526
14. O’Hara DA, Fragen RJ, Kinzer M, Pemberton D. Ketorolac tromethamine as compared with morphine sulfate for treatment of postoperative 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 nefopam hydrochloride after upper abdominal surgery: a study using patient controlled analgesia. Br J Surg 1988; 75: 779-81. 16. Moffat AC, Kenny GNC, Prentice JW. Postoperative nefopam and diclofenac: evaluation of their morphine-sparing effect after upper abdominal surgery. Anaesthesia 1990; 45: 302-05. 17. Keenan DJM, Cave K, Langdon L, Lea RE. Rectal indomethacin for control 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 and indomethacin on blood loss, bleeding time and plasma prostanoids in man. Eur J Anaesthesiol 1987; 4: 429-34. 19. Spowart K, Greer TA, McLaren M, Lloyd J, Bullingham RES, Forbes CD. 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 pain after 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 pain following 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 treating postoperative pain. Curr Ther Res 1988; 43: 1173-83. 24. Galasko CSB, Russell S, Lloyd J. Double-blind investigation of multiple oral doses of ketorolac tromethamine compared with dihydrocodeine and placebo. Curr Ther Res 1989; 45: 844-52. 25. McLoughlin C, McKinney MS, Fee JPH, Boules Z. Diclofenac for day-care arthroscopy surgery: comparsion with a standard opioid therapy. Br J Anaesth 1990; 65: 620-23.
When is .
a
fetus
a
dead
baby?
Loss of a pregnancy at any stage after the mother’s awareness and acceptance of it will precipitate a grief reaction. The strength of that reaction is not governed by the gestational age. In Britain, a death in utero is called an abortus before 28 weeks and a stillbirth after 28 weeks. There is a legal obligation to register the stillborn baby with formal documentation to the registrar of births and deaths. The abortus has no such status. To compound this legislative insensitivity it is deemed that "the complete expulsion or extraction from its mother of a product of conception, irrespective of the duration of pregnancy, which breathes or shows other evidence of life"1 for even a few moments must be regarded as a live birth. Such an inconsistency was lately highlighted in an editorial.2 Many of these babies would have been abortuses had they not gasped. This live birth must be recorded with a birth certificate and a death certificate. There are even more troubles for the parents of babies who have received intensive care if, because of lack of intensive care cots, the baby was born in one district and died in another since the birth has to be registered in the district 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 28 weeks, because the 1929 Infant Life (Preservation) Act presupposes that viability starts at that gestation; viability is now reckoned to begin at least 4 weeks younger. Hence, no formal documentation is
required. The only legal constraints are concerned with the disposal site. The parents have no legal rights over their baby and, until lately, most such babies committed to the hospital incinerator.3 were However, the stillborn baby and any liveborn baby must be buried or cremated. Fortunately, many hospitals now recognise this inconsistency and any member of the medical staff may produce a letter for the parents to take to a funeral director as a formal release 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 the Stillbirth and Neonatal Death Society (SANDS)’ and the Miscarriage Association,5it is realised that the abortus must be considered in the same way as the loss of a baby. Nevertheless, the law still does not reflect this attitude. Even the debate last year on abortion with respect to the Human Fertilisation and Embryology Act did not lead to a redefinition of stillbirths, although the allowable limit for termination was reduced to 24 weeks-ie, leaving a 4-week limbo from termination through spontaneous abortion to stillbirth. The published Polkinghome report has added fuel to the fire.The Committee’s intent was to confer a greater respect for the fetus. The stringent recommendation that mothers must sign a form giving blanket agreement to examination of tissues, removal of tissues for research or therapy, and use of the fetus as a teaching aid seems in keeping with the aim, yet one recommendation disallows the mother 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 and inconsistencies have been addressed by a group from SANDS, who have produced a comprehensive booklet on the subjeCt7 that draws together the practical aspects of baby death and combines them with parental anecdotes which soften and blur legal barriers. Why should the death of a baby be a unique zone of grief? Perhaps it is because to the parents, and to the mother in particular, an unknown potential has been lost. Whatever the reason, surely it is time the law became more sensitive, listened to parents, and shed those artificial barriers of the classification of baby life. 1. International Classification of Diseases. 9th revision. Geneva: World Health 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 Her
Majesty. 7. Stillbirth and Neonatal Death neonatal death: guidelines for SANDS at address given in ref
Society. Miscarriage, stillbirth and professionals, 1991 (obtainable from 4).
14. O’Hara DA, Fragen RJ, Kinzer M, Pemberton D. Ketorolac tromethamine as compared with morphine sulfate for treatment of postoperative 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 nefopam hydrochloride after upper abdominal surgery: a study using patient controlled analgesia. Br J Surg 1988; 75: 779-81. 16. Moffat AC, Kenny GNC, Prentice JW. Postoperative nefopam and diclofenac: evaluation of their morphine-sparing effect after upper abdominal surgery. Anaesthesia 1990; 45: 302-05. 17. Keenan DJM, Cave K, Langdon L, Lea RE. Rectal indomethacin for control 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 and indomethacin on blood loss, bleeding time and plasma prostanoids in man. Eur J Anaesthesiol 1987; 4: 429-34. 19. Spowart K, Greer TA, McLaren M, Lloyd J, Bullingham RES, Forbes CD. 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 pain after 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 pain following 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 treating postoperative pain. Curr Ther Res 1988; 43: 1173-83. 24. Galasko CSB, Russell S, Lloyd J. Double-blind investigation of multiple oral doses of ketorolac tromethamine compared with dihydrocodeine and placebo. Curr Ther Res 1989; 45: 844-52. 25. McLoughlin C, McKinney MS, Fee JPH, Boules Z. Diclofenac for day-care arthroscopy surgery: comparsion with a standard opioid therapy. Br J Anaesth 1990; 65: 620-23.
When is .
a
fetus
a
dead
baby?
Loss of a pregnancy at any stage after the mother’s awareness and acceptance of it will precipitate a grief reaction. The strength of that reaction is not governed by the gestational age. In Britain, a death in utero is called an abortus before 28 weeks and a stillbirth after 28 weeks. There is a legal obligation to register the stillborn baby with formal documentation to the registrar of births and deaths. The abortus has no such status. To compound this legislative insensitivity it is deemed that "the complete expulsion or extraction from its mother of a product of conception, irrespective of the duration of pregnancy, which breathes or shows other evidence of life"1 for even a few moments must be regarded as a live birth. Such an inconsistency was lately highlighted in an editorial.2 Many of these babies would have been abortuses had they not gasped. This live birth must be recorded with a birth certificate and a death certificate. There are even more troubles for the parents of babies who have received intensive care if, because of lack of intensive care cots, the baby was born in one district and died in another since the birth has to be registered in the district 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 28 weeks, because the 1929 Infant Life (Preservation) Act presupposes that viability starts at that gestation; viability is now reckoned to begin at least 4 weeks younger. Hence, no formal documentation is
required. The only legal constraints are concerned with the disposal site. The parents have no legal rights over their baby and, until lately, most such babies committed to the hospital incinerator.3 were However, the stillborn baby and any liveborn baby must be buried or cremated. Fortunately, many hospitals now recognise this inconsistency and any member of the medical staff may produce a letter for the parents to take to a funeral director as a formal release 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 the Stillbirth and Neonatal Death Society (SANDS)’ and the Miscarriage Association,5it is realised that the abortus must be considered in the same way as the loss of a baby. Nevertheless, the law still does not reflect this attitude. Even the debate last year on abortion with respect to the Human Fertilisation and Embryology Act did not lead to a redefinition of stillbirths, although the allowable limit for termination was reduced to 24 weeks-ie, leaving a 4-week limbo from termination through spontaneous abortion to stillbirth. The published Polkinghome report has added fuel to the fire.The Committee’s intent was to confer a greater respect for the fetus. The stringent recommendation that mothers must sign a form giving blanket agreement to examination of tissues, removal of tissues for research or therapy, and use of the fetus as a teaching aid seems in keeping with the aim, yet one recommendation disallows the mother 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 and inconsistencies have been addressed by a group from SANDS, who have produced a comprehensive booklet on the subjeCt7 that draws together the practical aspects of baby death and combines them with parental anecdotes which soften and blur legal barriers. Why should the death of a baby be a unique zone of grief? Perhaps it is because to the parents, and to the mother in particular, an unknown potential has been lost. Whatever the reason, surely it is time the law became more sensitive, listened to parents, and shed those artificial barriers of the classification of baby life. 1. International Classification of Diseases. 9th revision. Geneva: World Health 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 Her
Majesty. 7. Stillbirth and Neonatal Death neonatal death: guidelines for SANDS at address given in ref
Society. Miscarriage, stillbirth and professionals, 1991 (obtainable from 4).
