Report Fetal Death Form – Fill Out and Use This PDF

MOTHER

19. MOTHER’S EDUCATION (Check the

20. MOTHER OF HISPANIC ORIGIN? (Check

21. MOTHER’S RACE (Check one or more races to indicate

box that best describes the highest

the box that best describes whether the

□ White

to be)

what the mother considers herself

degree or level of school completed at

mother is Spanish/Hispanic/Latina. Check the

the time of delivery)

“No” box if

mother is not Spanish/Hispanic/Latina)

□ Black or African American

□ 8th grade or less

□

No, not Spanish/Hispanic/Latina

□

American Indian or Alaska Native

□ Yes, Mexican, Mexican American, Chicana

□

(Name of the enrolled or principal tribe)________________

□ 9th - 12th grade, no diploma

Asian Indian

□

□ High school graduate or GED

Yes, Puerto Rican

□

Chinese

□

□

Filipino

completed

Yes, Cuban

□

Japanese

□ Some college credit but no degree

□

Yes, other Spanish/Hispanic/Latina

□

Korean

□ Associate degree (e.g., AA, AS)

(Specify)_____________________________

□

Vietnamese

□ Bachelor’s degree (e.g., BA, AB, BS)

□ Other Asian (Specify)______________________________

□

Native Hawaiian

□ Master’s degree (e.g., MA, MS,

□

Guamanian or Chamorro

MEng, MEd, MSW, MBA)

□

Samoan

□ Doctorate (e.g., PhD, EdD) or

□

Other Pacific Islander (Specify)______________________

Professional degree (e.g., MD, DDS,

□

Other (Specify)___________________________________

DVM, LLB, JD)

22. MOTHER MARRIED?

23a. DATE OF FIRST PRENATAL CARE VISIT

23b. DATE OF LAST PRENATAL

24. TOTAL NUMBER OF PRENATAL

(At delivery, conception, or anytime

CARE VISIT

VISITS FOR THIS PREGNANCY

between) □ Yes □ No

______ /________/ __________ □ No Prenatal Care

______ /________/ __________

_________ (If none, enter “0".)

M M

D D

YYYY

M M

D D

YYYY

25. MOTHER’S HEIGHT

26. MOTHER’S PREPREGNANCY WEIGHT

27. MOTHER’S WEIGHT AT DELIVERY

28. DID MOTHER GET WIC FOOD FOR HERSELF

_______ (feet/inches)

_________ (pounds)

_________ (pounds)

DURING THIS PREGNANCY? □ Yes □ No

29. NUMBER OF PREVIOUS

30. NUMBER OF OTHER PREGNANCY

31. CIGARETTE SMOKING BEFORE AND DURING PREGNANCY

LIVE BIRTHS

OUTCOMES (spontaneous or induced

For each time period, enter either the number of cigarettes or the number of packs of

losses or ectopic pregnancies)

cigarettes smoked.

IF NONE, ENTER “0".

29a. Now Living

29b. Now Dead

30a. Other Outcomes

Average number of cigarettes or packs of cigarettes smoked per day.

Number _____

Number _____

Number (Do not include this fetus) ____

# of cigarettes

# of packs

Three Months Before Pregnancy

_________

OR

________

□ None

□ None

□ None

First Three Months of Pregnancy

_________

OR

________

Second Three Months of Pregnancy

_________

OR

________

Third Trimester of Pregnancy

_________

OR

________

29c. DATE OF LAST LIVE BIRTH

30b. DATE OF LAST OTHER

32. DATE LAST NORMAL

33. PLURALITY - Single,

34. IF NOT SINGLE BIRTH-

_______/________

PREGNANCY OUTCOME

MENSES BEGAN

Twin, Triplet, etc.

Born First, Second, Third, etc.

MM

Y Y Y Y

_______/_______

____ /_____/ __________

MM

Y Y Y Y

MM D D

Y Y Y Y

(Specify)_______________

(Specify)_______________

35. MOTHER TRANSFERRED FOR MATERNAL MEDICAL OR FETAL INDICATIONS FOR DELIVERY?

□ Yes

□

No

IF YES, ENTER NAME OF FACILITY MOTHER TRANSFERRED FROM: _________________________________________________________________________

MEDICAL

36. RISK FACTORS IN THIS PREGNANCY (Check all that apply):

37. INFECTIONS PRESENT AND/OR TREATED DURING

THIS PREGNANCY (Check all that apply)

AND

Diabetes

□

Prepregnancy

(Diagnosis prior to this pregnancy)

□

Gonorrhea

HEALTH

□

Gestational

(Diagnosis in this pregnancy)

□

Hypertension

Syphilis

INFORMATION

□

Prepregnancy

(Chronic)

□

Chlamydia

□

Gestational

(PIH, preeclampsia)

□

Eclampsia

□

Listeria

□

Previous preterm birth

□

Group B Streptococcus

□ Other previous poor pregnancy outcome (Includes perinatal death, small-for-gestational age/intrauterine

□

Cytomegalovirus

growth restricted birth)

□

□ Pregnancy resulted from infertility treatment-If yes, check all that apply:

Parvovirus

□

□ Fertility-enhancing drugs, Artificial insemination or

Toxoplasmosis

□ None of the above

Intrauterine insemination

□ Assisted reproductive technology (e.g., in vitro fertilization (IVF), gamete intrafallopian transfer (GIFT))

□

Other (Specify)______________________________

□ Mother had a previous cesarean delivery

If yes, how many __________

□ None of the above

38. METHOD OF DELIVERY

39. MATERNAL MORBIDITY (Check all that apply)

40. CONGENITAL ANOMALIES OF THE FETUS

(Complications associated with labor and delivery)

(Check all that apply)

A. Was delivery with forceps attempted but unsuccessful?

□ Yes

□

No

□

Maternal transfusion

□

Anencephaly

□

Meningomyelocele/Spina bifida

B. Was delivery with vacuum extraction attempted but

□

Third or fourth degree perineal laceration

□ Cyanotic congenital heart disease

unsuccessful?

□

Congenital diaphragmatic hernia

□

Ruptured uterus

□

Omphalocele

□ Yes

□

No

□

Gastroschisis

□

Unplanned hysterectomy

□ Limb reduction defect (excluding congenital

C. Fetal presentation at delivery

amputation and dwarfing syndromes)

□

Cephalic

□ Admission to intensive care unit

□ Cleft Lip with or without Cleft Palate

□

Breech

□

Cleft Palate alone

□

Other

□ Unplanned operating room procedure following

□

Down Syndrome

delivery

□

Karyotype confirmed

D. Final route and method of delivery (Check one)

□

Karyotype pending

□ Vaginal/Spontaneous

□ None of the above

□

Suspected chromosomal disorder

□ Vaginal/Forceps

□

Karyotype confirmed

□ Vaginal/Vacuum

□

Karyotype pending

□ Cesarean

□

Hypospadias

If cesarean, was a trial of labor attempted?

□ None of the anomalies listed above

□ Yes

□ No

E. Hysterotomy/Hysterectomy

□ Yes

□

No