separate existence, as a baby in a vertex delivery

can breathe after the head and thorax have been

delivered but before delivery of the lower body.
The flotation test, which used to be the definitive
test for breathing, and hence separate existence,
and which was depended upon for many centuries,
is now considered to be unreliable, although it still
appears in some textbooks. All that can be said with
regard to flotation of the lungs is that if a lung or piece
of lung sinks in water, the baby had not breathed
sufficiently to expand that lung and so the child may
have been stillborn. The converse is definitely not
true, as the lungs of babies who are proven to have
been stillborn sometimes float. This test is useless
in differentiating between live-born and stillborn
infants and should no longer be used (Figure 7.2).

Figure 7.2 (a) Thoracic organs from a stillbirth. The lungs are fi rm
and heavy with no crepitation when squeezed. (b) Microscopy
of lungs from stillbirths showing partial expansion of terminal
air spaces as a consequence of hypoxia-induced inspiratory
efforts. Note also meconium aspiration.

Figure 7.3 Newborn infant disposal with decompositional/

putrefactive skin changes.

To complicate matters further, many dead newborn

babies are hidden shortly after birth and may
not be discovered until decomposition has begun,
which precludes any reliable assessment of the
state of expansion of the lungs. Even with fresh
bodies, the problems are immense and any attempt
at mouth-to-mouth resuscitation or even chest compression
will prevent any reliable opinion being
given on the possibility of spontaneous breathing.
Conversely, if there is milk in the stomach or if
the umbilical cord remnant is shrivelled or shows
an inflammatory ring of impending separation, the
child must have lived for some time after birth.
Establishing the identity of the infant and the
identity of the mother is often a matter of great difficulty,
as these babies are often found hidden or
abandoned (Figure 7.3). When the baby is found in
the home, there is seldom any dispute about who
the mother is. DNA may be used to confirm identity
and parentage.
In those cases where the mother is traced, further
legal action depends on whether the patho logist
can definitely decide if the baby was born alive or

was stillborn. If live-born, no charge of infanticide

can be brought in English law unless a wilful act
of omission or commission can be proved to have
caused the death. Omission means the deliberate
failure to provide the normal care at birth, such as
tying and cutting the cord, clearing the air passages
of mucus and keeping the baby warm and
fed. The wilful or deliberate withholding of these
acts, as opposed to simple ignorance and inexperience,
is hard to prove. Acts of commission are more
straightforward for the doctor to demonstrate as they may include a range of trauma, including
head
injuries, stabbing, drowning and strangulation.
The maturity of the infant is rarely an issue as
most infants found dead after birth are at or near
full term of 3840 weeks. The legal age of maturity
in Britain is now 24 weeks, although medical
advances have allowed fetuses of only 20 weeks or
less gestation to survive in specialist neo natal units.
In infanticide, the maturity is not legally material
as it is the deliberate killing of any baby that has
attained a separate existence, and this does not
depend directly upon the gestational age.

The estimation of maturity

of a newborn baby or fetus
Legal requirements may need an estimation of gestational
age of the body of a baby or fetus in relation
to an abortion, stillbirth or alleged infanticide. The
following are considered rule of thumb formulae
for estimating maturity (and should be considered to
provide very rough estimates):
1 Up to the twentieth week, the length of the fetus
in centimetres is the square of the age in months
(Haases rule);
2 After the twentieth week, the length of the
fetus in centimetres equals five times the age in
months.
There is considerable variation in any of the measured
parameters owing to sex, race, nutrition and
individual variation, but it is considered possible to
form a reasonable estimate of the maturity of a fetus
by using the brief notes in Box 7.1.

Box 7.1 Estimation of fetal maturity

4

weeks 1.25 cm, showing limb buds, enveloped in villous chorion

weeks 9 cm long, nails formed on digits, placenta well formed
lanugo all over body
20 weeks 1825 cm, weight 350450 g, hair on head
24 weeks 30 cm crownheel, vernix on skin
28 weeks 35 cm crownheel, 25 cm crownrump, weight
9001400 g
32 weeks 40 cm crownheel, weight 15002000 g
36 weeks 45 cm crownheel, weight 2200 g
40 weeks (full term) 4852 cm crownheel, 2832 cm crown
rump, 3338 cm head circumference, lanugo now absent or present
only over shoulders, head hair up to 23 cm long, testes palpable in
scrotum/vulval labia close the vaginal opening, dark meconium in large
intestine
12

Development can also be assessed using the

femur length, ossification centres and the histological
appearances of the major organs. It may be
necessary to seek expert advice, from radiologists
and forensic anthropologists, when determining
gestational age.

Sudden infant death

syndrome
The incidence of sudden infant death syndrome
(SIDS) also known as cot death or crib death has
declined in many developed countries from approximately
2 to 0.5 per 1000 live births, and was 0.28
per 1000 live births in England and Wales in 2007.
This decline has coincided with social and housing
improvements as well as a worldwide Back to Sleep
campaign in the early 1990s, which encouraged
mothers to place babies on their back to sleep rather
than face down or on their side. Publicity campaigns
have also advised mothers to refrain from smoking
during pregnancy or near to their babies after birth
and to avoid overheating babies by wrapping them
up too closely. However, despite this significant
decline, SIDS still forms the most common cause of
death in the post-perinatal period in countries with a
relatively low infant mortality rate.
SIDS has been defined as the sudden unexpected
death of an infant <1 year of age, with onset
of the fatal episode apparently occurring during
sleep, that remains unexplained after a thorough
investigation, including the performance of a complete
autopsy and a review of the circumstances of
death and the clinical history. The following are
the main features of the syndrome.
Most deaths take place between 1 month and
6 months, with a peak at 2 months.
There is little sex difference, although there is
a slight preponderance of males similar to that
seen in many types of death.
The incidence is markedly greater in multiple
births, whether identical or not. This can be
partly explained by the greater incidence of premature
and low birth-weight infants in multiple
births.
There is a marked seasonal variation in temperate
zones: SIDS is far more common in the colder
and wetter months, in both the northern and
southern hemispheres.