9. Female genital mutilation
The presence of grade 3 female genital mutilation (FGM) with ob- struction of the vaginal introitus following infibulation requires staff appropriately trained in defibulation. Best practice consists ofantena tal identification ofwomen with FGM and the offer of defibulation be- fore the onset of labor, supported by appropriate counseling. When a woman presents in labor, defibulation should be undertaken only when the tissues are stretched as the fetal head descends Defibulation should be performed before evaluating the need for epi- siotomy, which may not be required. The practice of "double episiot- omy" is damaging and should be avoided.