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When Cultures Collide: Female Genital Cutting and U.S. Obstetric Practice

Rosenberg, Leah B.1; Gibson, Keri MD2; Shulman, Joanna F. MD4

doi: 10.1097/AOG.0b013e3181998ed3
In the Trenches

CASE: A 28-year-old primigravida at 41 weeks of gestation, previously unregistered, presented to a tertiary care Labor and Delivery unit reporting painful uterine contractions 7 minutes apart. The patient, a recent immigrant from a Northeastern African country, was accompanied by her extended family. She promptly disclosed that as a 10-year-old she underwent genital cutting in her country of origin.

Physical examination revealed the results of Type III female circumcision, or total removal of the clitoris and labia minora, and infibulation, or sewing together, of the labia majora. The prepuce and body of the clitoris were completely absent. In addition, the external urethral orifice was not visible due to extensive scar tissue overlying the infibulation. The scar tissue was pale gray, avascular, and extended almost the entire length of the labia majora, leaving a relatively small opening. As active labor continued, it became clear that the constricted opening would not allow for fetal descent. The obstetrician in attendance subsequently performed a midline episiotomy through the perineal body. A healthy male neonate was delivered. During the postpartum examination, the obstetrician identified extensive lacerations as well as an almost total separation of the previously fused labia majora.

The obstetrician explained the reasoning for midline episiotomy repair to the patient and her sister, who was continuously at the bedside. The obstetrician also informed the patient that the infibulation separated. As the obstetrician began repairing the internal lacerations, the patient insisted that the labia majora be sewed back together (reinfibulation). Although the obstetrician explained the risks of poor wound healing and infection from suturing a devascularized tissue plane, the sister emphasized the importance of infibulation in their culture and the need to have the circumcised anatomy restored. After careful consideration, the obstetrician performed a repair of the lacerated tissue, including a partial reinfibulation.

As more women with a history of female genital cutting deliver in the United States, obstetrician–gynecologists face ethical and practical issues, including requests for postpartum reinfibulation.

From the 1Mount Sinai School of Medicine, New York, New York; 2University of Utah Hospitals and Clinic, Salt Lake City, Utah; and 3Department of Obstetrics, Gynecology & Reproductive Science, The Mount Sinai Medical Center, New York, New York.

Ms. Rosenberg is a fourth-year medical student at Mount Sinai School of Medicine who has a strong interest in biomedical ethics.; Dr. Gibson is a fourth year resident in Obstetrics and Gynecology at the University of Utah whose interest in this subject began as a Peace Corps volunteer in Mali.; Dr. Shulman is Assistant Professor of Obstetrics and Gynecology at The Mount Sinai School of Medicine in New York. Over the years she has encountered a few patients who had undergone female genital cutting in their home countries before coming to New York; these women have sparked many passionate discussions of the ethical and patient care issues involved.

Address correspondence to Consultant Editor for Clinical Case Series: Ingrid Nygaard, MD, MS, University of Utah School of Medicine, Department of Obstetrics and Gynecology, 30 North 1900 East, Room 2B200, Salt Lake City, UT 84132; e-mail: ingrid.nygaard@hsc.utah.edu.

Financial Disclosure The authors did not report any potential conflicts of interest.

© 2009 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.