WISSP - Clinical Examination Document

CLINICAL EXAMINATION OF STILLBORN INFANT

[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