when is a fetus a dead baby?

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14. O’Hara DA, Fragen RJ, Kinzer M, Pemberton D. Ketorolactromethamine as compared with morphine sulfate for treatment ofpostoperative pain. Clin Pharmacol Ther 1987; 41: 556-61.

15. McLintock TTC, Kenny GNC, Howie JC, McArdle CS, Lawrie S,Aitken H. Assessment of the analgesic efficacy of nefopamhydrochloride after upper abdominal surgery: a study using patientcontrolled analgesia. Br J Surg 1988; 75: 779-81.

16. Moffat AC, Kenny GNC, Prentice JW. Postoperative nefopam anddiclofenac: evaluation of their morphine-sparing effect after upperabdominal surgery. Anaesthesia 1990; 45: 302-05.

17. Keenan DJM, Cave K, Langdon L, Lea RE. Rectal indomethacin forcontrol of postoperative pain. Br Med J 1984; 288: 240.

18. Rorarius MGF, Baer GA, Metsa-Ketela T, Miralles J, Palomaki E,Vapaatalo H. Effects of peri-operatively administered diclofenac andindomethacin on blood loss, bleeding time and plasma prostanoids inman. Eur J Anaesthesiol 1987; 4: 429-34.

19. Spowart K, Greer TA, McLaren M, Lloyd J, Bullingham RES, ForbesCD. Haemostatic effects of ketorolac with and without concomitant

heparin in normal volunteers. Thromb Haemost 1988; 60: 382-86.20. Orme ML. Non-steroidal anti-inflammatory drugs and the kidney. Br

Med J 1986; 292: 1621-22.21. Cashman JN, Jones RM, Foster JMG, Adams AP. Comparison of

infusions of morphine and lysine acetyl salicylate for the relief of painafter surgery. Br J Anaesth 1985; 57: 255-58.

22. Brown CR, Moodie JE, Evans SA, Clarke PJ, Rotherham BA, Bynum L.Efficacy of intramuscular (IM) ketorolac and meperidine in painfollowing major oral surgery. Clin Pharmacol Ther 1988; 43: 161.

23. Esteene B, Julien M, Charleux H, Arsac M, Arvis G, Loygue J.Comparison of ketorolac, pentazocine, and placebo in treatingpostoperative pain. Curr Ther Res 1988; 43: 1173-83.

24. Galasko CSB, Russell S, Lloyd J. Double-blind investigation of multipleoral doses of ketorolac tromethamine compared with dihydrocodeineand placebo. Curr Ther Res 1989; 45: 844-52.

25. McLoughlin C, McKinney MS, Fee JPH, Boules Z. Diclofenac forday-care arthroscopy surgery: comparsion with a standard opioidtherapy. Br J Anaesth 1990; 65: 620-23.

When is a fetus a dead baby?. Loss of a pregnancy at any stage after the mother’sawareness and acceptance of it will precipitate a griefreaction. The strength of that reaction is not governedby the gestational age. In Britain, a death in utero iscalled an abortus before 28 weeks and a stillbirth after28 weeks. There is a legal obligation to register thestillborn baby with formal documentation to the

registrar of births and deaths. The abortus has no suchstatus. To compound this legislative insensitivity it isdeemed that "the complete expulsion or extractionfrom its mother of a product of conception,irrespective of the duration of pregnancy, whichbreathes or shows other evidence of life"1 for even afew moments must be regarded as a live birth. Such aninconsistency was lately highlighted in an editorial. 2

Many of these babies would have been abortuses hadthey not gasped. This live birth must be recorded witha birth certificate and a death certificate. There areeven more troubles for the parents of babies who havereceived intensive care if, because of lack of intensivecare cots, the baby was born in one district and died inanother since the birth has to be registered in thedistrict of birth and the death in the district of death.These vagaries extend to the final disposal of the body.There is no legal acceptance of a life in utero before 28weeks, because the 1929 Infant Life (Preservation)Act presupposes that viability starts at that gestation;viability is now reckoned to begin at least 4 weeksyounger. Hence, no formal documentation is

required. The only legal constraints are concernedwith the disposal site. The parents have no legal rightsover their baby and, until lately, most such babieswere committed to the hospital incinerator. 3

However, the stillborn baby and any liveborn babymust be buried or cremated. Fortunately, manyhospitals now recognise this inconsistency and anymember of the medical staff may produce a letter forthe parents to take to a funeral director as a formalrelease certificate so that babies born before 28 weeks

may be dealt with according to the parents’ wishes.Slowly the appeals of the grieving parents have been

listened to and, thanks to self-help groups such as theStillbirth and Neonatal Death Society (SANDS)’ andthe Miscarriage Association,5 it is realised that theabortus must be considered in the same way as the lossof a baby. Nevertheless, the law still does not reflectthis attitude. Even the debate last year on abortionwith respect to the Human Fertilisation and

Embryology Act did not lead to a redefinition ofstillbirths, although the allowable limit fortermination was reduced to 24 weeks-ie, leaving a4-week limbo from termination through spontaneousabortion to stillbirth. The published Polkinghomereport has added fuel to the fire. The Committee’sintent was to confer a greater respect for the fetus. The

stringent recommendation that mothers must sign aform giving blanket agreement to examination oftissues, removal of tissues for research or therapy, anduse of the fetus as a teaching aid seems in keeping withthe aim, yet one recommendation disallows themother access to what finally occurs to her baby.There is no doubt that the profession, led by

society, more readily accepts that miscarriage,termination, stillbirth, and neonatal death lie in a

spectrum of the same grief. These dilemmas andinconsistencies have been addressed by a group fromSANDS, who have produced a comprehensivebooklet on the subjeCt7 that draws together the

practical aspects of baby death and combines themwith parental anecdotes which soften and blur legalbarriers.

Why should the death of a baby be a unique zone ofgrief? Perhaps it is because to the parents, and to themother in particular, an unknown potential has beenlost. Whatever the reason, surely it is time the lawbecame more sensitive, listened to parents, and shedthose artificial barriers of the classification of baby life.

1. International Classification of Diseases. 9th revision. Geneva: WorldHealth Organisation, 1977-78.

2. Editorial. Perinatal mortality rates-time for a change? Lancet 1991; 337:331.

3. Editorial. Disposal of the previable fetus. Lancet 1988; ii: 611-12.4. Stillbirth and Neonatal Death Society. 28 Portland Place, London W1N

4DE.5. Miscarriage Association. PO box 24. Ossett, West Yorkshire WF5 9XG.6. Review of the Guidance on the Research Use of Fetuses and Fetal

Material, July, 1989: presented to Parliament by Command of HerMajesty.

7. Stillbirth and Neonatal Death Society. Miscarriage, stillbirth andneonatal death: guidelines for professionals, 1991 (obtainable fromSANDS at address given in ref 4).