General Fetal Death Entry/Printing Rules
INDIANA STATE - CERTIFICATE OF FETAL DEATH
State Form 11410 (R5/06-08)
|Local No: | |THE RECORDS IN THIS SERIES ARE CONFIDENTIAL PER IC 16-37-1-10 |State File No: | |
|1. NAME OF FETUS (optional at the discretion of the parents) |2. Time of |3. SEX (M/F/Unk) |4. DATE OF DELIVERY (Mo/Day/Yr) |
| |Delivery | | |
| |(24 hr) | | |
|5a. CITY, TOWN, OR LOCATION OF DELIVERY |7. PLACE WHERE DELIVERY OCCURRED (Check one) |8. FACILITY NAME (If not institution, give street and |
| |Hospital Freestanding birthing center |number) |
| |Home Delivery:Planned to deliver at home?Yes | |
| |No Clinic/Doctor’s Office Other Specify: | |
|5b. ZIP CODE OF DELIVERY | | |
|6. COUNTY OF DELIVERY | |9. FACILITY I.D. (NPI) |
|10a. MOTHER’S CURRENT LEGAL NAME (First, Middle, Last, Suffix) |10b. DATE OF BIRTH (Mo/Day/Yr) |
|10c. MOTHER’S NAME PRIOR TO FIRST MARRIAGE (First, Middle, Last, Suffix) |10d. BIRTHPLACE (State, Territory, or Foreign Country) |
|11a. RESIDENCE OF MOTHER – STATE |11b. COUNTY |11c. CITY, TOWN, OR LOCATION |
|11d. STREET AND NUMBER |11e. APT # |11f. ZIP CODE |11g. INSIDE CITY LIMITS? Yes |
| | | |No |
|12a. FATHER’S CURRENT LEGAL NAME |12b. DATE OF BIRTH (Mo/Day/Yr) |12c. BIRTHPLACE (State, Territory, or Foreign |
| | |Country) |
|13. METHOD OF DISPOSITION: Donation |14. ATTENDANT’S NAME AND NPI | 14a. Title: MD DO CNM/CM OTHER MIDWIFE OTHER |
|Burial Cremation Hospital Disposition| |Specify |
|Removal from State Other Specify: | | |
|___________ | | |
|15. Name of Funeral Home: |15a. PLACE OF DISPOSITION: |
|15b. Signature Of Indiana Funeral Service Licensee: |15c. License Number (Of Licensee): |
|16. Signature of Local Health Officer: |16a. FILE DATE (month,day,year) |
|17.CAUSE/CONDITIONS CONTRIBUTING TO FETAL DEATH |
|17a. INITIATING CAUSE/CONDITION |17b. OTHER SIGNIFICANT CAUSES OR CONDITIONS |
|Among the choices below, please select the one that most likely began the sequence |Select or specify all other conditions contributing to death in Item 17a. |
|of events resulting in the death of the fetus. | |
|Maternal Conditions/Diseases (Specify): | | |Maternal Conditions/Diseases | | |
| | | |(Specify): | | |
| | | | | | |
|Complications of Placenta, Cord, or Membranes |Complications of Placenta, Cord, or Membranes |
| Rupture of membranes prior to onset of labor | Rupture of membranes prior to onset of labor |
|Abruptio placenta |Abruptio placenta |
|Placental insufficiency |Placental insufficiency |
|Prolapsed cord |Prolapsed cord |
|Chorioamnioitis |Chorioamnioitis |
|Other (Specify): | | |Other (Specify): | | |
|Other Obstetrical or Pregnancy Complications (Specify): | | |Other Obstetrical or Pregnancy Complications | | |
| | | |(Specify): | | |
| | | | | | |
|Fetal Anomaly (Specify): | | |Fetal Anomaly (Specify):| | |
| | | | | | |
|Fetal Injury (Specify): | | |Fetal Injury | | |
| | | |(Specify): | | |
| | | | | | |
|Fetal Infection (Specify): | | |Fetal Infection | | |
| | | |(Specify): | | |
| | | | | | |
|Other Fetal Conditions/Disorders (Specify): | | |Other Fetal Conditions/Disorders | | |
| | | |(Specify): | | |
| | | | | | |
| Unknown | Unknown |
| | | | | | |
|17c. Mother’s Manner of | Natural Accident |17d. DATE OF INJURY |17e. TIME OF |17f. INJURY AT |17g. DESCRIBE HOW INJURY OCCURRED |
|Death (if applicable): |Suicide Homicide |(Mo/Day/Yr) |INJURY |WORK? | |
|check one box | | | |Yes No | |
| | Pending Investigation|17h. PLACE OF INJURY—at home, farm, street,|17i. LOCATION (Street & Number or Rural Route Number, City or Town, |
| | |factory, etc. |State) |
| | |Specify: | |
| | Could not be | | |
| |determined | | |
|17j. DATE PRONOUNCED DEAD (Month, Day, Year) |17k. MOTOR VEHICLE ACCIDENT? Yes No |17l. IF YES, SPECIFY DRIVER, PASSENGER, PEDESTRIAN, ETC. |
|17m. WEIGHT OF FETUS (grams preferred, specify unit) |17o. ESTIMATED TIME OF FETAL DEATH |17p. WAS AN AUTOPSY PERFORMED? |
| | | grams lb/oz | Dead at time of first assessment, no labor | Yes No Planned |
| | | |ongoing | |
| | Dead at time of first assessment, labor ongoing| |
| | Died during labor, after first assessment |17q. WAS A HISTOLOGICAL PLACENTAL EXAMINATION PERFORMED? |
|17n. OBSTETRIC ESTIMATE OF GESTATION AT DELIVERY | Unknown time of fetal death | Yes No Planned |
| | |(completed weeks) |17r. WERE AUTOPSY OR HISTOLOGICAL PLACENTAL EXAMINATION RESULTS USED IN DETERMINING THE CAUSE OF FETAL DEATH? |
| | | |Yes No |
| | | | |
|18. Signature, Of Person Certifying Cause Of Death: |18a. License Number |
|18b. Name, Address And Zip Code Of Person Certifying Cause Of Death: |18c. Date Certified (month,day,year) |
|19. MOTHER’S EDUCATION |20. MOTHER OF HISPANIC ORIGIN? |21. MOTHER’S RACE |
|(Check the box that best describes the highest degree |(Check the box that best describes whether the mother|(Check one or more races to indicate what the mother |
|or level of school completed at the time of delivery) |is Spanish/Hispanic/Latina. Check the “No” box if |considers herself to be) |
|8th grade or less |mother is not Spanish/Hispanic/Latina.) |White |
|9th-12th grade, no diploma |No, not Spanish/Hispanic/Latina |Black or African American |
|High school graduate or GED completed |Yes, Mexican, Mexican American, Chicana | |
|Some college credit but no degree |Yes, Puerto Rican | |
|Associate degree (e.g., AA, AS) |Yes, Cuban | |
|Bachelor’s degree (e.g., BA, AB, BS) |Yes, other Spanish/Hispanic/Latina | |
|Master’s degree (e.g., MA, MS, MEng, MEd, MSW, MBA) | | |
|Doctorate (e.g., PhD, EdD) or professional degree | | |
|(e.g., MD, DDS, DVM, LLB, JD) | | |
| | | American Indian or Alaska Native (Name of the enrolled or |
| | |principal | |
| | |tribe) | |
| | | Asian Indian |
| | |Chinese |
| | |Filipino |
| | |Japanese |
| |Specify: | | Korean |
| | | |Vietnamese |
| | | |
| | | Other Asian |Specify| |
| | | |: | |
| | | Native Hawaiian |
| | |Guamanian or Chamorro |
| | |Samoan |
| | | Other Pacific Islander |
| | |Specify: | |
| | | Other |Specify| |
| | | |: | |
| | | | | |
|22. MOTHER MARRIED? |23a. DATE OF FIRST PRENATAL CARE VISIT |23b. DATE OF LAST PRENATAL CARE |23c. TOTAL NUMBER. OF PRENATAL |
|(At delivery, conception, or anytime between) | |VISIT |VISITS FOR THIS PREGNANCY |
|Yes No | | | |
| | MM/DD/YYYY | No Prenatal Care |MM/DD/YYYY | |If none, enter “0” |
|24. MOTHER’S HEIGHT |25. MOTHER’S PREPREGNANCY WEIGHT |26. MOTHER’S WEIGHT AT DELIVERY|27. DID MOTHER GET WIC FOOD FOR HERSELF |
| | | |DURING THIS PREGNANCY? Yes No |
|(feet/inches) |(pounds) |(pounds) | |
|28. NUMBER OF PREVIOUS LIVE BIRTHS |29. NUMBER OF OTHER PREGNANCY |30. CIGARETTE SMOKING BEFORE AND DURING PREGNANCY (For each time | |
| |OUTCOMES (spontaneous or |period, enter either the number of cigarettes or the number of packs| |
| |induced losses or ectopic |of cigarettes smoked. IF NONE, ENTER “0” | |
| |pregnancies) | | |
| | |Avg. # of cigarettes, or packs, smoked/day # Cigarettes | |
| | |# Packs | |
|28a. NOW LIVING |28b. NOW DEAD |29a. Other Outcomes |Three months before | |
| | | |pregnancy | |
|MM/DD/YYYY |MM/DD/YYYY |MM/DD/YYYY |Specify: | |
|33. MOTHER TRANSFERRED FOR MATERNAL MEDICAL OR FETAL |IF YES, ENTER NAME| |
|INDICATIONS FOR DELIVERY? Yes No |OF FACILITY MOTHER| |
| |TRANSFERRED FROM: | |
| | | |
|34. RISK FACTORS IN THIS PREGNANCY (check all that apply) |35. INFECTIONS PRESENT AND/OR TREATED DURING THIS PREGNANCY (check all that apply)|
|Diabetes |Gonorrhea |
|Prepregnancy (diagnosis prior to this pregnancy) |Syphilis |
|Gestational (diagnosis in this pregnancy) |Chlamydia |
|Hypertension |Listeria |
|Prepregnancy (chronic) |Group B Streptococcus |
|Gestational (PIH, preeclampsia) |Cytomegalovirus |
|Eclampsia |Parvovirus |
|Previous preterm birth |Toxoplasmosis |
|Other previous poor pregnancy outcome (includes perinatal death, small-for-gestational|None of the above |
|age/intrauterine growth restricted birth) | |
| | |
|Pregnancy resulted from infertility treatment- If yes, check all that apply: | |
|Fertility-enhancing drugs, Artificial insemination or intrauternine insemination | |
|Assisted reproductive technology(e:g: in vitro fertilization ( IVF), gamete | |
|intrafallopian transfer (GIFT)) | |
|Mother had a previous cesarean delivery,If checked, how many previous cesarean | |
|deliveries? | |
|None of the above | |
| | Other |Specify| |
| | |: | |
| |Was A Standard Licensed Diagnostic Test For Syphilis Performed For The Mother: |
| |YES NO UNKNOWN |
| |Date the blood specimen was taken: _________________ |
| |Was the test made During Pregnancy Time of Delivery |
| |If Test Not Given Specify Reason: |
| |Mother Refusal Syphilis Status Known Insurance Would Not Pay Other |
| |Unknown |
| |Other Specify: __________________________________ |
| | |
| |Was A Standard Licensed Diagnostic Test For Hiv Performed? YES NO UNKNOWN |
| |Test Given During Pregnancy or at Delivery: During Pregnancy At Delivery |
| |If Test Given Specify Date ________________ |
| |If Test Not Given, Specify Reason: Mother Refusal Syphilis Status Known|
| |Insurance Would Not Pay |
| |Other Unknown |
| |Other Specify: __________________________________ |
| | |
|36. METHOD OF DELIVERY |37. MATERNAL MORBIDITY (check |38. CONGENITAL ANOMALIES OF THE FETUS (check all that apply) |
|A. Was delivery with forceps attempted but |all that apply) |Anencephaly |
|unsuccessful? |Complications associated with |Meningomyelocele/Spina bifida |
|Yes No |labor and delivery |Cyanotic congenital heart disease |
|B. Was delivery with vacuum extraction attempted but |Maternal transfusion |Congenital diaphragmatic hernia |
|unsuccessful? |Third or fourth degree perineal|Omphalocele |
|Yes No |laceration |Gastroschisis |
|C. Fetal presentation at delivery |Ruptured uterus |Limb reduction defect (excluding congenital amputation and dwarfing syndromes) |
|Cephalic |Unplanned hysterectomy |Cleft Lip with or without Cleft Palate |
|Breech |Admission to intensive care |Cleft Palate alone |
|Other |unit |Down Syndrome |
|D. Final route and method of delivery (check one) |Unplanned operating room |Karyotype confirmed |
|Vaginal/Spontaneous |procedure following delivery |Karyotype pending |
|Vaginal/Forceps |None of the above |Suspected chromosomal disorder |
|Vaginal/Vacuum | |Karyotype confirmed |
|Cesarean | |Karyotype pending |
|If cesarean, was a trial of labor attempted? | |Hypospadias |
|Yes No | |None of the anomalies listed above |
|E. Hysterotomy/Hysterectomy | | |
|Yes No | | |
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Mother’s Name _______________________
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