Personal Details:
Name: Ms. Aisha Hassan
Age: 25
Medical Record:
Past medical history:
20 weeks pregnant
First pregnancy
No significant past medical history.
Regular medication: Folic acid, Vitamin D
Allergies: None known
Letter from midwife
Dear GP,
I would appreciate it if you could see Aisha, who I think had FGM as a child. I suggested a referral to the FGM clinic; however, she was reluctant. She has also refused a gynaecological examination. She has, however, agreed to chat with you. I would appreciate it if you could see her to discuss this further.
Yours sincerely,
Opening Sentence: “The midwife told me to come and talk to you about… my body. I don’t really want to. It's just a bit embarrassing.”
When I was a young child in my home country, I had a cut down below.
ICE:
Ideas: Views FGM as a cultural practice and is aware it is viewed differently in the UK. Wonders if it will affect her pregnancy or childbirth.
Concerns: Worried about judgment from healthcare professionals. Concerned about potential complications during childbirth. Anxious about her unborn child being subjected to FGM when she goes back home country. Fears legal repercussions or social services involvement.
Expectation: Wants reassurance that she won’t be judged and that her pregnancy will be managed safely. Hopes to avoid further invasive examinations or discussions about FGM.
How to Act: Reserved, anxious, avoids eye contact, speaks softly, protective of her cultural background.
More History (only if asked):
· Happened in early childhood, can’t remember exactly at what age.
· No specific physical complications reported since.
· Denies chronic pain, dyspareunia (painful intercourse), recurrent UTIs, or menstrual difficulties.
· No psychological symptoms reported, but appears distressed during the consultation, but mood is stable, doesn’t feel low, and the partner is very supportive.
· No history of previous pregnancies.
Social History:
Occupation: Homemaker.
Smoking: Non-smoker.
Alcohol: Doesn’t drink.
Home situation: Lives with husband. A big family back in the home country of Somalia. Visit your home country once a year.
Questions to ask: “Will this affect my baby?” “Will I be able to have a normal birth?” “Do I have to tell anyone else about this?”
Explain the situation, manage ICE:
Good morning, Aisha. Thank you for coming in to talk to me. I understand this is a very sensitive and difficult topic for you, and I want to assure you that everything we discuss here is confidential, and you are in a safe space. I also want to make it very clear that we are here to support you and your baby, and we will not judge you.
A medical procedure on a young woman is a deeply rooted cultural practice in many communities, and it is not something you choose.
My main concern, and the reason the midwife asked you to see me, is to ensure that we provide you with the best possible care during your pregnancy and childbirth. We also want to ensure the safety and well-being of your child. We know that the procedure you had done to you when you were small can sometimes lead to complications during childbirth, and by understanding your situation, we can plan for a safer delivery for both you and your baby.
Next Steps
The midwife you saw was keen to refer you to a specialist clinic at the hospital. To ensure you have the safest possible pregnancy and delivery, I wanted to go through with you in a bit more detail what this clinic does.
They have a team of doctors, midwives, and counsellors who are experienced. They can discuss potential implications for childbirth and offer procedures if needed, which can make childbirth easier and safer. They can also provide ongoing emotional support. They won’t rush things, and they will examine you in a sensitive way to make sure that the procedure you had when you were a child is not going to interfere with your pregnancy.
Safety of the unborn baby
As you are probably aware, medical procedures on young women are illegal in the UK, and I would want to do my best to support you in the future to protect your child from this procedure with as much support and information as I can.
Do you feel under any pressure from your husband regarding that? Do you think your family would plan FGM for your baby when you go back home? If you feel there is any chance this could happen, please let us know, as we can refer you to the safeguarding team, who can give the needed support to prevent that. I still want you to enjoy going back home and seeing your family, but you still have a duty of care to your daughter, and this remains illegal and could carry legal consequences if it still happens in Somalia.
I will send you more information from the NHS and government websites to read about that.
Continuity of care
It’s important to continue with your regular antenatal care. If you experience any pain, discomfort, or have any concerns related to your FGM, please don’t hesitate to contact us or the FGM clinic. We encourage you to ask any questions you have, no matter how small, so we can address them. Remember, we are here to support you.
What is scenario testing? This scenario tests the GP trainee’s ability to sensitively approach and manage a patient who has undergone Female Genital Mutilation (FGM), particularly during pregnancy. It assesses their ability to provide non-judgmental care, understand the cultural context, identify potential obstetric complications, and implement safeguarding measures for future generations. It also tests communication skills, empathy, and knowledge of legal obligations regarding FGM.
Important areas in data gathering:
• Explore more about FGM
• Physical symptoms: Pain, recurrent infections, dyspareunia, menstrual difficulties, urinary problems.
• Psychological impact: Trauma, anxiety, depression.
• Previous obstetric history: Any complications in prior pregnancies/deliveries related to FGM.
• Patient’s understanding and feelings about FGM: Cultural beliefs, desire for deinfibulation.
• Safeguarding concerns: Risk of FGM for female children. Partner and family views about it.
Highlight the management objectives,
• Non-judgmental Approach & Reassurance: Establish trust, reassure the patient about confidentiality and support, and explicitly state that her child will not be removed.
• Referral to Specialist FGM Services: Facilitate referral to a multidisciplinary FGM clinic for comprehensive assessment, counseling, and management (e.g., deinfibulation).
• Antenatal Care Planning: Ensure the birth plan is adapted to account for FGM, anticipating potential complications during labor and delivery.
• Safeguarding: Discuss the illegality of FGM in the UK and provide information and support to prevent FGM for any female children.
• Emotional Support: Offer psychological support and counseling.
• Education: Provide clear information about FGM, its health consequences, and available support.
https://www.endfgm.eu/editor/files/2020/05/HTTAFGM_EndFGMEU.pdf
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