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 _____________________________