[Clinical description is often critical in the etiologic evaluation of stillborns. Yet it is often given less attention than it deserves in most formal postmortem evaluations. This is a suggested, simple and relatively non-jargon filled outline for such a clinical evaluation; it also includes space to provide brief notation of relevant prenatal, perinatal and family history.]
| I. General Information | Date ____ ____ ____ |
| Baby's Name____________________ | Mother's Name____________________ |
| Father's Name____________________ | |
| Hospital____________________ | Parents' Address____________________ |
| Attending Physician___________________ |
Person performing this evaluation ________________________
II. Brief History
| Prior Pregnancy History -- | Pregnancies____ | Deliveries____ | Liveborn____ |
| Spont. Ab. ____ | Ind. Ab.____ | Prior Stillborns____ |
Relevant maternal history and health [e.g. diabetes, hypertension, thyroid disease, etc.]
________________________________________________________________
Significant problems in this pregnancy ________________________
________________________________________________________________
Relevant family history [if not supplied in other records]________________________
________________________________________________________________
III. General Data on Baby
Gestational age:____weeks; How determined -- dates ultrasound clinical exam other
Degree of Maceration:
____Fresh; no skin peeling
____Slight; focal minimal skin slippage
____Mild; some skin sloughing, moderate skin slippage
____Moderate; much skin sloughing but no secondary compressive changes or decomposition
___Marked, advanced
IV. Measurements
Crown-heel [stretched] ______ Weight ______
Head Circumference ______
V. Head and Face
Head is --
collapsed_____
Anencephalic____
Apparently hydrocephalic_____
abnormally shaped_____; describe ____________________
relatively normal_____check for and describe any:
scalp defects_____;________________________________________
cranial masses_____;________________________________________
Eyes --
normal_____; sunken_____; prominent_____;
abnormally far apart_____; abnormally close together____;
straight____;upslanting [V]____; or downslanting [/\]___
on opening the lids the following is found --
eyelids are fused____
globes appear normal_____
globes are apparently absent____
eyes seem extremely small____
eyes seem extremely large____
opacities are present____of the corneas____
of the lenses____
other________________________________________
Nose --
normal____; abnormally small____; abnormally large____;
asymmetric____
nostrils are: apparently patent____; obstructed____;
Single nostril only____other ________________________________________
Mouth --
size: normal____; large____; small____
upper lip: intact____; cleft____; if cleft give location of cleft--
Left__, Right__, Bilateral__, Midline__
palate: intact____; cleft____
mandible: normal___; very small____; asymmetric____
other ________________________________________
Ears --
normal____; abnormal in form____; if abnormal describe or draw --
lowset____; posteriorly rotated____;
preauricular tags___; preauricular pits____
other ________________________________________
VI. Neck
normal____; short____; excess or redundant skin____;
cystic mass [hygroma]____
other ________________________________________
VII. Chest
normal____; asymmetric____; small and constricted____; barrelled____
other ________________________________________
VIII. Abdomen
normal____; flattened____; distended____;
wall defects____ [omphalocele____; gastroschisis____; hernia____]
umbilical cord -- number of vessels____ clinical abnormality [describe]
other ________________________________________
IX. Back
normal____; spina bifida____ [level of defect_____]; scoliosis____;
kyphosis____
other ________________________________________
X. Limbs
length: normal____; short____; long____
if short, what segment(s) seem short
form: normal____; asymmetric____; have missing parts____
describe any asymmetry or missing parts
position: normal____; clubfoot____; other positional abnormality____
describe if abnormal ________________________________________
Xa. Hands
normal appearing____; abnormal____ if abnormal, describe
fingers -- numbers present ___+___ [if not 5+5, describe ]
unusual form of fingers ____; describe
unusual position of fingers____; describe
abnormal webbing or syndactyly____; describe
Xb. Feet
normal appearing____; abnormal____ if abnormal, describe
toes -- numbers present___+___ [if not 5+5, describe ]
abnormal spacing of toes____; describe
XI. Genitalia
Anus -- normal____; imperforate____; other
Male --
penis -- normal___; hypospadias___[level of opening_________];
very small____; chordee____
other ________________________________________
scrotum -- normal____; abnormal____[describe ]
testes -- descended____; undescended____
other ________________________________________
Female --
urethral opening -- present____; absent/unidentifiable____
vaginal introitus -- present____; absent____
clitoris -- normal____; enlarged____; unidentifiable____
other ________________________________________
Ambiguous____; Describe
