A Brit Milah is considered an extremely safe surgical procedure.

Like any surgical procedure, however, complications may occur. Fortunately, the vast majority of these are minor and either resolve on their own without any intervention or with simple treatment. An example of this may be the start of bleeding which can simply be resolved with a bandage to the area.

Regardless of the problem, your first point of call should always be the Mohel. The Mohel is highly trained to deal with any issues or complications. Again, most of these are minor and of no consequence, however frightening they may be to you as a parent.

The Mohel will have checked on the baby after the Brit Milah to make sure that he is happy and that everything is ok and that the bleeding has sufficiently stopped. Before leaving the location of the ceremony, he will have given you his contact details. Please do not hesitate to call the Mohel if you have any concerns.

If you do call the Mohel, you will find most problems can simply be sorted out with telephonic advice from the Mohel. If the Mohel feels that it cannot be resolved over the telephone, he will arrange to see the baby.

If the Mohel is not immediately available, he will usually have a deputy covering on his behalf. Please contact the deputy (locum) in this case. If, for whatever reason, you are unable to get hold of either, then please proceed to your local hospital casualty or GP/Paediatrician to get a medical opinion.

Thankfully, most of the time, complications will have resolved without consequence.

If you are worried about something, but it is not an emergency, then consider waiting for the follow-up visit or phone the Mohel to discuss it with him. The Mohel will have booked a follow-up visit with you to check on the wound, as well as to answer any further questions you may have.

In the unlikely event that the Mohel cannot handle a problem with the Brit Milah, he will refer you to the appropriate medical specialist for an opinion. This specialist will usually be a Urologist or Paediatric Surgeon.

What are some of the possible complications?

Bleeding

The most common complication of a Brit Milah is bleeding. Every Brit Milah can be expected to bleed a little as it entails a surgical incision, however some do bleed more than usual. This bleeding can usually be controlled by following advice from the Mohel on how to re-bandage the wound. Some cases may require the Mohel to see the bleeding for himself. It is rare to have bleeding that requires anything more than a re-bandage. In severe cases the Mohel may need to refer you to a medical professional.

Infections

The next most common complication is an infection. These are almost always mild and resolve spontaneously. Other complications do exist, and range from mild to severe. They are, however, rare.

References

1. Wilcken A. Traditional male circumcision in eastern and southern Africa: a systematic review. Bull World Health Organ. 2010;88:907-914.
2. Spitzer J. Handbook for Mohelim. London: Senprint; 2013.

• After the procedure it is perfectly normal for the baby to cry. This should not persist for very long or be extremely intense.
• The Mohel will check the baby for any bleeding within thirty minutes of the Brit Milah;
• The Mohel will not leave until he has personally checked the baby and is absolutely satisfied that all bleeding has stopped.
• The Mohel will give clear verbal and ideally written instructions to the parents on how to care for the baby after the Brit Milah.
• The Mohel will give clear verbal and ideally written instructions to the parents about what to do if they become concerned and how to contact the Mohel if necessary.
• The Mohel will not leave until he is satisfied that the parents have understood these instructions and have no further concerns or questions.
• The Mohel will contact the parents within 6 hours of the procedure to enquire whether there have been any changes noted in the baby’s behaviour, and specifically enquire whether there has been any bleeding and whether the baby has passed urine.
• The Mohel or a suitably qualified nominated deputy must be available to deal with any complications in the first two days after the Brit Milah and must also be available to respond at short notice if an urgent concern or emergency arises. If in an emergency, it is not possible to reach the baby in an appropriate time frame, he must refer the baby immediately to the nearest hospital and should consider advising the parents to use the local emergency services to transport the baby there.
• The Mohel is trained to dress the wound and monitor its healing. Different Mohalim may use different dressings. All of these dressings work well and are used according to personal preference. The Mohel will discuss the dressing with you, and when it is safe to remove and/or change it. Generally, the pressure dressing should be removed within 24 hours. Any subsequent pressure dressings must also be removed within 24 hours by the Mohel or a nurse or a paramedically qualified person.

It is normal to have a little bleeding around the dressing soon after the Brit Milah. Once your baby starts to urinate, the urine will mix with the blood and form a pink fluid in the nappy. This is normal. If you feel that there is too much blood in the nappy (and that it is very red and not pink), then discuss this with your Mohel to ascertain if there is ongoing bleeding or not.

The nappy should be checked 2 hours after the Brit Milah for bleeding and for passage of urine. If there is fresh bleeding (dark blood, sticky in nature) then contact the Mohel. Similarly, if the baby has not passed urine after about 3 hours, inform the Mohel. The baby should definitely have passed urine by 6 hours. If not, the Mohel will need to come and re do the dressing.

During the healing process, a yellowish/whitish film may form over the wound and the end of the penis. This film cannot be easily removed by wiping it, and one should not attempt to remove it as this will hinder the healing process. This is normal and does not indicate a problem. It is sometimes called ‘exudate’ or ‘slough’.

Redness and swelling is normal initially, but should start getting better after 24 to 48 hours. If a brownish/yellowish film develops that can easily be wiped away and has a foul smell this may indicate a possible infection. Infection is usually associated with an increase in redness and swelling. The baby may also be generally unwell, not want to eat, have a fever, and be generally irritable.

General after-care

It is normal for the nappies to have a pink discolouration which is blood mixed with urine. This colour will get lighter each day until clear.

The Mohel will advise you on when he wants the initial dressing to be removed. Once removed, you can change the dressings, if the Mohel is satisfied. You should then apply a piece of gauze smeared with Vaseline over the tip of the penis whenever the previous dressing becomes wet or dirty. These gauze dressings should be used for about 2 weeks, but some Mohalim may suggest that only Vaseline is required after a time and not the gauze.

You can bath the baby normally from 3 days after the Brit Milah ensuring that you are especially gentle with the circumcised area. Some Mohalim advocate bathing the baby sooner and is best to check this with your Mohel.

Assessing the health of your baby

• The health of your baby and the safety of the procedure is of paramount importance.
• The Mohel will wash his hands with an alcohol based bactericidal soap and dry his hands on a clean towel before touching your baby at any time.
• The Mohel will assess the health of your baby to ensure that he is fit for Brit Milah. This includes taking a thorough history and performing a physical examination of your baby.
• The Mohel will not perform a Brit Milah in instances of any concerns about your baby’s health until authorisation has been given to the baby’s parents/legal guardians by the doctor caring for the baby.

When will the Mohel not perform a Brit Milah?

• Any baby weighing less than 2.5 kg.
• Any baby over the age of 6 months, unless the Mohel is a medical practitioner, or unless previously authorised in writing by the Medical Officer of The Regulatory Board.
• When your baby has jaundice unless it is minimal and resolving (see below).
• Presence of blood dyscrasias or abnormalities (for example haemophilia, von Willebrand’s disease, other clotting factor deficiencies etc.), until deemed safe by an appropriate medical specialist.
• A family history of bleeding disorders until it has been established by an appropriate medical specialist whether your baby has inherited the condition.
• Congenital disorders of the penis including hypospadias, congenital chordee or deficient shaft skin, such as penoscrotal fusion or congenital buried penis, unless advised in writing that it is safe to do so by an appropriate medical specialist.
• In the case of a home birth, until the Mohel has confirmed from the attending midwife that your baby has received vitamin K in accordance with standard practice in new born care.

 What is Jaundice?

Jaundice refers to a yellow discolouration of the skin and eyes. Jaundice in newborn babies is fairly common (more than 50% of babies) and should not cause undue alarm. This type of jaundice is called “physiological jaundice” and is essentially due to an immature liver that is developing or due to breastfeeding. This jaundice is not harmful to your baby. It resolves on its own and should not be a reason to stop breastfeeding your baby.

Your Mohel is an expert in making decisions about this jaundice. He will be able to advise if this is no cause for concern (physiological jaundice) or whether there may be an underlying problem (pathological jaundice). Pathological jaundice is usually present at birth and is most often picked up in the birthing room by the medical or nursing staff. It will require a medical diagnosis by a doctor.

Your Mohel will also be able to advise you on the correct timing of the Brit Milah in relation to the jaundice. If you notice the presence of  jaundice in your baby, contact your Mohel as soon as possible. Please be aware that the presence of jaundice may result in the Brit Milah being delayed.

The venue and what your baby should wear

The Mohel will ensure that your proposed venue is suitable for the procedure.

• The Mohel will advise you to ensure your baby is clean in preparation for the procedure.
• The Mohel will give you specific instructions on what your baby should wear that is appropriate for the procedure, and that provides easy access to the operative site, whilst being sympathetic to family traditions.

Pain Control

Pain may be controlled with simple measures. Breastfeeding your baby before the Brit Milah will help make him calm and works like a painkiller for the actual procedure. Another well recognised ‘strong’ pain killer for babies is sucrose (sugar water). Medical studies have proven that this is an effective pain killer for babies. Your Mohel may give your baby some drops of Kiddush wine to suck on. This wine contains the sucrose needed and will help as a pain killer for your baby. You should notice almost immediate calming of your baby when sucking the wine.

You can also give your baby infant Paracetamol (Panado, Calpol) as a painkiller. Unless your doctor or paediatrician has told you that there is a specific contra-indication to Paracetamol, it is usually quite safe to administer to newborn babies. The Mohel will advise on the correct dose according to your baby’s weight or please follow the dosage instructions on the actual bottle or the leaflet inside the box.

It is not routine to give an anaesthetic for a Brit Milah. Please discuss pain control with your Mohel if you require further information.

The Beth Din has approved a number of Mohalim to perform Brit Milah. A list of these Mohalim and their contact details and curriculum vitae is found here.

The Regulatory Board is in the process of accrediting these Mohalim, in accordance with its latest guidelines, policies and procedures, and expects to complete this process by December 2017.

We recommend you only make use of Mohalim approved by the Beth Din and in time, only those Mohalim who have been fully accredited by The Regulatory Board.

What can you expect from a Mohel?

• A Mohel will uphold the values of  Orthodox Judaism and adhere to the halachic rulings of the Beth Din.
• The Mohel will adhere to the highest standards of Brit Milah and ensure that the safety and wellbeing of your baby are paramount, while ensuring the procedure is completed according to the precise halachic requirements.
• In terms of conducting a Brit Milah, a Mohel will not have any contact with a baby nor undertake any procedure if he is or believes he may be becoming ill in a way which will or may affect the health of the baby.
• A Mohel will be in good health and will stop practising where there is a change in his own health which might affect performance or pose risk to your baby or family.

What information and advice should your Mohel give you?

A Mohel should offer you or the baby’s carers clear, consistent verbal and ideally written information and advice throughout all stages of the circumcision process. This should include the risks of any complications, bleeding and surgical site infections, what is done to reduce them and, if complications occur, how they are best managed. | Read More

Consent to perform a Brit Milah

• The Mohel must obtain written, informed consent from parents before performing the circumcision.To view or download the consent form, please click here

Confidentiality

The Mohel will keep contemporaneous notes relating to all encounters with your baby and family including a record that written consent for the procedure was obtained. He will also complete an electronic registration and procedure document, which will be submitted to the Beth Din.

The Mohel must respect the confidentiality of the family and must not share any medical information he may receive without the express consent of the baby’s parents unless this disclosure is in the best interests of the baby.

If a Mohel is concerned that a child is at risk of abuse or neglect, he must inform the Medical Officer of The Regulatory Board in the first instance for advice on how to escalate this concern.

The Regulatory Board, in accordance with its latest guidelines, policies, and procedures, and experts is proud to announce that a group of Mohalim has successfully completed their accreditation process. A list of these fully accredited Mohalim and their contact details and curriculum vitae is found below.

We recommend you only make use of Mohalim who have been fully accredited by the Regulatory Board.

The Regulatory Board is responsible for ensuring the highest standards of care and safety are maintained for all babies undergoing a Brit Milah, as well as ensuring that this sacred and holy procedure is conducted according to the strict halachic principles.

We thus encourage parents, relatives and/or the broader public to share with us any concerns that may arise and also share compliments or suggestions regarding the care and services rendered by Mohalim.

To lodge a complaint or record a compliment and/ or make an enquiry click here.

We undertake to ensure that:

•  Any complaint, compliment or suggestion will be acknowledged within 24 hours.
• A full investigation will be initated of the registered concern or complaint. Dependent on the nature of the complaint and the investigation required, it may take up to four weeks to complete.
• Complainants will be given weekly feedback as to progress.
• The outcome of the investigation will be communicated verbally and in writing.
• All complaints will be handled on a strictly confidential basis and all personally identifiable information concerning the matter will only be disclosed or shared on a need-to-know basis and protected from disclosure where possible.

The Regulatory Board of South Africa is empowered through its terms of reference to identify any corrective actions and quality improvement opportunities and convey this to the appropriate person or Mohel involved for implementation and follow-up. Following an investigation, in the case of a complaint deemed sufficiently serious, The Regulatory Board reserves the right to refer the case to the Beth Din and Office of the Chief Rabbi.