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