Legal Med 2.03 Birth, Abortion, Infanticide.docx

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October, 2017 BIRTH, ABORTION, INFANTICIDE

Atty. Malaya Capulong, MD, DFM, LLB Department of Bioethics and Legal Medicine

TOPIC OUTLINE I. Medico-legal Importance of Determining Pregnancy a. Signs of Pregnancy b. Proof of Previous Pregnancy II. Abortion a. Clinical Types of Abortion b. Articles of Revised Penal Code on Abortion c. Three Stages of a Crime III. Methods of Abortion a. General Violence b. Local Violence c. Use of Drugs d. Surgical Intervention IV. Therapeutic Abortion V. Proof of Live Birth VI. Infanticide a. Post-mortem Findings VII. Infa

*Text in boxes are notes from Doc

MEDICO-LEGAL IMPORTANCE OF DETERMINING PREGNANCY   

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In cases of abortion, it is important to confirm whether the woman had been recently pregnant In civil controversies concerning the estate of the dead spouse, the pregnancy of the wife affects the disposition of property and succession. Under the Rules of Court, the advanced pregnancy of a woman can excuse her attendance in court. The execution of the death sentence of a pregnant woman can be postponed until she delivers and until the infant is weaned. In the crime of infanticide, it must be shown that the woman previously gave birth to a live infant. To support the claim of adultery against the wife, pregnancy can be made material evidence. Signs of Pregnancy Pregnancy – state of a woman who has within her body the growing product of conception. o commences from fertilization and terminates upon delivery. o 270 to 280 days from 1st day of LMP. Presumptive of Probable Signs o Cessation of menses o Morning sickness o Changes in her breast o Progressive enlargement of the abdomen o Changes in vagina and the cervix  Jacquemin-Chadwick’s sign – violet discoloration of ant. wall of vagina  Hegar’s sign  Goodell’s sign o Funic or umbilical soufflé o Ballotement o Braxton-Hick’s Sign o Bladder irritability o Capricious Appetite o Abnormality in pigmentation – linea nigra

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o Easy Fatigability Positive Signs o Fetal heart sounds o Outline of fetal parts o Movement of fetus o Radiologic Examination  Xray  Ultrasound Proof of Previous Pregnancy Presence of pink-to-pale scars or abdominal striae = striae gravidarum Fourchette is markedly retracted There may be an episiotomy scar Vaginal examination may show laceration scars of the cervix Darkened nipple areola Linea nigra Hymen either vanishes or small remnants remain (carunculae multiformes)

ABORTION       

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The termination of pregnancy, before full term or before the age of viability by the removal or expulsion from the uterus, resulting in or caused by its death (embryo/fetus) An abortion can occur spontaneously due to complications during pregnancy It can be induced Refer to willful killing of the fetus in the uterus Violent expulsion of the fetus from the uterus resulting in its death All abortions in our country are illegal Clinical Types of Abortion Missed Abortion o Usually occurs before the 4th month of gestation when the fertilized ovum/embryo is destroyed by hemorrhage into the choriospace o The embryo is either macerated or absorbed Threatened Abortion o Hemorrhage without dilatation of the internal cervical os Inevitable Abortion o Hemorrhage with dilatation of the internal os accompanied by rhythmical abdominal pain Incomplete Abortion o Abortion where not all products of conception were expelled from the uterus o Usually necessitates completion curettage to remove the retained fetal elements Complete Abortion o Products of conception are completely expelled Spontaneous Abortion o Aka miscarriage o Expulsion of embryo or fetus due to accidental trauma or natural causes before approx. 22nd week of gestation

BIRTH, ABORTION, AND INFANTICIDE

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Induced Abortion o Therapeutic abortion  Abortion induced to preserve the health of the gravida o Criminal abortion o Defined under the Revised Penal Code Articles of Revised Penal Code on Abortion Article 256: Intentional Abortion Article 257: Unintentional Abortion Article 258: Abortion practiced by the woman of her parents Article 259: Abortion practiced by physician or midwife or dispensing of abortives Article 256: Intentional Abortion Pregnant woman Application of violence or the administration of drug, especially an abortifacient (Misoprostol) The fetus dies as a result Intent is to abort the fetus – intent is proved by the surrounding circumstances (proof of intent) Known in Med Ethics as direct abortion MUST HAVE A MOTIVE/PROOF OF INTENT Article 257: Unintentional Abortion Pregnant woman Application of violence Fetus is aborted as a result No intent to abort the fetus Example: You punched a pregnant not knowing she is pregnant. The fetus is aborted as a result. You can be charged with unintentional abortion. Under the criminal law, it is not your intended crime that is punished but rather, the end of your intended act.

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Article 259: Abortion Praticed by a Physician or Midwife or Dispensing of Abortives  A physician or midwife who, taking advantage of their scientific knowledge or skill, shall cause an abortion.  Any pharmacist who, without proper prescription from a physician, shall dispense any abortive—even if the abortion is just a secondary effect; especially if the effect is imminent (e.g. antineoplastic agent)  There is a built-in aggravating circumstance which can never be cancelled out by a mitigating circumstance; higher penalty than RA 258

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Three Stages of a Crime Consummated o End point is realized/achieved o Example: Napatay mo yung tao. Attempted o Plan was executed but the end-point was not met o Example: Papatayin mo sana pero hindi mo napatay Frustrated o There was planning and preparation but the plan was not executed o Example: You were planting a bomb, but you were caught by the police

METHODS OF ABORTION    

Article 258: Abortion Practiced by The Woman or her Parents Pregnant woman Intent is to abort the fetus Committed by the woman or her parents, never the man/husband Penalty is lower that the intentional abortion of Article 256 because it is on the presumption that it is an unwanted pregnancy There is built-in mitigating circumstance; the law recognizes that the woman and her parents may not be acting out of evil intentions but rather a desire to protect their family from shame

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Yields higher penalty since these people are supposed to rpeserve life All of the ff. elements should be present to consider abortion as a crime: o Pregnant woman o Intent is to abort the fetus o A physician or midwife induced or assisted in causing the abortion A physician or midwife who practices abortion is meted a higher penalty because they make use of their special knowledge and training for the destruction of human life rather than it preservation, which is contrary to the oath they took. It speaks if greater perversity of evil design.

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General violence Local violence Use of drugs Surgical intervention General Violence Pressure o Exerted on the abdomen, usually through kneading, blows, kicks, tight lacing Exercise o Riding on horseback, hiking, lifting heavy weights, cycling Cupping o Placing a lighted wick over the hypogastrium and turning a big glass, mouth downward over the wick o This probably causes separation of the placenta Application of leeches o To the pudenda, perineum Local Violence Douches Injection of fluid into uterine cavity o Saline used in abortions performed during the 2nd trimester Laminaria tent o Sticks of seaweed which absorbs fluid swell  promote dilatation of the cervix o Induces dilatation of cervix leading to abortion Instrumentation o Insertion of foley catheter, hangers or other instruments into the cervix and uterus Use of Drugs Acting directly on the uterus o Emmenagogues

BIRTH, ABORTION, AND INFANTICIDE

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o Ecbolics Acting through the GUT o Hyoscine N-butylbromide o Oil of tamsy o Turpentine Acting through the GIT o Castor oil o Magnesium sulfate With poisonous effect on the body o RU 486 or mifepristone o Misoprostol o Methotrexate o Prostaglandins Drugs Acting Directly on the Uterus Emmenagogues: increases menstrual flow o Direct  Ergot  Cantharides  Potassium permanganate  Bora o Indirect  Iron  Arsenic  Strychnine  Liver extracts  Castor oil Ecbolics: stimulates uterine contraction

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Surgical Intervention 

Cervical dilatation

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Drugs Acting through the Gastrointestinal Tract Causes uterine contractions reflexively o Castor oil o Magnesium sulfate Drugs with Poisonous Effect to the Body RU 486/Mifepristone o Synthetic steroid compound used as an abortifacient in the first two months of pregnancy o Blocks progesterone receptors that directly cause:  Endometrial decidual degeneration  Cervical softening and dilatation  Release of endogenous prostaglandins  Increase in the sensitivity of the myometrium to the contractile effects of prostaglandins  Aka “morning-after pill”

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In the first 12 weeks, suction-aspiration or vacuum abortion is the most common method o Manual vacuum aspiration (MVA)  Consists of removing the fetus or embryo, placenta and membranes by suction using a manual syringe o Electric vacuum aspiration (EVA)  Uses an electric pump Dilation and curettage (D&C) o A standard gynecological procedure performed for:  Examination of the uterine lining for possible malignancy  Investigation of abnormal bleeding  Abortion (usually in the 1st trimester) Dilation and evacuation (D&E) o Used from the 15th week until approx.. 26th week AOG o Consists of opening the cervix of the uterus and emptying it using surgical instruments and suction o

Spasm relief

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Suction

Drugs Acting through the Geniturinary Tract Drugs which produce irritation of the GUT and reflexively incite uterine contractions o Oil of Tamsy o Turpentine o Hyoscine N-Butylbromide  Relaxes the smooth muscle of the gastrointestinal, biliary, and urinary tracts. Inhibits cholinergic transmission in the abdominal and pelvic parasympathetic ganglia

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Misoprostol o A prostaglandin initially developed and marketed as a drug to prevent the development of NSAID-induced gastric ulcers o Acts by promoting uterine contractions and ripening (effacement or thinning) of the cervix o Available in oral preparations and suppositories o Very effective. One tables is enough. o DOC for abortion according to Doc. Methotrexate o Stops embryonic cells from dividing and multiplying and is a non-surgical method of ending pregnancy in its early stages Prostaglandins o Within a few days or weeks of receiving an injection of Methotrexate, the pregnancy ends through an experience similar to an early miscarriage.

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STUDY BREAK GAME! Name that thing: A. Pleat B. Front C. Yoke D. Placket

BIRTH, ABORTION, AND INFANTICIDE

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A crime is committed but the perpetrator is absolved of liability, provided the following concur: o Evil sought to be avoided actually exists o Injury feared is greater than that done o No other practical or less harmful way of avoiding injury This is not exempting; you are still found guilty of a crime but your criminal liability is not penalized Magrereflect sa NBI clearance. You are still considered a criminal

MEDICO-LEGAL IMPORTANCE OF DETERMINING PREGNANCY 

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Partial birth abortion (3rd trimester abortion) o Performed during a later stage of pregnancy o Late-term abortion is more controversial than abortion in general because the fetus is more developed and sometimes viable (usually done during the second half of 3rd trimester) o Induced abortion procedure that occurs after 20th week AOG o Intact dilation and extraction, intact dilation and evacuation, intrauterine cranial decompression o You are delivering the baby to kill it.

Guided by ultrasound, the baby's leg is grasped with forceps. The baby's leg is pulled out into the birth canal. The baby's entire body, except for the head, is delivered. A scissor is jammed into the baby's skull. The scissors are removed and a suction catheter is inserted. The child's brains are sucked out, causing the skull to collapse. The dead baby is then removed.

THERAPEUTIC ABORTION Article 11, No. 4, Revised Penal Code – Justifying Circumstances

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BIRTH DETERMINES PERSONALITY o Article 40, civil code  Birth determines personality.  The conceived child shall be considered born for all purposes that are favorable to it, provided it be born later with the conditions specified in the following article. o Article 41, civil code  For civil purposes, the fetus is considered born if it is alive at the time it is completely delivered from the mother’s womb.  However, if the fetus had an intrauterine life of less than 7 months, it is not deemed born if it dies within 24 hours after its complete delivery from the maternal womb. SCENARIO IMPLICATION  If born full term, and  Issuance of a birth survives at least within 24 certificate is a must hours  All beneficial things given  Regarded as having to him before birth shall been born be granted  The state recognizes his estate; his legal heirs will be his parents  If born