CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care

Standard Terminology for Fetal, Infant, and Perinatal Deaths Wanda D. Barfi eld, MD, MPH, COMMITTEE ON FETUS AND NEWBORN

Accurately defi ning and reporting perinatal deaths (ie, fetal and infant abstract deaths) is a critical fi rst step in understanding the magnitude and causes of these important events. In addition to obstetric health care providers, neonatologists and pediatricians should have easy access to current and updated resources that clearly provide US defi nitions and reporting requirements for live births, fetal deaths, and infant deaths. Correct identifi cation of these vital events will improve local, state, and national data so that these deaths can be better addressed and prevented.

This document is copyrighted and is property of the American INTRODUCTION Academy of Pediatrics and its Board of Directors. All authors have fi led confl ict of interest statements with the American Academy of Pediatrics. Any confl icts have been resolved through a process Perinatal mortality is the combination of fetal deaths and neonatal approved by the Board of Directors. The American Academy of deaths. In the United States in 2013, the fetal mortality rate for gestations Pediatrics has neither solicited nor accepted any commercial of at least 20 weeks (5.96 fetal deaths per 1000 live births and fetal involvement in the development of the content of this publication. deaths)1 was similar to the infant mortality rate (5.98 infant deaths per The views expressed in this document are not necessarily those of the 2 Centers for Disease Control and Prevention or the US Department of 1000 live births). Depending on the definition used, fetal mortality Health and Human Services. contributes to approximately 40% to 60% of perinatal mortality. Clinical reports from the American Academy of Pediatrics benefi t from Understanding the etiologies of these events and predicting risk begins expertise and resources of liaisons and internal (AAP) and external with accurately defining cases; the collection and analysis of reliable reviewers. However, clinical reports from the American Academy of Pediatrics may not refl ect the views of the liaisons or the organizations statistical data are an essential part of in-depth investigations on local, or government agencies that they represent. state, and national levels. The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking Fetal and infant deaths occur within the clinical practice of several types into account individual circumstances, may be appropriate. of health care providers. Although obstetric practitioners report fetal All clinical reports from the American Academy of Pediatrics deaths, certain situations can occur during a delivery in which viability automatically expire 5 years after publication unless reaffi rmed, revised, or retired at or before that time. or possibility of survival is unclear; the pediatrician or neonatologist may attend the delivery to assess the medical condition of the fetus or infant, DOI: 10.1542/peds.2016-0551 assess pre-viable gestational age, provide care as indicated, and report a PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). subsequent infant death, if it occurs. Incorrectly defining and reporting Copyright © 2016 by the American Academy of Pediatrics fetal deaths and early infant deaths may contribute to misclassification of these important events and result in inaccurate fetal and infant mortality rates.3 Within this context, the American Academy of Pediatrics provides To cite: Barfi eld WD and AAP COMMITTEE ON FETUS AND definitions and reporting requirements of fetal death, live birth, and NEWBORN. Standard Terminology for Fetal, Infant, and Perinatal Deaths. Pediatrics. 2016;137(5):e20160551 infant death to emphasize that neonatologists and pediatricians play an

Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 137 , number 5 , May 2016 :e 20160551 FROM THE AMERICAN ACADEMY OF PEDIATRICS important role in recording accurate Live Birth are categorized specifically as and timely information surrounding miscarriages. these events. This role includes A live birth is defined as the making the determination of the complete expulsion or extraction Infant Death from the mother of a product of specific vital event during delivery, A live birth that results in death human conception, irrespective of recording information surrounding within the first year (<365 days) the duration of pregnancy, which, the event on the appropriate is defined as an infant death. after such expulsion or extraction, certificate or report in compliance Infant deaths are characterized as breathes or shows any other with state-specific requirements, and neonatal (<28 days) and further evidence of life, such as beating of the documenting information that is as subdivided into early neonatal (<7 heart, pulsation of the umbilical cord, complete and as accurate as possible, days), late neonatal (7–27 days), or or definite movement of voluntary including the underlying cause postneonatal (28–364 days). of death, when known. Although muscles, regardless of whether the guidance for these definitions is umbilical cord has been cut or the Perinatal Death provided elsewhere,4–6 it may not be placenta is attached. Heartbeats are Perinatal deaths refer to a readily available to pediatricians in to be distinguished from transient combination of fetal deaths and the delivery room. cardiac contractions; respirations are to be distinguished from fleeting live births with only brief survival (days or weeks) and are grouped on Both the collection and use of respiratory efforts or gasps. the assumption that similar factors information about fetal, infant, are associated with these losses. and perinatal deaths have been Fetal Death Perinatal death is not a reportable hampered by lack of understanding A fetus is defined from 8 weeks vital event, per se, but is used for of differences in definitions, after conception until term while in statistical purposes. Three definitions statistical tabulations, and reporting the uterus. Fetal death is defined as of perinatal deaths are in use: requirements among providers and death before the complete expulsion state, national, and international • Definition I includes infant deaths or extraction from the mother of bodies. Distinctions can and should that occur at less than 7 days of age a product of human conception, be made between the definition of an and fetal deaths with a stated or irrespective of the duration of event and the reporting requirements presumed period of gestation of pregnancy that is not an induced for the event. The definition indicates 28 weeks or more. termination of pregnancy. The the meaning of a term (eg, live birth, death is indicated by the fact that, • Definition II includes infant deaths fetal death). A reporting requirement after such expulsion or extraction, that occur at less than 28 days of is that part of the defined event for the fetus does not breathe or show age and fetal deaths with a stated which reporting is mandatory. any other evidence of life such as or presumed period of gestation of beating of the heart, pulsation of the 20 weeks or more. umbilical cord, or definite movement • Definition III includes infant deaths DEFINITIONS of voluntary muscles. Heartbeats are that occur at less than 7 days of age to be distinguished from transient and fetal deaths with a stated or Challenges in consistent definitions cardiac contractions; respirations presumed gestation of 20 weeks or of fetal and infant death mostly are to be distinguished from fleeting more. stem from the perception of respiratory efforts or gasps. viability, which should not change From national and international the definition of the event. In other For statistical purposes, fetal deaths perspectives, perinatal deaths words, an extremely preterm infant are further subdivided as “early” have important implications for born at 16 weeks’ gestation may (20–27 weeks’ gestation) or “late” both public health and clinical be defined as a live birth but is (≥28 weeks’ gestation). The term interventions. However, the not currently viable outside of the “stillbirth” is also used to describe interpretations of these definitions womb. On the basis of international fetal deaths at 20 weeks’ gestation vary globally on the basis of cultural standards set by the World Health or more. Stillbirth is not specifically perspectives, clinical definitions Organization, 7 the National Center divided into early and late gestations, of viability, and availability of for Health Statistics of the Centers but for international comparisons information. The National Center for for Disease Control and Prevention the World Health Organization Health Statistics currently classifies defines live birth, fetal death, defines stillbirth as at or after 28 perinatal deaths according to the infant death, and perinatal death as weeks’ gestation. Fetuses that die first 2 definitions. Definition I is used follows.4 in utero before 20 weeks’ gestation by the National Center for Health

Downloaded from www.aappublications.org/news by guest on September 25, 2021 e2 FROM THE AMERICAN ACADEMY OF PEDIATRICS TABLE 1 Reporting Requirements for Fetal Death According to State or Reporting Area, 2014 Criteria State/Reporting Area Gestational age criteria only All periods Arkansas, Colorado, Georgia, Hawaii, New York,a Rhode Island, Virginia, Virgin Islands ≥16 weeks Pennsylvania ≥20 weeks Alabama, Alaska, California, Connecticut, Florida, Illinois, Indiana, Iowa, Maine, Maryland,b Minnesota, Nebraska, Nevada, New Jersey, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Texas, Utah, Vermont,c Washington, West Virginia, Wyoming ≥5 months Puerto Rico Both gestational age and birth weight criteria ≥20 weeks or ≥350 g Arizona, Idaho, Kentucky, Louisiana, Massachusetts, Mississippi, Missouri, New Hampshire, New Mexico, South Carolina, Tennessee, Wisconsin, Guam ≥20 weeks or ≥400 g Michigan ≥20 weeks or ≥500 g District of Columbia Birth weight criteria only ≥350 g Delaware,d Kansas, Montanad ≥500 g South Dakota Data source: National Center for Health Statistics, National Vital Statistics Reports. a Includes New York city, which has separate reporting. b If gestational age is unknown, weight of ≥500 g. c If gestational age is unknown, weight of ≥400 g, ≥15 ounces. d If weight is unknown, ≥20 weeks’ completed gestation.

Statistics and the World Health unknown, of 20 completed weeks’ include weight, gestational age, and Organization to make international gestation or more. However, states cause of death. Accurate completion comparisons to account for have the authority to register of these vital records is important variability in registering births and these vital events and might not for generating accurate data to deaths between 20 and 27 weeks’ necessarily follow the Model Law, determine the magnitude and causes gestation.8 However, definition II is which results in differences in birth of fetal, infant, and perinatal deaths. more inclusive and hence is more weight and gestational age criteria appropriate for monitoring perinatal for reporting fetal deaths (Table 1). deaths throughout gestation, because States also vary in the quality of the PRACTICAL CONSIDERATIONS the majority of fetal deaths occur data reported, which include missing A flow diagram for the determination before 28 weeks’ gestation. data.9 of appropriate reporting of perinatal deaths was developed by the All live births, regardless of National Association for Public gestational age, are reported as REPORTING REQUIREMENTS Health Statistics and Information vital record events. Infant deaths Systems (Fig 1). The diagram In the United States, states and involve both the reporting of a delineates the sequence of reporting independent reporting areas (ie, live birth event and a death event and can be used in delivery rooms New York City; Washington, DC; using a certificate of live birth and to appropriately report perinatal and the US territories) register a certificate of death, respectively. events. Induced termination of the certificates of live birth, death, Information from the certificate of pregnancy is included in the flow and fetal death. These certificates/ live birth, including demographic diagram but is beyond the scope of reports include clinical information. information, selected maternal this report. Challenges in consistent reporting risk factors, maternal labor and of fetal death, in particular, stem delivery information, and infant In the circumstance of delivery from the variation in reporting weight and gestational age, is events in which the fetus is of requirements among states.9 linked to information on the uncertain viability, if the infant is Recommended definitions and infant death certificate to include determined to be a live birth, the reporting requirements are issued cause-of-death information. The event is reported regardless of birth through the Model State Vital fetal death certificate or report, weight, length of gestation, survival Statistics Act and Regulations (the a single document, includes time, or other clinical information Model Law).10, 11 The Model Law maternal demographic information, (eg, Apgar scores). If fetal death is recommends fetal death reporting selected maternal risk factors, determined, the event is reported by for deaths that occur at 350 g birth labor and delivery information, the obstetric health care provider on weight or more or, if the weight is and information about the fetus to the basis of state criteria, including

Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 137 , number 5 , May 2016 e3 FIGURE 1 Hospital guidelines for reporting live births, infant deaths, fetal deaths, and induced terminations of pregnancy. (Adapted with permission from the National Association for Public Health Statistics and Information Systems; www.naphsis. org [available on request].) both birth weight and gestational are essential for understanding to be distinguished from age. The careful use of accurate causes and researching potential transient cardiac contractions; definitions is of utmost importance solutions. respirations are to be in medical record documentation distinguished from fleeting of these events. Because there are respiratory efforts or gasps. no signs of life at delivery, fetal SUGGESTIONS deaths are not assigned Apgar scores ⚬ Fetal death: Death before the 1. Vital events are best defined and and are usually not admitted to complete expulsion or extraction reported as follows: the nursery or NICU. Postmortem from the mother of a product of examination of the fetus or infant ⚬ Live birth: The complete human conception, irrespective and placenta may provide important expulsion or extraction from of the duration of pregnancy that information as to the cause of death; the mother of a product of is not an induced termination however, the actual evaluation and human conception, irrespective of pregnancy. The death is management of fetal and infant death of the duration of pregnancy, indicated by the fact that, after are beyond the scope of this guidance which, after such expulsion or such expulsion or extraction, and have been reported elsewhere.12 extraction, breathes or shows the fetus does not breathe or any other evidence of life show any other evidence of life In summary, the accurate and timely such as beating of the heart, such as beating of the heart, reporting of live birth and fetal and pulsation of the umbilical pulsation of the umbilical infant death is the cornerstone of cord, or definite movement of cord, or definite movement of perinatal mortality data. Because voluntary muscles, regardless voluntary muscles. Heartbeats reducing fetal and infant mortality of whether the umbilical cord are to be distinguished from is among the nation’s health goals, has been cut or the placenta transient cardiac contractions; accurate definitions of these events is attached. Heartbeats are respirations are to be

Downloaded from www.aappublications.org/news by guest on September 25, 2021 e4 FROM THE AMERICAN ACADEMY OF PEDIATRICS distinguished from fleeting Tonse N.K. Raju, MD, FAAP – National Institutes of 6. Committee on Obstetric Practice. ACOG respiratory efforts or gasps. Health Committee opinion: perinatal and Wanda D. Barfi eld, MD, MPH, FAAP – Centers for ⚬ infant mortality statistics. Number 167, Infant death: A live birth that Disease Control and Prevention December 1995. Int J Gynaecol Obstet. results in death within the first Erin Keels, MS, APRN, NNP-BC – National 1996;53(1):86–88 year (<365 days). Association of Neonatal Nurses 7. World Health Organization. 2. Obtain accurate information on STAFF International Statistical Classifi cation state law to file the fetal death Jim Couto, MA of Diseases and Related Health certificate/report according to Problems, Tenth Revision. Vol 2. state requirements. Geneva, Switzerland: World Health REFERENCES Organization; 2006 3. Complete reporting of live births, infant deaths, and fetal deaths 1. MacDorman MF, Gregory ECW. Fetal 8. World Health Organization. Neonatal and perinatal mortality: United (in support of obstetrician and Perinatal Mortality: Country, States, 2013. Natl Vital Stat Rep. reporters) with the most Regional and Global Estimates. Geneva, 2015;64(8):1–8 accurate information possible to Switzerland: World Health Organization; 2006 include pertinent demographic 2. Centers for Disease Control and Prevention. Deaths: fi nal data for 2013. information, maternal medical 9. Martin JA, Hoyert DL. The National Available at: www.cdc. gov/ nchs/ data/ history, and fetal or infant Fetal Death File. Semin Perinatol. nvsr/ nvsr64/ nvsr64_ 02. pdf. Accessed 2002;26(1):3–11 diagnoses. July 2015 3. MacDorman MF, Martin JA, Mathews 10. Centers for Disease Control and LEAD AUTHOR TJ, Hoyert DL, Ventura SJ. Explaining Prevention; National Center for Health Wanda Denise Barfi eld, MD, MPH, FAAP the 2001-02 infant mortality increase: Statistics. Model State Vital Statistics [email protected] data from the linked birth/infant Act and Regulations: 1992 revision. death data set. Natl Vital Stat Rep. Hyattsville, MD: National Center for COMMITTEE ON FETUS AND NEWBORN, 2005;53(12):1–22 Health Statistics; 1994. Available 2014–2015 at: www.cdc. gov/ nchs/ data/ misc/ 4. Centers for Disease Control and mvsact92b. pdf. Accessed July 7, 2015 Kristi Watterberg, MD, FAAP, Chairperson Prevention. State defi nitions and William Benitz, MD, FAAP reporting requirements for live births, 11. Centers for Disease Control and James Cummings, MD, FAAP fetal deaths, and induced terminations Prevention; National Center for Health Eric Eichenwald, MD, FAAP of pregnancy. Hyattsville, MD: National Statistics. 2003 Revisions of the U.S. Brenda Poindexter, MD, FAAP Center for Health Statistics; 1997. Standard Certifi cates of Live Birth Dan L. Stewart, MD, FAAP Available at: www.cdc. gov/ nchs/ data/ and Death and the Fetal Death Report. Susan W. Aucott, MD, FAAP misc/ itop97. pdf. Accessed July 7, 2015 Hyattsville, MD: National Center for Karen M. Puopolo, MD, FAAP Health Statistics; 2014. Available 5. American Academy of Pediatrics; Jay P. Goldsmith, MD, FAAP at: www.cdc. gov/ nchs/ nvss/ vital_ American College of Obstetrics and certifi cate_revisions. htm. Accessed LIAISONS Gynecology. Appendix F: standard July 7, 2015 Kasper S. Wang, MD, FAAP – AAP Section on terminology for reporting reproductive Surgery health statistics. In: Guidelines for 12. American College of Obstetricians and Thierry Lacaze, MD – Canadian Pediatric Society Perinatal Care. 7th ed. Elk Grove Gynecologists. ACOG Practice Bulletin Maria Ann Mascola, MD – American College of Village, IL: American Academy of No. 102: management of stillbirth. Obstetricians and Gynecologists Pediatrics; 2012:497–512 Obstet Gynecol. 2009;113(3):748–761

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Downloaded from www.aappublications.org/news by guest on September 25, 2021 Standard Terminology for Fetal, Infant, and Perinatal Deaths Wanda D. Barfield and COMMITTEE ON FETUS AND NEWBORN Pediatrics 2016;137; DOI: 10.1542/peds.2016-0551 originally published online April 18, 2016;

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Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2016 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

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