation

Female genital mutilation (FGM), also known as female circumcision, is deeply rooted in the traditions and religion of about 30 countries. In the UK it is most commonly seen amongst immigrants from Somalia, Eritrea, Mali, Sudan, Ethiopia, Sierra Leone, and Nigeria. The practice has been outlawed in the UK, and parents found to be carrying out this practice, or returning to their country of origin for this to be undertaken, are at risk of severe penalties.

Definition

FGM involves a variety of invasive procedures that result in partial or total removal of the external female genitalia and/or other injury to the female genital organs, for cultural or any other non-therapeutic reason.

Classification

• Type 1: excision of the prepuce, with or without excision of part or all of the clitoris.
  
• Type 2: excision of the prepuce and clitoris, together with partial or total excision of the labia minora.
  
• Type 3: excision of part or all of the external genitalia and stitching/ narrowing of the vaginal opening (infibulation).
  
• Type 4: unclassified: includes pricking, piercing, or incision of the clitoris and/or labia; stretching of the clitoris and or labia; cauterization by burning the clitoris and surrounding tissues; scraping of the vaginal orifice or cutting the vagina; introduction of corrosive substances to the vagina to cause bleeding, or herbs placed in the vagina to cause tightening or narrowing of the vagina; any other procedure that falls under the above definition.
  

  Cultural and historical background
  

• Most parents believe they are doing their best for their daughters and that they are adhering to sound cultural practices.
  
• A circumcised woman is regarded as spiritually pure and clean. An uncircumcised woman is regarded as shameful and unnatural by society and therefore not fit to marry or have children.
  
• It is believed she must undergo this procedure in order for her to identify with the everyday hardships of being a woman.
  
• Religious reasons—some women see it as a religious obligation. There are no references in the Bible or the Koran referring to FGM.
  
• It is claimed to promote chastity and virginity.
  
• It negates sexual pleasure.
  
• It is advocated as improving fertility and preventing maternal and infant
  mortality. The opposite is true, FGM puts the health of the woman and
  

  the baby at great risk during pregnancy and childbirth.
  

• It is claimed to ensure that a woman is faithful to her husband, thereby preventing promiscuity.
  
• It is believed to promote cleanliness.
  
• Parents believe that FGM ensures a good marriage for their daughters.
  

Prevalence

FGM is commonly performed on girls between the ages of 4 and 10 years, but may also be performed soon after birth, at adolescence, at the time of

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marriage, or during the first pregnancy. The procedure is usually carried out by a traditional midwife or a woman within the local community. FGM is practised widely on the African continent, with countries such as Somalia and Sudan performing infibulation on 90–98% of girls. The WHO estimates that over 120 million women from 30 different countries have undergone FGM.

Complications

Following FGM, immediate complications are haemorrhage, pain, shock, infection, urine retention, injury to surrounding tissue, ulceration of genital area, and death. Long-term complications include:

Complications during labour and birth

exposes the urethra and clitoris (which is often buried under scar tissue)

is performed during labour. Prompt assessment of suturing requirements following birth should be attended to, and sensitive follow-up care of the woman’s physical and psychological welfare should be ongoing.

Recommended reading

Momoh C (ed.) (2005).
Female Genital Mutilation
. Abingdon: Radcliffe Publishing Ltd.

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Conduct of normal vaginal delivery

If a woman and her birthing partner have established a good rapport with their midwife, the environment is peaceful and unhurried, there is low lighting and privacy, with good communication and information, then the woman is likely to have a positive and empowering experience of birth.

The woman should be enabled to adopt a position for birth that she feels comfortable with, and should be relaxed enough to verbalize (shouting, grunting, etc.) to relieve tension and anxiety and to prevent breath-holding.

Preparation

• When birth is anticipated, put on protective glasses (in case of blood spillages).
  
• Wash your hands thoroughly, put on protective wear and gloves, and prepare the necessary equipment. A sterile area for equipment will need to be organized and accessible.
  
• The immediate birthing area should be prepared, e.g. mattress, birthing chair, etc.
  
• Prior to the birth, wash the vulva with water/lotion, drape sterile towels around the immediate area, and place a sterile pad over the anus to prevent faecal contamination.
  
• If the woman is in an upright position, the anal area will need to be kept free from faecal material.
  

  Delivery
  

• Encourage the woman to work with her contractions as before.
  
• At crowning, encourage her to breathe gently and/or to pant her baby’s head out in a slow and controlled way. This helps to minimize perineal trauma, empowers the mother’s experience, and prevents the need for too much hands-on intervention.
  
• Be ready to prevent sudden delivery of the head. There is no physiological rationale for the application of firm pressure and resistance to maintain flexion, which serves only to increase the diameters of the fetal skull (b see Flexion technique, p. 277).
  
• Encourage the mother, both verbally and by non-verbal communication. This is crucial in helping to maintain her efforts and confidence. Make plenty of eye contact and give her praise, using a quietly spoken and supportive tone throughout.
  
• The Ritgen manoeuvre is generally not required if the birth is proceeding normally. Grasping the parietal eminences to overextend the head serves only to increase the diameters of the fetal skull (b see
  

  Care of the perineum, pp. 276–8).
  

• Checking for the cord around the neck of the baby can cause considerable discomfort for the woman, and opinions are mixed as to whether this procedure is routinely necessary.
  
  • If the cord is around the neck, it can usually be untangled following delivery.
    
  • If the cord is very tight, some suggest cutting the cord: two pairs of artery forceps are applied 2.5cm apart and the cord cut between
    

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    285
    

    them, using cord scissors, and then unwound. However, this can often be a difficult procedure and may result in lower Apgar scores.
    

    • Others suggest that cutting the cord is unnecessary, as the baby will be born through the loops of cord.