Female genital mutilation: Stop the scars

The one quote on Reddit that I most resonate with is, "Rape is about violence, not sex. If a person hits you with a spade you would not call that gardening." This could very well apply to female genital mutilation or cutting as the more diplomatic persons prefer to call it. It really is about violence. And unfortunately, it is mostly violence against people who truly have no voice. There is no gardening happening with this spade; not by a long shot.

This takes me back to sometime over a decade ago, when dawn was just breaking; after a chaotic night shift in the maternity unit. We were just catching a breather, penning off the last of the patient notes in the files in preparation for handing over to the incoming shift.

Just when we thought we were done, we heard the squeaking sound of a wheelchair in need of lubrication, making its way towards the nursing station. The patient on the wheelchair was most certainly in pain, but that notwithstanding, she bore a miserably defeated look on her face. Her husband walked beside the wheelchair, carrying her belongings. His anxiety was palpable.

Asma* bore her labour pains stoically while her husband filled us in. He noted that she had been in labour through the night, but the pain had gotten worse about an hour back. As the nurse settled her into one of the beds, Asma’s husband went on to process her admission into the ward. This was Asma’s first pregnancy and she had an antenatal booklet documenting her antenatal journey.

It appeared that Asma’s pregnancy had been uneventful; but on her birth plan, it was indicated that Asma was to deliver by caesarian section due to marked scarring of the vulva as a result of female genital mutilation. As per the notes in the little booklet, Asma was scheduled for caesarian delivery five days prior, but by the look of things, she had chosen not to honour that appointment.

I quickly figured that this was not something she had wanted, hence the delay at home, praying that she would go into labour and have a vaginal birth. I knew my work was cut out for me; convincing the couple that the caesarian delivery was still going to be the way to go.

Nothing prepared me for what I witnessed upon examining Asma. Her vulva was unrecognizable. The clitoris, labia minora and part of the labia majora was gone. She had glistening, non-elastic scar tissue instead. The urethral opening was gaping slightly at an awkward angle due to the tugging of the scar tissue, and the vaginal opening looked like it could not expand to accommodate even a finger at the examination.

My best attempt at a vaginal examination to determine how far Asma was in labour did not yield much fruit. However, Asma’s baby was ready to come as evidenced by Asma’s urge to push and the stretching of the scarred vulva during a contraction! I momentarily stiffened. We had no time to get Asma to the theatre. The baby was coming in a few minutes, whether we were ready or not.

We hurriedly transferred Asma to the delivery suite and got her all prepped, draped and ready for delivery. We were firing instructions left, right and centre to both Asma and her husband, giving them a running commentary of what we were going to do as we worked. Asma quickly received a generous local anaesthetic block at the vulva to enable us to give her an episiotomy on either side of the vagina. These cuts were extending from her vaginal opening on either side, to release her scarred area and open up hopefully enough space to allow the baby through with no further tearing.

Of note is that normal tissue around the vagina is quite elastic, with the capacity for a wide level of stretch. That is not the case with scarring. Scar tissue is inelastic and prone to dramatically tearing and causing complications. Through all this, Asma remained quiet, only biting her lip in pain when she was having contractions.

The baby seemed to have noticed that we had made our way. She quickly came through, taking her first breath and rewarding us with a lusty howl. Asma was overwhelmed with pure joy. She finally let on her true feelings, thanking Allah for the miracle of life. She could not wait to hold her little one. Her little girl may have come but that was just one hurdle scaled. The placenta was delivered easily enough, allowing us to inspect Asma and see how well she had survived the delivery.

Unfortunately, it was not great. Despite our best efforts, the episiotomy on the left side had extended with the force of the baby coming through and we could tell that her anal sphincter had been damaged some.

Asma was also bleeding a lot as multiple small blood vessels around the vulva were torn as the baby came through. This was not going to be an easy repair for either of us. Despite avoiding a caesarian section, Asma still had to go to the operating theatre for the repair of her episiotomies and tears.

It took approximately three hours to complete this repair, ensuring that all the bleeding had been halted and the anal sphincter was back to proper function. Nothing could be done for Asma at this time about her scarring. Any intervention required would be done much later when she was out of the pregnancy period. For now, she needed a blood transfusion as she had lost a significant amount even as we strived to complete the repair with my senior colleague.

Looking at the damage occasioned by the mutilation, I quietly wondered how Asma even got pregnant in the first place, as I could not even imagine how intercourse would take place. She must have suffered enormous pain. While Asma recovered from anaesthesia in the post-anaesthesia care unit, I stepped out of the theatre to inform her husband that Asma was going to be fine. He was so relieved that he stopped pacing about and slumped down on the bench.

I could not hold back my curiosity. I asked him what he thought of this whole cultural practice that had led us to this point. He was livid. He vowed that if anyone as much as suggested the same for his precious little daughter in the nursery down the corridor, he would kill them. He vowed that for his young family, the practice would end with his wife, even if it caused them to be ostracized from the community!

The little one born on that day is a teenager today. I truly hope that her father kept his word and that she was truly safe from the horrors her mother had to go through in life. Indeed, it is time to get the spade off our girls and call out the violence for what it is. It is not gardening!

Dr Bosire is an obstetrician/ gynaecologist