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Infant deaths and female feticide

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Infant deaths and female feticide

  1. 1. DR. ARIF MASOOD PRINCIPAL ANANYA COLLEGE OF HOMOEOPATHY KALOL, GANDHINAGAR M.D.(HOM)
  2. 2.  Introduction All infants are susceptible, like adults to natural disease from which they could die. They may also die as a result of congenital anomalies or by application of violence or may present as case of sudden death.
  3. 3. Infanticide Definitions 1. Infanticide: It means unlawful destruction of a newly born child and is regarded as murder in law. It is punishable under Sec 302 of IPC. 2. Feticide: It means killing of fetus prior to birth. 3. Neonaticide: It means killing of neonate. 4. Filicide: It is defined as killing of a child or a step-child, aged between 0 and 18 years, by his or her parents.Filicide is broad term and includes neonaticide infanticide and pedicide
  4. 4. Causes Death due to application of violence and may be caused either by: 1. Acts of commission or 2. Acts of omission 1. Acts of Commission: These are the willful acts done to cause the death of infant. It includes: 1. Suffocation 2. Strangulation 3. Drowning 4. Head injury 5. Fracture-dislocation of cervical spine 6. Concealed puncture marks (pithing) 7. Poisoning
  5. 5. Causes Acts of Omission: Acts of omission refer to failure to take care of child or negligent towards the child during or after birth. It includes: 1. Failure to provide assistance during labor. 2. Failure to clear the air passage after birth. 3. Failure to cut and ligate the umbilical cord. 4. Failure to feed the child. 5. Failure to protect the child from heat or cold.
  6. 6. Medicolegal Questions Following questions are raised while doing autopsy in infanticide case: 1. Was the child still-born or dead born? 2. Was the child born alive (i.e. live born)? 3. If born alive, how long did the child survive the birth? 4. What was the cause of death?
  7. 7. Still-Born (Still Birth) Child • Definition: “The child which has issued forth from the mother after the 28th week of pregnancy and did not any time, after being completely expelled, breathes, or shows any other signs of life”. • Thus, a still-born child is alive in uterus up to the initiation of birth process and died during the process (i.e. delivery) but did not show any sign of life after being completely born. In other words, after birth, the child was still (immobile) and therefore the term still born child.
  8. 8.  Dead-born Child (Dead Birth) • Definition: A dead-born child is one, which had died in uterus before the birth process begins and may show rigor mortis, maceration or mummification at birth. • Fetal death has been defined by World Health Organization (WHO) as “death before complete expulsion or extraction from its mother of a product of conception, irrespective of the duration of pregnancy”. Rigor Mortis • Rgor mortis may set in early stages of death. • Presence of rigor mortis may cause difficulty in delivery.
  9. 9. Maceration • Definition: It is a process of aseptic autolysis occurringin fetus that remains dead in the uterus surrounded byliquor amnii. • Maceration in fetus is sign of death. • Mechanism: The cells of fetus break down after death and due to enzymatic action (autolysis) body becomes soft and flaccid. Unlike putrefaction or decomposition, there is no bacterial action in maceration. • Duration required: If fetus remains in uterus after death,then the earliest sign of maceration is seen at about 6 to 12hours in form of areas of desquamation and appearanceof brown-red discolouration of umbilical cord stump • The macerated fetus is soft and flabby and flattens when kept on table. • Emits sweetish disagreeable smell • The earliest sign of maceration is skin slippage (seen at 6-12 hours)
  10. 10. Maceration • Definition: It is a process of aseptic autolysis occurringin fetus that remains dead in the uterus surrounded by liquor amnii. • Maceration in fetus is sign of death. • Mechanism: The cells of fetus break down after death and due to enzymatic action (autolysis) body becomes soft and flaccid. Unlike putrefaction or decomposition, there is no bacterial action in maceration. • Duration required: If fetus remains in uterus after death,then the earliest sign of maceration is seen at about 6 to 12hours in form of areas of desquamation and appearance of brown-red discolouration of umbilical cord stump
  11. 11. Maceration • The macerated fetus is soft and flabby and flattens when kept on table. • Emits sweetish disagreeable smell • The earliest sign of maceration is skin slippage (seen at 6-12 hours) Mummification • It is drying and shriveling of fetus occurring in uterus after death • It results when liquor amnii is scanty and no air enters the uterus. Putrefaction If the membranes are ruptured early and air enters the uterus, then the dead fetus shows signs of putrefaction instead of maceration
  12. 12. Live-born Child (Live-birth) • A child showing a sign of life, even when only part of the child is out of mother, though the child has not breathed or completely born, is considered as live-born child. • Causing death of such child is treated in the same manner as homicide. Viability of Child • Viability means the ability of fetus to lead a separate existence after birth by virtue of certain degree of development. • A child is viable after 210 days or 7 months or 30 weeks of intrauterine life
  13. 13. Live-born Child (Live-birth) • A child showing a sign of life, even when only part of the child is out of mother, though the child has not breathed or completely born, is considered as live-born child. • Causing death of such child is treated in the same manner as homicide. Viability of Child • Viability means the ability of fetus to lead a separate existence after birth by virtue of certain degree of development. • A child is viable after 210 days or 7 months or 30 weeks of intrauterine life
  14. 14. Evidence of Live Birth (Signs of Live Birth) The law in India presumes that every child found dead was born dead unless the contrary is proved. Proof of live birth is required in civil or criminal cases. In Civil Cases Following are considered as signs of live birth. 1. Crying of baby 2. Movement of body or hand or foot 3. Muscle twitching or twitching of eyelid
  15. 15. Evidence of Live Birth (Signs of Live Birth) In Criminal Cases In criminal cases, signs of live birth have to be demonstratedby autopsy examination of the child. Following are the external and internal autopsy findings in live birth. External changes 1. Changes in chest 2. Changes in skin 3. Changes in umbilicus Internal changes 1. Changes in lung 2. Position of diaphragm 3. Changes in heart and circulation 4. Changes in gastrointestinal tract 5. Changes in middle ear 6. Changes in kidneys 7. Changes in blood
  16. 16. External Findings at Autopsy 1. Changes in Chest: A live birth child will respire and due to act of respiration, certain changes are induced.(Next Slide) 2. Changes in Skin • After live birth, color of skin is pinkish red and darkens after 2 to 3 days. The permanent complexion ofskin comes by seven days after birth. • Desquamation of skin is seen by 2nd day onwards • Physiologic jaundice manifests by 2nd day.
  17. 17. Changes in Chest:
  18. 18. 1. Changes in Chest:
  19. 19. 3. Changes in Umbilicus and Umbilical Cord The changes occurring in umbilicus and umbilical cord are summarized in Table
  20. 20. INTERNAL CHANGES Signs of live birth observed in internal examination are as follows I. Changes in Lungs: Due to respiration, following changes occur in lungs of live birth child. Differences between respired and unrespired lungs are summarized in Table below. A) Gross and microscopic examination 1. Volume: non-respired lungs appear small, collapsed, lie in the back part of chest on side of vertebral column whereas respired lungs appear voluminous; filling the whole pleural cavities and medial margin overlaps the mediastinum and pericardium. 2. Colour, consistency and appearance: Before respiration, the lungs are uniformly reddish-brown and hard in consistency like that of liver, non-crepitant. The pleurae over lungs are loose and wrinkled. After respiration, air cells (alveoli) are distended with respired air. The distended alveoli are raised above the surface
  21. 21. INTERNAL CHANGES I. Changes in Lungs A) Gross and microscopic examination However, lungs may be crepitant in dead fetus if the fetus is showing: • Signs of decomposition (putrefaction) or • If fetus is given artificial respiration. 3. On cut section: In non-respired lungs, the cut surfaces are uniform, hard and exude little froth-less fluid. In respired lungs, the cut surfaces are spongy and exude frothy blood.
  22. 22. INTERNAL CHANGES I. Changes in Lungs B). TESTS 1. Static test or Fodere’s test • Before respiration – average weight of lung (both) varies from 30 to 40 gm • After respiration – the average weight of both lungs increases and varies from 60 to 70 gm. The increase in weight is due to increase in circulation. 2. Ploucquet’s test • Before respiration – the weight of both lungs is about 1/70th of the weight of whole fetus. • After respiration – the weight of both lungs is about 1/35th of the weight of whole fetus. 3. Specific gravity • Non-respired lung – specific gravity is 1040 to 1050 • Respired lung – specific gravity is 0.940 to 0.950
  23. 23. INTERNAL CHANGES I. Changes in Lungs B). TESTS 4. Hydrostatic test • Also called as floatation test • The test is used to differentiate between respiredand non- respired lungs and is based on following principle: • Principle: If an infant breaths after birth, air will enter in lungs and makes them lighter and floats in water. • Procedure: Ligate the bronchi at hilum and placed individual lung in water. If the lung floats in water, remove lung and cut into many pieces and then squeeze or press the pieces between sponges and again place the individual pieces into water. A piece of liver may be used that will serve as control.
  24. 24. • Inference: Depending on floatation or sinking of lung/ pieces following inference can be drawn • If lung pieces floats – respired lung • If lung pieces sinks – unrespired lung • If liver piece floats – inconclusive Reason: Floating of lung and pieces can be explained as • In first part – lung floats because – after respiration is established, air will expand the collapsed alveoli. The specific gravity of lung before respiration varies from 1040 to 1050. However, after respiration, the specific gravity is about 0.940- 0.950, which is less than that of water. Thus the floatation of lung in water indicates the act of respiration and lung is respired one. • In second part – the pieces of lungs float because – after respiration, residual air is present in respired lung. The residual air cannot be squeezed out by pressing. Thus due to presence of air in lung pieces, the pieces will float. It indicates that child has respired after birth.
  25. 25. Drawbacks or fallacies of hydrostatic test 1. Respired lung may sink in following conditions: • Pulmonary edema • Pneumonia • Atelectasis – non-expansion of lung • Obstruction by alveolar duct membrane • Due to feeble respiration. 2. Non-respired lung may float in following conditions: • Putrefaction – presence of gases of decompositionmay cause floatation of unrespired lung • Artificial respiration
  26. 26. Hydrostatic Test is Not Necessary or Indicated in: 1. Fetus is dead born with signs of maceration/mummification. 2. Born before 180 days of gestation (non-viable). 3. The stomach contains milk. 4. Umbilical cord separated and scar formed at umbilicus. 5. When fetus has gross congenital anomalies incompatible with life, for example, anencephaly, monster etc.
  27. 27. Evidence of Live Birth (Signs of Live Birth) In Criminal Cases In criminal cases, signs of live birth have to be demonstratedby autopsy examination of the child. Following are the external and internal autopsy findings in live birth. External changes 1. Changes in chest 2. Changes in skin 3. Changes in umbilicus Internal changes 1. Changes in lung 2. Position of diaphragm 3. Changes in heart and circulation 4. Changes in gastrointestinal tract 5. Changes in middle ear 6. Changes in kidneys 7. Changes in blood
  28. 28. II. Position of Diaphragm • In fetal autopsy, abdomen is opened first to note the position of diaphragm. The features of diaphragm in respired infant are mentioned in Table below. • The position of diaphragm may be affected by presence of gases of decomposition developing within the chest and abdominal cavity.
  29. 29. II. Position of Diaphragm
  30. 30. III. Changes in Heart and Circulation The changes occurring in heart and circulation of live birth child are mentioned in Table below.
  31. 31. IV. Changes in Gastrointestinal Tract 1. Radiological evidence: Presence of air, demonstrated on X-ray, in gastrointestinal tract is a strong evidence of respiration. It is suggested that during the act of respiration, some air is swallowed in stomach and due to peristaltic movement; the air gradually descends in small and large intestine that can be demonstrated on X-rays. The presence of air in GIT may be confused with
  32. 32. IV. Changes in Gastrointestinal Tract
  33. 33. IV. Changes in Gastrointestinal Tract 2. Breslau’s second life test or stomach-bowel test • The test is based on following principle Principle: Air is swallowed in stomach during respiration. Stomach and intestine will float in water if air is present. Procedure: Stomach and intestine are removed after tying ligature at each end. Then they are placed in water. Result and interpretation: The results and inferences are as follows: • If stomach and intestine floats – it indicates presence of air in GIT and suggest child has respired after birth. • If stomach and intestine sinks in water – it indicates absence of air and suggest non-establishment of respiration in a child after birth. • The test has less utility and act as corroborative evidence rather than conclusive evidence • Drawbacks: The test may be positive (i.e. float in water): • If air or gases is present in GIT due to decomposition • If air or gases is present in GIT due to artificial respiration Advantages: The test is useful when air is prevented from entering into lungs by:•Foreign body or • Due to occlusion of bronchi or • Due to presence of tracheo-bronchial fistula
  34. 34. IV. Changes in Gastrointestinal Tract 2. Breslau’s second life test or stomach-bowel test • Drawbacks: The test may be positive (i.e. float in water): • If air or gases is present in GIT due to decomposition • If air or gases is present in GIT due to artificial respiration  Advantages: The test is useful when air is prevented from entering into lungs by:•Foreign body or • Due to occlusion of bronchi or • Due to presence of tracheo- bronchial fistula 3. Demonstration of air under water: if stomach is dissected under water, air bubbles will be released from stomach if the child has respired. 4. Presence of milk or liquid food in stomach is a definitive evidence of live birth of child and establishes that child had lived for some time.
  35. 35. Sudden infant death syndrome (SIDS) Also Called as Cot Death, Crib Death or SIDS In international conference held in 1969, Beckwith proposed following definition “the sudden death of any infant or young child which is unexpected by history and in whom a thorough necropsy fails to demonstrate an adequate cause of death”. A more comprehensive definition was proposed in 1989 by the National Institute of Child Health and Human Development stressing the need of examination of scene of death. It defines infant deaths to be classified as SIDS if: 1. The death of infant occurs up to the age of 1 year of age 2. A thorough postmortem examination fails to demonstrate an adequate cause of death. 3. A death scene investigation is conducted and yields no evidence of unnatural cause of death and 4. A review of the infant and the mother’s medical records reveal no history of medical condition that might have caused death.
  36. 36. Factors Influencing the Risk of SIDS 1. Age: Death is common between 2 weeks to 2 years with peak incidence occurs at around three month. 2. Sex: The incidence is more with male baby and most surveys show the ratio of 1:1 3. Twins: The incidence is more in a member of a twin pair as opposed to singletons. Etiology and Theories of Causation of SIDS Many theories are proposed for the causation of SIDS but all remain speculative. Following are the proposed theories: 1. Allergy to cow’s milk 2. Allergy to house-mite 3. Spinal hemorrhages.
  37. 37.  Battered baby syndrome • Also called as Caffey’s syndrome, child abuse syndrome, maltreatment syndrome, non-accidental injury of childhood • Definition: A battered child is one that suffers repetitive physical injuries inflicted by parent or guardian, which are non-accidental in nature. • Caffey (1946) first reported the unusual combination of recurrent subdural hematoma with fracture of long bones but thought that the phenomenon could be due to metabolic abnormality. Silverman (1953) was the first to point out that both, subdural hematoma and bone fracture were the result of severe recurrent trauma. Kempe et al (1962) coined the term “battered child syndrome” now frequently called the “battered baby syndrome
  38. 38. Features of Battered Baby Syndrome10 • Age is usually less than 2 years • Seen slightly more in male sexes • There is general condition of neglect in child • Disproportionate amount of soft tissue injury and history is inconsistent with pattern of injury • Occurrence of injuries at different times • History given by parents are incompatible with clinical findings • There may be history of multiple admission to hospital • Such children usually belong to broken families, low socioeconomic strata or the child may be result of unwanted pregnancy or as a result of illegitimate sexual relationship.
  39. 39. Diagnosis • Nature of injuries inconsistent with history provided by parents • Recurrent injuries and injuries of different age with different stage of healing • Purposeful delay in seeking medical aid by parents. Medicolegal Implications 1. In India, the incidence of battered baby syndrome is less. 2. If death of child occurs, a charge of homicide may be labeled against offending parent.
  40. 40. Cinderella syndrome • This syndrome was first described by Peter Lewin13 in 1976. • In some family, a single child, particularly female child, is chosen for battering. The child is usually the youngest or eldest child in the family. The child is repeatedly abused while other children (i.e. brother or sisters) of same family are spared. • The child may develop inattention disorder, temper tantrums, failing grades and may leave the home.13 • In other variety of syndrome, few adopted female child accuse their step-parents of maltreatment
  41. 41. Shaken baby syndrome • Shaken baby syndrome was first described by Guthkelch in 1971. • Shaken baby syndrome is violent act of abuse that can cause myriad neurological, cognitive and other functional deficits. In the most serious cases, deaths can result. • It is a form of child abuse characterized by retinal, subdural and/or subarachnoid hemorrhage caused by severe shaking
  42. 42. Preconception and prenatal Diagnostic Techniques Act 2003 (PCPNDT) prohibits sex selection before or after conception and the use of pre-natal diagnostic techniques to determine sex of fetus. Sex can be Determined By: 1. Amniocentesis 2. Chorionic villous biopsy 3. Ultrasonography scan and imaging techniques
  43. 43. Features of PCPNDT Act • Act prohibits sex selection before or after conception • Regulates the use of prenatal diagnostic techniques • Gynecologist or RMP have to conduct pre-natal diagnostic techniques at recognized place • Nursing home or RMP or hospital where ultrasonography is used have to display the board stating “hospital does not do sex determination test”. • Prenatal diagnostic techniques can be conducted for purpose of determination of chromosomal or genetic or congenital abnormalities. • Written consent of pregnant woman is must to undergo PC and PND technique • Doctor contravening the provisions of Act shall be punished for 3 years imprisonment and fine of Rs. 10,000. • Any person seeking help for sex selection shall also be held guilty and a provision of punishment for 3 years and fine of Rs. 50,000 is made under the Act. • Doing sex determination test amounts to misconduct by Medical Council of India
  44. 44. Pre-Requisite for Doing PCPNDT PCPNDT should not be carried out unless any one or more conditions, mentioned below, are fulfilled: 1. History of two or more spontaneous abortion. 2. Age of two pregnant female is above 35 years. 3. History of exposure to teratogenic drug, radiation or infections. 4. History of mental or physical deformities or genetic disease in family.
  45. 45. Indications PCPNDT is carried out only to detect: 1. Chromosomal abnormalities 2. Genetic or metabolic abnormalities 3. Hemoglobinopathies 4. Sex-linked genetic diseases 5. Congenital anomalies

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