Virginity , Pregnancy

&
Delivery
 Virginity
• Also known as Virgo Intacta.

• Definition: Virgin is a female who has not experienced

sexual intercourse.

Signs of virginity :
1. Extra genital signs (in breast)
2. Genital signs
GENITALS
• LABIA MAJORA
• LABIA MINORA
• VAGINAL WALL
• VESTIBULE
• POSTERIOR COMMISURE
• FORCHETTE
• FOSSA NAVICULARIS
• HYMEN
TYPES OF HYMEN
1) SEMILUNAR
2) ANNULAR
3) INFANTILE
4) CRIBRIFORM
5) VERTICAL
6) SEPTATE
7) IMPERFORATE
8) CARUNCULAE MYRTIFORMIS
features virginity Defloration
1.Basic difference No experience of sexual Have experience of sexual
intercourse intercourse

2.hymen Intact Torn except in false virgin

3.introitus Does not admit more than tip of May admit 2 fingers , it is painless
little finger, it is painful
4.vagina. Marked rugosity on wall Rugosity diminishes
Full length of a finger cannot be Full length of finger can be
admitted admitted
5.Fossa navicularis Less conspicuous More conspicuous after sexual
intercourse
6.Fourchette Intact Healed tear
7.Labia minora Smaller pinkish, covered with enlarged, pigmented, not covered
majora
8.Labia majora Thick, fleshy, both majora are in Less fleshy, not in full apposition
close apposition
9.Breasts Smaller, firm, pinkish smaller Larger, flabby, pendulous, wider
areola, and small nipple areola, large and raised nipple
Other conditions which may affect signs of virginity

Trauma or Accident
Surgical operation or Gynaecological examination
Sanitary tampons
Foreign body – sola pith (APTAE VARIS)
Scratching due to irritation from uncleaniness
Masturbation
Ulceration – d/t diphtheria , fungus, etc.
 False Virgins
• Hymen is intact but the woman has had
sexual intercourse.
Point of True virgin False virgin
difference
1.Basic difference The woman has no experience of Has experience of sexual intercourse
sexual intercourse

2.Hymen Not ruptured. It is thin flap of tissue of Not ruptured. It is thick , fleshy or fibrous
regular shape and appearance elastic with folds

3.Introitus Does not admit more than the tip of May admit 2 fingers, it is not painful
little finger, it is painful

4.Vagina. Marked rugosity on wall Rugosity diminishes

Full length of a finger cannot be Full length of finger can be admitted
admitted
5.Fossa Less conspicuous More conspicuous after
navicularis sexual intercourse
6.Fourchette Intact Healed tear

7.Labia minora Smaller pinkish, covered with enlarged, pigmented, not

majora covered

8.Labia majora Thick, fleshy, both majora are Less fleshy, not in full
in close apposition apposition

9.Breasts Smaller, firm, pinkish smaller Larger, flabby,

areola and small nipple pendulous, wider areola,
large and raised nipple
Medico legal importance of virginity

In Civil cases:
1.Nullity of marriage
2.Divorce
3.Defamation of character
4.Rape
 Pregnancy
• It is a physiological condition develops in a female with in her child
bearing age due to fertilisation of ova by spermatozoa results in
developing embryo or foetus in the uterus till its birth.

• Signs of pregnancy in living:

1.Presumptive signs
2.Probable signs
3.Positive or conclusive signs
Presumptive signs of pregnancy
• Amenorrhoea
• Morning sickness
• Changes in breasts
• Changes in the Vagina
• Urinary disturbances- increased frequency of micturition
• Chloasma - 24th week
• Quickening - 16 – 20 weeks
• Linea nigra - 20th week
• Striae gravidarum
• Sympathetic change -increased salivation
-PICA (perverted appetite)
-irritable temper.
• Changes in Breasts :
• Breasts enlarged & nodular(2nd month)
• Surface veins prominent
• Areola enlarged, pigmented with
prominent Montgomery’s tubercles (2nd
month).
• Nipples enlarged
• Colostrum (3rd month).

• Changes in Vagina :
• Jackquemier’s sign or Chadwick’s sign:
violet or bluish discolouration of vaginal
mucosa (after 4th week).
PROBABLE SIGNS OF
PREGNANCY
• Enlargement of abdomen

• Height of uterus.

• Palmer’s sign- regular rhythmic

contractions of uterus at 4th to
8th week.
Fundal height
•Hegar’s sign

-Bimanual examination
at 6th - 8th week
• Goodell’s sign -softening of cervix at
4th month

• Osiander’s sign – increase pulsation

felt through lateral fornices at 8th week

• ‘Piskacek’s sign – asymmetrical

enlargement of uterus if there is lateral
implantation.

Goodell’s sign
 PROBABLE SIGNS OF PREGNANCY
• Braxton-hick’s sign -After 15-16 weeks
of pregnancy

• Ballottement: internal and external

(during 4th and 5th month)
External ballottement
• Uterine soufflé at end of 4th month

• Biological tests : Presence of

gonadotropins in pregnant woman’s
blood and their excretion in urine
Internal ballottement
• Immunological tests :
a)Inhibition (Indirect) Latex slide test
b)Direct Latex slide test

• Haemagglutination inhibition test.

• RIA and ELISA

 POSITIVE SIGNS OF
PREGNANCY
• Auscultation of foetal heart sounds- positive after 18-20 wks
• Palpation of foetal part
• Feeling foetal movements
• Radiograph of foetus -after 3 months
• USG : 6 wks - Gestational sac
7 wks - Embryo
10 wks - Heart beat
14 wks - Head and Thorax
• Presence of foetal cells in mother’s blood.
Signs of pregnancy in Dead
• Products of conception

• Enlarged Uterus & other uterine change.

• Corpus luteum
Medicolegal importance of pregnancy
•In Civil cases:
• Nullity of marriage
• Inheritance of property
• Higher maintenance allowance in case of divorce
• Compensation cases
• Illegitimate baby
• Maternity leave
• Compensation case if allegation of pregnancy against
unmarried woman or widow.
In Criminal cases:
•Execution of death sentence.
•Advantage during trial in court.
•It is positive proof in a trial of rape.
•An unmarried pregnant woman bring a
charge of criminal breach of trust against a man.
•Adultery.
•In criminal abortion and to foeticide or infanticide.
•Motive for suicide or murder.
• Pseudocyesis / False Pregnancy / Spurious
Pregnancy / Phantom Pregnancy.

• Superfoetation

• Superfecundation

• Foetus Papyraceous / Foetus Compressus

•QUESTIONS
3. A pregnant woman sentenced to death cannot be hanged till-
a)Delivery
b)Delivery and attainment of 6 months of age by new born
c)Delivery and one year after that
d)None of the above

4. Pseudocyesis is found in-

a)Young married woman
b)Aged unmarried girl
c)Menopausal ladies
d)Adolescent girl
5. Impregnation of an ovum discharged from a previous ovulation has
been developed is called-
a)Fecundation
b)Superfecundation
c)Super foetation
d)None of the above

6. Which of the following statements is true for virgo intacta-

a)Breasts are large and nodular
b)Labia majora not apposed with each other
c)Fossa navicularis is disappeared
d)Labia minora completely covered by labia majora
 DELIVERY
• Definition :
Expulsion of products of conception
from within the uterus at term.
Signs of
Recent delivery in Living :
General appearances of indisposition :
Woman looks pale, exhausted and ill.

Breasts :
• Enlarged, full, firm, tense.
• Darkening of areola.
• Prominent Montgomery tubercles .
• Surface veins are prominent .
• Striae are seen.
• Colostrum can be squeezed out for 2-3 days after delivery.
Abdomen:
• Striae gravidarum (pink)
• Lineae albicantes (silvery white)
• Linea nigra (black)

External genitalia :
• Labia are tender, swollen and lacerated.
• Fourchette is ruptured.
• Perineum is lacerated.
• Internal os begins to close within 24 hrs
• External os is patent admitting two fingers initially and later one finger with
difficulty at the end of a week.
• Vaginal discharge known as Lochia ( for 2-3 weeks) :
During first 4-5 days -lochia rubra (red)
During the next 4 days -lochia serosa (pale or serous)
After 9th day -lochia alba (yellowish grey or turbid)
Signs of
Recent delivery in Living :
• Extent of signs depends upon whether the woman is primiparous or
multiparous
• Breast: pendulous
• Hyperpigmentation present
• Montgomery's tubercles are prominent
• Stria are present
• Abdomen: abdominal wall is lax
• Linea albicantes
• Linea nigra
Signs of
Remote delivery in Living :
• External genitalia: labia are lax
• Vaginal rugae are lost
• Fourchette is lost
• Hymen: carunculae myrtiformis
• Os in Nulliparous:- Internal os is well defined
- External os is rounded and orifice closed
• Os in Multiparous:-Internal os is not well defined
External os is transverse irregular and may admit
a tip of finger
Sign of
Recent delivery in the Dead :
• Same as are found in living
• Additional findings are found in uterus and its appendages
• Uterus is firm and returns to a permanent reduced size
• Placental site can be identified by its dark colour and
coarse granular appearance and covered with blood clots,
lymph and decidua.
• Ovaries and fallopian tubes are congested
• Histopathological examination:
- trophoblastic cells and chorionic villi are present in
endometrium
- one large corpus luteum is present in one ovary
Signs of
Remote delivery in Dead :
• Same as are found in remote delivery in living
• Additional findings are present in uterus and its appendages
• Uterus is concave inwards.
• Fundus is above the line of fallopian tube
• Length of body is twice the length of cervix in multiparous and it is equal in
nulliparous.
• External os is enlarged, irregular and patulous and admits tip of finger
• Internal os is not well defined
• Arbor vitae: lost in parous woman
Different immediately After3days After1 week after2weeks after3weeks
measures

Outer length 20cm 17cm 14cm 12cm 10cm

Outer breadth 13-14cm 10cm 8cm 7cm 6cm

Thickness 5cm 5cm 4cm 3cm 2.5cm

Inner length 15cm 12cm 10cm 8cm 7cm

Weight 1kg 7oogm 500gm 300gm 80-100gm

Dia of the site of 10cm 7cm 4cm 2.5cm 1.5cm

placental
attachment
Point of differences nulliparous parous

size 7cm x 5cm x 2 cm 10cm x 6cm x 2.5cm

weight 40 gm 80-100 gm

Ratio between Body/Cervix Equal 2:1

Upper surface of fundus Less convex More convex

Uterine cavity convex concave

Scar for placental attachment absent present

External os round transverse

Internal os Circular , well defined Ill defined , margin wrinkled

 Abortion
•Definition:

“Termination of pregnancy due to premature

expulsion of product of conception at any time from
the uterus.”
 ABORTION
1.SPONTANEOUS
A)NATURAL
B)ACCIDENTAL
2. INDUCED
A)LEGAL
B)CRIMINAL
Medical termination of pregnancy
(MTP)act 1971
• Came into force in 1972
• Amendments in 1975, 2002 and 2003
Grounds for MTP:
• Therapeutic : risk to pregnant woman
• Eugenic : risk to the child to be born
• Humanitarian : pregnancy caused by rape
• Socioeconomic : pregnancy due to failure of contraceptive,
Unwanted pregnancy with low SE status
• Environemental: no one to help from society
Duration of pregnancy for MTP
Below 12 weeks :only one medical officer alone can
take decision for MTP
Between 12 to 20 weeks: decision is taken by two
medical officers for MTP
After 20 weeks: MTP can not be done, except in
emergency conditions.
(In emergency conditions decision can be taken by only
a single doctor.)
 Places for MTP
• Any government or semi-government
hospital

• Any non-government hospital approved by

government or CMO or district health officer
Qualification and Experience of
doctors for MTP
• Up to 12 weeks: By any RMP who has performed at
least 25 cases of MTP and out of which 5 have been
performed independently in an approved place.
• By doctor with any of the following:
-PG degree or diploma in OBG
-6 month of house surgency in OBG
-Experience of one year or more in OBG at any
hospital
• In emergency cases: By any RMP , at any place ,
irrespective of duration of pregnancy.
 Consent
• Only consent of pregnant woman is necessary

• No need to obtain consent from her husband

• In case of minor (less than 18 year of age),and

mentally ill woman, consent from guardian is
required
 Common methods of MTP
• Medical : mifepristone and misoprostol
• Dilatation and curettage (D&C)
• Vacuum aspiration technique or surgical abortion
• Intra-embryonic instillation of PG
• Extra-embryonic instillation of hypertonic saline
• Surgical
 Complications
Immediate:
• Haemorrhagic shock
•Perforation of uterus, perineum or intestine
•Laceration of cervix or vagina
•Incomplete abortion
•Embolism
•Thrombophlebitis
 Delayed:
•PID
•Menstrual irregularities
•Sterility
•Endometritis
•Cervicitis
•Vaginitis
 Criminal Abortion :
•Abortion done against the provision of
MTP act.
Legal aspects of criminal abortion:
Sec.312 IPC: Criminal abortion with the consent of
patient
• Punishment to both for upto 3 year,and +/- fine
• If the woman is quick with child then may extend upto
7years
Sec 313 IPC: if abortion done without her consent
• Punishment upto 10 years and fine
Sec 314 IPC:if woman dies by this act
• Punishment upto 10 years and fine
Sec 315 IPC : Any act with the intent to
prevent the child being born alive or cause
its death before birth
• Punishment : upto 10 years and/or fine.

Sec 316 IPC : any act which cause death of

quick unborn child amount to culpable
homicide
• Imprisionment upto 10 years and fine
Methods adopted for criminal
abortion
•I. Abortifacient drugs
• Drugs acting directly on the Uterus
• Irritants of Genito-Urinary tract
• Irritants of GI tract
• Drugs having poisonous effect on Body
•II. General violence
•III. Local violence
I. Abortifacient drugs:
1. Drugs acting directly on the Uterus :
A.ECBOLICS : (Increase Uterine Contraction)
Eg. Ergot
Hydrastis canadensis
Quinine
Lead ( lead oleate or lead plaster)
Decoction of cotton root bark
Nitrobenzol
Picrotoxin and strychnine
• B. EMMENAGOGUES : (Increase Menstrual Flow)
Eg. :- savin
borex
apiol
rue
laburum
oestrogen
sanguinarin
caulophyllin
hallebore
2. Irritants of Genito-urinary
tract:
• Oil of pennyroyal
• Oil of tansy
• Oil of turpentine
• Cantharides
• KMnO4
3. Irritants of GI tract :
• Saline cathartics eg. - MgSO4
• Purgatives eg. - aloes
- calomel
- castor oil
- croton oil
• Emetic eg. tartar
4.Drugs having poisonous effect on Body:
• Inorganic: Pb , Cu , Fe ,Hg , Sb

• Organic: cantharides , unripe fruits of

papaya and pine apple, juice of calotropis ,
bark of plumbago rosea , methi ,saffron
II. General violence:
Intensional
1. Severe pressure on abdomen: by blow, kick,
jumping or kneeling
2.Violent exercise: horse riding, cycling, jumping from
height, severe jolting, carrying or lifting heavy weights
3.Cupping
4. Very hot and cold bath alternately
III. Local violence :
• Syringing: by Higginson’s syringe
• Syringe aspiration
• Vacuum aspiration
• Rupture of membrane
• Use of laminaria tent /slippery elm
• Abortion sticks
• Utus paste (thymol, iodine, salt of mercury)
• Electric current
• Air insufflations
CAUSE OF DEATH AND
DANGERS OF CRIMINAL
ABORTION
A. Cause of Rapid death:
•Haemorrhage
• Perforation
•Vagal shock
• Fat embolism
•Air embolism
B. Cause of delayed death
•Peritonitis
•Local infection getting complicated
•Tetanus
•Septicaemia
•Pyaemia
C. Remote causes :
• Renal failure
• Meningitis
• Endocarditis
• Pneumonitis
• Hepatitis

•D. Toxic effects of Abortifacient drugs:

- causing early or delayed deaths
Duties of doctor in suspected criminal abortion
• Doctor must ask the patient to make a statement about the criminal
abortion.
• If she refuses, he should not pursue the matter, but inform the
police.
• He should keep all the information secret to maintain professional
secrecy.
• He must arrange to record the dying declaration in case woman’s
condition is serious.
• If woman dies, he must not issue the death certificate, but should
inform police for post-mortem examination.
• Any foreign materials collected from genitals should be kept
preserved.
 Examination of Living
•individual
Requisition from the concerned authority
• Identification of female
• Written informed consent
• A female must be present
• Brief history
• Clothing must be examined
• Clinical examination: sign of ill health, GIT disturbances,
exhaustion
• Local examination
• Laboratory investigations
 Examination of Dead body
Sudden death of a woman of child bearing age
should give rise the suspicion of criminal abortion if:
1.The deceased was pregnant and deeply cyanosed
2.Instrument to procure the abortion or abortifacient
drugs are found at scene of death.
3.Underclothing appears to be disturbed after death.
4.Fluid ,soapy material or blood coming out of
vagina.
Following points should be proved to convict
the abortionist:
1.The dead woman was pregnant
2.The accused was responsible for the act which
resulted in the interruption of pregnancy
3.The accused acted for purpose of procuring
illegal abortion
4.Death occurred as a result of attempt to
interrupt the pregnancy
Medical evidence of Abortion
In a Living victim :
• Breasts-pigmented
• Colostrum
• Linea nigra and albicans may present
• Congestion of labia majora and minora
• Tags of membrane may be present in uterus
• Swab taken from cervical canal may show chemical used
• HCG in urine up to 7 days
• Aborted material, if available ,should be subjected to visual
or histological examination.
Medical evidence of abortion
In a dead victim (autopsy findings)
• Face may appear pale.
• Undergarment may show blood clots and fragments
of product of conception.
• Congestion of labia and post. commissure
• Signs of peritonitis.
• Vaginal fluid for chemical analysis.
• In case of suspected air embolism X-ray & CT-Scan.
• Uterus and ovary may also be sent for chemical
analysis to detect abortifacients.
Factor suggestive of Spontaneous /
natural Abortion
• Blighted embryo
• Degenerative change of chorionic villi
• Hydatidiform mole
• Attenuated trophoblastic layer and myxomatous
avascular stroma
• Macerated foetus and placenta
• Foetal abnormalities
 Questions
• 1.In India MTP act was first introduced in
 a. 1947
 B.1966
 C.1971
 D.1975
2.MTP act extends all over India ,except, the city/state
a.Delhi
b.Mumbai
c.Chennai
d.Jammu and kashmir
 Questions(contd)
• 3.under MTP act one doctor can terminate the pregnancy upto
• A. six weeks
• B. twelve weeks
• C. Twenty weeks
• D. Twenty weeks
• 4.if criminal abortion is performed with the consent of the woman ,the
doctor will be charged under section
• A.310IPC
• B.312IPC
• C.313IPC
• D.320IPC
 Questions (contd)
• 5. Age of pregnant woman to give consent in MTP act is
• A.12years
• B.16years
• C.18years
• D.21years
• 6.Injection of soap water into vagina during criminal abortion can cause
• A.Air embolism
• B.fat embolism
• C.neurogenic shock
• D.peritonitis
Questions (contd)
• 7.Intra-amniotic injection of prostaglandins is successful in causing abortion
in the
• A. First trimester
• B. Second trimester
• C. Third trimester
• D. After viability of fetus
• 8. If criminal abortion is performed without the consent of woman , the
doctor will be charged under section
• A.310IPC
• B.312IPC
• C.313IPC
• D.320IPC
 Questions (contd)
• 9. Under MTP act pregnancy can be terminated at any stage on the ground
of
• A. Eugenic
• B. Therapeutic
• C. Social
• D. Humanitarian
• 10 Consent required for termination of pregnancy ,in an adult woman is
• A. Husband and herself
• B. mother
• C. Mother
• D. Herself only