Pregnancy, virginity and delivery by Dr Saswata Biswas, MBBS, MD

1. PREGNANCY,
DELIVERY AND
LEGITIMACY
Dr. Saswata Biswas
MBBS,MD
Medical College and Hospital, Kolkata

2. PREGNANCY
• Pregnancy is the condition of having a developing embryo or foetus in
the female, when an ovum is fertilized by a spermatozoon.
• Timeline of the events (following ovulation):
• 12-24 hours: Ovum is fertilized in the ampulla of fallopian tube.
• 4th day: Fertilized ovum (zygote) comes down to uterine cavity.
• 7th day: Impregnation occurs in uterine wall known as implantation.
After implantation it is known as EMBRYO.
• 8th week: After this it is known as FOETUS.
• Childbirth usually occurs about 38 weeks after conception.

3. DIAGNOSIS of PREGNANCY
• Ordinarily it is not difficult but in medicolegal practice in the diagnosis
has to be full proof.
• In therapeutic purposes clinical steps are taken according to the
available signs and symptoms.
• The position of a medico-legalist is some what different where
assertion of pregnancy or its absence is expected to solve certain
litigation and the opinion of the medical man in such a case clear the
conception of the code of law.
• Accordingly the signs of pregnancy are categorized as presumptive ,
probable and positive signs.

4. PRESUMPTIVE SIGNS of PREGNANCY
Probability of pregnancy is about 25%
• Amenorrhea (Earliest sign)
• Breast changes:
 Up to 8 weeks: Tenseness and tingling in breasts
 After 2nd month: Increase in size, becomes nodular, superficial veins
become distinct, nipples become pigmented and erectile, areola
becomes dark. Montgomery’s tubercles are seen.
3rd month: Colostrum is secreted.
6th month: Striae are seen on breasts.
• Fatigue

6. PRESUMPTIVE SIGNS of PREGNANCY
• Morning sickness
• Hyperpigmentation
 Linea nigra
 Melasma gravidarum (mask of pregnancy)
• Quickening: Slight fluttering movement felt by the mother from
about 16th to 20th weeks of pregnancy.
• Sympathetic disturbances
• Urinary disturbances: during early weeks and few weeks before term.

8. PRESUMPTIVE SIGNS of PREGNANCY
• Vaginal changes:
 Colour change in the vulvovaginal mucosa: changes from rose colour
in non pregnant state to pale violet in early pregnancy. Seen at 4th
week. Known as Chadwick’s Sign/ Jacquemier’s Sign/ Jacquemin’s
Sign.
Flattening of anterior vaginal wall.
Softening of vulval and vaginal tissues with increase in secretion of
mucus.
Vaginal pulsation can be felt.
• Vascular changes: Angiomas[Vascular spiders] and Palmar Erythema.

10. PROBABLE SIGNS of PREGNANCY
Probability is about 50%.
• Enlargement of abdomen:
o > 12th week[3 months]: Uterus above pelvic brim.
o 20th week[5th month]: Midway between symphysis and umbilicus
o End of 6th month: Uterus at umbilicus. Striae gravidarum appears.
o End of 7th month: Midway between umbilicus and xiphisternum.
o End of 8th month: At xiphoid cartilage
o 10th month: descends in pelvis and falls forward due to its weight.

12. PROBABLE SIGNS of PREGNANCY
• Uterus:
o Hegar’s Sign: Important sign in early pregnancy. Becomes positive at
6th week. One hand is placed on the abdomen and two fingers are
placed in the vagina. Firm cervix, elastic uterus and in between the
isthmus is felt as a soft, compressible area.
• Cervix:
o Goodell’s Sign: Softening of vaginal part of cervix. Starts at 8 weeks
and is well marked by 4th month. Towards the last months of
pregnancy the cervix becomes shorter and the orifice becomes
circular from transverse.
• Braxton Hick’s sign: painless contractions. Felt after 4th month.

14. PROBABLE SIGNS of PREGNANCY
• Ballottement: It is a palpatory technique for confirmation of
pregnancy, as the foetus can be tossed up and down like a ball within
the uterus. It becomes positive by 16-20 weeks. External ballottement
is done on the abdominal wall and internal ballottement is done with
two fingers inserted into the anterior fornix. False negative tests occur
when amniotic fluid are scanty.
• Ladin’s sign: Softening at the uterus and cervix junction. 6th week +ve
• Osiander’s sign: Pulsations felt at lateral fornix. 8th week +ve
• Palmer’s sign: Rhythmic contractions of uterus. 8th week +ve
• Piskacek’s sign: Asymmetrical enlargement of uterus. 8th week +ve
• Uterine souffle: Soft blowing murmur due to increased blood flow in
uterine vessels.

16. Immunological tests for Pregnancy
• Based on fetoplacental products, like hCG.
• First voided urine is taken, gives result within 2 minutes with 98%
accuracy.
• Different tests are available: Latex agglutination test [Indirect test and
Direct test], Hemagglutination inhibition test, ELISA,
Fluoroimmunoassay, Immunoradiometric assay, Radioimmunoassay .
• Timeline of immunological tests:
Days after LMP Features
14 Ovulation and fertilization.
21 Implantation. hCG appears in maternal blood.
25 hCG appears in maternal urine.
28 Immunological tests are positive in 98% cases.
35 Negative results rule out pregnancy.

18. POSITIVE SIGNS of PREGNANCY
Probability of pregnancy is 100%.
• Foetal movements: felt by 24th week by placing hand over abdomen.
• Foetal parts: palpated and identified by 36th week.
• Foetal heart sounds: first heard between 18-20 weeks.
• Placental souffle
• Umbilical souffle
• Ultrasonography: 6th week-gestational sac.
• X-ray: 16th week.
• Foetal cells in mother’s blood: Kleihauer-Betke test: positive by 5th
week.

21. Medicolegal aspects
 Capital sentence:
If a woman sentenced to death is pregnant, the High Court shall commute the
sentence to imprisonment for life. [s.416 CrPC, 2009 amendment]
 Gestation period:
Average period: 280 days [10 cycles]
Maximum period: 359 days
Minimum period with viability: Generally accepted is 28 weeks[196 days]
 Posthumous child:
It is a child born after the death of father, the mother having conceived by the said
father.
• Compensation case against mother for slander.
• Inheritance of property.

22. Medicolegal aspects
Pregnancy without being aware of it. [Unconscious pregnancy]
Pseudocyesis:
Pseudocyesis, false pregnancy or hysterical pregnancy is the appearance of clinical
signs and symptoms associated with pregnancy when the female is not pregnant.
Determination of period of pregnancy:
Mcdonald’s rule: Applicable from 22-34 weeks of gestation.
Foetal age(in weeks)= fundal height in cm(measured from symphysis pubis to top of
uterus) X 8/7
Foetal age(in months)= fundal height in cm(measured from symphysis pubis to top
of uterus) X 2/7
Sex selection: PCPNDT Act, 1994

23. Medicolegal aspects
Superfecundation: It is fertilization of two or more ova from the same
menstrual cycle in separate copulatory events. Age of foetus is same. Mono
paternal superfecundation vs. hetero paternal superfecundation.
Superfetation: It is fertilization of an ovum in the presence of an existing
pregnancy. Age of foetus is different. Foetus papyraceus and Vanishing twin
syndrome.
Trauma and pregnancy
Avoidance of attendance in a court of law or in any commission of
enquiry.
Feigning pregnancy.

24. Medicolegal aspects
To get greater compensation
Divorce
Breach of promise of marriage
For blackmail or to compel marriage
Abductor of children
Nullity of marriage
Smugglers of drugs
Honour killing of unmarried daughter or widow.

25. LEGITIMACY AND
PATERNITY

26. Legitimacy
• A child is said to be legitimate if it is born:
i. During the continuation of legal marriage
ii. Within 280 days of death of husband
iii. Within 280 days after the dissolution of marriage by divorce
• The child is illegitimate if the alleged father :
i. Is under the age of puberty
ii. Is physically incapable to beget children
iii. Did not have access to his wife when the child was begotten
iv. Displays a blood group or DNA profile which is not compatible with
that of child.

27. When does the question of legitimacy arise ?
Inheritance of property
Affiliation case: An affiliation case refers to a legal dispute in which
the paternity of an illegitimate child is sought to be determined, and
the obligation of contributing to its support is enforced. [ s.125 CrPc
governs these cases. 1st class magistrate may order the father to pay a
monthly allowance of any sum]
Suppositious children: A suppositious (fictitious) child is one
produced by a woman who claims it as her own whereas in actual fact
it is not her child.
Disputed paternity
Posthumous births
Wrongful life

28. Methods to solve question of legitimacy
• Comparing the age of the child with the period when she was
pregnant.
• Signs of recent delivery
• Blood, HLA and DNA profile
• Examination of alleged father
• Parental likeness [exception-Atavism]
• Developmental defects
 Atavism: It is the tendency of an organism to revert its characteristics
to those of a remote ancestor, eg. grandparents, great grandparents
rather than its parents.

29. DELIVERY
Delivery is the natural or assisted expulsion of the child at full term.

30. Signs of Recent Delivery in the living
• General Indisposition: Pale, exhausted with tachycardia,
↑temperature for first 2-3 days.
• Breast changes
• Abdominal changes
• Perineal changes
• Uterus:
i. Morphology : Contracted, upper border lies 3 cm below umbilicus,
diminishes in size @ 1.5 cm/day. By 2 weeks, the uterus become a
pelvic organ and by 9 weeks it returns to normal condition.
ii. Intermittent contractions present for first 4 -5 days.

31. Signs of Recent Delivery in the living
• Cervix: Immediately after: soft and dilated with torn edges and
transverse lacerations, Internal os closes by 24 hours, external os
closes by end of 2 weeks.
• Labia: Swollen and tender, bruised.
• Vagina: Smooth walled, capacious and relaxed. Recent tears heal by
7th day. Rugae begin to appear by 3rd week.
• Lochia: is a discharge from uterus which lasts for 2-3 weeks.
i. Lochia rubra: Bright red in colour, contents-blood clots, decidual
cells, foetal membrane, lasts for 4-5 days.
ii. Lochia serosa: lasts for 4 days from 6th to 9th day. Pale coloured.
iii. Lochia alba: lasts for 10th to 21st day. Thick, yellowish to white
coloured.
• Lab tests: Blood and urine pregnancy test +ve up to 7-10 days.

32. Signs of Recent Delivery in the dead
• Similar to those of living.
• Uterus: flabby, cavity almost obliterated, length and breadth are
more.
• Placental site: irregular, nodular elevated area covered with clotted
blood, lymph and portions of decidua.
• Ovaries and fallopian tubes: Congested. Corpus luteum- quite large.
• Peritoneum in lower segment of uterus: folded.
• Urinary bladder: oedematous and congested.

33. Signs of Remote Delivery in the living
• Abdomen: Wall is lax, shows multiple white scars on lateral aspects,
linea nigra present.
• Breasts: Pendulous, linea albicantes present, nipples-enlarged,
areolae-dark, Montgomery tubercles present.
• Vulva: partially gaping, labia do not oppose orifice completely.
• Vagina: walls are relaxed, rugae are absent, partially open.
• Perineum: may show scar of an old tear.

34. Difference between nulliparous and parous
uterus
FEATURE NULLIPAROUS UTERUS PAROUS UTERUS
SIZE Smaller, thinner. 7.5 * 5 * 2.5 cm Larger, thicker. 10 * 6 * 2.5 cm
WEIGHT 40-60 gm 80-120 gm
LENGTH Body is of same length as that of cervix. Body is twice the length of cervix.
FUNDUS Top of fundus is less convex and on the
same level of line of broad ligament.
Top of fundus is convex and on a higher level
than the line of broad ligament.
CAVITY Walls are convex from inside, cavity is
smaller and triangular from inside.
Walls are concave from inside, cavity is wider
and rounded from inside.
EXTERNAL OS Rounded. Appears as a small hollow in
the centre of cervix. Orifice closed.
Transverse, irregular, fissured. Orifice admits
tip of finger.
INTERNAL OS Circular, well defined. Not well defined.
CERVIX Regular, no scars. Mucus membrane
smooth and intact.
Irregular. Edges show scar.

35. Causes of death after Caesarean section
• ARDS
• Haemorrhage
• Incidental surgical injuries/mistakes
• Infection
• Pre-existing diseases
• Thromboembolism

36. Medicolegal aspects of delivery
• Abortion
• Amniotic fluid embolism
• Blackmailing by producing a suppositious child
• Chastity
• Concealment of birth
• Divorce:
i. After marriage: Delivery of a child fathered by someone other than husband:
Ground for divorce.
ii. Before marriage: Not a ground for divorce.
iii. During marriage: Voidable marriage.

37. Medicolegal aspects of delivery
• Feigned delivery
• Infanticide
• Legitimacy
• Precipitate labour
• Water births