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essay from Sudan

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essay from Sudan

Post by mandible on Mon Jul 05, 2010 2:51 am

A 23 year old is pregnant for the first time. She is from Sudan. She is now @ 8 weeks' and a victim of Female Genital Mutilation (FGM)

a. How do you approach this patient initially? (8 Marks)
b. What specific measures will be taken in her further management (antenatal, intrapartum and postpartum)? (12 Marks)
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Re: essay from Sudan

Post by mandible on Mon Jul 05, 2010 2:54 am

Detailed history regarding LMP, past obstetrical history,history of medical disorders, any familial diseases.Rubella status. Enquire regarding alcohol, smoking and substance abuse
Examine regardiong BP.BMI, genital examination
Investigate for HIV, Hepatitis B and C, FBC, urine analysis, blood group, Rubella status
Ultrasound for confirmation of gestation
Look for anemia and thalsemia or sickle cell disease
Provide folic acid 400ug daily supplementation

If any risk factors involved plan more frequent visits or admission otherwise monthly visits till 28 weeks, fortnightly visits till 36 weeks and then weekly visits.
At each visit Bp monitoring and urine analysis
May need iron supplementation in case of anemia in second trimester.
Depending upon on degree of genital mutilation delivery may be planned vaginally or by cesarean section.
If there is extensive perineal damage with narrowing of vagina cesaren section may be less damaging than vaginal delivery
She is at high risk of preterm delivery because of her age and possible mal-nourishment
Also the risk of PIH and pre-eclampsi is more in Africans and younger primigravidas
Counselling of the couple regarding delivery
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Re: essay from Sudan

Post by mandible on Mon Jul 05, 2010 2:56 am

identification and assessment of FGM is very important as it has serious physical as well as psychological implications.she should be dealt sensitively and active knowledge and respect should be demonstrated. A psychological assessment and psychiatric referral should be considered.language difficulties and cultural differences should be taken into account.there is no place for expressions of disapproval or disgust.clear documentation in the records with diagramatic representation or medical photographs should be done to avoid repeated examination.severity of infibulation with extent of scarring,involvement of labia majora ,minor and clitoris should be evaluated by an experienced obstetrician .A prospective plan should be discussed with the woman for the timing of defibulation, possible need of anterior episiotomy, place and mode of delivery and possible complications of the condition
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Re: essay from Sudan

Post by mandible on Mon Jul 05, 2010 2:57 am

.i tried to answer the ist part. at ist time i couldnt write much.but after going through the guidelines again i reframed the answer. please do comment and suggest any correction. thanx

The patient should be approached in a sensitive way.
active knowledge and respect should be demonstrated
.Language difficulties , psychological vulnerability and cultural differences should be taken into account.
terminology used should not cause upset or a sense of disapproval to the woman.
a psychological assessment and referral to psychiatrist should be discussed .
thorough physical examination by an experienced gynaecologist is recommended to identify whether antenatal surgery will be beneficial.
there may be a difficulty in vaginal examination.clear documentation of the type and severity of infibulations should be recorded either on a preformatted sheet or predrawn diagrams or by medical photography after informed consent to avoid repeated examinations
.A plan for antepartum intrapartum care should be formulated and documented with the need and timing of defibulation .Possible complications and risks and reinfibulation should be discussed.
Contact no of support groups should be provided
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Re: essay from Sudan

Post by mandible on Mon Jul 05, 2010 2:59 am

The woman should be managed at a centre with available expertise in FGM.
after initial evaluation for the severity of infibulations by a senior gynaecologist,the woman should be discussed the need of defibulation to facilitate delivery. The possible complications like increased risk of caesarean section, likelihood of postpartum haemorrhage, severe perineal lacerations , episiotomy,should be explained. Any fear of vaginal delivery should be allayed and dealt sensitively
The timing of defibulation should be decided according to the severity of condition. It can be done at 20 weeks to reduce the risk of miscarriage. Or during ist stage of labour under epidural analgesia. Or by anterior episiotomy in 2nd stage of labour at time of crowning of head.
the procedure should be performed by an experienced gynaecologist in operation theatre. Urine should be screened for bacteriuria. Blood should be taken for group and save .urethra should be identified and catheterised before the procedure. Incision should be made at the previous scar.prophylactic antibiotics should be given.cutting diathermy reduce the amount of bleeding Fine absorbale sutures like polygalactin 910 should be used. Womans psychological need and analgesia requirement should be taken into account.as any amount of pain may precipitate previous traumatic flash back
. Woman should be strongly recommende to deliver at a maternity unit with availability of emergency caesarean section. i.v acess ,group and save serum is strongly recommended.epidural analgesia is recommended if there is difficult and painful vaginal examinations and an anterior episiotomy is needed .Genital mutilation itself is not a direct indication of caesarean unless it is extremely severe and defibulation is not possible.Episiotomy should be recommended if inelastic scar prevent the progress of labour.Any repairafter birth should be done to reappose the raw edges and to control bleeding but must not result in a narrow vaginal opening
.Postpartum woman should be monitored for postpartum haemorrhage.Adequate analgesics should be given.Appointmentshould be fixed and counselling should be done regarding long term implications of infibulations including sexual dysfunction, anorgasmia, dyspareunia,recurrent urinary infections and difficulty in vaginal examinations and cervical screeing. All efforts should be made to educate the woman and partner to eradicate the practise. Cultural differences and ritual issues should be taken account into consideration. In case the baby is a girl , the risk for the baby to undergo genital mutilation should be assessed .A child protection specialist should be involved if any risk to the female baby is suspected.
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Re: essay from Sudan

Post by mandible on Mon Jul 05, 2010 3:03 am

Reply Author: Ir
This woman requires to be dealt with a sensitive and empathic approach taking into consideration the difference in cultural practices and attitudes. It would be appropriate to use the word "cutting" in place of female genital mutilation (FGM). I would take a routine antenatal history first and then discuss her views on childbirth and delivery. I would explain to her that difficulties will mainly arise during labour and will depend on the degree of the "cutting".
At the first antenatal visit, a routine antenatal history and examination is done. I will offer her antenatal blood tests including Hepatitis B and HIV. I will offer first trimester screening for chromosaomal anomalies at 12 weeks. After discussing with her the implications of FGM on delivery, I would refer her to an experience midwife or obstetrician for examination to ascertain the degree of mutilation and to assess whether she would benefit from a defibulation procedure. If such a surgery is deemed beneficia, it should be planned at about 20 weeks gestation to miimise the risk to fetus.
It would be appropriate to document the grade of FGM on predrawn diagrams in the case notes or to attach pictures with the patient's permission. It would lessen the need for repeated examinations at subsequent visits and aid in referral to centres experienced in FGM.
She should be given information leaflets and websites of support groups. If she feels appropriate, she can be referred to a psychologist for counselling.
She would get routine antenatal care with fetal anomaly scan between 20 - 23 weeks and growth scan at 32 weeks. FGM is not an absolute indication for cesarean delivery. Epidural anaesthesia is recommended during labour. Episiotomy may be given if the scarred tissue prevents decent of head and delivery. Episitony repair should be done by vicryl rapide. Cesarean should be done for obstetric indications. Rest postpartum care would be as usual.
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