Fetal Death/Stillborn Autopsy Request
To accompany body to morgue
Date
Medical Record #
Mother
Fetus
Fetus weight_______  Sex     Apgar 1min  Apgar 5 min
Name
LMP
Estimated gestational age _____________weeks
Gravida____ Para____ A____ Living children____
Ultrsaound Dx:  ____________________________ __________________________________________ __________________________________________
Cord examination (measurement of cord length, number of
vessels, position attached to the newborn) 
 __________________________________________ __________________________________________ __________________________________________
Cytogenetics obtained:
Blood:     ____ Yes   ____ No
Skin:       ____  Yes  ____ No  
Alpha-fetoprotein ____________________________
Prenatal assessment __________________________ __________________________________________
Labor: Spontaneous: __________________________ Induced:___________________________________  
Delivery:
Date _______________ Time__________________
Vaginal ___________________________________ Cesarean__________________________________  
Pregnancy complications______________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________
Delivery complications________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________
Indication(s) for pathologic examination
 __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________
Special requests for gross and microscopic evaluation __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________  
Attending clinician___________________________
Phone number _____________________________