1.
Center Name Baby's Hospital Record No. * Mother's Hospital Record No. NBBD Number *
: (eg. 20-Feb-2019) Intramural * Yes No
1. Basic Information
Date of Still Birth *
Mother’s Age * Consanguineous Marriage * Yes No Unknown
2. Pregnancy Care
Obstetrical History
Gravida * Para * Abortion *
Anemia Urinary Infection TORCH Obesity Hypertension Under Nutrition Gestational Diabetes Mellitus
Previous Birth Defect * Prev C-section * RH Negative * Unknown
TT Vaccination: TT2+/ TT1/ TT Booster/ Not needed/ Not given/ Unknown
Syphilis Test: Syphilis positive/ Negative/ Not done/ Unknown
Antenatal Care Received * None/ At least 1/ Minimum 4/ 4+ visit / 8+ visit / Unknown
Iron/Folic Acid * ( ) Given ( ) Not Given ( ) Unknown
Hemoglobin: Not done/ >11 gm/dl/ 10.9-10 gm/dl/ 9.9-7 gm/dl/ <7 gm/dl/ Unknown
Malaria: Not available/ IPT3+/ IPT2/ IPT1/ Unknown
Pre-Natal Ultrasound: Anomaly (BD) detected/ Normal/ Not done/ Unknown
3. Examination - Labour & Birth
Examination on Admission
Present Absent Unknown
Done Not Done
Yes No Fever * Yes No
Delivery Details Partograph Used Used Not Used Type of Labour: Spontaneous/ Induced
Ante-Partum / Macerated Stillbirth (MSB) Intra-Partum / Fresh Stillbirth (FSB)
STILL BIRTH
Yes No Yes No Yes No
HIV Status: HIV-positive/ HIV-negative/ Not done/ Unknown
Fetal Heart Sound*
Blood Pressure*
Per Vaginal Bleeding *
Mode of Delivery* Normal Vaginal Delivery/ Breech Delivery/ Instrumental Delivery/ Emergency Cesarean Section/ Elective Cesarean Section
(in gram) Sex of the Baby * Male/ Female/ Ambiguous
weeks & days Confirmation of Gestation Age by: Last Mansuration Period LMP / Ultrasound USG/ Unknown
Birth Details Baby Weight
Gestation Age* &
4.1 - Maternal Condition Associated with Fetal Death (M) * M - Maternal Conditions
[ ] M1 Complications of Placenta, Cord & Membranes
[ ] M2 Maternal Complications of Pregnancy
[ ] M3 Other Complecations of Labour and Delivery
[ ] M4 Maternal Medical & Surgical Conditions; Noxious Influences
[ ] M5 No Maternal condition identified (healthy mother)
4.2 - Fetal Death Main Cause [Ante-Partum Death (MSB) (A)]* A - Antepartum Deaths
[ ] A1 Birth Defect
[ ] A2 Infection
[ ] A3 Antepartum Hypoxia
[ ] A4 Other Specified Antepartum Disorder
[ ] A5 Disorders Related to Fetal Growth
[ ] A6 Unspecified Cause of Antepartum Death
4.2 - Fetal Death Main Cause [Intra-Partum Death (FSB) (I)]* I - Intrapartum Deaths
[ ] I1 Birth Defect
[ ] I2 Birth Trauma
[ ] I3 Acute Intrapartum Event
[ ] I4 Infection
[ ] I5 Other Specified Intrapartum Disorder
[ ] I6 Disorder Related to Fetal Growth
[ ] I7 Other
4.3 - Other Associated Conditions (O) * Critical Delay: [ ] Delay in Recognizing [ ] Need for Care Delay Seeking Care [ ] Delay Receiving Care
Modifiable Factors:
21 Feb 2019
Refer the PDF for sub options
Refer the PDF for sub options
Refer the PDF for sub options
Unknown
Past History *
Previous Still Birth * Yes No
4. Details of Stillbirth
Type of Stillbirth *
Name of the Professional Filling the Form: __________________________________________________ Date: ______/______/______
1-Family Related: Late/no antenatal care/ Cultural inhibition to seeking care/ No knowledge of danger signs/ Financial constraints /Partner restricts care-seeking/ Use of
traditional/herbal medicine / Smoking / drug / alcohol abuse/ Attempted termination / Other
2-Administration Related: Neonatal facilities/ Theatre facilities / Resuscitation equipment / Blood products / Lack of training/ Insufficient staff numbers/ Anesthetic delay/ No antenatal documentation/ Other
3-Provider Related:Partogram not used/ Action not taken/ Inappropriate action taken/ Iatrogenic delivery / Delay in referral / Inadequate monitoring/ Delay in calling for assistance/ Inappropriate
discharge/ Other 4-Unknown