Determination of live birth and viability in the examination of corpses of fetuses and newborns. Conducting swimming trials of Galen and Breslau, their expert evaluation. Examination of corpses of fetuses and newborns
The criterion for live birth is the occurrence of extrauterine pulmonary respiration in a viable fetus. A stillbirth is the birth of a fetus that does not breathe spontaneously after delivery. To determine the live birth, the so-called vital tests (pulmonary and gastrointestinal) are used and histological examination lung tissue. The presence of air in the lungs and gastrointestinal tract before autopsy can be established by radiography of the corpse.
Pulmonary vital test is based on the change in the density of breathing lungs compared to non-breathing ones. The lungs of a non-breathing newborn are airless and dense (Fig. 102), their surface is smooth and uniform. They are small in volume, lie deep in the pleural cavities and are covered in front by the heart and thymus gland. The relative density of non-breathing lungs is greater than 1 (1.05-1.056), so they sink in water. On the cut, their tissue is uniformly reddish, anaemic.
With the first breath. the child's lungs begin to expand and fill with air, their volume increases, relative density becomes less than 1, so they float in the water. From the surface and on the incision, their tissue is motley, marble-like, light red areas alternate with darker ones, with pressure, not only blood, but also bloody foam is released from the surface of the incision.
The technique for conducting a lung test is as follows: before opening the chest cavity, the trachea is separated and bandaged together with the esophagus. After that, they open the chest cavity, remove the lungs, heart and thymus gland in a single complex and lower them into a spacious vessel with water. If the complex sinks, then the heart is separated from it, then the thymus gland.
If even some lungs sink, then separate lobes are cut off from them and placed in water; if they sink, then pieces are separated from them, similar to straightened ones, and lowered into the same place. Separate pieces are squeezed under water and observe whether air bubbles are released from them.
Expert evaluation of the results of this test is sometimes difficult. Positive result(lungs float in water) observed when the newborn was breathing. Also, rotten breathing and non-breathing lungs do not sink, so the lung test is unreliable with putrefactive changes in the corpse.
Partially floating lungs of a stillborn who was mechanically ventilated, as well as frozen and incompletely thawed lungs of both live and stillborn. Negative result(when the lungs sink) occurs in stillborns, as well as in secondary atelectasis, when the lungs of a breathing infant collapse, but did not live long.
Usually secondary atelectasis develops in preterm infants. Histochemical examination of the lung tissue in such cases often shows the absence or a sharp underdevelopment of the anti-atelectatic substance - surfactant.
It is believed that the surfactant, located on the surface of the alveoli, lowers the surface tension and prevents them from falling.
Gastrointestinal test . Simultaneous with the onset of spontaneous breathing (and sometimes even earlier), the infant develops swallowing movements, during which air enters gastrointestinal tract. At the same time, the stomach and intestines acquire the ability to swim in water, and the gastrointestinal test is based on this. To perform it, before removing the organs of the chest and abdomen, the stomach is tied up at the entrance and exit with two ligatures. Ligatures are also applied to the loops of the small and large intestines. The extracted complex, as well as the lungs, is tested for buoyancy. Swimming of the entire complex or only one stomach indicates a live birth. However, air can enter the stomach when carrying out IVL. In decayed corpses, this test is also not conclusive due to the formation of putrefactive gases in the intestines.
Usually the results of pulmonary and gastrointestinal tests are the same. However, other combinations of the results of these tests are also possible: the lungs float, the stomach and intestines sink - the newborn lived, breathed a short time, for which the air did not have time to penetrate into the gastrointestinal tract. If the lungs sink and the stomach floats, this may be an indication of secondary atelectasis. True, the latter option is very rare.
Histological examination of the lungs is mandatory when establishing live and stillbirth. Alveoli and bronchioles of the lungs of a stillborn collapsed, various shapes and size, the alveolar epithelium is cubic, elastic fibers are arranged in the form of bundles and spirals. In the breathing lungs, the alveoli are straightened, their walls are thin, the alveolar epithelium is flattened, the capillaries are full-blooded, the elastic fibers follow the contours of the straightened alveoli. In some forms of congenital pulmonary insufficiency, especially in preterm infants, hyaline membranes are found in the alveoli and alveolar ducts. They do not occur in stillborns, so hyaline membranes can be considered a sign of live birth.
To establish live birth, it is also proposed to use a histological examination of the umbilical cord, umbilical ring and birth tumor, as well as the study of protein fractions of blood serum using the electrophoretic method and inorganic elements of organs and tissues of the corpses of newborns using the emission spectral analysis method.
Ministry of Health of the Russian Federation and the State Statistics Committee of the Russian Federation
Instruction
on the definition of criteria for live birth, stillbirth, perinatal period
For the purpose of international comparability of domestic statistics in the field of perinatology and in connection with the transition to the criteria for live birth and stillbirth, adopted World Organization health authorities, health authorities should adhere to the following definitions and concepts of live birth, stillbirth, perinatal period and parameters physical development newborn (fetus).
1. Live birth
Live birth is the complete expulsion or removal of the product of conception from the mother's body, regardless of the duration of pregnancy, and the fetus after such separation breathes or shows other signs of life, such as a heartbeat, pulsation of the umbilical cord or voluntary movements of the muscles, regardless of whether the umbilical cord has been cut and separated placenta. Each product of such a birth is regarded as a live birth.
2. Stillbirth
Stillbirth is the death of the product of conception before its complete expulsion or removal from the mother's body, regardless of the duration of pregnancy. Death is indicated by the absence of respiration in the fetus after such separation or any other signs of life, such as heartbeat, pulsation of the umbilical cord, or voluntary muscle movements.
3. Weight at birth
Birth weight is the result of the first weighing of the fetus or newborn, recorded after birth. This weight should preferably be established within the first hour of life before significant postnatal weight loss occurs. Measurement of the length of a newborn (fetus) must be made with its extended position on a horizontal stadiometer.
Newborns (fetuses) born weighing less than 2500 g are considered low birth weight fetuses; before 1500 - very low; up to 1000 - with extremely low.
4. Perinatal period
The perinatal period begins at 28 weeks of pregnancy, includes the period of childbirth and ends after 7 full days newborn life.
5. Health care institutions register in medical records all those born alive and dead, having a birth weight of 500 g or more, regardless of the presence of signs of life, in the manner established by order of the USSR Ministry of Health 12.06.86 N 848 p.p.1, ( appendix 2 and 3).
6. The following are subject to registration in the registry office:
Born alive or dead with a body weight of 1000 g or more (or, if the birth weight is unknown, the body length is 35 cm or more or the gestation period is 28 weeks or more), including newborns weighing less than 1000 g - with multiple births;
All newborns born with a body weight from 500 to 999 g are also subject to registration with the registry office in cases where they have lived more than 168 hours after birth (7 days).
For each case of death in the perinatal period, a "Certificate of Perinatal Death" is filled out. Fetuses born with a body weight of 500 grams or more are subject to pathological examination.
Registration in the registry offices of stillborns and cases of death of newborns in the perinatal period is carried out by those institutions that issue a certificate of perinatal death in the manner established by order of the Ministry of Health of the USSR N 1300 of November 19, 1984.
7. For the purposes of international comparability of domestic statistics, when calculating the perinatal mortality rate, the number of fetuses and newborns with a body weight of 1000 g or more (or, if birth weight is unknown, a body length of 35 cm or more or a gestational age of 28 weeks or more) is used.
Industry statistics on perinatal mortality, in accordance with WHO recommendations, include all births of a fetus and newborn weighing 500 g or more (or, if birth weight is unknown, a body length of 25 cm or more or a gestational age of 22 weeks or more ).
Now doctors will have to fight for the lives of babies born at the gestational age from 22 weeks with a weight of 500 grams
Until now, the registry offices have registered live births with a body weight of 1000 g or more.
Those born alive with a body weight of 500 to 999 g were subject to registration with the registry office as live births if they lived more than 168 hours after birth.
If such a child died without having lived these hours, the death was not registered. such a child was considered newborns, A fruit.
President of the National Medical Chamber, Director of the Moscow Research Institute of Emergency Pediatric Surgery and Traumatology Leonid Roshal believes that the introduction of new standards will give impetus to the development of pediatrics, resuscitation, intensive care and other areas of medicine in Russia.
Russian doctors reacted very ambiguously to this innovation. http://abbottgrowth.ru/doctors/tables/list.aspx?tmid=9&tid=9082&p=3#220041
1. It is worrying that far from all settlements in Russia have conditions for nursing such children.
2. All indicators of the work of obstetricians and neonatologists will sharply deteriorate, since the mortality rate among such children will be very high.
3. There are fears that such children, most often, will be "inferior". Like, these disabled people will become a burden for mothers and residents of orphanages.
It seems to me that it is necessary to introduce new criteria.
And that's why:
1. Money will be allocated for this program and this will make it possible to better equip the clan. at home, intensive care units in them
2. Obstetricians, neonatologists, resuscitators will have to improve.
Demand from them will be stricter.
After all, if they begin to punish for not nursing a 500-gram child, then for the death of a full-weight and born on time, they will be shot in the backyard by the garbage heap.
I agree with the principle that in Russia, in order to achieve at least some results, it is necessary to set difficult, sky-high goals.
These goals may not be achieved, but things will get off the ground.
3. And do not decide everything for the parents! Parents are different.
For example, we actively operate on infants with hydrocephalus (of various origins). When we started doing this many years ago, we were told the same way, wringing our hands: “Oh, experiment, oh, and parents will cry, why prolong the life of handicapped people? … etc.
It turned out that many of them survive and develop normally and the mothers are happy.
Of course, if they are sane mothers.
There are also those who abandon such children, marinate them at home, (one burned a seven-month-old in the oven) ... and so on.
But do we have to focus our work on these cannibals?
It seems to me that every life is valuable. We did not give it and it is not for us to decide who lives and who does not.
When they want to do something, they look for opportunities; when they don’t want to, they look for reasons.
Signs of live birth are:
spontaneous breathing
heartbeat
cord pulsation
voluntary active movements
If at least one sign is present, he needs to take resuscitation measures.
Sp iri diseases of newborns: purulent-inflammatory diseases of newborns.
Vesiculopustulosis - one of the most common forms of local infection. This is a pustular disease that can begin in newborns in the first months of life.
Clinical manifestations:
in the natural folds of the skin, on the trunk, scalp, limbs, small superficially located vesicles appear, filled at the beginning with transparent, and then with cloudy purulent contents
bubbles open, forming erosion, crusting
the general condition of the child does not suffer.
Prognosis: may be complicated by the development of infiltrates and multiple abscesses.
Pemphigus - is a type of pyoderma. Occurs 3-5 days after birth.
Clinical manifestations:
suddenly, on unchanged skin, multiple blisters of round and oval shape (up to several centimeters in diameter), single-chamber, with serous fluid that becomes cloudy, appear. The walls are thin, easily opened, forming erosion.
More often localized on the back, abdomen, in the area of \u200b\u200bthe axillary and inguinal skin folds
Rashes occur in shocks, so the rash is polymorphic.
The child's condition is severe, intoxication is pronounced, the temperature is 39 degrees, the child is lethargic, refuses to breastfeed, and gains weight poorly.
Forecast: at timely treatment recovery occurs in 2-3 weeks, however, in case of an unfavorable course, the disease may result in sepsis.
EXFOLIATIVE DERMATITIS - the most severe form of staphylococcal skin lesions of the newborn.
Clinical manifestations:
A diffuse hyperemia appears around the navel or mouth, after a while the epidermis detaches, while large erosive areas are exposed, the affected area gradually increases, and after 8-12 days the skin of the newborn takes on the appearance of burnt.
The condition is serious, symptoms of intoxication are expressed, high fever is noted, the child is lethargic, refuses to breastfeed
Abscesses and phlegmon often join.
Pseudofurunculosis - inflammation sweat glands.
The disease can begin with prickly heat, vesiculopustulosis. The most favorite localization is the skin of the scalp, the back of the neck, the skin of the back, buttocks, and limbs.
Clinical manifestations:
In place of the excretory ducts of the sweat glands, red subcutaneous seals appear, later purulent contents appear in the center of the inflammatory focus, and a scar remains after healing.
The child's condition is disturbed, symptoms of intoxication, body temperature periodically rises
Enlargement of regional lymph nodes
The disease proceeds for a long time and in waves.
Prognosis: with timely treatment, recovery occurs in 2-3 weeks, with untimely treatment, it can end in sepsis.
Phlegmon of newborns - one of the most severe purulent-inflammatory diseases, which is an inflammatory process of subcutaneous fatty tissue with the subsequent development of necrosis.
The inflammatory process is more often localized on the chest, abdomen, sacro-buttock region.
Clinical manifestations:
At first, limited redness appears on the skin, dense to the touch, which later quickly increases in size, swelling increases, bright purple in color.
It is gradually anesthetized, thinning and detachment of the skin occurs, and after its rejection, large defects are formed with undermined edges and purulent pockets, the process can spread to the depth of the underlying tissues, the skin over the affected area becomes black
The child's condition is very serious, symptoms of intoxication, high fever, vomiting, dyspepsia, sleep disturbance, appetite.
Prognosis: leads to the development of sepsis.
Purulent omphalitis - an inflammatory process on the tissue around the umbilical ring and severe symptoms of intoxication.
Purulent omphalitis may begin with symptoms of catarrhal omphalitis.
Clinical manifestations:
The skin around the navel is hyperemic, edematous, the venous network on the anterior abdominal wall is expanded.
The umbilical wound is an ulcer covered with fibrin plaque, with pressure, a purulent plaque is released.
Gradually, the umbilical region begins to swell, deep tissues are involved
The umbilical vessels are inflamed
The child's condition is serious, symptoms of intoxication are expressed, he is lethargic, sucks poorly, heat does not gain weight.
Prognosis: with timely treatment, recovery occurs in 2-3 weeks, but may be complicated by sepsis.
Sepsis - it's heavy infection, characterized by a generalized course of inflammatory processes, resulting from the penetration of pathogenic microbes and their toxins into the blood, against the background of reduced body immunity.
Risk factors for developing sepsis:
severity and virulence of the infection
immunodeficiency state of the body
late start of treatment and poor sanitation of local forms of purulent-septic infection
child care violation
violation of the rules of asepsis and antisepsis
chronic foci of maternal infection
According to the localization of the primary focus, sepsis is distinguished:
pulmonary
intestinal
otogenic
umbilical
There are the following clinical forms sepsis:
Septicemia
Septicopyemia
Septicemia (septic shock) occurs due to the massive influx of pathogenic microorganisms into the bloodstream, more often manifested in premature babies.
Clinical manifestations:
severe intoxication
high fever
pale skin with a cyanotic tint
dyspeptic disorders
changes from the CCC
weight loss
septic hepatitis develops
The child dies from septic shock.
Septicopyemia is characterized by an undulating course due to constant development in the body of new pyemic foci. This form is more common in term infants.
Clinical manifestations:
severe intoxication
signs of respiratory failure
signs of CCC insufficiency
development of new purulent foci (osteomyelitis, meningitis, otitis media, paraproctitis, purulent pneumonia)
According to the duration of the course of sepsis, there are:
acute course - from 3 to 6 weeks
subacute course - from 1.5 months to 3 months
protracted course - more than 3 months.
