Medicolegal tips for MTP in private practice: Dr. Dilip Walke
M3 India Newsdesk Aug 20, 2019
Medical Termination of Pregnancy (MTP) in our country is governed by an act and contravention of the act amounts to criminal offense against the state and is liable for punishment. Dr. Dilip Walke throws light on this critical area.
MTP is the most common and probably the first surgery that any Gynaecologist performs when he or she starts private practice. While the Gynaecologist may have fulfilled all the requirements to start his clinic or nursing home or hospital, it is very important that he fulfills the requirements of a legal MTP. The reason is that MTP in our country is governed by an act and contravention of the act amounts to criminal offense against the state and is liable for punishment.
This act no 34 was passed by Parliament on 10th August 1971 following the Rajya Sabha bill of 1969. The act was in response a movement by NGO’s against criminal abortion for which a committee (Shantilal Committee) was working from 1964. Since 1971 there have been two amendments in the act. The first was in 1975 and second was in 2002, which was published in the official gazette on 18th June 2003.
Described below is a step by step approach for doing MTP in private practice which is safe medicolegally and clinically.
Point no 1: Decide whether one is qualified to perform MTP. The minimum requirements for being a registered medical practitioner qualified to perform MTP are as follows
- One having a postgraduate degree or diploma in ObGyn is automatically qualified by virtue of his/her degree or diploma
- Those registered before the commencement of the Act need to have an experience of 3 years in Obstetrics and Gynaecology
- Those registered after commencement of the Act should possess experience certificate of:
- 6-month house surgeoncy post in ObGyn or,
- More than 1 year experience in any hospital in ObGyn or,
- Assisted 25 or more MTPs in a government hospital or recognised training centre- out of which 5 or more should have been done independently (this is applicable only for 1st trimester MTPs)
A registered Medical Practitioner is one who has a medical qualification under Indian Medical Council Act no 102 of 1956, section 2 clause having his/her name in the State Medical Register.
Point no 2 : If one is an RMP under the MTP act, one can perform MTP with medicines in any clinic or consulting room provided the following is fulfilled:
- RU 486 is presently approved only upto 49 days of amenorhoea, but this is likely to be extended. The implication of this fact is that it cannot be used legally for 2nd trimester MTP. In case of induction of labour, the Drug Controller of India has approved used of 25 microgram tablet of RU 486
- Following certificate has to be displayed from owner of a recognized MTP center
- That the services of the centre is available in case of emergency admission for check curettage in the event of an incomplete MTP
- All records of MTP centre (which are described later) have to be maintained by the centre to which the clinic is affiliated
Some medicolegal tips for MTP by medical method are:
- Confirm intrauterine pregnancy by TVS or counsel about ectopic pregnancy. Performing USG prior to MTP however is not a statutory compulsion.
- Do not forget to document that you have asked the patient to follow up in case of pain/fever/excessive bleeding.
- Do not forget the follow-up USG to r/o incomplete MTP.
- Counsel that in case of failure surgical termination is advisable.
Point no 3: If one is planning to start MTP by surgical method in his/her centre one has to apply for registration of the centre.
Following the 2002 amendment, the appropriate authority for registration has been decentralised (section 4). A district level 3 to 5-member committee is formed with the CMO or civil surgeon as the chairman having at least one female member and one FOGSI representative.
Application is made in form A. The appropriate authority on receiving the application inspects the centre within two months and sends recommendations to the committee. The committee finally approves or rejects the application in the next 2 months. Approval is given in form B in duplicate. One copy of form B has to be displayed visibly in the centre.
Point 4: Before the appropriate authority visits the center for inspection confirm that the centre fulfills all the requirements.
These are very simple and basic requirements which almost all nursing homes can easily fulfill.
Minimum requirements are as follows;
- In case of the first trimester, that is, up to 12 weeks of pregnancy:
- A gynaecology examination table
- Resuscitation and sterilisation equipment as mentioned in the act
- Drugs and parental fluids as mentioned in the act
- Back up facilities for treatment of shock
- Facilities for transportation
- In case of second trimester, that is, up to 20 weeks of pregnancy:-
- An operation table and instruments for performing abdominal or gynaecological surgery
- Anaesthetic equipment, resuscitation equipment and sterilisation equipment;
- Drugs and parental fluids for emergency use as may be notified by the Government of India from time to time.
Point no 5: Read the form B (of approval) carefully. This is to find out whether the centre has got approval for only 1st trimester MTP or for both 1st and 2nd trimester MTP. In case of 1st trimester, MTP opinion of single RMP is enough. But in case of 2nd trimester, MTP opinion of two doctors who are qualified under the MTP act is a requirement.
Presently MTP is not allowed beyond 20 weeks of pregnancy. However, in case we find a patient having a severe congenitally malformed foetus and is beyond 20 weeks, an application can be made for allowing termination of pregnancy in the respective high court. A 3-judge bench looks into the case and may refer to a committee in a medical college. In case the committee allows termination, the needful can be done. Several NGOs have now come forward to help these women in distress and they facilitate the court procedures free of charge.
Point no 6: Study all the documents that the centre receives upon getting registration.
The list is as follows:
- FORM A-APPLICATION FOR APPROVAL OF PLACE UNDER CLAUSE (B) OF SECTION 4
- FORM B-CERTIFICATE OF APPROVAL SUB-RULE 6 OF RULE 4. TO BE DISPLAYED
- FORM C- CONSENT FORM RULE 8
- FORM 1- DOCTORS APPROVAL FORM
- FORM 2- MTP REPORTING FORMAT
- FORM 3- MTP ADMISSION REGISTER
Point no 7: Observe the following steps while performing any MTP
- Step no 1: Take the consent of the patient in Form C
- Step no 2: Complete the Form I — “Doctor's approval form”
- Step no 3: Complete the MTP
- Step no 4: Fill the Form 2 -- MTP reporting format
- Step no 5: Put the three forms, .(Form C, Form 1, and Form 2) in an envelope
- Write the name and address of the RMP (of both RMPs in case of 2nd trimester MTP)
- Put the serial number of the patient as assigned in the admission register
- Write the date of the MTP
- It is marked as SECRET and sealed by the RMP
- Step no 6: Send it to the owner of the centre for his/her custody
- Every month before the 5th, the owner of the centre is supposed to send a monthly statement of the MTP cases in form II to the chief medical officer of the district or MOH in case of cities. It is an offense if reporting is not done.
While taking consent in form C one has to remember that the consent is expected to be an informed consent, which means that a proper counseling about the procedure, its risks, benefits, and alternatives is done. If the patient is an adult (>18 years), her own consent is enough. Husband's consent is legally not required. If the patient's age is less than 18 years, a guardian’s consent is needed. One lacuna in form C is that Form C doesn't mention indication for MTP. So it is prudent to take a separate signature on another consent form designed by FOGSI.
Indications for MTP are mentioned in the form 1 or the doctors approval form which we have to fill before performing the MTP. The indications mentioned below have to be properly selected and ticked:
- To save her life
- To prevent her from grave injury to physical or mental health
- In view of a substantial risk that if the child was born it would suffer from physical or mental abnormalities as to be seriously handicapped
- Pregnancy alleged to be caused by rape
- Pregnancy caused by failure of contraception used by herself or by her husband for limiting the number of children
Some points which we need to remember about indications are;
- “MTP on demand” is not an indication. So the most common indication in married woman can be “failure of contraception”. However, we need to mention which method failed on the OPD/indoor paper
- For unmarried woman, the proper indication is “in order to prevent grave injury to physical and mental health of the pregnant women” unless there is a history of rape.
- In case of rape, one has to remember that rape is a cognizable offense which means police can arrest the accused without warrant. Our responsibility with regards to reporting a case of rape to police has to include the following points:
- If the girl is a major and does not want to report the rape
- Inform police that you are treating a rape victim and performing the MTP but that she does not want to disclose her name and the onus of maintaining the secrecy is now with the police
- If the girl is minor and less than 15
- It has to be reported because sex in <15 years is rape even if done with consent
- Between 15 and 18 yrs is grey zone area
- Report rape in any case.
- Inform name if guardian accepts
Point no 8: One has to remember that MTP act recognises and protects the right to secrecy of the patient and hence her name has to be kept a secret even from her husband.
Once a patient comes for MTP, enter her name in the “admission register” and assign her a number. Such numbering should start afresh every year e.g 1/2010, 2/2020,3/2010 and so on. From now onwards her name cannot be entered in the indoor paper, OT register, or discharge card. She has to be addressed only by the number assigned in the admission register. Admission register has to be maintained for 5 years as a secret document. Special situations when this document needs to be shown are
- To the Secretary of the Government of India doing departmental inquiry
- To First class Magistrate doing inquiry
- To a court of law where a court case of MTP is going on
- To a patient who applies for the same on some valid grounds.
Point no 9 : We are liable for punishment amounting to 2-7 yrs of imprisonment
This is if:
- The person doing the MTP is not an RMP
- The person is doing the MTP at unregistered place
- You are the owner of the unregistered place where illegal MTP is carried out
Point no 10: There is a section in the act (section no 8) which protects us from medicolegal cases in MTP, but one has to read the section carefully.
“No suit or other legal proceeding shall lie against any registered medical practitioner for any damage caused or likely to be caused by anything which is done in good faith PROVIDED IT IS DONE UNDER THIS ACT”.
Some landmark MTP cases
Dr. Mrs Gayatri S Bhatwal Vs Smt Mangal S Dhake. State Forum, Mumbai President-Justice Vagyani/ Members-Anjali Karadkhedkar/ Mr. Nagrale. This was a case of MTP failure but the forum observed the following:
- Doctor was RMP under the act
- Centre was recognized
- All documents were maintained
- Indication was valid
- “100% termination is a myth”
- Doctor is immune due to section 8
Surendra Chauhan vs. State of MP 2000
- Electrohomeopathy doctor performed 2nd trimester MTP. Since he is not an RMP under the act he was awarded a compensation of Rs 25,000/- + one and half year rigorous imprisonment
Vinitha Ashok vs. Laxmi Hospital (SC)
- Case of cervical pregnancy which bled and died in spite of caesarian hysterectomy. Complainants plea was that USG not done before MTP. Supreme Court concluded that USG is not necessary to be done before MTP.
Dr. Lalitha Krishna vs. Deepa Nair APSCDRC
- A case of failure of MTP. The doctor said that in her hand MTP cannot fail and alleged that patient was lying. The patient however produced USG report of continued pregnancy. Hence the doctor lost the case.
P N Bhaskaran Vs Mrs Molly Robinson Kerala SCDRC
- State forum concluded that less than 6 weeks MTP are likely to fail. Both D&C and SE are methods of MTP
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