1. Medico legal Aspects in
Obstetrics and Gynecology
PCPNDT Act
MTP Act
Sexual Assault

2. Preconceptional and Prenatal
Diagnostic Techniques Act

3. Rahul
weds Kavita

4. Kavita
is
Pregnant

5. Waiting for the right time

6. On the most awaited day

7. BEHIND
THE
SCENES

8. Rahul
weds
Kavita

9. Kavita
is
Pregnant
(Was it a concealed pregnancy; it must be a boy)

10. Waiting for the right time
(Is it a feigned pregnancy;It is definitely a boy)

11. On the most awaited day
A girl was born;
it was not his
child

12. Female feticide
• Indeed unethical problem is deep rooted
• Attention needs to be focused on the root cause, attitude of
society and elevate the status
• The decline in sex ratio from 972 in 1901 to 933 in 2001
forced the government authorities to take some action at
administrative level
• Mid 1980’s: some NGO’s started campaign in Maharashtra
resulting in ban on prenatal diagnostic techniques in 1986
• 1994 PNDT act was formed, became operational in 1996.
• Even then hardly any case was booked till 2001 when census
showed sex ratio of 933
• PIL filed in 2001 by two NGO’s and by amendment it came
into action by 2003

13. Is Female feticide an unethical practice?
Those who disagree:
• Amniocentesis and abortion are less traumatic and repugnant than killing of girl
after birth
• Why support unwanted female fetus, who will born to suffer throughout life
• Elevate the status of women and importance by creating their shortage
• Sex selective abortions will further increase in illegal septic abortions resulting
increase in maternal mortality and morbidity
Those who are against female feticide:
• Result in î incidence of sexual abuse, trafficking and polyandry.
• Regions have low sex ratio in India buy their brides from far off regions.

14. Why is female feticide a problem ?
• Increase in violence against women- violation of
their human rights.
• Abortion due to family pressures to have male
child-
• effect on mental and physical health of
woman.
• More men in society due to sex selective
abortions.

15. Pre-natal Diagnostic Techniques includes
 Ultra-sonography,
 Foetoscopy,
 Taking samples of amniotic fluid, embryo, blood or
any tissue or fluid of pregnant women before or
after conception,
 Testing samples in Genetic Laboratory to detect
genetic disorders, abnormalities or sex-linked
diseases

16. Imposes restrictions on:
• Clinics, medical personnel and sale of
machines
Only registered genetic clinics can use pre-
natal diagnostic techniques
By qualified medical practitioner
Prohibition of sex-selection
Prohibition on sale of ultrasound machine to
unregistered laboratories, clinics & persons

17. No person, including a specialist or a team of
specialists in the field of infertility, shall conduct or
cause to be conducted or aid in conducting by
himself or by any other person, sex selection on a
woman or a man or on both or on any tissue,
embryo, conceptus, fluid, or gametes derived from
either or both of them.
Sec.3A Prohibition of sex selection

18. Sec.3B Prohibition on sale of ultrasound
machine, etc., to persons, laboratories, clinics,
etc., not registered under this act.
No person shall sell any ultrasound machine
or imaging machine or scanner or any other
equipment capable of detecting sex of foetus
to any Genetic counseling center, Genetic
clinic, and Genetic Laboratory or any other
person not registered under this act.

19. can be used for detection of
Chromosomal Abnormalities
Genetic Metabolic Diseases
Haemoglobinopathies
Sex-linked genetic diseases
Congenital abnormalities
Any other abnormalities

20. conditions:
Age of pregnant women is above 35 years
Two or more spontaneous abortions
Pregnant women has been exposed to drugs,
radiation, infection or chemicals
Family history of mental retardation or
physical deformities
Any other condition

21. Essential communications
Explanation of all known side/ after effects & test
procedures
Written consent in prescribed form & its copy given to
her
Not to disclose sex of the fetus by words, signs etc.
Display prominently in local language that disclosure
of sex of fetus prohibited under law.
Registration certificate to be displayed prominently in
the clinic.

22. Persons with following qualifications:
• A gynecologist or a pediatrician having 6 months
experience or 4 weeks training in genetic counseling
• A medical geneticist
• A radiologist having post graduate qualification in
USG
• An RMP with name entered in state medical register
who has post graduate qualification in imaging
techniques or 6 months experience or 1 year training
in sonography.

23. Regulatory Body
Policy Making
Body
Implementing Body Advisory Committee
Central
Supervisory Board
Sub-District
Appropriate Authority
District Appropriate
Authority
State Appropriate
Authority
Sub District
Advisory Committee
District Advisory
Committee
State Advisory
Committee
State Supervisory
Board

24. • Husbands and relatives
Cannot ask or encourage pre-natal diagnostic
techniques expect for reasons permitted under
law.
• Publishing and advertising
Illegal: No person, organization, counseling
centre, clinic or laboratory is allowed.

25. Offences and penalties
• All offences are cognizable, non bailable and non compoundable
• Advertisement in any manner including internet regarding availability
of services of PNDT at any center, clinic or lab, punishable for upto 3
years, fine upto Rs 10000.
• Subsequent conviction, fine may extend to 50000,imprisonment upto
5 years
• Husband or any relative liable for abatement of offence with
imprisonment of 3 years , fine upto 50000
• The penalty for doctors performing this test includes rigorous
imprisonment up to 3 years and fine of INR 10,000

26. Implementation of PCPNDT Act
Implemented by Appropriate Authority
• Role
To grant, suspend or cancel registration
Enforce standards
Investigate complaints of breach of provisions
• Complaints
Can be made by any person/social organisation
The chief medical officer to investigate
Can approach court if chief medical officer does not
take action
• Court
Judicial Magistrate First Class or Metropolitan
Magistrate

27. Advisory committee
The advisory committee shall consist of –
 Three medical experts from gynaecologists,
obstetricians, paediatricians and medical
geneticist;
 One legal expert
 One officer to represent the dept. dealing with
information and publicity of the State govt.
 Three eminent social workers, at least one from
the women’s organisations.

28. Registration of Center/lab/clinic
• Done by state appropriate authority after submitting application
form, Form A. Rs 25,000 for a clinic or lab and Rs 35,000 for a hospital
or nursing home
• Two certificates issued, one copy should be displayed at a
conspicuous place at its place of business
• Grant and rejection of certificate done within 90 days from the
receipt
• In case of change of ownership or management of center, fresh
application if mandatory
• Valid for period of 5years
• Renewal to be done 30 days prior to expiry, renewal fee half of
original i.e. Rs 12,500.

29. Maintenance of records
• Forms A to H are available
• Should be filled up for maintenance of records as per the norms laid
down under the act.
• All records, documents, charts should be maintained for at least a
period of 2 years or for such period as may be prescribed
• If any criminal proceedings are instituted, records should be
preserved till their final disposal
• Every registered center is liable to send complete report of all
procedures/techniques/tests to concerned authorities by 5th day of
every month

30. Forms A to H
Form A An application for registration shall be made to the A.A., in duplicate, in
form A duly accompanied by an affidavit
Form B The Appropriate Authority shall after holding an inquiry and after satisfying
itself ,grant a certificate in of registration in the prescribed form
Form C If after holding inquiry the appropriate authority is satisfied that the applicant
has not complied with the requirements of this act or the rules , reject the
application for registration and will be communicated to applicant
Form D The record to be maintained by every Genetic counselling center, in respect
of each women counselled
Form E The record to be maintained by every Genetic Laboratory, in respect of each
man or woman subjected to any pre-natal diagnostic procedure/technique/test
Form F The record to be maintained by every Genetic Clinic, in respect of each man
or woman subjected to any pre-natal diagnostic procedure/technique/test
Form G Informed consent by the doctor/RMP and the woman availing the PND test in a
language that she can understand.
Form H The A.A. shall maintain a register a permanent record of application for grant

42. Role of Doctors
• Should not indulge in monetary gains, would cost them their careers
and bring disrepute to whole fraternity.
• Can play as role models to curb this heinous practices in cooperation
with other people of society like politicians, religious leaders,
teachers
• Bodies like IMA and FOGSI great role to play.
• Overall change in role, status and economic value of woman

43. Medical Termination of
Pregnancy Act
1971 (Amended 1975 and 2002)

44. Introduction
Problem of unsafe abortion:
• Accounts for 13% mortality worldwide, 20% in parts of Africa and Asia
• 6.7 million induced abortions in India out of which 4 million unsafe
• India,15-24 abortions occur per 1000 woman of reproductive age
• Mortality rate is 70-89/ 100000 live births, risk of death 1 in 250 procedures
• Until the MTP act was passed, abortion was punishable under (IPC 1860) Sec 312
• Causing a woman to miscarriage other than in good faith for purpose of saving her
life punishable by imprisonment and/or fine.
• Sec 313-316 dealt with punishment when death due to procedure
• Shantilal Shah committee was set up in 1966 to stem high mortality and morbidity
with abortions rationalising of laws related to abortion
• Finally MTP act passed in 1971, enforced nationwide in 1972, adopted by J&K in
1980,
• At present all states and UT except Sikkim are implementing the act

45. MTP Act
• Does not confer right to have abortion legally
• Act lays down certain indications which make abortion services
available
• Service is provider centric , onus of decision making is only with
provider.
• Thrust needs to be changed, to make it woman centric
• Punishment for not following is incorporated into the act itself.
• Rigorous punishment of 2 years extended upto 7 years

46. When can pregnancies be terminated?
Up to 20 weeks gestation
With the consent of the women. If the women is below
18 years or is mentally ill, then with consent of a guardian
With the opinion of a registered medical practitioner,
formed in good faith, under certain circumstances
Opinion of two RMPs required for termination of
pregnancy between 12 and 20 weeks

47. MTP rules: Who can perform?
A medical practitioner (RMP)
– who has a recognized medical qualification as
defined in clause (h) of section 2 of Indian
Medical Council Act, 1956
– Whose name has been entered in a State
Medical Register and
– Who has such experience or training in
Gynecology and Obstetrics as prescribed by
Rules made under the Act

48. MTP rules: training requirement - 1
For termination up to 12 weeks:
– A practitioner who has assisted a registered
medical practitioner in performing 25 cases of
MTP of which at least 5 were performed
independently in a hospital established or
maintained or a training institute approved for
this purpose by the Government

49. MTP rules: training requirement - 2
For termination up to 20 weeks:
– A practitioner who holds a post-graduate degree or diploma
in Obstetrics and Gynecology
– completed six months house job in Obstetrics and
Gynecology
– at least one-year experience in practice of Obstetrics
and Gynecology at a hospital which has all facilities
– registered in state medical register immediately before
commencement of the Act, experience in practice of
Obstetrics and Gynecology for a period not less than three
years.

50. MTP Act: Indications
Continuation of pregnancy constitutes risk to the life or
grave injury to the physical or mental health of woman
Substantial risk of physical or mental abnormalities in the
fetus as to render it seriously handicapped
Pregnancy caused by rape (presumed grave injury to
mental health)
Contraceptive failure in married couple (presumed grave
injury to mental health)

51. MTP Act: Place for conducting MTP
A hospital established or maintained by
Government
• OR
A place approved for the purpose of this Act by
a District-level Committee constituted by the
government with the CMHO as Chairperson

52. MTP Act amendment 2002
Decentralizes site registration to a 3-5 member district
level committee chaired by the CMO/DHO
Approval of sites that can perform MTPs under the act
can now be done at the district level
Strict penalties for MTPs being done in a un-approved
site or by a persons not permitted by the act

53. Common Methods of terminating pregnancy
under MTP Act
Dilatation and curettege
Dilatation followed by oxytocin infusion
Vacuum aspiration technique
Intraembryonic instillation of prostaglandins
Extraembryonic instillation on hypertonic saline
With drugs: Mifepristone (RU486), and Misoprostol (early pregnancy)
Hysterotomy (after 12-14 weeks)

54. Common methods of Terminating pregnancy
VAT

55. Common methods of Terminating pregnancy
D-C

56. MTP Regulations
• MTP Regulations, 2003 consists of all the regulations:
– Forms to be required for making opinion,
admission register and reporting of MTPs
(Form 3, to be preserved for 5 years)
– Custody of forms
•

57. Medical Abortion
• Allowed to be administered upto 7 weeks POG
• RMP as prescribed under section 2(d) and rule 3
• Under section 4 (d) and rule 5 of MTP rules
• Means : even if a place is not registered, provider can
prescribe medical abortion provided he/she displays a
certificate proclaiming that he/she has a surgical backup for
a place formally registered for MTP

58. Forms for MTP
Form A Application form for approval of a place under clause b of Section 4
Form B Certificate of Approval
Form C Informed written consent given by the woman/guardian if woman is minor
Form I Declaration by RMP that the MTP performed was in good faith, under the
indications mentions under the MTP act with the Serial No. mentioned in the
Admission Register
Form II Name of hospital/clinic with details of patient and indication for MTP duly signed by
Officer Incharge
Form III Admission Register, (To be destroyed on the expiry of five years from the dated of
the last entry in the register)

63. 1st Trimester MTP by surgical method
Consent Form in PGIMER

64. FOGSI Statement on Medical Methods for
Early Abortion, April 2002
 Recognises the universal evidence on the effectiveness and safety of mifepristone-
misoprostol administration for inducing MTP up to 49 days from the LMP as
approved for use by the Drug Controller in India.
 only be administered by gynecologists and RMPs recognised for performing MTPs
by the MTP Act of 1971.
 Close monitoring of distribution and use of these drugs be undertaken
 Medical profession and the pharmaceutical industry exercise due diligence in their
promotion and use
 Consumers be educated about this recently-introduced method and counselled
regarding its advantages, drawbacks, risks and limitations.

65. Further amendments?
Several lacunae need to be addressed with amendments
• Requirement of 2 opinions for 2nd trimester abortion could be
dispensed.
• Extension for termination upto 22 weeks POG as vast majority are
diagnosed around this time
• Simplifying bureaucratic procedures to speed up registration
• Subsection of section 2: Married couples who have failure of
contraception as eligible for MTP, word ‘married’ needs to be
omitted

66. Sexual assault

67. WHO definition
‘Any sexual act, attempt to obtain a sexual act, unwanted sexual
comments/ advances and acts to traffic, or otherwise directed
against a person's sexuality, using coercion, threats of harm, or
physical force, by any person regardless of relationship to the victim
in any setting, including but not limited to home and work." (WHO,
2003) Sexual assault, a form of sexual violence, is a term often used
synonymously with rape. However, sexual assault could include
anything from touching another person's body in a sexual way
without the person's consent to forced sexual intercourse --- oral and
anal sexual acts, child molestation, fondling and attempted rape.’

68. Criminal Law Amendment Act 2013
Expanded the definition of rape to include
• All forms of sexual violence-penetrative (oral, anal, vaginal) including
by objects/weapons/fingers and non-penetrative (touching, fondling,
stalking, etc.) and recognized right to treatment for all
survivors/victims /victims of sexual violence by the public and private
health care facilities.
• Failure to treat is now an offence under the law.
• The law further disallows any reference to past sexual practices of
the survivor.

69. • Refusal of medical care to survivors/victims of
sexual violence and acid attack amounts to an
offence under Section 166B of the Indian
Penal Code read with Section 357C of the
Code of Criminal Procedure

70. Duties of a health personnel
First responsibility is to provide medical treatment and attend to
the survivor's needs. Section 164 (A) of CrPC lays out following legal
obligations of the health worker:
• Examination shall be conducted by a registered medical practitioner (RMP)
employed in a hospital run by the government or a local authority and in the
absence of such a practitioner, by any other RMP.
• Conducted without delay and a reasoned report to be prepared by the RMP.
• Record consent obtained.
• Exact time of start and close of examination to be recorded.
• RMP to forward report without delay to Investigating Officer (IO), and in turn IO to
Magistrate.

71. SOP
Every hospital must have a Standard Operating Procedure (SOP) for
management of cases of sexual violence
• Any RMP can conduct the examination not mandatory for a gynecologist to
examine
• If female doctor is not available, a male doctor should conduct the examination in
the presence of a female attendant.
• Police personnel must not be allowed. If the survivor requests, her relative may be
present .
• No delay in conducting an examination and collecting evidence.
• Providing treatment and necessary medical investigations is the prime
responsibility. Admission, evidence collection or filing a police complaint is not
mandatory for providing treatment.
• The history taking & examination carried out in complete privacy in the special
room set up in the hospital.

72. Stepwise Approach of reporting
• I. Initial resuscitation/ first Aid
• ii. Informed consent for examination, evidence collection, police procedures
• iii. Detailed History taking
• iv. Medical Examination
• v. Age Estimation (physical/dental/radiological) – if requested by the
investigating agency.
• vi. Evidence Collection as per the protocol
• vii. Documentation
• viii. Packing, sealing and handing over the collected evidence to police
• ix. Treatment of Injuries
• x. Testing/prophylaxis for STIs, HIV, Hepatitis B and Pregnancy
• xi. Psychological support & counseling
• xii. Referral for further help (shelter, legal support)

73. Informed consent
A survivor may approach a health facility under three circumstances:
• a) on his/her own only for treatment for effects of assault;
• b) with a police requisition after police complaint; or
• c) with a court directive.
• Come directly to the hospital without the police requisition, the hospital is bound
to provide treatment. A police requisition is not required for this.
• does not want to pursue a police case, a MLC must be made and informed refusal
must be documented.
• come with a police requisition or wishes to lodge a complaint later, the
information about medico-legal case (MLC) no. & police station should be
recorded.

74. Informed Consent
• At the time of MLC intimation being sent to the police, a clear note stating
“informed refusal for police intimation” should be made in case of refusal.
• In life threatening situation, the doctor may initiate treatment without consent as
per section 92 of IPC.
The consent form must be signed by 3 persons.
• Person him/herself if he/she is above 12 yrs,
• Guardian/ parent if under the age of 12 years.
• Examining doctor
• Any major 'disinterested', person may be considered a witness
Record the complete history of the incident, in survivor's own words as it has
evidentiary value in the court of law.

75. Protocol in PGIMER
• According to the protocols laid down by Sexual
Harassment Assessment Committee in PGI and the
guidelines provided by the MOHFW:
• Any female survivor of sexual assault who reports
PGIMER, a separate isolated room has been made
in Septic Labor Room
• This is equipped with all the basic pre requisites for
thorough physical and local examination

76. Majors
A.Victim More than 12 years
(Patient reaching PGI emergency or Advanced Trauma Centre)
Acute care & first aid to be provided by the on duty doctor
Inform SMO/MHA resident about need for assessment for sexual
assault
Medico legal report to be prepared by the SMO in consultation with SR
Gyne & on duty doctor
SMO/MHA resident to send information to the following for specific
examination & sample collection for sexual assault:
Gyne SR on duty
Forensic resident on duty

77. Minors
Victim Less than 12 years
(Patient reaching Pediatric Emergency or PGI emergency or ATC)
Acute care &first aid to be provided by the on duty doctor
Inform SMO/MHA resident about need for assessment for sexual assault
. Medico legal report to be prepared by the SMO in consultation with SR
Paediatrics, SRGyne & on duty doctor
SMO/ MHA resident to send information to the following for specific
examination & sample collection for sexual assault
Pediatrics SR
Gyne SR
Forensic Medicine SR
Chief security Officer

78. • (i) Two kits each for sample collection to be
kept in SLR & Pediatrics emergency along with
LIST of samples
• ii) All samples would be handed over to the
SMO/ MHA resident by Gyne SR

79. Evaluation of female adult sexual
assault victim
• Assessment and treatment of physical injury with
special focus on genitalia
• Forensic Evaluation
• Prevention of STD
• Prevention of Pregnancy
• Follow up

80. Examination
• Should be undressed with a sheet underneath to
capture any debris for evidence
• Emotional state should be assessed. Take help of
psychologist
• Evidence of trauma( Extra genital more common)
• If required, photographs of injuries with consent
• Components of examination should not be done if they
require sedation
• Look for bruise, abrasion, erythema on thigh, upper
arm, face, neck
• Examination of breasts, vagina, anus , rectum

81. Examination Table

82. Trauma
• Evidence of trauma more likely within 72 hours
• Common sites of injury
• Posterior fourchette, labia minora
• Genital trauma more common in postmenopausal and adolescents.
• Detectable Trauma of vaginal, anal penetration, mostly in virgins
• Colposcopic examination enhances detection of areas of minor
genital trauma
• Woods light/UV bulb identifies foreign body, semen on skin
• Enhances evidence of anogenital trauma.

83. Forensic Evaluation
• Sheets, debris, clothing kept in a bag
• Use collection kits (SAFE) Sexual assault forensic
examination kits for collection
• Samples sealed, labeled, stored using kit specific
directions.
• Sperms and acid phosphatase detected in vaginal
samples for 72 hours, anal for 24 hours
• Two swabs from each site, vulva vagina anus buccal
cavity, cervix, breast any other area suspecting saliva or
semen
• Two slides per swab made, air dry and pack slides
surface facing each other.

84. SAFE KIT

85. SAFE Kit
S no. Item Quantity
1 Disposable Syringes 2
2 Needle 23 G 2
3 EDTA vial 1
4 Sodium Fluoride Tube 1
5 Glass Slides 8
6 Swabs 2
7 Comb 2
8 Self Sealing Plastic bags 4
9 Sterile Containers 2
10 Draw Sheet (Small and large) 1 each
11 Cotton Cloth Bag 1
12 Disposable Gloves 2
13 Hi Medial Swabs 8
14 Nail Cutter 1
15 Marker 1

86. Almirah medicines/utilities

87. • Combed specimens from scalp and pubic hair
• Finger scrapings and clippings
• Whole blood sample(DNA,HIV, HbsAg, RPR)
• Saliva sample
• Urine Sample

88. Prevention of STD
• Empirical therapy:
• Ceftriaxone 200 mg IM or cefixime 400 mg PO single dose for
gonorrhea
• Azithromycin 1gm PO sinel dose or Doxycycline 100 mg bd for 7 days
for chlamydia
• Metronidazole 2 gm PO for Trichomonas Vaginalis and Bacterial
Vaginosis
• Post Exposure Prophylaxis
• Hep B vaccine or HBIg if already vaccinated
• HIV: low risk of transmission and lack of evidence regarding starting
ARV drugs
• Start within 4 hours, not if more than 72 hours elapsed

89. Prevention of Pregnancy
• Emergency contraception provided without regard
to menstrual cycles
• LNG 1.5 mg as single dose
• Yuzpe regime: 100 µg EE plus .5 mg LNG repeat
after 12 hours, 4 tabs Mala D or N, (repeat after 12
hours)
• Mifepristone 600mg single dose

90. Follow up
• 2 weeks
• Psychological counseling
• STD testing
• Pregnancy Testing
• Hep B vaccine, complete course,
• Repeat HIV, RPR test at 12 and 24 weeks

92. CONCLUSION
• Medical students taught to keep detailed record of the
patients they are treating.
• Patient and husband should sign informed consent in
vernacular language.
• Media reporters must have adequate medical
knowledge and analyze case properly.
• Judges should consider expert medical opinion.
• Medical ethics should be a part of undergraduate and
postgraduate curriculum.
• All practising doctors should have medical indemnity
policy to protect them from financial loss.

93. Thank You