1. Fetal Demise/Neonatal Death Algorithm By, Briana Schafer

2. Clinical Definitions Induced or Spontaneous Abortion Diagnosed as FETAL DEATH Fetus <20 weeks gestational age <23 weeks from LMP if GA not known <500g if GA and LMP not known Stillbirth Fetus is BORN DEAD Fetus >20 weeks gestational age >23 weeks from LMP if GA not known >500g if GA and LMP not known Neonatal Death Fetus born alive then expires after delivery Fetus is any gestational age Born with purposeful movement Born with vital signs

3. Induced OR Spontaneous AB. Fetus < 20 weeks gestational age, or <23 weeks from LMP, or < 500g if GA and LMP not known, AND diagnosed as fetal death. Nurse to offer memory box and pictures to parents If burial/cremation not requested, put remains and placenta in formalin for pathology examination, send to pathology with requisition Mortuary Release form NOT NEEDED unless family requesting burial or cremation. Family must sign form Primary NURSE: Refer to Social Services BEFORE delivery and give bereavement services packet “Resolve Through Sharing” Charge Nurse/Team Leader gives assignment Inform charge nurse and arrange for LDR 9 or appropriate room at a distance from active labor patients

4. Was Stillbirth Fetus >20 weeks, LMP > 23 weeks, or > 500 g if gestational age and LMP not known AND born dead. Stillbirth Fetus >20 weeks, LMP > 23 weeks, or > 500 g if gestational age and LMP not known AND born dead. Was fetus alive on admission with documented heart tones? Baby issued a Fetal Death Certificate, NO BIRTH CERTIFICATE If YES, Intrapartum Fetal Death If NO, Antepartum Fetal Death Follow Policy & Procedure protocol. Notify NM/HS. Notify One Legacy w/in 1 hour of delivery, fill out form with # they give you State law requires burial or cremation of infant. Discuss plans with parents and social services. Obtain signed Release to Mortuary/Coroner form with name of mortuary selected by parents If parents refuse to dispose of remains, obtain signed Permit to Retain and Dispose form. Parents will be billed. Obtain weight and length of infant. If appropriate complete memory box with footprints, use digital camera for photos. Place appropriate ID bands on baby (if neonatal death, use assigned MRN)). Wrap in chux, label outside with mother’s name/MRN/delivery data & time/sex of infant/baby’s stillbirth or MRN. Bring infant to morgue, chart to Decedent Affairs (if no autopsy) IN PERSON on day of death Send placenta to Pathology with pathology requisition including delivery data & time, notation of infant death, gestational age Primary NURSE: Refer to Social Services BEFORE delivery and give bereavement services packet “Resolve Through Sharing.” Notify NM/HS. Notify One Legacy w/in 1 hour of delivery, fill out form with # they give you State law requires burial or cremation of infant. Discuss plans with parents and social services. Obtain signed Release to Mortuary/Coroner form with name of mortuary selected by parents If parents refuse to dispose of remains, obtain signed Permit to Retain and Dispose form. Parents will be billed. Obtain weight and length of infant. If appropriate complete memory box with footprints, use digital camera for photos. Place appropriate ID bands on baby (if neonatal death, use assigned MRN). Wrap in chux, label outside with mother’s name/MRN/delivery data & time/sex of infant/baby’s stillbirth or MRN. Notify transport & security, bring infant to morgue, chart to Decedent Affairs (if no autopsy) IN PERSON on day of death Send placenta to Pathology with pathology requisition including delivery date & time, notation of infant death, gestational age Primary NURSE: Refer to Social Services BEFORE delivery and give bereavement services packet “Resolve Through Sharing.” Notify NM/HS. Notify One Legacy w/in 1 hour of delivery, fill out form with # they give you State law requires burial or cremation of infant. Discuss plans with parents and social services. Obtain signed Release to Mortuary/Coroner form with name of mortuary selected by parents If parents refuse to dispose of remains, obtain signed Permit to Retain and Dispose form. Parents will be billed. Obtain weight and length of infant. If appropriate complete memory box with footprints, use digital camera for photos. Place appropriate ID bands on baby (if neonatal death, use assigned MRN). Wrap in chux, label outside with mother’s name/MRN/delivery data & time/sex of infant/baby’s stillbirth or MRN. Notify transport & security, bring infant to morgue, chart to Decedent Affairs (if no autopsy) IN PERSON on day of death Send placenta to Pathology with pathology requisition including delivery date & time, notation of infant death, gestational age IF AUTOPSY/SPECIAL EXAM DESIRED BY MD: MD to fill out Autopsy Consultation form and notify pathologist on call MD to fill out Autopsy Consent form, obtain parent signature, RN witness Form 18 filled out ONLY for Coroner’s cases. MD to call Coroner. Coroner’s cases include criminal abortions, drug abuse, gunshot/poisoning, other criminal activity (see Coroner criteria for complete listing). UCLA Autopsy form filled out only for HIV or Creutzfeldt-Jakob Syndrome disease cases only. Yellow AUTOPSY CASE form goes on top of chart, chart goes to Pathology. Baby goes to morgue. Charge/Primary nurse to notify Decedent Affairs. IF AUTOPSY/SPECIAL EXAM DESIRED BY MD: MD to fill out Autopsy Consultation form and notify pathologist on call MD to fill out Autopsy Consent form, obtain parent signature, RN witness Form 18 filled out ONLY for Coroner’s cases. MD to call Coroner. Coroner’s cases include criminal abortions, drug abuse, gunshot/poisoning, other criminal activity (see Coroner criteria for complete listing). UCLA Autopsy form filled out only for HIV or Creutzfeldt-Jakob Syndrome disease cases only. Yellow AUTOPSY CASE form goes on top of chart, chart goes to Pathology. Baby goes to morgue. Charge/Primary nurse to notify Decedent Affairs.

5. Neonatal Death Fetus is any gestational age, born alive with purposeful movement &/or vital signs and then expires after delivery. Neonatal Death Fetus is any gestational age, born alive with purposeful movement &/or vital signs and then expires after delivery. Use standard baby number Complete standard L&D documentation Admit and enter data into Health Connect MD must pronounce Time of Death and document in progress note Have parents complete birth certificate worksheet Baby will be issued standard birth AND death certificate Use standard baby number Complete standard L&D documentation Admit and enter data into Health Connect MD must pronounce Time of Death and document in progress note Have parents complete birth certificate worksheet Baby will be issued standard birth AND death certificate Primary NURSE: Refer to Social Services BEFORE delivery and give bereavement services packet “Resolve Through Sharing” Notify NM/HS. Notify One Legacy w/in 1 hour of delivery, fill out form with # they give you State law requires burial or cremation of infant. Discuss plans with parents and social services. Obtain signed Release to Mortuary/Coroner form with name of mortuary selected by parents If parents refuse to dispose of remains, obtain signed Permit to Retain and Dispose form. Parents will be billed. Obtain weight and length of infant. If appropriate complete memory box with footprints, use digital camera for photos. Place appropriate ID bands on baby (if neonatal death, use assigned MRN). Wrap in chux, label outside with mother’s name/MRN/delivery data & time/sex of infant/baby’s stillbirth or MRN. Notify transport & security, bring infant to morgue, chart to Decedent Affairs (if no autopsy) IN PERSON on day of death Send placenta to Pathology with pathology requisition including delivery date & time, notation of infant death, gestational age Primary NURSE: Refer to Social Services BEFORE delivery and give bereavement services packet “Resolve Through Sharing” Notify NM/HS. Notify One Legacy w/in 1 hour of delivery, fill out form with # they give you State law requires burial or cremation of infant. Discuss plans with parents and social services. Obtain signed Release to Mortuary/Coroner form with name of mortuary selected by parents If parents refuse to dispose of remains, obtain signed Permit to Retain and Dispose form. Parents will be billed. Obtain weight and length of infant. If appropriate complete memory box with footprints, use digital camera for photos. Place appropriate ID bands on baby (if neonatal death, use assigned MRN). Wrap in chux, label outside with mother’s name/MRN/delivery data & time/sex of infant/baby’s stillbirth or MRN. Notify transport & security, bring infant to morgue, chart to Decedent Affairs (if no autopsy) IN PERSON on day of death Send placenta to Pathology with pathology requisition including delivery date & time, notation of infant death, gestational age IF AUTOPSY/SPECIAL EXAM DESIRED BY MD: MD to fill out Autopsy Consultation form and notify pathologist on call MD to fill out Autopsy Consent form, obtain parent signature, RN witness Form 18 filled out ONLY for Coroner’s cases. MD to call Coroner. Coroner’s cases include criminal abortions, drug abuse, gunshot/poisoning, other criminal activity (see Coroner criteria for complete listing). UCLA Autopsy form filled out only for HIV or Creutzfeldt-Jakob Syndrome disease cases only. Yellow AUTOPSY CASE form goes on top of chart, chart goes to Pathology. Baby goes to morgue. Charge/Primary nurse to notify Decedent Affairs. IF AUTOPSY/SPECIAL EXAM DESIRED BY MD: MD to fill out Autopsy Consultation form and notify pathologist on call MD to fill out Autopsy Consent form, obtain parent signature, RN witness Form 18 filled out ONLY for Coroner’s cases. MD to call Coroner. Coroner’s cases include criminal abortions, drug abuse, gunshot/poisoning, other criminal activity (see Coroner criteria for complete listing). UCLA Autopsy form filled out only for HIV or Creutzfeldt-Jakob Syndrome disease cases only. Yellow AUTOPSY CASE form goes on top of chart, chart goes to Pathology. Baby goes to morgue. Charge/Primary nurse to notify Decedent Affairs.

6. Kaiser Permanente Medical Center Perinatal Services Fetal Demise/Neonatal Death Algorithm Induced OR Spontaneous AB. Fetus < 20 weeks gestational age, or <23 weeks from LMP, or < 500g if GA and LMP not known, AND diagnosed as fetal death. Stillbirth Fetus >20 weeks, LMP > 23 weeks, or > 500 g if gestational age and LMP not known AND born dead. Neonatal Death Fetus is any gestational age, born alive with purposeful movement &/or vital signs and then expires after delivery. Nurse to offer memory box and pictures to parents If burial/cremation not requested, put remains and placenta in formalin for pathology examination, send to pathology with requisition Mortuary Release form NOT NEEDED unless family requesting burial or cremation. Family must sign form Primary NURSE: Refer to Social Services BEFORE delivery and give bereavement packet “Resolve Through Sharing” Charge Nurse/Team Leader gives assignment Inform charge nurse and arrange for LDR 9 OR appropriate room at a distance from active labor patients Was fetus alive on admission with documented heart tones? Baby issued a Fetal Death Certificate, NO BIRTH CERTIFICATE If YES, Intrapartum Fetal Death If NO, Antepartum Fetal Death Use standard baby number Complete standard L&D documentation Admit and enter data into Health Connect MD must pronounce Time of Death and document in progress note Have parents complete birth certificate worksheet Baby will be issued standard birth AND death certificate Refer to Social Services BEFORE delivery and give bereavement services packet “Resolve Through Sharing.” Notify NM/HS. Notify One Legacy w/in 1 hour of delivery, fill out form with # they give you State law requires burial or cremation of infant. Discuss plans with parents and social services. Obtain signed Release to Mortuary/Coroner form with name of mortuary selected by parents If parents refuse to dispose of remains, obtain signed Permit to Retain and Dispose form. Parents will be billed Obtain weight & length of infant. If appropriate, complete memory box with footprints, use digital camera for photos Place appropriate ID bands on baby (if neonatal death, use assigned MRN)). Wrap in chux, label outside with mother’s name/MRN/delivery data & time/sex of infant/baby’s stillbirth or MRN Notify transport & security, bring infant to morgue, chart to Decedent Affairs (if no autopsy) in person on day of death Send placenta to Pathology with pathology requisition including delivery date & time, notation of infant death, gestational age Refer to Social Services BEFORE delivery and give bereavement services packet “Resolve Through Sharing.” Notify NM/HS. Notify One Legacy w/in 1 hour of delivery, fill out form with # they give you State law requires burial or cremation of infant. Discuss plans with parents and social services. Obtain signed Release to Mortuary/Coroner form with name of mortuary selected by parents If parents refuse to dispose of remains, obtain signed Permit to Retain and Dispose form. Parents will be billed Obtain weight & length of infant. If appropriate, complete memory box with footprints, use digital camera for photos Place appropriate ID bands on baby (if neonatal death, use assigned MRN)). Wrap in chux, label outside with mother’s name/MRN/delivery data & time/sex of infant/baby’s stillbirth or MRN Notify transport & security, bring infant to morgue, chart to Decedent Affairs (if no autopsy) in person on day of death Send placenta to Pathology with pathology requisition including delivery date & time, notation of infant death, gestational age IF AUTOPSY/SPECIAL EXAM DESIRED BY MD: MD to fill out Autopsy Consultation form and notify pathologist on call MD to fill out Autopsy Consent form, obtain parent signature, RN witness Form 18 filled out ONLY for Coroner’s cases. MD to call Coroner. Coroner’s cases include criminal abortions, drug abuse, gunshot/poisoning, other criminal activity (see Coroner criteria for complete listing). UCLA Autopsy form filled out only for HIV or Creutzfeldt-Jakob Syndrome disease cases only. Yellow AUTOPSY CASE form goes on top of chart, chart goes to Pathology. Baby goes to morgue. Charge/Primary nurse to notify Decedent Affairs. IF AUTOPSY/SPECIAL EXAM DESIRED BY MD: MD to fill out Autopsy Consultation form and notify pathologist on call MD to fill out Autopsy Consent form, obtain parent signature, RN witness Form 18 filled out ONLY for Coroner’s cases. MD to call Coroner. Coroner’s cases include criminal abortions, drug abuse, gunshot/poisoning, other criminal activity (see Coroner criteria for complete listing). UCLA Autopsy form filled out only for HIV or Creutzfeldt-Jakob Syndrome disease cases only. Yellow AUTOPSY CASE form goes on top of chart, chart goes to Pathology. Baby goes to morgue. Charge/Primary nurse to notify Decedent Affairs.

7. Management of the Body INDUCED/SPONTANEOUS ABORTION or STILLBIRTH Management of the Body INDUCED/SPONTANEOUS ABORTION or STILLBIRTH 1.) Weigh, measure, obtain vital statistics and document on mother’s chart 2.) Take pictures, apply footprints to card, and give to parents 3.) Place placenta in 10% Formalin, label with label with date, name, PF#. 4.) If spontaneous abortion, place fetus in 10% Formalin, label with patient’s name and MRN. 5.)Generate Pathology form. Send fetus with form to Pathology. Fetus will be examined and pathology report will be generated and sent with remains to mortuary. If fetus is 20 weeks or less (Induced/Spontaneous Abortion), parents must REQUEST cremation.

8. Management of the Body NEONATAL DEATH Management of the Body NEONATAL DEATH 1.) Wipe infant clean especially face and hands, if condition of body permits. 2.) Wrap infant snugly and cover head with stockinet. 3.) Allow parents/family to hold baby according to their wishes. 4.) Weigh and measure infant. 5.) Document ALL pertinent statistics on Baby at Birth. 6.) Band infant as in regular live birth (DO NOT BAND MOTHER). Keep mother’s ID bracelet in her chart. AFTER DELIVERY OF BABY

9. Management of the Body STILLBIRTH/NEONATAL DEATH Management of the Body STILLBIRTH/NEONATAL DEATH #3.) Care of Remains Wrap infant in chux, baby blanket and then place in SHROUD (located in Dirty Utility Room, upper right) Attach THIRD luggage tag to BODY BAG #4.) Transport Notify Security ext. 2370 to open Morgue prior to transport (transport staff member MUST accompany body to morgue) Place infant in the Crypt Attach FOURTH luggage tag on refrigerator door Enter infant information in morgue log AFTER ALL PROCEDURES ARE DONE AND FAMILY IS FINISHED VIEWING THE BABY #1.) Memory Box Place hat on head if possible Take pictures for parents. Location (LDR or Utility Room) depends on condition of demise. Take footprints with Identifier Footprint Sheet and Wipes (located by Unit Secretary desk). Give to parents. #2.) Labeling Apply stamped luggage tags found in fetal demise packet, include “Baby Boy/Girl of (mother’s name)” Attach FIRST luggage tag to infant’s ANKLE Attach SECOND luggage tag to infant’s WRIST #5.) After transport, bring fetal demise packet and envelope to Decedent Affairs Mother’s chart stays with her Give NKE to oncoming staff receiving mother (for example, if patient requires autopsy)