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INFANT DEATH

INTRODUCTIONA1l infants are susceptible, like adults to natural diseasefrom which they could die. They may also die as a resultof congenital anomalies or by application of violence ormay present as case of sudden death. The causes of deathin infant are summarized in Table below at the right side.

Definitions

l. Infanticide: It means unlawful destruction of a newlyborn child and is regarded as murder in law. 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.

CAUSES

Death due to application of violence and may be causedEither by:1. Acts of commission or2. Acts of omission

Acts of Commission

These are the willful acts done to cause the death of infant.It includes:

1. Suffocation2. Strangulation

Infanticides by Dr. ALY SAMY, FORENSIC MEDICIEN, MCST 2014

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3. Drowning4. Head injury5. Fracture-dislocation of cervical spine6. Concealed puncture marks (pithing)7. Poisoning.

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.

MEDICO LEGAL QUESTIONS

The following questions are raised while doing autopsy in infant:

1. was the child stillborn or dead?2. Was the child born alive (i.e. live born?)3. If born alive, how long did the infant live the birth?4. What was the cause of death?

Status of infant: was the Child Stillborn,Dead-born or Live-born? An infant may be live, born, dead born or still born. Theterms are defined as below.

Still-Born (Still Birth) Child

Definition: The child which has issued forth from themother after the 28th week of pregnancy and did not anytime, after being completely expelled, breathes, or showsany other signs of life".. Thus, a still-born child is alive in uterus up to the initiation of birth processand died during the process (i.e.delivery) but did not show any sign of life after beingcompletely born. In other words, after birth, the child wasStill (immobile) and therefore the term still born child.


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. Causes of still-birth are mentioned in Table at right side

Dead-born Child (Dead Birth)

Definition: A dead-born child is one, which had diedin uterus before the birth process begins and may showrigor 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

. Rigor mortis may set in early stages of death.

. Presence of rigor mortis may cause difficulty in delivery.

MacerationDefinition: 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 deathand due to enzymatic action (autolysis) body becomessoft 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 l2hours in form of areas of desquamation and appearanceof brown-red discoloration of umbilical cord stumpa.


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Featuresof Maceration. The macerated fetus is soft and flabby and flattenswhen kept on table.. Emits sweetish disagreeable smell. The earliest sign of maceration is skin slippage (seenat 6-12 hours).. Skin is sodden and shows red or purple coloration with large blebs (or blisters) containing serousor sero-sanguineous fluid. The epidermis is easilypeeled off leaving moist, greasy areas underneath.Abdomen is distended.Joints become abnormally mobile or flexible withBones get flexible and are easily detached from thesoft parts.. Skull bones show loss of alignment and they overrideover each other due to shrinkage of brain after death,known as Spalding sign. Brain becomes pulpy andgrayish-red in color.. Body cavities contain reddish serous fluid.. Internal organs become soft and edematous. Umbilical cord is red, smooth, softened and thickened.

Mummification

. It is drying and shrinking of fetus occurring in uterusafter death.. It results when liquor amnii is scanty and no air entersthe uterus.

Putrefaction

If the membranes are ruptured early and air enters the uterus,then the dead fetus shows signs of putrefaction instead ofmaceration.

Live-born Child (Live-birth)


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A child showing a sign of life, even when only part of thechild is out of mother, though the child has not breathedor 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 separateexistence after birth by virtue of certain degree of development.A child is viable after 210 days or 7 months or 30 weeksof intrauterine life.

Evidence of Live Birth (Signs of Live Birth)Following are considered as signs of live birth.

1. Crying of baby2. Movement of body or hand or foot3. Muscle twitching or twitching of eyelid.

These signs are sufficient to establish the proof oflive birth in civil cases. Crying of a child is considered as strong proof of live birth but, at times, it ispossible that (after rupture of membrane) fetus maycry even when it is in uterus or in vagina.

Followingtwo conditions are considered:

l. Vagitusuterinus: Crying of a child even when it is in uterus2. Vagitusvaginalis: Crying of a child even when it is invagina. Thus, it may possible that child may didn't showany sign when it comes out although cry of child isheard by people. So crying of child is not conclusiveproof of live birth.

ln Criminal Cases


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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 changesl. Changes in chest2. Changes in skin3. Changes in umbilicus

Internal changes1. Changes in lung2. Position of diaphragm3. Changes in heart and circulation4. Changes in gastrointestinal tract5. Changes in middle ear6. Changes in kidneys7. Changes in blood

External Findings at Autopsy

1. Changes in Chest:

A live birth child will respire and due to act of respiration,

2. Changes in Skin

. After live birth, color of skin is pinkish red and darkens after 2 to 3 days. The permanent complexion of skin comes by seven days after birth.. Desquamation of skin is seen by 2nd day onwards.. Physiologic jaundice manifests by 2nd day.

3. Changes in umbilicus and umbilical CordThe changes occurring in umbilicus and umbilical cord are


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summarized in Table at the right side

lnternal ChangesSigns of live birth observed in internal examination are asfollowsl. Changes in Lungs

Due to respiration, following changes occur in lungs of livebirth child.

Differences between respired and unrespiredlungs are summarized in Table below:

A) Gross and microscopic examination;


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1. Volume: In non-respiredlungsappear small, collapsed, liein the back part of chest on side of vertebral column.In respired lungsappear voluminous;filling thewhole pleural cavities and medial margin overlaps themediastinum and pericardium.

2.Color, consistency and appearance: In non-respiredlungs;the lungs are uniformly reddish-brown and hard in consistency like that ofliver, noncrepitant. The pleurae overlungs are loose and wrinkled.In respired lungs;air cells(alveoli) are distended with respired air. The distendedalveoli are raised above the surface. With initiation ofrespiration, the blood in lungs becomes oxygenated andbright red or pinkish color to lungs with mottled appearance. The respired lungs are spongy, elasticand crepitant. However, lungs may be crepitant in deadfetus if the fetus is showing:. Signs of decomposition (putrefaction) or. If fetus is given artificial respiration.

3. On cut section: In non-respiredlungs, the cut surfacesare uniform, hard and exude

little froth-less fluid. Inrespired lungs, the cut surfaces are spongy and exude

frothy blood.

4. Margins: In non-respiredlungs, margins of lungs aresharp. In respired lungs, the lung margins becomerounded.

6. Blood in lung bed: The amount of blood in lung bedIn non-respiredlungsare about twice that of blood found instillborn child.

6. Microscopy: Respired lung alveoli appear expanded with


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flattening of epithelium and increased vascularization.In non-respired lungs, the alveolar lining epithelium iscuboidal to columnar with less vascularization.

B) TESTS

l. Static test or Fodere's testIn non-respiredlungs; average weight of lungs (both)varies from 30 to 40 gm.In respired lungs- the average weight of both lungsincreases and varies from 60 to 70 gm. The increasein weight is due to increase in circulation.

2. Ploucquet's testIn non-respiredlungs- the weight of both lungs is about1/70th of the weight of whole fetus.In respired lungs- the weight of both lungs is about1/35th of the weight of whole fetus.

3. Specific gravityIn non-respiredlungsspecific gravity is 1040 to 1050In respired lungs- specific gravity is 940 to 950

4. Hydrostatic testThe test is used to differentiate between respiredand non-respired lungs and is based on followingprinciple:If an infant breaths after birth, air will enterin lungs and makes them lighter and floats in water.Procedure: Ligate the bronchi at hilum and placedindividual lung in water. If the lung floats in water,remove lung and cut into many pieces and thensqueeze or press the pieces between sponges andagain place the individual pieces into water. A pieceof liver may be used that will serve as control.Inference:

Depending on floatation or sinking of lungpieces following inference can be drawn.In non-respiredlungsthe lung pieces sink.


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In respired lungsthe lung pieces float.. If liver piece floats - inconclusiveReason: Floating of lung and pieces can be explained as. In first part - lung floats because - after respiration is established, air will expand the collapsedalveoli. The specific gravity of lung before respiration varies from 1040 to 1050. However, afterrespiration, the specific gravity is about 940-950, which is less than that of water. Thus thefloatation of lung in water indicates the act ofrespiration and lung is respired one.In second part - the pieces of lungs float because- after respiration, residual air is present inrespired lung. The residual air cannot be squeezedout by pressing. Thus due to presence of air inlung pieces, the pieces will float. It indicates thatchild has respired after birth.

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 decomposition

may cause floatation of unrespired lung. Artificialrespiration.

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 incompatiblewith life, for

example, anencephaly, monster etc.


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ll. Position of Diaphragm. In fetal autopsy, abdomen is opened first to note the position of diaphragm. . The position of diaphragm may be affected by presenceof gases of decomposition developing within the chestand abdominal cavity.

lll. Changes in Heart and Circulation

The changes occurring in heart and circulation of live birthchild are mentioned inTable

lV. Changes in GastrointestinalTract

l. Radiological evidence:


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Presence of air, demonstrated onX-ray, in gastrointestinal tract is a strong evidence of respiration. It is suggested that during the act of respiration, someair is swallowed in stomach and due to peristaltic movement;the air gradually descends in small and large intestine thatcan be demonstrated on X-rays.

Air in stomach.; Minutes after birth Air in small intestine; 1-2 hours after birth Air in large intestine; 5-6 hours after birth

The presence of air in GIT may be confused with:. Putrefaction gases in gastrointestinal tract. Artificialrespiration.

2. Breslau's or stomach-bowel test. The test is based on following principlePrinciple: Air is swallowed in stomach during respiration. Stomach and intestine will float in water if air is present.Procedure: Stomach and intestine are removed aftertying ligature at each end. Then they are placed inwater.Result and interpretation: The results and inferencesare as follows:. If stomach and intestine floats - it indicates presence of air in GIT and suggest child has respiredafter 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 inwater):. If air or gases is present in GIT due to decomposition.If air or gases is present in GIT due to artificialrespirationAdvantages: The test is useful when air is preventedfrom entering into lungs by:. Foreign body or. Due to occlusion of bronchi or. Due to presence of tracheo-bronchial fistula3. Demonstration of air under water: if stomach is dissectedunder water, air bubbles will be released from stomach if thechild has respired.4. Presence of milk or liquid food in stomach is a definitiveevidence of live birth of child and establishes that child had


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lived for some time.

V. Changes in middle Ear (Wredin's Test)Middle ear contains gelatinous material before birth. If childrespires after birth, with act of respiration, the sphincter atpharyngeal end of Eustachian tube relaxes and air enters inmiddle air replacing the gelatinous substance within few hours.

Vl. Changes in KidneysDeposition of uric acid, in form of brownish yellow crystallinestreaks, in pelvis of the kidneys has been regarded as a proofof live birth. But this is not reliable evidence of live birth.

VII Miscellaneous Evidences of Live Birth1. Blood: Following changes are noted;. Nucleated RBCs disappear from blood within 24hours after birth. Fetal hemoglobin, which is 80 percent at birth,decreases to 7 to 8 percent at 3rd month.

2. Caput succedaneum:. Caput succedaneum is an edematous swelling occurring in the scalp at the presenting part of head in vertexpresentation of fetus. This swelling occurs due to compression ofhead during delivery and causes extravasation of fluid in the subcutaneous tissue. The swellingis diffuse, boggy and is not limited by the suture line.It disappears spontaneously within 24 hours after birth.. Presence of caput succedaneum indicates fetus beingalive during delivery.. This swelling has to be differentiated from cephalhematoma.


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medicineg.wikispaces.com 2... · Web viewIn fetal autopsy, abdomen is opened first to note the position of diaphragm. . The position of diaphragm may be affected by presenceof gases