Form Dch-0615 - Report Of Fetal Death - Michigan Department Of Community Health Page 2
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1
2Mother's Name __________________________________________
Mother's Medical Record No. __________________
32. RISK FACTORS IN THIS PREGNANCY
36. CONGENITAL ANOMALIES OF THE
D. Final route and method of
33. INFECTIONS PRESENT AND/OR
(Check all that apply or check “None”)
FETUS (Check all that apply or check
delivery (check one)
TREATED DURING THIS
“None”)
1
Vaginal/Spontaneous
PREGNANCY (Check all that apply)
Diabetes
2
Vaginal/Forceps
01 Prepregnancy
1
Anencephalus
3
Vaginal/Vacuum
1
Gonorrhea
(Diagnosis prior to this pregnancy)
4
Cesarean
2
Syphillis
2
Meningomyelocele/Spina Bifida
02 Gestational (Diagnosis in this pregnancy)
3
Genital Herpes
3
Congenital heart disease
Hypertension
If Cesarean, was a trial of
4
Chlamydia
03 Prepregnancy (Chronic)
labor attempted?
4
Cyanotic congenital heart disease
5
Listeria
04 Gestational (PIH, preeclampsia)
1
Yes
2
No
6
Group B streptococcus
5
Congenital diaphragmatic hernia
05 Eclampsia
7
Cytomegalovirus
6
Omphalocele
06 Previous preterm birth
E. Hysterotomy/Hysterectomy
8
Parvo virus
07 Other previous poor pregnancy outcome
1
Yes
2
No
7
Gastroschisis
9
Toxoplasmosis
(includes perinatal death, small-for gestational age/
10
Other (Specify) _____________
8
Limb reduction defect (excluding
intrauterine growth restricted birth)
0
None of the above
08 Vaginal bleeding during this pregnancy prior to
congenital amputation and
the onset of labor
dwarfing syndromes)
35. MATERNAL MORIDITY
09 Pregnancy resulted from infertility treatment --
34. METHOD OF DELIVERY
(Complications associated with
9
Cleft Lip with or without Cleft Palate
If yes, check all that apply:
labor and delivery) (Check all
10 Fertility-enhancing drugs, artificial
10
Cleft Palate alone
that apply or check “None”)
A. Was delivery with forceps
insemination or intrauterine insemination
1
Maternal transfusion
Down Syndrome
attempted but unsuccessful?
11 Assisted reproductive technology (e.g.,
2
Third or fourth degree
1
Yes
2
No
11
Karyotype confirmed
in vitro fertilization (IVF), gamete
perineal laceration
intrafallopian transfer (GIFT))
12
Karyotype pending
3
Ruptured uterus
B. Was delivery with vacuum
12 Mother had a previous cesarean delivery
4
Unplanned hysterectomy
extraction attempted but
Suspected chromosomal disorder
If yes, how many? _______________
5
Admission to intensive
unsuccessful?
13
Karyotype confirmed
13 Alcohol use during pregnancy
care unit
1
Yes
2
No
00 None of the above
14
Karyotype pending
6
Unplanned operating
99 Unknown
room procedure
C. Fetal presentation at delivery?
15
Hypospadias
following delivery
1
Cephalic
16
Other (specify) _______________
0
None of the above
2
Breech
00
None of the anomalies listed above
3
Other
CAUSE/CONDITIONS CONTRIBUTING TO FETAL DEATH
37a. INITIATING CAUSE/CONDITION (Among the choices
37b. OTHER SIGNIFICANT CAUSES OR CONDITIONS
38. ESTIMATED TIME OF FETAL DEATH
below, please select the one which most likely began
(Select or specify all other conditions contributing to death
the sequence of events resulting in the death of the
in Item 37a, or check “Unknown”)
Dead at time of first assessment,
fetus or check “Unknown”)
no labor ongoing
Maternal Conditions/Diseases (Specify) ___________________
Maternal Conditions/Diseases (Specify) ________________
Dead at time of first assessment,
___________________________________________________
________________________________________________
labor ongoing
Complications of Placenta, Cord, or Membranes
Complications of Placenta, Cord, or Membranes
Died during labor, after first
assessment
1
Rupture of membranes prior to onset of labor
1
Rupture of membranes prior to onset of labor
2
Abruptio placenta
2
Abruptio placenta
Unknown time of fetal death
3
Placental insufficiency
3
Placental insufficiency
4
Prolapsed cord
4
Prolapsed cord
39a. WAS AN AUTOPSY PERFORMED?
5
Chorioamnionitis
5
Chorioamnionitis
1
Yes
2
No
3
Planned
6
Other (Specify) __________________________
6
Other (Specify) _____________________________
Other Obstetrical or Pregnancy Complications (Specify)
Other Obstetrical or Pregnancy Complications (Specify)
__________________________________________
_____________________________________________
__________________________________________
_____________________________________________
39b. WAS A HISTOLOGICAL PLACENTAL
EXAMINATION PERFORMED?
_________________________
____________________________
Fetal Anomaly (Specify)
Fetal Anomaly (Specify)
1
Yes
2
No
3
Planned
__________________________________________
_____________________________________________
___________________________
______________________________
Fetal Injury (Specify)
Fetal Injury (Specify)
39c. WERE AUTOPSY OR HISTOLOGICAL
__________________________________________
_____________________________________________
PLACENTAL EXAMINATION RESULTS
USED IN DETERMINING THE CAUSE
Fetal Infection (Specify) _____________________________
Fetal Infection (Specify) ________________________________
OF FETAL DEATH?
_______________________________________
____________________________________________
____
_
1
Yes
2
No
Other Fetal Conditions/Disorders (Specify) ______________
Other Fetal Conditions/Disorders (Specify) _________________
________________________________________________
___________________________________________________
9
Unknown
9
Unknown
40a. NAME AND TITLE OF PERSON COMPLETING THE REPORT (Type or Print)
40b. DATE REPORT COMPLETED
(Month, Day, Year)
DCH-0615 (11/13)
Please return to: Michigan Department of Community Health
Vital Records and Health Statistics Section
P.O. Box 30691, Lansing, Michigan 48909
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