Registry of Vital Records and Statistics
Report of fetal death / Form R304W-102014
Mother’s Medical Record Number / Place Where Delivery Occurred (Check one)
Hospital Home Delivery Planned to deliver at home?
Clinic/Doctor’s office Yes No
Freestanding birthing center
Unknown
Other (specify)______
Fetus / Name of Fetus (optional-at the discretion of the parents)
First Name / Time of Delivery (24 hr) / Sex
ð Male
ð Female
ð Unknown / Weight of Fetus (grams) / Obstetric Estimate of Gestation at Delivery (completed weeks)
Middle Name / Date of Delivery (Month, Day, Year)
Last Name / Plurality (specify)
ð Single ð Other______
ð Twin / Birth Order (specify if plural birth)
ð 1st ð 3rd
ð 2nd ð Other _____ / Clinical Estimate of Gestation
(in weeks)
Mother/Parent / Mother’s Name
First Name / Middle Name
Last Name / Surname at Birth or Adoption (Maiden Name)
Date of Birth (Month, Day, Year) / Birthplace (City/Town, State, Country)
Residence of Mother- Please give the actual address where the mother lives now, including the name, number and proper city/town name. Do NOT give the mailing address. Do not use neighborhood designations or locality names: e.g. write “BOSTON” not “DORCHESTER”.
Apt # / City/Town / County / State / Zip Code / Inside City Limits? (if not MA resident)
Yes No
Marital Status / Mother’s Marital Status
ð Married
ð Never Married / ð Widowed
ð Divorced
Father/Parent / Father’s Name
First Name / Middle Name
Last Name / Surname at Birth or Adoption
Date of Birth (Month, Day, Year) / Birthplace (City/Town, State, Country)
Method of Disposition / Place of Disposition
ð Burial
ð Cremation
ð Entombment
ð Removal from state
ð Donation
ð Medical waste
ð Other (specify):______/ Name ______City/Town, State:______
(i.e., cemetery, crematory, hospital, etc.)
Funeral Service Licensee (if any): ______License# ______
Name of Facility (if any): ______
Date of Disposition: ______
(Month, Day, Year)
Cause of Fetal Death / Cause/Conditions Contributing to Fetal Death
Initiating Cause/Condition
(Among the choices below, please select the ONE which most likely began the sequence of events resulting in the death of the fetus) / Other Significant Causes or Conditions
(Select or specify all other conditions contributing to death in Other Significant Causes or Conditions)
Maternal Conditions/Diseases (specify)
______
Complications of Placenta, Cord, or Membranes
ð Rupture of membranes prior to onset of labor
ð Abruptio placenta
ð Placental insufficiency
ð Prolapsed cord
ð Chorioamnionitis
ð Other (specify)
______
Other Obstetrical or Pregnancy Complications (specify)
______
Fetal Anomaly (specify)
______
Fetal Injury (specify)
______
Fetal Infection (specify)
______
Other Fetal Conditions/Disorders (specify)
______
ð Unknown / Maternal Conditions/Diseases (specify)
______
Complications of Placenta, Cord, or Membranes
ð Rupture of membranes prior to onset of labor
ð Abruptio placenta
ð Placental insufficiency
ð Prolapsed cord
ð Chorioamnionitis
ð Other (specify)
______
Other Obstetrical or Pregnancy Complications (specify)
______
Fetal Anomaly (specify)
______
Fetal Injury (specify)
______
Fetal Infection (specify)
______
Other Fetal Conditions/Disorders (specify)
______
ð Unknown
Estimated Time of Fetal Death / Was the case referred to a Medical Examiner? / Was a histological placental examination performed? / Were autopsy or histological placental examination results used in determining the cause of fetal death?
ð Dead at time of first assessment, no labor ongoing
ð Dead at time of first assessment, labor ongoing
ð Died during labor, after first assessment
ð Unknown time of fetal death / ð Yes ð No
Was an autopsy performed? / ð Yes
ð No
ð Planned / ð Yes
ð No
ð Not Applicable
ð Yes
ð No
ð Planned
Certifier / Is Certifier a Medical Examiner?
ðYes ðNo
______Title ð MD ð DO ð NP
Type or Print-Name of Certifier or Medical Examiner
License#:______
/ ______
______
Certifier Street # and Address
______
City/Town State Zip Code
Attendant
(if different) / ______
Type or Print-Name of Attendant
Title ð MD ð DO ð CNM/CM ð Other Midwife ð Other (Specify) ______License #______
Prenatal Care Information
Date of First Prenatal Care Visit / Date of Last Prenatal Care Visit / Total # of prenatal care visits for this pregnancy (If none, enter “0”) / Did mother get WIC food for herself during this pregnancy? / Insurance (Prenatal Care Source of Payment)
______/______/______
MM / DD / YYYY
ð No Prenatal Care / ______/______/______
MM / DD / YYYY / ð Yes
ð No
ð Refused
ð Unknown / ð Medicaid
ð Private Insurance
ð Self-pay
ð Indian Health
Service / ð CHAMPUS/TRICARE
ð Other Government (Fed, State, Local)
ð Other ______
ð Unknown
Pregnancy History
Number of Previous Live Births: Now Living / Number of Previous Live Births: Now Dead / Date of Last Live Birth / Number of Other Pregnancy Outcomes (do not include this fetus): / Date of Last Other Pregnancy Outcome
#______ð None / #______ð None / ______/______
MM / YYYY / # ______ ð None / ______/______
MM / YYYY
Date Last Normal Menses Began / Mother’s Weight at Delivery / Mother’s Prepregnancy Weight / Mother’s Height
______/______/______
MM / DD / YYYY / ______(pounds) / ______(pounds) / ______(feet) ______(inches)
Delivery Information
Fetal presentation at delivery (Check one) / Final route and method of delivery (Check one) / Hysterotomy/Hysterectomy / Was mother transferred for maternal medical or fetal indications for delivery? ð Yes ð No
If yes, enter name of facility mother transferred from:
______
ð Vaginal/Spontaneous
ð Vaginal/Forceps
ð Vaginal/Vacuum
ð Cesarean
If cesarean, was a trial of labor attempted? ð Yes ð No / ð Yes
ð No
ð Cephalic
ð Breech
ð Other
Medical Information
Risk Factors in this pregnancy (Check all that apply) / Infections Present and/or Treated During This Pregnancy (Check all that apply) / Congenital Anomalies of the Fetus (Check all that apply)
ð Diabetes – Prepregnancy (Diagnosis prior to this pregnancy)
ð Diabetes – Gestational (Diagnosis in this pregnancy)
ð Hypertension – Prepregnancy (Chronic)
ð Hypertension – Gestational (PIH, preeclampsia)
ð Hypertension – Eclampsia
ð Previous preterm birth
ð Other previous poor pregnancy outcome (includes perinatal death, small-
for-gestational age/intrauterine growth restricted birth)
ð Pregnancy resulted from infertility treatment (If checked, please see Birth
Trends and Technologies section)
ð Mother had a previous cesarean delivery
If yes, how many ______
ð None of the above / ð Chlamydia
ð Cytomegalovirus
ð Gonorrhea
ð Group B Streptococcus
ð Listeria
ð Syphilis
ð Parvovirus
ð Toxoplasmosis
ð Other (Specify)
______
ð None of the above / ð Anencephaly
ð Cleft Lip with or without Cleft Palate
ð Cleft Palate alone
ð Congenital diaphragmatic hernia
ð Cyanotic congenital heart disease
ð Down Syndrome
ð Karyotype confirmed
ð Karyotype pending
ð Gastroschisis
ð Hypospadias
ð Limb reduction defect (excluding congenital
amputation and dwarfing syndromes)
ð Meningomyelocele/Spina bifida
ð Omphalocele
ð Suspected chromosomal disorder
ð Karyotype confirmed
ð Karyotype pending
ð None of the above
Maternal Morbidity (Check all that apply) Complications associated with labor and delivery
ð Admission to intensive care unit
ð Maternal transfusion
ð Ruptured uterus
ð Third or fourth degree perineal laceration / ð Unplanned hysterectomy
ð Unplanned operating room procedure following delivery
ð None of the above
Birth Trends and Technologies: If Mother/Parent took any fertility drugs or received any medical procedures from a doctor, nurse, or other health care worker to help get pregnant with this current pregnancy (this may include infertility treatments such as fertility-enhancing drugs or assisted reproductive technology), check all that apply:
ð Fertility-enhancing drugs
ð Artificial insemination
ð Intrauterine insemination / ð Assisted reproductive technology
ð Other medical treatment
Other (Specify) ______/ ð Anonymous egg donor
ð Anonymous sperm donor / ð Surrogacy
ð None of these apply
Reported Alcohol and Tobacco Use
Cigarette Smoking Before and During Pregnancy (For each time period, enter either the average number of cigarettes or the average number of packs of cigarettes smoked per day. If none, enter “0”.) / Alcohol Use Before and During Pregnancy (For each time period, enter the number of drinks mother had in an average week. If none, enter “0”.)
3 months before pregnancy / Second 3 months of pregnancy / 3 months before pregnancy / Second 3 months of pregnancy
#______ð Cigarettes ð Packs / #______ð Cigarettes ð Packs / #______/ #______
First 3 months of pregnancy / Third Trimester of pregnancy / First 3 months of pregnancy / Third Trimester of pregnancy
#______ð Cigarettes ð Packs / #______ð Cigarettes ð Packs / #______/ #______
Demographic Information
Mother/Parent Race (Check one or more boxes that best describes the mother/parent’s race) / Mother/Parent Ethnicity (Check one or more boxes that best describes the mother/parent’s ethnicity)
ð American Indian/Alaska Native/Native
American
ð Asian
ð Black
ð Guamanian or Chamorro
ð Hispanic/Latina/Black
ð Hispanic/Latina/White
ð Hispanic/Latina/Other
…Specify (Other Hispanic Latina) ______
ð Native Hawaiian
ð Samoan
ð White
ð Other Pacific Islander
ð Other
…Specify (Other) ______
ð Refused
ð Unknown / ð African
….Specify (African) ______
ð African American
ð American
ð Asian Indian
ð Brazilian
ð Cambodian
ð Cape Verdean
ð Caribbean Islander
…Specify (Caribbean Islander) ______
ð Chinese
ð Colombian
ð Cuban
ð Dominican
ð European
…Specify (European) ______
ð Filipino / ð Guatemalan
ð Haitian
ð Honduran
ð Japanese
ð Korean
ð Laotian
ð Mexican, Mexican American, Chicana
ð Middle Eastern
…Specify (Middle Eastern) ______
ð Native American/American Indian/Alaskan Native
...Specify (Tribe) ______
ð Portuguese
ð Puerto Rican
ð Russian
ð Salvadoran
ð Vietnamese / ð Other Asian
…Specify (Other Asian) ______
ð Other Central American
….Specify (Other Central American) ______
ð Other Pacific Islander
...Specify (Other Pacific Islander) ______
ð Other Portuguese
…Specify (Other Portuguese) ______
ð Other South American
…Specify (Other South American) ______
ð Other
…Specify (Other) ______
ð Unknown
ð Refused
Mother/Parent Education (Check the box that best describes the highest degree or level of school that the mother/parent completed at the time of delivery)
ð 8th grade or less
ð 9th-12th grade, no diploma
ð High School graduate or GED completed / ð Some college credit but no degree
ð Certificate
ð Associate Degree / ð Bachelor’s Degree
ð Master’s Degree
ð Doctorate or Professional Degree / ð Unknown
ð Refused
Mother/Parent Occupation (Please list the mother/parent’s occupation over the past year) / Mother/Parent Industry (Please list the mother/parent’s industry over the past year)
Father/Parent Race (Check one or more boxes that best describes the father/parent’s race) / Father/Parent Ethnicity (Check one or more boxes that best describes the father/parent’s ethnicity)
ð American Indian/Alaska Native/Native
American
ð Asian
ð Black
ð Guamanian or Chamorro
ð Hispanic/Latino/Black
ð Hispanic/Latino/White
ð Hispanic/Latino/Other
…Specify (Other Hispanic Latino) ______
ð Native Hawaiian
ð Samoan
ð White
ð Other Pacific Islander
ð Other
…Specify (Other) ______
ð Refused
ð Unknown / ð African
….Specify (African) ______
ð African American
ð American
ð Asian Indian
ð Brazilian
ð Cambodian
ð Cape Verdean
ð Caribbean Islander
…Specify (Caribbean Islander) ______
ð Chinese
ð Colombian
ð Cuban
ð Dominican
ð European
…Specify (European) ______
ð Filipino / ð Guatemalan
ð Haitian
ð Honduran
ð Japanese
ð Korean
ð Laotian
ð Mexican, Mexican American, Chicano
ð Middle Eastern
…Specify (Middle Eastern) ______
ð Native American/American Indian/Alaskan Native
...Specify (Tribe) ______
ð Portuguese
ð Puerto Rican
ð Russian
ð Salvadoran
ð Vietnamese / ð Other Asian
…Specify (Other Asian) ______
ð Other Central American
….Specify (Other Central American) ______
ð Other Pacific Islander
...Specify (Other Pacific Islander) ______
ð Other Portuguese
…Specify (Other Portuguese) ______
ð Other South American
…Specify (Other South American) ______
ð Other
…Specify (Other) ______
ð Unknown
ð Refused
Father/Parent Education (Check the box that best describes the highest degree or level of school that the father/parent completed at the time of delivery)
ð 8th grade or less
ð 9th-12th grade, no diploma
ð High School graduate or GED completed / ð Some college credit but no degree
ð Certificate
ð Associate Degree / ð Bachelor’s Degree
ð Master’s Degree
ð Doctorate or Professional Degree / ð Unknown
ð Refused
Father/Parent Occupation (Please list the father/parent’s occupation over the past year) / Father/Parent Industry (Please list the father/parent’s industry over the past year)
NAME OF PERSON COMPLETING REPORT / TITLE / date completed (MM/DD/YYYY)
HOSPITAL WORKSHEET FOR REPORT OF FETAL DEATH Page 1 of 4