Stillborn Infants

Delivery of a severely macerated infant indicates to even the most inexperienced observer that the child was dead intrauterine for a prolonged time. Presentation to an emergency room, EMS crew, or police agency, of a full-term child born without a physician present and showing very early or minimal signs of maceration has resulted in misinterpretation of maceration as evidence of trauma during or immediately after delivery. This is illustrated by the following case.

A full-term child delivered at home by a midwife did not immediately cry and was placed in warm water for "stimulation," and scrubbed to remove the vernix caseosa. The child did not respond and "died." The midwife contended that the child had taken a few breaths prior to being placed in the water, though no one else had witnessed this. The child was brought to an emergency room to be pronounced dead. The emergency room physician saw the child and called the police, stating that there were scalding burns of almost the complete body. On examination of the body by one of the authors (VJMD), there was slippage of the skin of the trunk, extremities, and lower half of the face, with sparing only of the palms and soles of the feet (Figure 20.4). Internal examination showed early decomposition, with non-aerated, totally atelectatic lungs that sank on placement in water. Blood-tinged fluid was in the pleural and peritoneal cavities. The child was obviously a stillborn showing early signs of maceration.

Delivery of a macerated infant is absolute evidence of an intrauterine death. When a fetus dies in utero, it is suspended in sterile fluid within an intact amniotic sac. There, it undergoes aseptic autolytic changes, i.e., maceration, due to the infant's tissue and cellular enzymes aided by the favorable body temperature. The earliest sign of maceration in a stillborn is skin slippage (separation of the epidermis from the dermis). This may be present as early as 6 h after death in utero and is expected after more than 12 h.28,29 As intrauterine decomposition proceeds, bullae may form under the skin. On rupture, the exposed skin, initially raw, dries out, becoming reddish brown. The tissue will develop a reddish coloration caused by hemolysis. Serosanguinous fluid will accumulate in the thoracic and abdominal cavities. The internal organs will undergo decomposition, becoming diffluent. If the child is retained several days intrauterine, the skull will collapse and the brain will become semi-liquefied.

Images Stillborn Infants
Figure 20.4 A stillborn showing evidence of intrauterine decomposition. Incorrectly diagnosed as scalding injuries following a live birth.

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